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      Análisis de la evolución de consultas atendidas en los servicios de urgencias españoles durante la primera ola pandémica Translated title: Analysis of the evolution of patients attended in Spanish emergency departments during the first wave of the pandemic

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          Resumen

          Fundamento

          Describir el número de consultas, total y por COVID-19, atendidas en servicios de urgencias hospitalarios (SUH) españoles durante marzo y abril de 2020, compararlo con el mismo periodo del año anterior, cuantificar el cambio de actividad asistencial e investigar la posible influencia del tamaño del hospital y de la seroprevalencia provincial de COVID-19.

          Métodos

          Estudio transversal. Se envió una encuesta a todos los responsables de SUH españoles del sistema público de salud sobre el número de consultas atendidas durante marzo y abril de 2019 y de 2020. Se calculó el cambio de actividad asistencial por comunidad autónoma, y se comparó en función del tamaño del hospital y del impacto provincial de la pandemia.

          Resultados

          Participaron el 66% de los 283 SUH. Se observó un descenso del 49,2% de las consultas totales (solo los SUH de Castilla-La Mancha mostraron un descenso inferior al 30%) y del 60% de las consultas no-COVID-19 (solo los SUH de Asturias y Extremadura mostraron un descenso inferior al 50%). el cambio de actividad asistencial no difirió en función del tamaño del hospital, pero sí en relación al impacto provincial de la pandemia, con una correlación directa respecto al descenso de actividad no-COVID-19 (a mayor impacto, mayor descenso; R 2 = 0,05; p = 0,002) e inversa en relación a la actividad global (a mayor impacto, menor descenso; R 2 = 0,05; p = 0,002).

          Conclusiones

          Durante la primera ola pandémica descendió el número de consultas en los SUH, si bien dicho descenso no se explica únicamente por la incidencia local de la pandemia.

          Abstract

          Background

          To describe the number of visits (total and per COVID-19) attended by the Spanish hospital emergency departments (EDs) during March and April 2020 compared to the same period in 2019, and to calculate the quantitative changes in healthcare activity and investigate the possible influence of hospital size and regional COVID-19 seroprevalence.

          Method

          Cross-sectional study that analyzes the number of visits to Spanish public EDs, reported through a survey of ED chiefs during the study periods. Changes in healthcare activity were described in each autonomous community and compared according to hospital size and the regional impact of the pandemic.

          Results

          The 66% of the 283 Spanish EDs participated in the study. The total number of patients attended decreased to 49.2% (< 30% in the Castilla-La Mancha region), with a 60% reduction in non-COVID-19 patients (reduction < 50% only in the regions of Asturias and Extremadura). While there were no differences in changes of healthcare activity according to the size of the hospital, there were differences in relation to the regional impact of the pandemic, with a direct correlation related to the decrease in non-COVID-19 activity (the greater the impact, the greater the decrease; R 2 = 0.05; p = 0.002) and an inverse correlation to the overall activity (the greater the impact, the lesser the decrease; R 2 = 0.05; p = 0.002).

          Conclusion

          There was a very significant decrease in the number of ED visits during the first pandemic wave, although this decrease cannot be explained solely by the local incidence of the pandemic.

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          Most cited references46

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          Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study

          Summary Background Spain is one of the European countries most affected by the COVID-19 pandemic. Serological surveys are a valuable tool to assess the extent of the epidemic, given the existence of asymptomatic cases and little access to diagnostic tests. This nationwide population-based study aims to estimate the seroprevalence of SARS-CoV-2 infection in Spain at national and regional level. Methods 35 883 households were selected from municipal rolls using two-stage random sampling stratified by province and municipality size, with all residents invited to participate. From April 27 to May 11, 2020, 61 075 participants (75·1% of all contacted individuals within selected households) answered a questionnaire on history of symptoms compatible with COVID-19 and risk factors, received a point-of-care antibody test, and, if agreed, donated a blood sample for additional testing with a chemiluminescent microparticle immunoassay. Prevalences of IgG antibodies were adjusted using sampling weights and post-stratification to allow for differences in non-response rates based on age group, sex, and census-tract income. Using results for both tests, we calculated a seroprevalence range maximising either specificity (positive for both tests) or sensitivity (positive for either test). Findings Seroprevalence was 5·0% (95% CI 4·7–5·4) by the point-of-care test and 4·6% (4·3–5·0) by immunoassay, with a specificity–sensitivity range of 3·7% (3·3–4·0; both tests positive) to 6·2% (5·8–6·6; either test positive), with no differences by sex and lower seroprevalence in children younger than 10 years ( 10%) and lower in coastal areas (<3%). Seroprevalence among 195 participants with positive PCR more than 14 days before the study visit ranged from 87·6% (81·1–92·1; both tests positive) to 91·8% (86·3–95·3; either test positive). In 7273 individuals with anosmia or at least three symptoms, seroprevalence ranged from 15·3% (13·8–16·8) to 19·3% (17·7–21·0). Around a third of seropositive participants were asymptomatic, ranging from 21·9% (19·1–24·9) to 35·8% (33·1–38·5). Only 19·5% (16·3–23·2) of symptomatic participants who were seropositive by both the point-of-care test and immunoassay reported a previous PCR test. Interpretation The majority of the Spanish population is seronegative to SARS-CoV-2 infection, even in hotspot areas. Most PCR-confirmed cases have detectable antibodies, but a substantial proportion of people with symptoms compatible with COVID-19 did not have a PCR test and at least a third of infections determined by serology were asymptomatic. These results emphasise the need for maintaining public health measures to avoid a new epidemic wave. Funding Spanish Ministry of Health, Institute of Health Carlos III, and Spanish National Health System.
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            Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020

