EXECUTIVE SUMMARY

While COVID-19 continues surging in many regions, emergency departments across the country are confronting another significant problem: plummeting patient volumes. Many people with time-sensitive conditions such as stroke and heart attack are delaying or avoiding care, a reality that is leading to tragic results. To counteract this phenomenon, the Washington State Hospital Association (WSHA) is working with member hospitals to address patient fears, and help people understand when they should seek immediate care.

• An April survey of U.S. adults revealed nearly one-third of respondents had delayed or avoided medical care because they were worried about contracting COVID-19. Nearly three-quarters reported concerns about overstressing the healthcare system. More than half worried they would be unable to receive treatment if they needed care.

• The WSHA is addressing the problem with a statewide education campaign. Member hospitals are screening all patients, often before they enter a hospital or clinic, implementing physical distancing protocols, requiring masks, and boosting sanitation practices.

• The campaign is leveraging physicians to spread the word about these safety measures, the availability of healthcare resources, and the importance of accessing needed care.


With COVID-19 still a major problem, healthcare providers have observed a concerning byproduct: people with urgent or emergency care needs are reluctant to seek care, sometimes delaying a visit to the emergency department (ED) — to the point where adverse consequences that could have been prevented already are evident.

After a few weeks of sheltering in place, some normally bustling EDs in many U.S. regions started reporting empty waiting rooms. In late April, Morning Consult and the American College of Emergency Physicians (ACEP) released the results of a poll that revealed the specific reasons behind the dramatic decreases in volume.

Among 2,201 adults surveyed, 29% reported they had delayed or avoided medical care because they were worried about contracting the coronavirus. Seventy-three percent noted concerns about overstressing the healthcare system. More than half (59%) worried they would be unable to receive treatment if they needed care. (View the full results of this poll here.)

While such reticence to seek care is understandable, the concern is people with strokes, heart attacks, and other time-sensitive conditions are failing to act promptly. ACEP President William Jaquis, MD, FACEP, even made a direct appeal to patients not to delay care.

“Emergency physicians are expertly trained for these situations and have protocols in place to keep their patients protected even in the midst of a pandemic,” he said in a statement.

There has been some state-level action around the issue, too. By late May, EDs in Washington state were reporting that while patient volume was down, they were seeing increases in patients arriving in much worse shape because they had delayed seeking appropriate care.

“We had noticed, too, a drop-off in people coming to the hospital for stroke and heart attack,” explains Beth Zborowski, senior vice president for member engagement and communications at the Washington State Hospital Association (WSHA). “It was just remarkable that those [diagnoses] seemed to have disappeared with the arrival of COVID-19.” A decrease in certain types of cases was expected considering most people were not venturing far beyond their homes when the pandemic was at its peak. Car accidents and other types of trauma were less likely to occur, observes Zborowski, but the drop-off in strokes and heart attacks was worrying.

At first, WSHA heard from just a few hospitals about volume declines. However, reports started multiplying, along with unfortunate anecdotes about patients who had delayed seeking care — mirroring the feedback gathered in the Morning Consult/ACEP poll.

“One example involved a critical access hospital in southeastern Washington, a fairly small place that normally has between zero and two Life Flights out of their facility per month,” Zborowski shares. “They had, in one four-week period, [a total of] seven Life Flights because people were coming in for care for things that [the hospital] might have been able to treat [on site] had they come in earlier.”

The most common reason patients gave for not accessing care earlier was they were scared they might contract the coronavirus if they visited a hospital or even a clinic, but that was not the only concern.

“They were also worried that the healthcare system did not have space for them,” she says. “[They felt their] healthcare concerns were not as important or wouldn’t be paid attention to in the same way that [patients with] COVID-19 were being given attention and priority.”

Clearly, some of the state’s early messaging (i.e., urging people not to go to the hospital unless it was an emergency) was producing a sustained reluctance to seek care, even when it was warranted. “I think people were not understanding what was an emergency,” Zborowski offers.

To counteract such impressions, WSHA began working with its 112 member hospitals to determine what steps they could take collectively to encourage patients to seek the care they needed, and to provide reassurance patients would be safe. The result of these discussions was a campaign aimed at communicating to patients when they should definitely seek care, and what healthcare services were available under the state’s phased reopening plan.

Further, and most important to hospitals and EDs, the campaign stipulated a series of steps every hospital in the state was taking to keep patients safe. These include:

  • screening everyone who arrives, often before they enter the hospital or ED;
  • distancing people from one another, and putting protective barriers in some areas;
  • limiting visitors;
  • increasing the use of masks for staff and visitors;
  • changing the waiting room or, in some cases, eliminating the use of waiting rooms;
  • stepping up sanitation practices, particularly with respect to high-touch items in common areas.

Zborowski acknowledges there is variation in how some steps are carried out based on community and institutional needs, but the steps are general enough to allow for such differences. For instance, while some EDs and clinics have eliminated their waiting rooms, other sites have taken steps to ensure there is enough distance between people seated in waiting areas. “There are some hospitals and clinics where you will get a text or a phone call when it is time for your appointment ... and then you go straight back into a room,” she explains. “There is consistency in the screening [practices] to make sure that anyone with respiratory symptoms is not sitting next to someone who does not have a respiratory symptom.”

