OBJECTIVE: Since the beginning of the COVID-19 pandemic, several frontline workers have expressed their concerns about reduced emergency department (ED) utilization. We aimed to examine the changes in ED utilization during the early phase of the COVID-19 pandemic, in a country with a well-developed primary care system. METHODS: Retrospective analysis of ED utilization in three Dutch hospitals during a 60-day period starting on February 15, 2020. The identical period in 2019 was used as a reference. ED visits were labeled as COVID (defined as COVID-19 suspected) or non-COVID related. Admission rates were compared using chi-square tests, and the reduction in ED visits was assessed descriptively. RESULTS: During the study period, daily ED volume was 18% lower compared to 2019. ED utilization further declined (-29%) during lockdown. Combined admission rates were higher in 2020 compared to 2019 (p<0.001), and were higher for COVID versus non-COVID ED visits (p<0.001). CONCLUSIONS: ED utilization was markedly reduced during the local rise of COVID-19 in a region with a well-developed primary care system and relatively low ED self-referral rates. Although it cannot directly be concluded from the findings of our study, this observation likely reflects a complex interaction between pure lockdown effects and viral fear, which warrants further research.

ObjectiveIn clinical prediction/diagnostic rules aimed at early detection of critically ill patients, the respiratory rate plays an important role. We investigated the accuracy and interobserver-agreement of respiratory rate measurements by healthcare professionals, and the potential effect of incorrect measurements on the scores of 4 common clinical prediction/diagnostic rules: Systemic Inflammatory Response Syndrome (SIRS) criteria, quick Sepsis-related Organ Failure Assessment (qSOFA), National Early Warning Score (NEWS), and Modified Early Warning Score (MEWS).MethodsUsing an online questionnaire, we showed 5 videos with a healthy volunteer, breathing at a fixed (true) rate (13–28 breaths/minute). Respondents measured the respiratory rate, and categorized it as low, normal, or high. We analysed how accurate the measurements were using descriptive statistics, and calculated interobserver-agreement using the intraclass correlation coefficient (ICC), and agreement between measurements and categorical judgments using Cohen’s Kappa. Finally, we analysed how often incorrect measurements led to under/overestimation in the selected clinical rules.ResultsIn total, 448 healthcare professionals participated. Median measurements were slightly higher (1-3/min) than the true respiratory rate, and 78.2% of measurements were within 4/min of the true rate. ICC was moderate (0.64, 95% CI 0.39–0.94). When comparing the measured respiratory rates with the categorical judgments, 14.5% were inconsistent. Incorrect measurements influenced the 4 rules in 8.8% (SIRS) to 37.1% (NEWS). Both underestimation (4.5–7.1%) and overestimation (3.9–32.2%) occurred.ConclusionsThe accuracy and interobserver-agreement of respiratory rate measurements by healthcare professionals are suboptimal. This leads to both over- and underestimation of scores of four clinical prediction/diagnostic rules. The clinically most important effect could be a delay in diagnosis and treatment of (critically) ill patients.

Background The onset of the COVID-19 pandemic was characterized by rapid increases in Emergency department (ED) patient visits. EDs required an appropriate transformation. The main challenges were: adapting capacity to respond to surges in the number of patient visits, protection of high risk (frontline) staff and the segregation of suspect-COVID-19 patients. To date, only a few studies have assessed the nation-wide response of EDs to the COVID-19 pandemic. This study was designed to review the preparations of Dutch EDs during the initial phase of this public health crisis. Methods The study was designed as a nation-wide, cross-sectional, questionnaire-based study of Dutch hospital organizations having one or more EDs. One respondent completed the questionnaire for each hospital. The questionnaire was conducted between the first and the second COVID-19 wave in the Netherlands. It contained close-ended and open-ended questions on changes in ED infrastructure, ED workforce adaptions and the role of emergency physicians (EPs) in each hospital crisis management team. Results The questionnaire was completed by 58 respondents. This represented 80% of the total number of EDs. All respondents had made preparations in anticipation of a COVID-19 patient surge. Treatment capacity was expanded in 70% of EDs, with a median increase of 49% (IQR 33–73%). Suspect-COVID-19 was segregated from non-COVID-19 patients in 89% of EDs. Alternative locations (such as outpatient departments) were more often used to assess non-COVID-19 patients, than for suspect-COVID-19 patients. Staff was expanded in 82% of EDs. This largely concerned nursing staff. A formal role for Emergency Physicians (EPs) in the hospital’s crisis management team was reported by 94% of hospital organizations employing EPs. Conclusion All Dutch EDs responded to the COVID-19 pandemic in a very short time span despite much uncertainty. Preparations predominantly concerned expansion of treatment capacity and segregation of COVID-19 ED care. EPs played a prominent role, both in direct COVID-19 care and in the hospital crises management team. It is vital for EDs to adapt to community needs swiftly. The ability of EDs to respond to the pandemic varied considerably.

ObjectiveResearch on serious infections/sepsis has focused on the hospital environment, while potentially the most delay, and therefore possibly the best opportunity to improve quality of care, lies in the prehospital setting. In this study we investigated the prehospital phase of adult emergency department (ED) patients with an infection.MethodsIn this prospective pilot study all adult (≥18y) patients with a suspected/proven infection, based on the notes in the patient’s ED chart, were included during a 4-week period in 2017. Prehospital course, ED findings, presence of sepsis and 30-day outcomes were registered.ResultsA total of 440 patients were identified, with a median symptom duration before ED visit of 3 days (IQR 1–7 days). Before arrival in the ED, 23.9% of patients had used antibiotics. Most patients (83.0%) had been referred by a general practitioner (GP), while 41.1% of patients had visited their GP previously during the current disease episode. Patients referred by a GP were triaged as high-urgency less often, while vital parameters were similar. Emergency Medical Services (EMS) transported 268 (60.9%) of patients. Twenty-two patients (5.0%) experienced an adverse outcome (30-day all-cause mortality and/or admission to intensive care).ConclusionsPatients with a suspected infection had symptoms for 3 (IQR 1–7) days at the moment of presentation to the ED. During this prehospital phase patients often had consulted, and were treated by, their GP. Many were transported to the ED by EMS. Future research on severe infections should focus on the prehospital phase, targeting patients and primary care professionals.