            Temporary disruptions in routine and nonemergency medical care access and delivery have been observed during periods of considerable community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) ( 1 ). However, medical care delay or avoidance might increase morbidity and mortality risk associated with treatable and preventable health conditions and might contribute to reported excess deaths directly or indirectly related to COVID-19 ( 2 ). To assess delay or avoidance of urgent or emergency and routine medical care because of concerns about COVID-19, a web-based survey was administered by Qualtrics, LLC, during June 24–30, 2020, to a nationwide representative sample of U.S. adults aged ≥18 years. Overall, an estimated 40.9% of U.S. adults have avoided medical care during the pandemic because of concerns about COVID-19, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care. The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults* versus noncaregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions † versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18–24 years versus adults aged 25–44 years (aPR = 1.5); and persons with disabilities § versus those without disabilities (aPR = 1.3). Given this widespread reporting of medical care avoidance because of COVID-19 concerns, especially among persons at increased risk for severe COVID-19, urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay ( 3 ). During June 24–30, 2020, a total of 5,412 (54.7%) of 9,896 eligible adults ¶ completed web-based COVID-19 Outbreak Public Evaluation Initiative surveys administered by Qualtrics, LLC.** The Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. This activity was also reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. †† Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. The 5,412 participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) persons who had completed a related survey §§ during April 2–8, 2020. Among the 5,412 participants, 4,975 (91.9%) provided complete data for all variables in this analysis. Quota sampling and survey weighting ¶¶ were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity. Respondents were asked “Have you delayed or avoided medical care due to concerns related to COVID-19?” Delay or avoidance was evaluated for emergency (e.g., care for immediate life-threatening conditions), urgent (e.g., care for immediate non–life-threatening conditions), and routine (e.g., annual check-ups) medical care. Given the potential for variation in interpretation of whether conditions were life-threatening, responses for urgent and emergency care delay or avoidance were combined for analysis. Covariates included gender; age; race/ethnicity; disability status; presence of one or more selected underlying medical conditions known to increase risk for severe COVID-19; education; essential worker status***; unpaid adult caregiver status; U.S. census region; urban/rural classification ††† ; health insurance status; whether respondents knew someone who had received a positive SARS-CoV-2 test result or had died from COVID-19; and whether the respondents believed they were at high risk for severe COVID-19. Comparisons within all these subgroups were evaluated using multivariable Poisson regression models §§§ with robust standard errors to estimate prevalence ratios adjusted for all covariates, 95% confidence intervals, and p-values to evaluate statistical significance (α = 0.05) using the R survey package (version 3.29) and R software (version 4.0.2; The R Foundation). As of June 30, 2020, among 4,975 U.S. adult respondents, 40.9% reported having delayed or avoided any medical care, including urgent or emergency care (12.0%) and routine care (31.5%), because of concerns about COVID-19 (Table 1). Groups of persons among whom urgent or emergency care avoidance exceeded 20% and among whom any care avoidance exceeded 50% included adults aged 18–24 years (30.9% for urgent or emergency care; 57.2% for any care), unpaid caregivers for adults (29.8%; 64.3%), Hispanic adults (24.6%; 55.5%), persons with disabilities (22.8%; 60.3%), persons with two or more selected underlying medical conditions (22.7%; 54.7%), and students (22.7%; 50.3%). One in four unpaid caregivers reported caring for adults who were at increased risk for severe COVID-19. TABLE 1 Estimated prevalence of delay or avoidance of medical care because of concerns related to COVID-19, by type of care and respondent characteristics — United States, June 30, 2020 Characteristic No. (%)† Type of medical care delayed or avoided* Urgent or emergency Routine Any %† P-value§ %† P-value§ %† P-value§ All respondents 4,975 (100) 12.0 — 31.5 — 40.9 — Gender Female 2,528 (50.8) 11.7 0.598 35.8 <0.001 44.9 <0.001 Male 2,447 (49.2) 12.3 27.0 36.7 Age group, yrs 18–24 650 (13.1) 30.9 <0.001 29.6 0.072 57.2 <0.001 25–44 1,740 (35.0) 14.9 34.2 44.8 45–64 1,727 (34.7) 5.7 30.0 34.5 ≥65 858 (17.3) 4.4 30.3 33.5 Race/Ethnicity White, non-Hispanic 3,168 (63.7) 6.7 <0.001 30.9 0.020 36.2 <0.001 Black, non-Hispanic 607 (12.2) 23.3 29.7 48.1 Asian, non-Hispanic 238 (4.8) 8.6 31.3 37.7 Other race or multiple races, non-Hispanic¶ 150 (3.0) 15.5 23.9 37.3 Hispanic, any race or races 813 (16.3) 24.6 36.4 55.5 Disability** Yes 1,108 (22.3) 22.8 <0.001 42.9 <0.001 60.3 <0.001 No 3,867 (77.7) 8.9 28.2 35.3 Underlying medical condition†† No 2,537 (51.0) 8.2 <0.001 27.9 <0.001 34.7 <0.001 One 1,328 (26.7) 10.4 33.0 41.2 Two or more 1,110 (22.3) 22.7 37.7 54.7 2019 household income, USD <25,000 665 (13.4) 13.9 0.416 31.2 0.554 42.8 0.454 25,000–49,999 1,038 (20.9) 11.1 30.9 38.6 50,000–99,999 1,720 (34.6) 12.5 30.5 41.1 ≥100,000 1,552 (31.2) 11.2 33.0 41.4 Education Less than high school diploma 65 (1.3) 15.6 0.442 24.7 0.019 37.9 0.170 High school diploma 833 (16.7) 12.3 28.1 38.1 Some college 1,302 (26.2) 13.6 29.7 40.3 Bachelor's degree 1,755 (35.3) 11.2 34.8 43.6 Professional degree 1,020 (20.5) 10.9 31.2 39.5 Employment status Employed 3,049 (61.3) 14.6 <0.001 31.5 0.407 43.3 <0.001 Unemployed 630 (12.7) 8.7 34.4 39.5 Retired 1,129 (22.7) 5.3 29.9 33.8 Student 166 (3.3) 22.7 30.5 50.3 Essential worker status§§ Essential worker 1,707 (34.3) 19.5 <0.001 32.4 0.293 48.0 <0.001 Nonessential worker 1,342 (27.0) 8.4 30.3 37.3 Unpaid caregiver status¶¶ Unpaid caregiver for adults 1,344 (27.0) 29.8 <0.001 41.0 <0.001 64.3 <0.001 Not unpaid caregiver for adults 3,631 (73.0) 5.4 27.9 32.2 U.S. Census region*** Northeast 1,122 (22.6) 11.0 0.008 33.9 0.203 42.5 0.460 Midwest 936 (18.8) 8.5 32.0 38.7 South 1,736 (34.9) 13.9 29.6 40.7 West 1,181 (23.7) 13.0 31.5 41.5 Rural/Urban classification††† Urban 4,411 (88.7) 12.3 0.103 31.5 0.763 41.2 0.216 Rural 564 (11.3) 9.4 30.9 38.2 Health insurance status Yes 4,577 (92.0) 12.4 0.036 32.6 <0.001 42.3 <0.001 No 398 (8.0) 7.8 18.4 24.8 Know someone with positive test results for SARS-CoV-2§§§ Yes 989 (19.9) 8.8 0.004 40.7 <0.001 46.6 <0.001 No 3,986 (80.1) 12.8 29.2 39.5 Knew someone who died from COVID-19 Yes 364 (7.3) 10.1 0.348 41.4 <0.001 46.3 0.048 No 4,611 (92.7) 12.2 30.7 40.5 Believed to be in group at high risk for severe COVID-19 Yes 981 (19.7) 10.0 0.050 42.5 <0.001 49.4 <0.001 No 3,994 (80.3) 12.5 28.8 38.8 Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019; USD = U.S. dollars. * The types of medical care avoidance are not mutually exclusive; respondents had the option to indicate that they had delayed or avoided more than one type of medical care (i.e., routine medical care and urgent/emergency medical care). † Statistical raking and weight trimming were employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census. § The Rao-Scott adjusted Pearson chi-squared test was used to test for differences in observed and expected frequencies among groups by characteristic for avoidance of each type of medical care (e.g., whether avoidance of routine medical care differs significantly by gender). Statistical significance was evaluated at a threshold of α = 0.05. ¶ “Other” race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other. ** Persons who had a disability were defined as such based on a qualifying response to either one of two questions: “Are you limited in any way in any activities because of physical, mental, or emotional condition?” and “Do you have any health conditions that require you to use special equipment, such as a cane, wheelchair, special bed, or special telephone?” https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf. †† Selected underlying medical conditions known to increase the risk for severe COVID-19 included in this analysis were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question “Have you ever been diagnosed with any of the following conditions?” with response options of 1) “Never”; 2) “Yes, I have in the past, but don’t have it now”; 3) “Yes I have, but I do not regularly take medications or receive treatment”; and 4) “Yes I have, and I am regularly taking medications or receiving treatment.” Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition. §§ Essential worker status was self-reported. ¶¶ Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years at any time in the last 3 months. Examples provided to survey respondents included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. *** Region classification was determined by using the U.S. Census Bureau’s Census Regions and Divisions. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. ††† Rural-urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. §§§ For this question, respondents were asked to select the following statement, if applicable: “I know someone who has tested positive for COVID-19.” In the multivariable Poisson regression models, differences within groups were observed for urgent or emergency care avoidance (Figure) and any care avoidance (Table 2). Adjusted prevalence of urgent or emergency care avoidance was significantly higher among unpaid caregivers for adults versus noncaregivers (2.9; 2.3–3.6); persons with two or more selected underlying medical conditions versus those without those conditions (1.9; 1.5–2.4); persons with health insurance versus those without health insurance (1.8; 1.2–2.8); Black adults (1.6; 1.3–2.1) and Hispanic adults (1.5; 1.2–2.0) versus White adults; young adults aged 18–24 years versus adults aged 25–44 years (1.5; 1.2–1.8); and persons with disabilities versus those without disabilities (1.3; 1.1–1.5). Avoidance of urgent or emergency care was significantly lower among adults aged ≥45 years than among younger adults. FIGURE Adjusted prevalence ratios* , † for characteristics § , ¶ , ** , †† associated with delay or avoidance of urgent or emergency medical care because of concerns related to COVID-19 — United States, June 30, 2020 Abbreviation: COVID-19 = coronavirus disease 2019. * Comparisons within subgroups were evaluated using Poisson regressions used to calculate a prevalence ratio adjusted for all characteristics shown in figure. † 95% confidence intervals indicated with error bars. § “Other” race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other. ¶ Selected underlying medical conditions known to increase the risk for severe COVID-19 were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question “Have you ever been diagnosed with any of the following conditions?” with response options of 1) “Never”; 2) “Yes, I have in the past, but don’t have it now”; 3) “Yes I have, but I do not regularly take medications or receive treatment”; and 4) “Yes I have, and I am regularly taking medications or receiving treatment.” Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition. ** Essential worker status was self-reported. For the adjusted prevalence ratios, essential workers were compared with all other respondents (including those who were nonessential workers, retired, unemployed, and students). †† Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years to help them take care of themselves at any time in the last 3 months. The figure is a forest plot showing the adjusted prevalence ratios for characteristics associated with delay or avoidance of urgent or emergency medical care because of concerns related to COVID-19, in the United States, as of June 30, 2020. TABLE 2 Characteristics associated with delay or avoidance of any medical care because of concerns related to COVID-19 — United States, June 30, 2020 Characteristic Weighted* no. Avoided or delayed any medical care aPR† (95% CI†) P-value† All respondents 4,975 — — — Gender Female 2,528 Referent — — Male 2,447 0.81 (0.75–0.87)§ <0.001 Age group, yrs 18–24 650 1.12 (1.01–1.25)§ 0.035 25–44 1,740 Referent — — 45–64 1,727 0.80 (0.72–0.88)§ <0.001 ≥65 858 0.72 (0.64–0.81)§ <0.001 Race/Ethnicity White, non-Hispanic 3,168 Referent — — Black, non-Hispanic 607 1.07 (0.96–1.19) 0.235 Asian, non-Hispanic 238 1.04 (0.91–1.18) 0.567 Other race or multiple races, non-Hispanic¶ 150 0.87 (0.71–1.07) 0.196 Hispanic, any race or races 813 1.15 (1.03–1.27)§ 0.012 Disability** Yes 1,108 1.33 (1.23–1.43)§ <0.001 No 3,867 Referent — — Underlying medical condition†† No 2,537 Referent — — One 1,328 1.15 (1.05–1.25)§ 0.004 Two or more 1,110 1.31 (1.20–1.42)§ <0.001 Education Less than high school diploma 65 0.72 (0.53–0.98)§ 0.037 High school diploma 833 0.79 (0.71–0.89)§ <0.001 Some college 1,302 0.85 (0.78–0.93)§ 0.001 Bachelor's degree 1,755 Referent — — Professional degree 1,020 0.90 (0.82–0.98)§ 0.019 Essential workers vs others§§ Essential workers 1,707 1.00 (0.92–1.09) 0.960 Other respondents (nonessential workers, retired persons, unemployed persons, and students) 3,268 Referent — — Unpaid caregiver status¶¶ Unpaid caregiver for adults 1,344 1.64 (1.52–1.78)§ <0.001 Not unpaid caregiver for adults 3,631 Referent — — U.S. Census region*** Northeast 1,122 Referent — — Midwest 936 0.93 (0.83–1.04) 0.214 South 1,736 0.90 (0.82–0.99)§ 0.028 West 1,181 0.99 (0.89–1.09) 0.808 Rural/Urban classification††† Urban 4,411 1.00 (0.89–1.12) 0.993 Rural 564 Referent — — Health insurance status Yes 4,577 1.61 (1.31–1.98)§ <0.001 No 398 Referent — — Know someone with positive test results for SARS-CoV-2§§§ Yes 989 1.22 (1.12–1.33)§ <0.001 No 3,986 Referent — — Knew someone who died from COVID-19 Yes 364 0.99 (0.88–1.12) 0.860 No 4,611 Referent — — Believed to be in a group at high risk for severe COVID-19 Yes 981 1.33 (1.23–1.44)§ <0.001 No 3,994 Referent — — Abbreviations: aPR = adjusted prevalence ratio; CI = confidence interval; COVID-19 = coronavirus disease 2019. * Statistical raking and weight trimming were employed to improve the cross-sectional June cohort representativeness of the U.S. population by gender, age, and race/ethnicity according to the 2010 U.S. Census. † Comparisons within subgroups were evaluated using Poisson regressions used to calculate a prevalence ratio adjusted for all characteristics listed, as well as a 95% CI and p-value. Statistical significance was evaluated at a threshold of α = 0.05. § P-value calculated using Poisson regression among respondents within a characteristic is statistically significant at levels of p<0.05. ¶ “Other” race includes American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or Other. ** Persons who had a disability were defined based on a qualifying response to either one of two questions: “Are you limited in any way in any activities because of physical, mental, or emotional condition?” and “Do you have any health conditions that require you to use special equipment, such as a cane, wheelchair, special bed, or special telephone?” https://www.cdc.gov/brfss/questionnaires/pdf-ques/2015-brfss-questionnaire-12-29-14.pdf. †† Selected underlying medical conditions known to increase the risk for severe COVID-19 were obesity, diabetes, high blood pressure, cardiovascular disease, and any type of cancer. Obesity is defined as body mass index ≥30 kg/m2 and was calculated from self-reported height and weight (https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html). The remaining conditions were assessed using the question “Have you ever been diagnosed with any of the following conditions?” with response options of 1) “Never”; 2) “Yes, I have in the past, but don’t have it now”; 3) “Yes I have, but I do not regularly take medications or receive treatment”; and 4) “Yes I have, and I am regularly taking medications or receiving treatment.” Respondents who answered that they have been diagnosed and chose either response 3 or 4 were considered as having the specified medical condition. §§ Essential worker status was self-reported. For the adjusted prevalence ratios, essential workers were compared with all other respondents (including those who were nonessential workers, retired, unemployed, and students). ¶¶ Unpaid caregiver status was self-reported. Unpaid caregivers for adults were defined as having provided unpaid care to a relative or friend aged ≥18 years at any time in the last 3 months. Examples provided to survey respondents included helping with personal needs, household chores, health care tasks, managing a person’s finances, taking them to a doctor’s appointment, arranging for outside services, and visiting regularly to see how they are doing. *** Region classification was determined by using the U.S. Census Bureau’s Census Regions and Divisions. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. ††† Rural/urban classification was determined by using self-reported ZIP codes according to the Federal Office of Rural Health Policy definition of rurality. https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html. §§§ For this question, respondents were asked to select the following statement, if applicable: “I know someone who has tested positive for COVID-19.” Discussion As of June 30, 2020, an estimated 41% of U.S. adults reported having delayed or avoided medical care during the pandemic because of concerns about COVID-19, including 12% who reported having avoided urgent or emergency care. These findings align with recent reports that hospital admissions, overall emergency department (ED) visits, and the number of ED visits for heart attack, stroke, and hyperglycemic crisis have declined since the start of the pandemic ( 3 – 5 ), and that excess deaths directly or indirectly related to COVID-19 have increased in 2020 versus prior years ( 2 ). Nearly one third of adult respondents reported having delayed or avoided routine medical care, which might reflect adherence to community mitigation efforts such as stay-at-home orders, temporary closures of health facilities, or additional factors. However, if routine care avoidance were to be sustained, adults could miss opportunities for management of chronic conditions, receipt of routine vaccinations, or early detection of new conditions, which might worsen outcomes. Avoidance of both urgent or emergency and routine medical care because of COVID-19 concerns was highly prevalent among unpaid caregivers for adults, respondents with two or more underlying medical conditions, and persons with disabilities. For caregivers who reported caring for adults at increased risk for severe COVID-19, concern about exposure of care recipients might contribute to care avoidance. Persons with underlying medical conditions that increase their risk for severe COVID-19 ( 6 ) are more likely to require care to monitor and treat these conditions, potentially contributing to their more frequent report of avoidance. Moreover, persons at increased risk for severe COVID-19 might have avoided health care facilities because of perceived or actual increased risk of exposure to SARS-CoV-2, particularly at the onset of the pandemic. However, health care facilities are implementing important safety precautions to reduce the risk of SARS-CoV-2 infection among patients and personnel. In contrast, delay or avoidance of care might increase risk for life-threatening medical emergencies. In a recent study, states with large numbers of COVID-19–associated deaths also experienced large proportional increases in deaths from other underlying causes, including diabetes and cardiovascular disease ( 7 ). For persons with disabilities, accessing medical services might be challenging because of disruptions in essential support services, which can result in adverse health outcomes. Medical services for persons with disabilities might also be disrupted because of reduced availability of accessible transportation, reduced communication in accessible formats, perceptions of SARS-CoV-2 exposure risk, and specialized needs that are difficult to address with routine telehealth delivery during the pandemic response. Increasing accessibility of medical and telehealth services ¶¶¶ might help prevent delay of needed care. Increased prevalences of reported urgent or emergency care avoidance among Black adults and Hispanic adults compared with White adults are especially concerning given increased COVID-19-associated mortality among Black adults and Hispanic adults ( 8 ). In the United States, the age-adjusted COVID-19 hospitalization rates are approximately five times higher among Black persons and four times higher among Hispanic persons than are those among White persons ( 9 ). Factors contributing to racial and ethnic disparities in SARS-CoV-2 exposure, illness, and mortality might include long-standing structural inequities that influence life expectancy, including prevalence and underlying medical conditions, health insurance status, and health care access and utilization, as well as work and living circumstances, including use of public transportation and essential worker status. Communities, health care systems, and public health agencies can foster equity by working together to ensure access to information, testing, and care to assure maintenance and management of physical and mental health. The higher prevalence of medical care delay or avoidance among respondents with health insurance versus those without insurance might reflect differences in medical care-seeking behaviors. Before the pandemic, persons without insurance sought medical care much less frequently than did those with insurance ( 10 ), resulting in fewer opportunities for medical care delay or avoidance. The findings in this report are subject to at least five limitations. First, self-reported data are subject to recall, response, and social desirability biases. Second, the survey did not assess reasons for COVID-19–associated care avoidance, such as adherence to public health recommendations; closure of health care provider facilities; reduced availability of public transportation; fear of exposure to infection with SARS-CoV-2; or availability, accessibility, and acceptance or recognition of telemedicine as a means of providing care in lieu of in-person services. Third, the survey did not assess baseline patterns of care-seeking or timing or duration of care avoidance. Fourth, perceptions of whether a condition was life-threatening might vary among respondents. Finally, although quota sampling methods and survey weighting were employed to improve cohort representativeness, this web-based survey might not be fully representative of the U.S. population for income, educational attainment, and access to technology. However, the findings are consistent with reported declines in hospital admissions and ED visits during the pandemic ( 3 – 5 ). CDC has issued guidance to assist persons at increased risk for severe COVID-19 in staying healthy and safely following treatment plans**** and to prepare health care facilities to safely deliver care during the pandemic. †††† Additional public outreach in accessible formats tailored for diverse audiences might encourage these persons to seek necessary care. Messages could highlight the risks of delaying needed care, especially among persons with underlying medical conditions, and the importance of timely emergency care. Patient concerns related to potential exposure to SARS-CoV-2 in health care settings could be addressed by describing facilities’ precautions to reduce exposure risk. Further exploration of underlying reasons for medical care avoidance is needed, including among persons with disabilities, persons with underlying health conditions, unpaid caregivers for adults, and those who face structural inequities. If care were avoided because of concern about SARS-CoV-2 exposure or if there were closures or limited options for in-person services, providing accessible telehealth or in-home health care could address some care needs. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay ( 3 ). Summary What is already known about this topic? Delayed or avoided medical care might increase morbidity and mortality associated with both chronic and acute health conditions. What is added by this report? By June 30, 2020, because of concerns about COVID-19, an estimated 41% of U.S. adults had delayed or avoided medical care including urgent or emergency care (12%) and routine care (32%). Avoidance of urgent or emergency care was more prevalent among unpaid caregivers for adults, persons with underlying medical conditions, Black adults, Hispanic adults, young adults, and persons with disabilities. What are the implications for public health practice? Understanding factors associated with medical care avoidance can inform targeted care delivery approaches and communication efforts encouraging persons to safely seek timely routine, urgent, and emergency care.
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              Impact of the COVID-19 Pandemic on Emergency Department Visits — United States, January 1, 2019–May 30, 2020

