Program Profile

COVID-19 Incidence After Emergency Department Visit

Fed Pract. 2023 July;40(7):224-227 | doi:10.12788/fp.0384

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Background: The emergency department (ED) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) saw a decrease in the number of visits during the early stages of the COVID-19 pandemic. Little is known whether risk mitigation procedures may help reduce the spread of COVID-19 infections for veterans visiting the ED. Therefore, we reviewed patient visits to the ED for diagnoses other than COVID-19 to assess whether these patients had an increased COVID-19 positivity rate within 21 days of the initial visit.

Observations: Risk mitigation procedures instituted by the VAGLAHS ED included a COVID-19 outdoor testing tent, immediate isolation of persons under investigation for COVID-19, disinfection protocols between high-risk patient encounters, dedicated training in donning and doffing personal protective equipment, implementation of 2-physician airway teams for COVID-19 intubations, use of electronic tablets to communicate with COVID-19 patients, and implementation of social distancing initiatives in the waiting room to minimize COVID-19 exposures. The average positivity rate at the VAGLAHS ED during this time frame was 0% to 6.7%, compared with 6.9% to 33.3% within the wider VAGLAHS.

Conclusions: Implementing risk mitigation procedures in the VAGLAHS ED helped minimize exposure and subsequent diagnosis of COVID-19 for veterans who visited the VAGLAHS ED for symptoms not associated with COVID-19 infection. Seeking acute medical care in the ED did not put patients at higher risk of contracting COVID-19.

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References

2. Fan T, Workman AD, Miller LE, et al. The impact of COVID-19 on otolaryngology community practice in Massachusetts. Otolaryngol Head Neck Surg. 2021;165(3):424-430. doi:10.1177/0194599820983732

3. Baum A, Kaboli PJ, Schwartz MD. Reduced in-person and increased telehealth outpatient visits during the COVID-19 pandemic. Ann Intern Med. 2021;174(1):129-131. doi:10.7326/M20-3026

4. Kranz AM, Chen A, Gahlon G, Stein BD. 2020 trends in dental office visits during the COVID-19 pandemic. J Am Dent Assoc. 2021;152(7):535-541,e1. doi:10.1016/j.adaj.2021.02.01

5. Ridgway JP, Robicsek AA. Risk of coronavirus disease 2019 (COVID-19) acquisition among emergency department patients: a retrospective case control study. Infect Control Hosp Epidemiol. 2021;42(1):105-107. doi:10.1017/ice.2020.1224

6. Bres Bullrich M, Fridman S, Mandzia JL, et al. COVID-19: stroke admissions, emergency department visits, and prevention clinic referrals. Can J Neurol Sci. 2020;47(5):693-696. doi:10.1017/cjn.2020.101

7. Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol. 2020;75(22):2871-2872. doi:10.1016/j.jacc.2020.04.011

8. LA County COVID-19 Surveillance Dashboard. Accessed July 25, 2022. https://covid19.lacounty.gov/dashboards

9. Wallace DW, Burleson SL, Heimann MA, et al. An adapted emergency department triage algorithm for the COVID-19 pandemic. J Am Coll Emerg Physicians Open. 2020;1:1374-1379. doi:10.1002/emp2.12210

10. Montrief T, Ramzy M, Long B, Gottlieb M, Hercz D. COVID-19 respiratory support in the emergency department setting. Am Journal Emerg Med. 2020;38(10):2160-2168. doi:10.1016/j.ajem.2020.08.001

11. Alqahtani F, Alanazi M, Alassaf W, et al. Preventing SARS-CoV-2 transmission in the emergency department by implementing a separate pathway for patients with respiratory conditions. J Complement Integr Med. 2022;19(2):383-388. doi:10.1515/jcim-2020-0422

12. Odorizzi S, Clark E, Nemnom MJ, et al. Flow impacts of hot/cold zone infection control procedures during the COVID-19 pandemic in the emergency department. CJEM. 2022;24(4):390-396. doi:10.1007/s43678-022-00278-0

13. Wee LE, Fua TP, Chua YY, et al. Containing COVID-19 in the emergency department: the role of improved case detection and segregation of suspect cases. Acad Emerg Med. 2020;27(5):379-387. doi:10.1111/acem.13984

14. Tan RMR, Ong GYK, Chong SL, Ganapathy S, Tyebally A, Lee KP. Dynamic adaptation to COVID-19 in a Singapore paediatric emergency department. Emerg Med J. 2020;37(5):252-254. doi:10.1136/emermed-2020-20963

15. Quah LJJ, Tan BKK, Fua TP, et al. Reorganising the emergency department to manage the COVID-19 outbreak. Int J Emerg Med. 2020;13(1):32. doi:10.1186/s12245-020-00294-w

16. Jinadatha C, Jones LD, Choi H, et al. Transmission of SARS-CoV-2 in inpatient and outpatient settings in a Veterans Affairs health care system. Open Forum Infect Dis. 2021;8(8):ofab328. doi:10.1093/ofid/ofab328

17. Riediker M, Briceno-Ayala L, Ichihara G, et al. Higher viral load and infectivity increase risk of aerosol transmission for Delta and Omicron variants of SARS-CoV-2. Swiss Med Wkly. 2022;152:w30133. doi:10.4414/smw.2022.w30133

