Emergency Department Visits Fell 42% Early in the COVID-19 Pandemic, 2020

The United States declared a national emergency over COVID-19 on March 13, 2020. Reports from Austria, Hong Kong, Italy and California soon suggested that far fewer people were seeking emergency care for other reasons. This CDC report, posted as an MMWR Early Release on June 3, 2020, measured the drop nationwide.

Some patients may be delaying emergency care: emergency department visits fell 42%. Figure from CDC's report.

The data

• Source: the National Syndromic Surveillance Program (NSSP), a network of CDC, state and local health departments, and academic and private partners that collects electronic health data in real time. Its national data cover EDs in 47 states (not Hawaii, South Dakota or Wyoming) — about 73% of U.S. ED visits; 3,552 EDs reported in the latest week.
• Comparison: the early pandemic period, March 29–April 25, 2020 (weeks 14–17), against March 31–April 27, 2019; weekly visits were tracked from January 1, 2019 to May 30, 2020.
• Reasons for visits came from ICD-10-CM codes grouped by the Clinical Classifications Software Refined tool, with a custom COVID-19 category (code U07.1), over the top 200 categories. Several states, two California counties and D.C. were left out of this part for incomplete coding, and 20.3% of eligible visits lacked a valid code.

The drop

• Weekly visits fell 42%, from an average of 2,099,734 in 2019 to 1,220,211 in the early pandemic period.
• The low point was April 12–18, 2020 (week 16); by May 24–30 visits had recovered somewhat but were still 26% below the same week of 2019.

Weekly emergency department visits, 2019 and 2020. Figure from CDC's report.

Children 10 and under made up 12% of ED visits in the 2019 period and 6% in 2020.

Declines in emergency department visits by age group and HHS region. Figure from CDC's report.

Why people came

Rises of more than 100 visits a week occurred in only 8 of the top 200 categories:

The biggest drops were for abdominal pain and other digestive symptoms (−66,456 a week), musculoskeletal pain (−52,150), high blood pressure (−45,184), nausea and vomiting (−38,536), upper respiratory infections (−36,189), sprains and strains (−33,709) and superficial injuries (−30,918). Visits for nonspecific chest pain (−24,258) and heart attack (acute myocardial infarction, −1,156) also fell.

As a share of all visits, infectious-disease exposure and screening was nearly four times as common (ratio 3.79), and lower respiratory disease (1.99), cardiac arrest (1.98) and pneumonia (1.91) about twice as common; influenza (0.16), missed immunizations (0.28), ear infections (0.35) and cancer-related visits (0.40) were much rarer.

Among children 10 and under, visits for flu fell 97%, ear infections 85%, and asthma, nausea and vomiting and upper respiratory conditions 84% each. Women's declines in the top categories were larger than men's, and they also made far fewer visits for urinary tract infections (−19,833 a week).

What it means

• Falls in visits for chest pain and heart attack, with rising cardiac arrest, suggest some people delayed care for conditions that can kill if untreated.
• Some declines — ear infections, minor injuries, sprains — were for things primary or urgent care can often handle; some may reflect real drops in injury and illness as activity changed.
• Declines were steepest where the pandemic was worst in April 2020. People who rely on the ED as a safety net, without access to primary care or telemedicine, may be hit hardest if fear keeps them away.

Recommendations: remind the public to seek care immediately for serious symptoms such as those of a heart attack; keep using virtual visits and triage help lines; and follow CDC infection control guidance in EDs to address fears of exposure.

Limits

• The hospitals reporting to NSSP changed: an average of 3,173 in April 2019 (about 66% of visits) and 3,467 in April 2020 (73%).
• Diagnostic codes were missing for about 20% of visits and may be used inconsistently; the COVID-19 code only arrived on April 1, 2020.
• Coverage is uneven across and within states.
• People treated outside EDs aren't captured.

Sources

Based on Hartnett KP, Kite-Powell A, DeVies J, et al., "Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020," MMWR Morbidity and Mortality Weekly Report, volume 69, Centers for Disease Control and Prevention; a work of the United States government in the public domain.