              On March 13, 2020, the United States declared a national emergency to combat coronavirus disease 2019 (COVID-19). As the number of persons hospitalized with COVID-19 increased, early reports from Austria ( 1 ), Hong Kong ( 2 ), Italy ( 3 ), and California ( 4 ) suggested sharp drops in the numbers of persons seeking emergency medical care for other reasons. To quantify the effect of COVID-19 on U.S. emergency department (ED) visits, CDC compared the volume of ED visits during four weeks early in the pandemic March 29–April 25, 2020 (weeks 14 to 17; the early pandemic period) to that during March 31–April 27, 2019 (the comparison period). During the early pandemic period, the total number of U.S. ED visits was 42% lower than during the same period a year earlier, with the largest declines in visits in persons aged ≤14 years, females, and the Northeast region. Health messages that reinforce the importance of immediately seeking care for symptoms of serious conditions, such as myocardial infarction, are needed. To minimize SARS-CoV-2, the virus that causes COVID-19, transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance. To assess trends in ED visits during the pandemic, CDC analyzed data from the National Syndromic Surveillance Program (NSSP), a collaborative network developed and maintained by CDC, state and local health departments, and academic and private sector health partners to collect electronic health data in real time. The national data in NSSP includes ED visits from a subset of hospitals in 47 states (all but Hawaii, South Dakota, and Wyoming), capturing approximately 73% of ED visits in the United States able to be analyzed at the national level. During the most recent week, 3,552 EDs reported data. Total ED visit volume, as well as patient age, sex, region, and reason for visit were analyzed. Weekly number of ED visits were examined during January 1, 2019–May 30, 2020. In addition, ED visits during two 4-week periods were compared using mean differences and ratios. The change in mean visits per week during the early pandemic period and the comparison period was calculated as the mean difference in total visits in a diagnostic category between the two periods, divided by 4 weeks ([visits in diagnostic category {early pandemic period} – visits in diagnostic category {comparison period}]/4). The visit prevalence ratio (PR) was calculated for each diagnostic category as the proportion of ED visits during the early pandemic period divided by the proportion of visits during the comparison period ([visits in category {early pandemic period}/all visits {early pandemic period}]/[visits in category {comparison period}/all visits {comparison period}]). All analyses were conducted using R software (version 3.6.0; R Foundation). Reason for visit was analyzed using a subset of records that had at least one specific, billable International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code. In addition to Hawaii, South Dakota, and Wyoming, four states (Florida, Louisiana, New York outside New York City, and Oklahoma), two California counties reporting to the NSSP (Santa Cruz and Solano), and the District of Columbia were also excluded from the diagnostic code analysis because they did not report diagnostic codes during both periods or had differences in completeness of codes between 2019 and 2020. Among eligible visits for the diagnostic code analysis, 20.3% without a valid ICD-10-CM code were excluded. ED visits were categorized using the Clinical Classifications Software Refined tool (version 2020.2; Healthcare Cost and Utilization Project), which combines ICD-10-CM codes into clinically meaningful groups ( 5 ). A visit with multiple ICD-10-CM codes could be included in multiple categories; for example, a visit by a patient with diabetes and hypertension would be included in the category for diabetes and the category for hypertension. Because COVID-19 is not yet classified in this tool, a custom category, defined as any visit with the ICD-10-CM code for confirmed COVID-19 diagnosis (U07.1), was created ( 6 ). The analysis was limited to the top 200 diagnostic categories during each period. The lowest number of visits reported to NSSP occurred during April 12–18, 2020 (week 16). Although visits have increased since the nadir, the most recent complete week (May 24–30, week 22) remained 26% below the corresponding week in 2019 (Figure 1). The number of ED visits decreased 42%, from a mean of 2,099,734 per week during March 31–April 27, 2019, to a mean of 1,220,211 per week during the early pandemic period of March 29–April 25, 2020. Visits declined for every age group (Figure 2), with the largest proportional declines in visits by children aged ≤10 years (72%) and 11–14 years (71%). Declines in ED visits varied by U.S. Department of Health and Human Services region,* with the largest declines in the Northeast (Region 1, 49%) and in the region that includes New Jersey and New York (Region 2, 48%) (Figure 2). Visits declined 37% among males and 45% among females across all NSSP EDs between the comparison and early pandemic periods. FIGURE 1 Weekly number of emergency department (ED) visits — National Syndromic Surveillance Program, United States,* January 1, 2019– May 30, 2020† * Hawaii, South Dakota, and Wyoming are not included. † Vertical lines indicate the beginning and end of the 4-week coronavirus disease 2019 (COVID-19) early pandemic period (March 29–April 25, 2020) and the comparison period (March 31–April 27, 2019). The figure is a line graph showing the weekly number of emergency department visits, using data from the National Syndromic Surveillance Program, in the United States, during January 1, 2019–May 30, 2020. FIGURE 2 Emergency department (ED) visits, by age group (A) and U.S. Department of Health and Human Services (HHS) region* (B) — National Syndromic Surveillance Program, United States,† March 31–April 27, 2019 (comparison period) and March 29–April 25, 2020 (early pandemic period) * Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; Region 2: New Jersey and New York; Region 3: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia; Region 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee; Region 5: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin; Region 6: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas; Region 7: Iowa, Kansas, Missouri, and Nebraska; Region 8: Colorado, Montana, North Dakota, and Utah; Region 9: Arizona, California, and Nevada; Region 10: Alaska, Idaho, Oregon, and Washington. † Hawaii, South Dakota, and Wyoming are not included. The figure is a bar chart showing the emergency department visits, by age