Among the unexpected phenomena of the COVID-19 crisis: Emergency departments have seen their volumes plummet.
"The hospitals are eerily quiet, except for COVID-19," wrote Harlan Krumholz, M.D., a cardiologist and healthcare researcher at Yale University and Yale New Haven Hospital in a column published this week in The New York Times.
That's been the experience up in Seattle area hospitals which initially expected a "tsunami of emergency department cases," Gregg Miller, the chief medical officer for Vituity, a physician staffing firm, said recently during the FierceHealthcare Coronavirus Virtual Series. The company works with about 150 emergency departments and 25 hospitalist programs around the country including Dignity Health, Providence St. Joseph Health and Sutter Health systems.
“There has not been a huge surge of emergency department visits with the shutdown of elective surgeries, with the closures of some clinics, with the social distancing that’s been taking place," Miller said. "There are less and less patients going into the emergency department—thank God, because I can’t imagine working shifts right now what this would be like if we were dealing with our normal volumes on top of what we’re dealing with our COVID patients."
But what is happening to many of those patients?
It's a question that hospitals need to be preparing for, said Joanne Roberts, senior vice president and chief value officer at Providence St. Joseph Health System based in Washington.
"If you just look at the big population trends across the country, people are just accessing healthcare less right now probably for lots of reasons: They’re anxious. They want to stay home. They don’t want to be around people. If they don’t have to go to the doctor, they’re not going to go to the doctor," Roberts said.
In the last week of March, the health system was seeing ED volumes down by more than 40%.
"We assume that people with chronic conditions are probably not getting the level of care they were getting before because it's not coming into the healthcare system," Roberts said.
That could be building up to become a later surge among patients with exacerbations in those chronic conditions, she said.
"Whether it's heart disease or cancer or whatever other chronic problems people may have, we are going to see more acute, exacerbations of those illnesses if we don't figure out a way to promote access in the next few weeks," Roberts said. "The country will squeak by for a few weeks but I'm not sure the country could squeak by for multiple months. At that point, we're going to start seeing more active disease coming into the hospitals."
For example, one of the more widely reported groups that have raised concerns are patients who have seen surgeries for slow-growing cancers delayed as both health systems and the government have pushed for cancellations of elective procedures to preserve protective equipment and bed capacity.
"Those decisions have been made with a whole lot of thought with specialists, and conferences of specialists, to make sure that nobody is going to be harmed by the delay in the surgeries. For example, any kind of fast-growing cancer is going to get surgery now," Roberts said. "But all of this stuff is going to back up. It will."
What should health systems be doing to prepare? Roberts said there is ongoing consideration of having hospitals devoted to non-COVID patients.
"That's easier said than done. It sounds like a great idea when you say it because of the testing delays we've had and the problems getting access to testing, it's hard to know who is and who isn't infected with COVID," she said. "Once we have enough rapid tests that we can look at an entire population of people than we probably can have facilities that only take care of COVID patients or only take care of non-COVID patients. That will probably vary market by market. My guess is that will be one remedy to do that."
She said once hospitals start feeling confident they have passed their peak of COVID cases, they can begin opening up regular beds to patients of all kinds.
Telehealth may help blunt the problem, Robert said.
"But I think that's going to be a longer-term proposition," she said. "Telehealth is exploding right now, but the explosion in telehealth services tends to be very focused on the COVID epidemic itself. So home monitoring around COVID, hospital at home around COVID, using telemedicine in our hospitals is around COVID," Roberts said. "Once this pandemic has peaked and we're on the back end of it, I expect we're going to start by seeing a whole lot more telehealth visits broadly with all kinds of issues. That's not really the case in any sort of systematic way right now."