At the onset of the COVID-19 pandemic, patient encounters with the health care system plummeted.^1-3 The perceived increased risk of contracting COVID-19 while obtaining care was thought to be a contributing factor. In outpatient settings, one study noted a 63% decrease in visits to otolaryngology visits in Massachusetts, and another noted a 33% decrease in dental office visits at the onset of the pandemic in 2020 compared with the same time frame in 2019.^2,4 Along with mask mandates and stay-at-home orders, various institutions sought to mitigate the spread of COVID-19 through different protocols, including the use of social distancing, limitation of visitors, and telehealth. Despite some of these measures, nosocomial infections were not uncommon. For example, one hospital in the United Kingdom reported that 15% of COVID-19 inpatient cases in a 6-week period in 2020 were probably or definitely hospital acquired. These patients had a 36% case fatality rate.⁵

Unlike outpatient treatment centers, however, the emergency department (ED) is mandated by the Emergency Medical Treatment and Labor Act to provide a medical screening examination and to stabilize emergency medical conditions to all patients presenting to the ED. Thus, high numbers of undifferentiated and symptomatic patients are forced to congregate in EDs, increasing the risk of transmission of COVID-19. This perception of increased risk led to a 42% decrease in ED visits during March and April 2020 at the onset of the COVID-19 pandemic.¹ Correspondingly, there was a 20% decrease in code stroke activations at a hospital in Canada and a 38% decrease in ST-elevation myocardial infarction activations across 9 United States hospital systems.^6,7

Limited studies have been conducted to date to determine whether contracting COVID-19 while in the ED is a risk. One retrospective case-control study evaluating 39 EDs in the US showed that ED colocation with known patients with COVID-19 was not associated with an increased risk of COVID-19 transmission.⁵ However, this study also recognized that infection control strategies widely varied by location and date.

In this study, we report the incidence of COVID-19 infections within 21 days after the initial visit for symptoms not associated with COVID-19 infection to the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) ED and compared it with that of COVID-19 infections for tests performed within the VAGLAHS.

References

1. Hartnett KP, Kite-Powell A, DeVies J, et al; National Syndromic Surveillance Program Community of Practice. Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(23):699-704. doi:10.15585/mmwr.mm6923e1

2. Fan T, Workman AD, Miller LE, et al. The impact of COVID-19 on otolaryngology community practice in Massachusetts. Otolaryngol Head Neck Surg. 2021;165(3):424-430. doi:10.1177/0194599820983732

3. Baum A, Kaboli PJ, Schwartz MD. Reduced in-person and increased telehealth outpatient visits during the COVID-19 pandemic. Ann Intern Med. 2021;174(1):129-131. doi:10.7326/M20-3026

4. Kranz AM, Chen A, Gahlon G, Stein BD. 2020 trends in dental office visits during the COVID-19 pandemic. J Am Dent Assoc. 2021;152(7):535-541,e1. doi:10.1016/j.adaj.2021.02.01

5. Ridgway JP, Robicsek AA. Risk of coronavirus disease 2019 (COVID-19) acquisition among emergency department patients: a retrospective case control study. Infect Control Hosp Epidemiol. 2021;42(1):105-107. doi:10.1017/ice.2020.1224

6. Bres Bullrich M, Fridman S, Mandzia JL, et al. COVID-19: stroke admissions, emergency department visits, and prevention clinic referrals. Can J Neurol Sci. 2020;47(5):693-696. doi:10.1017/cjn.2020.101

7. Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol. 2020;75(22):2871-2872. doi:10.1016/j.jacc.2020.04.011

8. LA County COVID-19 Surveillance Dashboard. Accessed July 25, 2022. https://covid19.lacounty.gov/dashboards

9. Wallace DW, Burleson SL, Heimann MA, et al. An adapted emergency department triage algorithm for the COVID-19 pandemic. J Am Coll Emerg Physicians Open. 2020;1:1374-1379. doi:10.1002/emp2.12210

10. Montrief T, Ramzy M, Long B, Gottlieb M, Hercz D. COVID-19 respiratory support in the emergency department setting. Am Journal Emerg Med. 2020;38(10):2160-2168. doi:10.1016/j.ajem.2020.08.001

11. Alqahtani F, Alanazi M, Alassaf W, et al. Preventing SARS-CoV-2 transmission in the emergency department by implementing a separate pathway for patients with respiratory conditions. J Complement Integr Med. 2022;19(2):383-388. doi:10.1515/jcim-2020-0422

12. Odorizzi S, Clark E, Nemnom MJ, et al. Flow impacts of hot/cold zone infection control procedures during the COVID-19 pandemic in the emergency department. CJEM. 2022;24(4):390-396. doi:10.1007/s43678-022-00278-0

13. Wee LE, Fua TP, Chua YY, et al. Containing COVID-19 in the emergency department: the role of improved case detection and segregation of suspect cases. Acad Emerg Med. 2020;27(5):379-387. doi:10.1111/acem.13984

14. Tan RMR, Ong GYK, Chong SL, Ganapathy S, Tyebally A, Lee KP. Dynamic adaptation to COVID-19 in a Singapore paediatric emergency department. Emerg Med J. 2020;37(5):252-254. doi:10.1136/emermed-2020-20963

15. Quah LJJ, Tan BKK, Fua TP, et al. Reorganising the emergency department to manage the COVID-19 outbreak. Int J Emerg Med. 2020;13(1):32. doi:10.1186/s12245-020-00294-w

16. Jinadatha C, Jones LD, Choi H, et al. Transmission of SARS-CoV-2 in inpatient and outpatient settings in a Veterans Affairs health care system. Open Forum Infect Dis. 2021;8(8):ofab328. doi:10.1093/ofid/ofab328

17. Riediker M, Briceno-Ayala L, Ichihara G, et al. Higher viral load and infectivity increase risk of aerosol transmission for Delta and Omicron variants of SARS-CoV-2. Swiss Med Wkly. 2022;152:w30133. doi:10.4414/smw.2022.w30133

COVID-19 Incidence After Emergency Department Visit

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