group and U.S. Department of Health and Human Services region, using data from the National Syndromic Surveillance Program, in the United States, during March 31–April 27, 2019 (comparison period) and March 29–April 25, 2020 (pandemic period). Among all ages, an increase of >100 mean visits per week from the comparison period to the early pandemic period occurred in eight of the top 200 diagnostic categories (Table). These included 1) exposure, encounters, screening, or contact with infectious disease (mean increase 18,834 visits per week); 2) COVID-19 (17,774); 3) other general signs and symptoms (4,532); 4) pneumonia not caused by tuberculosis (3,911); 5) other specified and unspecified lower respiratory disease (1,506); 6) respiratory failure, insufficiency, or arrest (776); 7) cardiac arrest and ventricular fibrillation (472); and 8) socioeconomic or psychosocial factors (354). The largest declines were in visits for abdominal pain and other digestive or abdomen signs and symptoms (–66,456), musculoskeletal pain excluding low back pain (–52,150), essential hypertension (–45,184), nausea and vomiting (–38,536), other specified upper respiratory infections (–36,189), sprains and strains (–33,709), and superficial injuries (–30,918). Visits for nonspecific chest pain were also among the top 20 diagnostic categories for which visits decreased (–24,258). Although not in the top 20 declining diagnoses, visits for acute myocardial infarction also declined (–1,156). TABLE Differences in mean weekly numbers of emergency department (ED) visits* for diagnostic categories with the largest increases or decreases† and prevalence ratios§ comparing the proportion of ED visits in each diagnostic category, for categories with the highest and lowest ratios — National Syndromic Surveillance Program, United States,¶ March 31–April 27, 2019 (comparison period) and March 29–April 25, 2020 (early pandemic period) Diagnostic category Change in mean no. of weekly ED visits* Prevalence ratio (95% CI)§ All categories with higher visit counts during the early pandemic period Exposure, encounters, screening, or contact with infectious disease** 18,834 3.79 (3.76–3.83) COVID-19 17,774 — Other general signs and symptoms** 4,532 1.87 (1.86–1.89) Pneumonia (except that caused by tuberculosis)** 3,911 1.91 (1.90–1.93) Other specified and unspecified lower respiratory disease** 1,506 1.99 (1.96–2.02) Respiratory failure, insufficiency, arrest** 776 1.76 (1.74–1.78) Cardiac arrest and ventricular fibrillation** 472 1.98 (1.93–2.03) Socioeconomic or psychosocial factors** 354 1.78 (1.75–1.81) Other top 10 highest prevalence ratios Mental and substance use disorders, in remission** 6 1.69 (1.64–1.75) Other specified encounters and counseling** 22 1.69 (1.67–1.72) Stimulant-related disorders** −189 1.65 (1.62–1.67) Top 20 categories with lower visit counts during the early pandemic period Abdominal pain and other digestive or abdomen signs and symptoms −66,456 0.93 (0.93–0.93) Musculoskeletal pain, not low back pain −52,150 0.81 (0.81–0.82) Essential hypertension −45,184 1.11 (1.10–1.11) Nausea and vomiting −38,536 0.85 (0.84–0.85) Other specified upper respiratory infections −36,189 0.82 (0.81–0.82) Sprains and strains, initial encounter †† −33,709 0.61 (0.61–0.62) Superficial injury; contusion, initial encounter −30,918 0.85 (0.84–0.85) Personal or family history of disease −28,734 1.21 (1.20–1.22) Headache, including migraine −27,458 0.85 (0.84–0.85) Other unspecified injury −25,974 0.84 (0.83–0.84) Nonspecific chest pain −24,258 1.20 (1.20–1.21) Tobacco-related disorders −23,657 1.19 (1.18–1.19) Urinary tract infections −23,346 1.02 (1.02–1.03) Asthma −20,660 0.91 (0.90–0.91) Disorders of lipid metabolism −20,145 1.12 (1.11–1.13) Spondylopathies/Spondyloarthropathy (including infective) −19,441 0.78 (0.77–0.79) Otitis media †† −17,852 0.35 (0.34–0.36) Diabetes mellitus without complication −15,893 1.10 (1.10–1.11) Skin and subcutaneous tissue infections −15,598 1.01 (1.00–1.02) Chronic obstructive pulmonary disease and bronchiectasis −15,520 1.05 (1.04–1.06) Other top 10 lowest prevalence ratios Influenza †† −12,094 0.16 (0.15–0.16) No immunization or underimmunization †† −1,895 0.28 (0.27–0.30) Neoplasm-related encounters †† −1,926 0.40 (0.39–0.42) Intestinal infection †† −5,310 0.52 (0.51–0.54) Cornea and external disease †† −9,096 0.54 (0.53–0.55) Sinusitis †† −7,283 0.55 (0.54–0.56) Acute bronchitis †† −15,470 0.59 (0.58–0.60) Noninfectious gastroenteritis †† −11,572 0.63 (0.62–0.64) Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019. * The change in visits per week during the early pandemic and comparison periods was calculated as the difference in total visits between the two periods, divided by 4 weeks ([visits in diagnostic category, {early pandemic period} – visits in diagnostic category, {comparison period}] / 4). † Analysis is limited to the 200 most common diagnostic categories. All eight diagnostic categories with an increase of >100 in the mean number of visits nationwide in the early pandemic period are shown. The top 20 categories with decreasing visit counts are shown. § Ratio calculated as the proportion of all ED visits in each diagnostic category during the early pandemic period, divided by the proportion of all ED visits in that category during the comparison period ([visits in category {early pandemic period}/all visits {early pandemic period})/(visits in category {comparison period}/all visits {comparison period}]). Ratios >1 indicate a higher proportion of visits in that category during the early pandemic period than the comparison period; ratios <1 indicate a lower proportion during the early pandemic than during the comparison period. Analysis is limited to the 200 most common diagnostic categories. The 10 categories with the highest and lowest ratios are shown. ¶ Florida, Hawaii, Louisiana, New York outside of New York City, Oklahoma, South Dakota, Wyoming, Santa Cruz and Solano counties in California, and the District of Columbia are not included. ** Top 10 highest prevalence ratios; higher proportion of visits in the early pandemic period than the comparison period. †† Top 10 lowest prevalence ratios; lower proportion of visits in the early pandemic period than the comparison period. During the early pandemic period, the proportion of ED visits for exposure, encounters, screening, or contact with infectious disease compared with total visits was nearly four times as large as during the comparison period (Table) (prevalence ratio [PR] = 3.79, 95% confidence interval [CI] = 3.76–3.83). The other diagnostic categories with the highest proportions of visits during the early pandemic compared