Visits to Canada’s EDs Have Rebounded From Previous Lows

Emergency department (ED) visits in British Columbia, Canada, rebounded after a sharp drop during the first year of the COVID-19 pandemic, new research suggests. Increases have been variable but sustained.

From February 2020 to May 2021, the overall volume of ED visits was reduced by about 322,300 visits, or 15%, compared with the expected volume. The findings could help in public health surveillance and ED capacity planning in the future, said the authors.

Dr Kate Smolina

“One of the most interesting and surprising findings is the variability in trends over time in different subgroups,” principal investigator Kate Smolina, DPhil, interim scientific director for analytic services and knowledge translation at the BC Center for Disease Control Data in Vancouver, told Medscape Medical News. “While some types of visits, such as those among children and for respiratory conditions, were reduced for over 16 months, others, such as visits for mental health, returned to normal volume much sooner.”

The study, led by Jiayun Yao, PhD, was published online September 5 in the Canadian Medical Association Journal.

Return to Baseline Varied

“There has been a return to the normal pattern of ED utilization, with a resumption of the increasing rate of some ED visit volumes that existed pre-pandemic,” said co-author Eric Grafstein, MD, chief medical information officer and regional emergency department head at Vancouver Coastal Health and Providence Health Care. “This is leading to significant pressure on ED resources.”

To examine changes in ED visits during the pandemic, the investigators analyzed data from Canada’s National Ambulatory Care Reporting System for 30 EDs across BC from 2016-2022. Overall, more than 10 million ED visits (monthly average of 127,400) were included in the analyses.

Reasons for ED visits were identified using the patients’ presenting complaints and the discharge diagnoses made by healthcare professionals. In one analysis, the return to the pre-pandemic baseline volume of ED visits was defined as the first month after February 2020 when the 95% confidence intervals of the estimated number of visits — with and without the impact of the pandemic — overlapped for at least 3 consecutive months. 

The largest and most sustained decreases were in respiratory-related visits, visits among children, visits among the oldest adults, and nonurgent visits. The largest reductions by age group were among children younger than 10 years, who accounted for close to one third of the visits that did not take place.

The nadirs in April and December 2020 indicated 55,900 and 24,800 fewer visits, respectively, representing a 42% reduction and 19% reduction, respectively.

The timing of the return to baseline volume of visits differed by subgroup. Total ED visits increased greatly in the summer of 2021, particularly among visits for cardiovascular and neurologic conditions, as well as for substance misuse; visits among adults aged 20-69 years; and the most urgent visits. Later in the pandemic, volumes increased for the highest-urgency visits, visits among children, and visits related to ear, nose, and throat (ENT) complaints.

Visits for cardiovascular and neurologic conditions temporarily exceeded expected levels shortly after returning to pre-pandemic baselines. However, visits for ENT and for general and minor reasons remained at higher-than-expected levels for extended periods. A surge in ENT visits after a brief return to baseline was driven by visits for sore throats and earaches, especially among children. “This finding highlights the need to consider all of these different factors when we plan for ED capacity,” said Smolina.

Visits for gastrointestinal and genitourinary conditions increased sharply in February to April 2022, driven by complaints of abdominal pain and nausea or vomiting. The authors note that these visits coincided with an increase in norovirus load in wastewater.

“The impact of the COVID-19 pandemic and associated mitigation strategies on ED visits in Canada was substantial,” the authors write. “Our findings and methods are relevant in public health surveillance and capacity planning for EDs in pandemic and nonpandemic times.”

The BC Center for Disease Control Data and other groups are assessing the societal impacts of the COVID-19 pandemic, including the impact on other health services utilization, Smolina added.

“Pressure Cooker Environment”

In an accompanying editorial, Catherine Varner, MD, deputy editor of CMAJ, wrote that unless capacity is increased with more acute care beds, “hospitals are on their own to grapple with [ED] crises.”

Varner previously commented for Medscape on overcrowding in Canada’s EDs, noting, “The distress emergency providers feel treating patients in the waiting room day after day is untenable. Many of our most experienced emergency medicine nurses and doctors in Canada have left or are leaving.”

In her current editorial, she decried the “pressure cooker environment” of crowded EDs, including its contribution to the violence experienced by ED staff. “Given federal and provincial leaders’ inertia over increasing acute care capacity, hospital leadership, staff, and physicians are left without system-level supports and will remain in a perpetual state of crisis management to mitigate harms to patients and staff.

“Deputy ministers and ministers of health should arrange a site visit to a Canadian ED on one of the last remaining evenings or weekends of the summer and hear firsthand experiences from emergency department patients and providers,” she writes. “Their experiences will no doubt underscore the urgent need for more acute care beds and for retaining, training, and hiring hospital personnel to staff them.”

Dr Howard Ovens

Commenting on the findings for Medscape, Howard Ovens, MD, staff emergency physician at Sinai Health in Toronto and professor of family and community medicine at the University of Toronto’s Temerty Faculty of Medicine, said, “Overall, the trends match [my] personal experience, information from colleagues across the country, and data I have seen.

“Canadian EDs are experiencing a…surge in volumes in a more challenging profile than before the pandemic, including more complex patients, more patients with mental health and addiction issues, and at times, increased waves of respiratory infections,” he said. “The pandemic has mainly exposed and exacerbated problems in emergency services and overall Canadian healthcare that were present chronically pre-pandemic.

“We have an immediate need to address these issues,” added Ovens, who wasn’t involved with the study, “but the message for future planning, most importantly, is the need to create more resilience in the system by creating more capacity in beds and staffing.”

The study was conducted without external funding. Smolina and Grafstein report no relevant financial relationships. Ovens receives payment for acting as an advisor to the Ontario government on emergency services.

CMAJ. Published online September 5, 2023. Full text, Editorial

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