Where have all the patients gone during COVID-19? Not to the ER. Star analysis reveals stark, nationwide trend

For three days, a man in B.C. suffered at home through chest pain and shortness of breath, unaware he’d had a heart attack.

A woman in Ontario had a stroke that paralyzed one of her arms. She waited at home for 12 hours, hoping the movement would come back.

In Quebec, a woman endured abdominal pain for three weeks before finding out she had a bowel obstruction that required surgery to clear.

Each of these patients needed urgent medical care in the pandemic. All of them delayed going to the emergency room because they feared COVID-19.

Across the country, emergency room physicians report startlingly similar experiences of providing care during the pandemic. Emergency rooms, usually teeming with patients, are quiet. Many patients who do show up are sicker after trying to tough it out at home.

Now for the first time, a Star analysis of emergency room data makes clear these individual stories are part of a stark, nationwide trend: The number of patients seeking emergency care during the pandemic in hospitals across the country has plummeted, from Halifax to Vancouver, Whitehorse to Toronto.

Between March 11, the date the World Health Organization declared a pandemic, and April 30, the number of patients going to emergency departments in Canada dropped by about 44 per cent compared to previous years, according to the Star analysis. That means roughly 840,000 fewer people nationwide went to emergency rooms during those seven weeks.

“People feel that staying at home is safer than coming to the emergency department but that’s not the case,” said Dr. Kyle Vojdani, chief and medical director of the emergency department at Toronto’s Michael Garron Hospital, which saw a decline of 35 per cent. “We feel like the people we see are just the tip of the iceberg, the cases that can no longer wait anymore. Now we are worried about who we aren’t seeing, who isn’t coming in for care.”

Emergency department volumes during the pandemic are not readily available to the public. To understand precisely when — and to what extent — patients stopped going to emergency rooms during COVID-19, the Star requested data from provincial and territorial health ministries, as well as some individual hospitals and health systems. The Star requested total patient volumes for every calendar day for the first four months of 2018, 2019 and 2020.

In most cases, health ministries provided data on emergency department volumes, some following initial refusals and after multiple requests. The Star was not able to obtain daily numbers from Saskatchewan, New Brunswick, Nunavut and Northwest Territories. In B.C., the health ministry did not provide daily emergency department volumes for the requested time period by deadline; in that province, the Star analyzed numbers from Vancouver Coastal Health, one of five regional health authorities.

Dr. Michael Schull, CEO and senior core scientist at ICES, a Toronto-based non-profit health research agency, said the Star analysis shows a “dramatic” reduction in emergency department volumes.

“There is this very consistent effect, right across the country,” said Schull, who is also an emergency room physician at Sunnybrook Health Sciences Centre. That emergency department saw a 40 per cent decline in patient volumes from mid-March to the end of April. “What is surprising to me, even in provinces with very little COVID activity, you’re seeing this big drop.”

In Yukon, which has only seen a total of 11 COVID-19 cases and no deaths, emergency room volumes dropped by 38 per cent between March 11 and April 30. Prince Edward Island, which has logged 27 cases and no deaths, saw a similar decline.

In Ontario, emergency room volumes dropped by 49 per cent between March 11 and April 30, with the lowest daily volume occurring on April 5 and accounting for roughly 11,000 fewer patient visits, compared to previous years. (A spokesperson for Ontario’s health ministry said the emergency room volumes for April 2020 are “early/preliminary.”)

Schull said the recent national trend is similar to what Canadian hospitals experienced during the SARS outbreak in 2003, where emergency department volumes and the number of critical diagnoses, such as heart attacks, dropped significantly.

Among the lessons learned from SARS was that public health and health system professionals need to do a better job of reminding people they need to get medical care and that hospitals are safe, Schull said.

“I don’t think we started that messaging (during the COVID-19 pandemic) until very late in the game,” he said. “Very early on, as we were telling people that we’re reducing elective admissions to create hospital capacity, we should have also been messaging: ‘Hospitals are safe. If you need care, go to the emergency department, we’re there for you, don’t be afraid.’”

By most measures, public health messaging from mid-March to the end of April was successful in slowing community spread of COVID-19. Canadians stayed home, largely preventing the first wave of coronavirus patients from overwhelming hospitals.

In May, emergency department volumes are inching back up. Although hospitals in Montreal, Canada’s epi of the pandemic, have recently reported a surge in COVID-19 patients, that province also saw a marked drop in emergency room patients in the first seven weeks of the pandemic, when volumes fell by 42 per cent.

Lockdown measures meant fewer accidents, from car crashes to bar fights, and led to a drop in non-COVID-19 infections, such as influenza and strep throat, as well as an explosion in virtual care.

But still, doctors worry too many patients with serious symptoms are staying away from hospitals, leading to unnecessary suffering and death. Some even say patients are taking physical-distancing messaging too much to heart and don’t come for care, not wanting to burden hospitals.

“I don’t think anybody believes the drop in volumes actually truly correlates with the true drop in illness in the community,” said Vojdani from Michael Garron Hospital, which has taken to social media to encourage patients to seek care when they need it. “The illness is still out there, it’s just waiting until it can no longer wait, which is a real problem for patients. It’s what keeps me up at night.”

Ottawa-based neurologist Dr. Dar Dowlatshahi treated the woman who waited 12 hours after having a stroke before going to hospital.