Knowing clinicians are the trusted voices in this pandemic, WSHA kicked off the campaign with a virtual press conference on May 14, during which several of Washington state’s leading physicians answered questions and relayed how their hospitals are responding to the pandemic.

Francis Riedo, MD, an epidemiologist at EvergreenHealth in Kirkland, noted everyone coming to his hospital is screened at the entrance with a temperature and symptom check. All are asked to wear a mask.

“Once [patients] come into our clinic, [they] will notice there are spacers in place asking people to remain six feet apart, Plexiglas shields [are being used], and there is a much more vigorous cleaning process,” he explained. “All of these measures are an attempt to decrease random contact with other patients. While [people] are in a provider’s presence, everyone is wearing a mask: medical assistants and the front office staff, as well as the provider.”

Elizabeth Wako, MD, the chief medical officer of the Swedish First Hill medical campus in Seattle, said one benefit that has emerged from the COVID-19 crisis is the huge emphasis on telehealth. “This is a space where we have seen a lot of success. At Swedish, we see this as something that is likely to continue ... even after COVID-19 is no longer prevalent in our community,” she shared.

However, Wako stressed there are times when it is important to access care in person. “Unfortunately, across the U.S., we are seeing close to a 20% drop in those calling with symptoms of stroke. This is significant,” she said. “There are real consequences to delaying care. Ultimately, it is the difference between recovery and disability.”

Wako recalled the recent case of an elderly woman who was afraid to come to the ED when she first started experiencing symptoms. “By the time she came in, it was pretty apparent that she had had a stroke in her home. Unfortunately, by the time she arrived, she was outside of the window for treatment,” Wako lamented.

The state’s “stay home, stay healthy” order issued early in the outbreak was a major factor in limiting the spread of the virus, acknowledged Sam Hsieh, MD, a general surgeon and the chief of staff for Couley Medical Center, a 25-bed critical access hospital and level four trauma center in Grand Couley. However, he stressed the order was never meant to keep patients from receiving vital care.

“We have heard that there is a belief that the healthcare system is so overwhelmed with taking care of COVID-19 patients that we simply don’t have the time to attend to others ... and I want to really bust that myth, and say it just isn’t true,” he said. “We have seen some patients who have waited too long to seek care for life-threatening and debilitating conditions.”

Hsieh pointed to specific examples, such as patients with high blood pressures leading to strokes and patients with diabetes that is uncontrolled, leading to ulcers, wounds, and (potentially) vision loss.

“I personally have seen [patients] with ruptured appendixes because they thought they would tough it out at home,” he related. “We have also seen delays in the diagnosis of cancers.”

The concern about care delays is particularly significant in rural settings because such delays can lead to even worse outcomes, Hsieh explained. “Many rural hospitals have infrastructures that can maybe stabilize a patient, but they then [often] need to transfer the patient to a larger facility to receive therapeutic treatments,” he said. “That further delays their overall care.”

Noting there is a yearning for accurate information, Hsieh stressed providers are well-positioned to help patients “sort through all the extra noise that is out there.”

Ruth McDonald, MD, interim chief medical officer of Seattle Children’s Hospital, said her organization has heard directly from families about how fearful they are about seeking care during this pandemic. That is evident in the hospital’s data.

“We have seen a drop-off in admissions, we have seen a drop-off in visits to our urgent care [centers] and to our ED,” she observed. “We have families in our ED express that they were just waiting it out at home, hoping that their child’s symptoms would resolve on their own rather than coming in to the ED.”

However, there are times when “waiting it out” leads to more severe consequences that could have been avoided if care had not been delayed, McDonald said. “One example of this is new-onset diabetes,” she explained. “There are potentially times when had the children been seen sooner, when their symptoms were milder, they might not have needed hospitalization.”

To ease fears of contracting COVID-19, McDonald’s facility has adopted a universal masking policy. Also, everyone is screened at all entryways for fever and respiratory symptoms.

“If a patient is seen and screens positive for symptoms, [he or she] is immediately taken back to an exam room rather placed in the waiting areas,” McDonald shared. She also noted physical distancing measures have been enacted to ensure patients and families remain safe.

Beyond WSHA’s coordinated efforts, each hospital is trying to spread the word about what their health system is doing to keep people safe when they arrive for care, according to Zborowski.

“We are still early in the pandemic recovery, and we have many counties that are still in the first phase of pandemic control with strict social distancing guidance,” she explains.

Zborowski’s advice to other EDs dealing with depressed volumes is to be totally up front with the community about what services people can expect and what symptoms require seeking immediate care. “Our [effort] is not a feel-good, warm-and-fuzzy campaign. We do have some messages that, on their face, might seem negative. But what we knew was people had these concerns ... and we wanted to confront them head-on,” Zborowski says. “We wanted to address where people were, and provide the facts and reassurance.”

While effects of the campaign remain unclear, Zborowski is hopeful people with urgent or emergency needs will seek the care they need promptly. “Even if we have half a dozen people who go in [to the hospital], and their lives are saved, I think that is worth it,” she says.