with the comparison period were other specified and unspecified lower respiratory disease, which did not include influenza, pneumonia, asthma, or bronchitis (PR = 1.99; 95% CI = 1.96–2.02), cardiac arrest and ventricular fibrillation (PR = 1.98; 95% CI = 1.93–2.03), and pneumonia not caused by tuberculosis (PR = 1.91; 95% CI = 1.90–1.93). Diagnostic categories that were recorded less commonly during the early pandemic period included influenza (PR = 0.16; 95% CI = 0.15–0.16), no immunization or underimmunization (PR = 0.28; 95% CI = 0.27–0.30), otitis media (PR = 0.35; 95% CI = 0.34–0.36), and neoplasm-related encounters (PR = 0.40; 95% CI = 0.39–0.42). In the 2019 comparison period, 12% of all ED visits were in children aged ≤10 years old, compared with 6% during the early pandemic period. Among children aged ≤10 years, the largest declines were in visits for influenza (97% decrease), otitis media (85%), other specified upper respiratory conditions (84%), nausea and vomiting (84%), asthma (84%), viral infection (79%), respiratory signs and symptoms (78%), abdominal pain and other digestive or abdomen symptoms (78%), and fever (72%). Mean weekly visits with confirmed COVID-19 diagnoses and screening for infectious disease during the early pandemic period were lower among children than among adults. Among all ages, the diagnostic categories with the largest changes (abdominal pain and other digestive or abdomen signs and symptoms, musculoskeletal pain, and essential hypertension) were the same in males and females, but declines in those categories were larger in females than males. Females also had large declines in visits for urinary tract infections (–19,833 mean weekly visits). Discussion During an early 4-week interval in the COVID-19 pandemic, ED visits were substantially lower than during the same 4-week period during the previous year; these decreases were especially pronounced for children and females and in the Northeast. In addition to diagnoses associated with lower respiratory disease, pneumonia, and difficulty breathing, the number and ratio of visits (early pandemic period versus comparison period) for cardiac arrest and ventricular fibrillation increased. The number of visits for conditions including nonspecific chest pain and acute myocardial infarction decreased, suggesting that some persons could be delaying care for conditions that might result in additional mortality if left untreated. Some declines were in categories including otitis media, superficial injuries, and sprains and strains that can often be managed through primary or urgent care. Future analyses will help clarify the proportion of the decline in ED visits that were not preventable or avoidable such as those for life-threatening conditions, those that were manageable through primary care, and those that represented actual reductions in injuries or illness attributable to changing activity patterns during the pandemic (such as lower risks for occupational and motor vehicle injuries or other infectious diseases). The striking decline in ED visits nationwide, with the highest declines in regions where the pandemic was most severe in April 2020, suggests that the pandemic has altered the use of the ED by the public. Persons who use the ED as a safety net because they lack access to primary care and telemedicine might be disproportionately affected if they avoid seeking care because of concerns about the infection risk in the ED. Syndromic surveillance has important strengths, including automated electronic reporting and the ability to track outbreaks in real time ( 7 ). Among all visits, 74% are reported within 24 hours, with 75% of discharge diagnoses typically added to the record within 1 week. The findings in this report are subject to at least four limitations. First, hospitals reporting to NSSP change over time as facilities are added, and more rarely, as they close ( 8 ). An average of 3,173 hospitals reported to NSSP nationally in April 2019, representing an estimated 66% of U.S. ED visits, and an average of 3,467 reported in April 2020, representing 73% of ED visits. Second, diagnostic categories rely on the use of specific codes, which were missing in 20% of visits and might be used inconsistently across hospitals and providers, which could result in misclassification. The COVID-19 diagnosis code was introduced recently (April 1, 2020) and timing of uptake might have differed across hospitals ( 6 ). Third, NSSP coverage is not uniform across or within all states; in some states nearly all hospitals report, whereas in others, a lower proportion statewide or only those in certain counties report. Finally, because this analysis is limited to ED visit data, the proportion of persons who did not visit EDs but received treatment elsewhere is not captured. Health care systems should continue to address public concern about exposure to SARS-CoV-2 in the ED through adherence to CDC infection control recommendations, such as immediately screening every person for fever and symptoms of COVID-19, and maintaining separate, well-ventilated triage areas for patients with and without signs and symptoms of COVID-19 ( 9 ). Wider access is needed to health messages that reinforce the importance of immediately seeking care for serious conditions for which ED visits cannot be avoided, such as symptoms of myocardial infarction. Expanded access to triage telephone lines that help persons rapidly decide whether they need to go to an ED for symptoms of possible COVID-19 infection and other urgent conditions is also needed. For conditions that do not require immediate care or in-person treatment, health care systems should continue to expand the use of virtual visits during the pandemic ( 10 ). Summary What is already known about this topic? The National Syndromic Surveillance Program (NSSP) collects electronic health data in real time. What is added by this report? NSSP found that emergency department (ED) visits declined 42% during the early COVID-19 pandemic, from a mean of 2.1 million per week (March 31–April 27, 2019) to 1.2 million (March 29–April 25, 2020), with the steepest decreases in persons aged ≤14 years, females, and the Northeast. The proportion of infectious disease–related visits was four times higher during the early pandemic period. What are the implications for public health practice? To minimize SARS-CoV-2 transmission risk and address public concerns about visiting the ED during the pandemic, CDC recommends continued use of virtual visits and triage help lines and adherence to CDC infection control guidance.
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                Author and article information