“We have a window of four-and-a-half hours to administer a therapy. Beyond four-and-a-half hours, there’s another window for some surgical therapies,” said Dowlatshahi, who practises at The Ottawa Hospital, and provided an assessment in this case through the province’s Telestroke network, which gives emergency physicians virtual access to stroke-care experts.

“With our stroke therapies we can restore full function to many people. Without the therapies, the vast majority are left disabled,” he said. “This patient was, unfortunately, because of that time delay, out of any possible therapy that we could offer her.”

Dowlatshahi said patients who suffer through stroke symptoms at home because of COVID-19 fears are gambling “without realizing it.”

The B.C. man who waited three days before seeking treatment following his heart attack “wanted nothing to do with the health-care system right now,” said the cardiologist who treated him in Vancouver, Dr. Sean Virani.

“He was scared that if he came to the hospital he would catch COVID. He was scared to leave his house,” Virani said.

It was only when the patient was so short of breath that he couldn’t sleep, and began to worry that this was a symptom of COVID-19, that he went to the emergency room.

“He did not have COVID,” Virani said. “He had congestive heart failure.”

Virani and his team inserted a stent to relieve a blockage in the patient’s heart, but it may have been too late to meaningfully improve his heart function.

“Ultimately, the heart muscle is dead. The damage had been done,” he said.

Virani said his patient “feels like he dropped the ball.”

“I don’t think it’s fair that he should feel that way,” he said. “I think he was responding to largely what he was told,” by public health officials about the need to stay home during COVID-19.

Many of the doctors interviewed for this story credited governments and public health officials across the country for the strong, effective messaging to Canadians about the need to flatten the curve in the early days of the pandemic.

Dr. Alan Drummond, co-chair of public affairs for the Canadian Association of Emergency Physicians, said “I don’t think there should be any apologies for the messaging.”

“We were certainly worried when we had seen what had happened in northern Italy and New York City, when we saw mature health-care systems with truly horrific, dystopian scenarios, with bodies being piled up, no ventilators,” said Drummond, who is an emergency physician at Perth and Smiths Falls District Hospital in Ontario. “Was the message too strong? I don’t think so. We could have been overwhelmed.”

However, Drummond said, “In retrospect, it would have been nice if we had a more balanced message.”

As the pandemic has stretched on, provincial governments, individual hospitals and a number of national health organizations, including the Canadian Cardiovascular Society and the Heart & Stroke Foundation, have sought to combat those fears with public messaging campaigns aimed at reassuring Canadians that emergency departments are safe. The doctors interviewed for this story described rigorous cleaning and screening procedures in their emergency departments, including separate waiting and clinical areas for patients with COVID-19 symptoms.

Vancouver-based cardiologist Dr. Andrew Krahn, president of the Canadian Cardiovascular Society and a Heart & Stroke-funded researcher, said the numbers the Star obtained are “compelling.” He said it underscores the need for Canada to speed up the release of this type of health data during the pandemic.

“Two years later, we’ll say ‘COVID was bad for people,’ as opposed to now, knowing, ‘Hang on, we should be shifting the way we’re doing things and altering our public messaging … from stay home to come in if you’re sick,’” Krahn said.

Dr. Prabhat Jha, an epidemiologist at the University of Toronto’s Dalla Lana School of Public Health, notes that data from previous years show that most emergency room visits in Canada are “due to broad symptoms, like abdominal pain and chest pain.”

He said the decline in emergency room visits “points to the need to understand what happened to the people that stayed at home.”

In Ontario, among the 10 hospitals with the largest volumes of emergency patients, the Scarborough Health Network saw the largest drop in the pandemic. Compared to the previous two years, nearly 50 per cent fewer patients went to emergency departments at the three-hospital network between March 11 and April 30.

Dr. Norman Chu, the network’s chief and medical director of emergency services, said front-line physicians saw fewer car accident victims, fewer playground mishaps and fewer work-related injuries, such as chemical splashes or hand wounds, from Scarborough’s industrial neighbourhoods. Travel restrictions have led to fewer out-of-country patients, including international students and overseas family members coming to visit Scarborough’s immigrant communities, he said.

Though he is concerned about emptier ERs, Chu said the hospital has purposefully put measures in place to safely divert people. Patients sick with fever or cough are being seen at the network’s two COVID-19 Assessment Centres and, in recent weeks, the hospital started offering telemedicine to 18 long-term-care homes in its catchment areas.

“They are able to call our emergency department and speak to a specialist who can answer their questions,” said Chu.

As emergency room volumes continue to inch back up, hospitals across the country are now adapting to a new normal.

“Until there’s a vaccine, I don’t see a time when we’ll be going to work without (wearing PPE),” said Dr. Eric Grafstein, regional head of emergency medicine for Vancouver Coastal Health and Providence Health Care. “I don’t think the public will tolerate going to the emergency department and sitting cheek-to-jowl with another sick person where, when you go to the grocery store, there’s two metres apart and everyone is wearing a mask.”

Grafstein said hospitals are actively exploring ways to ensure physical-distancing can continue, including putting up tents to expand waiting areas and using restaurant-style buzzers to let patients know when it’s their turn to be seen so they don’t have to wait inside.

“We used to say, anywhere where there’s a chair there’s a care space in an (emergency department). But that can’t be the case anymore.”

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvieGraphics by Nathan Pilla and Andres Plana. Nathan Pilla is a digital designer at the Star, based in Toronto. Reach him via email: [email protected]. Andres Plana is a digital designer at the Star, based in Toronto. Reach him via email: [email protected].