                Journal
                An Sist Sanit Navar
                An Sist Sanit Navar
                assn
                Anales del Sistema Sanitario de Navarra
                Gobierno de Navarra. Departamento de Salud
                1137-6627
                2340-3527
                18 June 2021
                May-Aug 2021
                : 44
                : 2
                : 243-252
                Affiliations
                [1 ] originalServicio de Urgencias. Hospital de la Santa Creu i Sant Pau. Barcelona. España. orgdiv1Servicio de Urgencias orgnameHospital de la Santa Creu i Sant Pau Barcelona, España
                [2 ] originalServicio de Urgencias. Hospital Clínic. IDIBAPS. Universitat de Barcelona. Barcelona. España. normalizedUniversitat de Barcelona orgdiv2Servicio de Urgencias orgdiv1Hospital Clínic. IDIBAPS orgnameUniversitat de Barcelona Barcelona, Spain
                [3 ] originalServicio de Urgencias. Hospital General Universitario Reina Sofía. Murcia. España. orgdiv1Servicio de Urgencias orgnameHospital General Universitario Reina Sofía Murcia, España
                [4 ] originalServicio de Urgencias. Hospital Universitario de Bellvitge. L’Hospitalet de Llobregat. Barcelona. España. orgdiv1Servicio de Urgencias orgnameHospital Universitario de Bellvitge. L’Hospitalet de Llobregat Barcelona, España
                [5 ] originalServicio de Urgencias. Hospital Universitario de Móstoles. Madrid. orgdiv1Servicio de Urgencias orgnameHospital Universitario de Móstoles Madrid, Spain
                [6 ] originalServicio de Urgencias. Hospital General Universitario de Alicante. Universidad Miguel Hernández. Elche. Alicante. normalizedUniversidad Miguel Hernández de Elche orgdiv2Servicio de Urgencias orgdiv1Hospital General Universitario de Alicante orgnameUniversidad Miguel Hernández Elche, Alicante, Spain
                [7 ] originalInstituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL). España. orgnameInstituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL) España
                [8 ] originalServicio de Urgencias. Hospital Universitario de Canarias. Tenerife. España. orgdiv1Servicio de Urgencias orgnameHospital Universitario de Canarias Tenerife, España
                [9 ] originalServicio de Urgencias. Hospital Clínico San Carlos. IDISSC. Universidad Complutense. Madrid. normalizedUniversidad Complutense de Madrid orgdiv2Servicio de Urgencias orgdiv1Hospital Clínico San Carlos. IDISSC orgnameUniversidad Complutense Madrid, Spain
                Author notes
                [Correspondencia: ] Òscar Miró. Área de Urgencias, Hospital Clínic Villarroel, 170, 08036 Barcelona, España. E-mail: omiro@ 123456clinic.cat
                Article
                10.23938/ASSN.0957
                10019547
                34142985
                a11fd169-698c-4da3-9ee5-88b8a27fe5e3

                Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons

                History
                : 11 November 2020
                : 04 January 2021
                : 11 January 2021
                Page count
                Figures: 3, Tables: 3, Equations: 0, References: 31, Pages: 10
                Categories
                Artículos Originales

                covid-19,servicio de urgencias,pandemia,gestión sanitaria,emergency department,pandemic,health management

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