Impact of the COVID-19 Pandemic on Acute Care Visits for Patients with Sickle Cell Disease
Authors: Orkoulas-Razis Dennis , Bishop Nicholas , Dupont Ellen , Baer Maria R. , Wilkerson Richard Gentry , Law Jennie Y. 
Published: November 2021

Abstract
Introduction: The COVID-19 pandemic significantly impacted emergency department (ED) and overall hospital utilization, with a substantial decline in non-COVID-19-related medical presentations. In the weeks following the declaration of a national health emergency, ED visits declined by 42%. Patients with sickle cell disease (SCD) are at risk for needing ED-based care and hospitalization due to disease-specific complications. We examined the impact of the COVID-19 pandemic on acute care utilization by patients with SCD at our institution.
Methods: We performed a retrospective cohort study at our institution comparing the period of the first "stay at home" order in Baltimore, MD (3/30/2020-6/8/2020) to the same date range in 2019. We included all adult patients with SCD who either presented to the ED or were directly admitted to the hospital. All SCD genotypes were included (HbSS, HbSC, HbSβ +/0 thalassemia). Data collected included presenting symptoms, disposition for ED visits, admission length of stay (LOS), re-admission within 7 days, as well as frequency of sickle cell-specific complications during hospitalization. We collected data regarding the acuity of patients' initial presentation using the emergency severity index (ESI), a five-tiered grading tool utilized by triage nurses to indicate the acuity and resource-intensiveness of a patient's presenting symptoms (1= highest urgency, 5= least urgency). We performed statistical analyses using Pearson's chi square test, Fisher's exact test and the Mann-Whitney U test.
Results: During the initial stay at home order in 2020, 77 patients presented to acute care services at our institution, compared to 163 patients during the same dates in 2019, a decrease of &gt; 50%. Statistically significant demographic differences between 2020 and 2019 included gender (53% vs 34% male gender, p = 0.004) and hemoglobinopathy type (2020: SS (66%), SC (27%), Sβ-thal (6.5%) vs 2019: SS (48%), SC (42%), Sβ-thal (10%), p = 0.03), whereas there was no difference in severity on presentation measured by ESI (median score of 3: 88% vs 90%, p = 0.13) or age (30 vs 30 years old, p = 0.925). More patients in 2020 presented with dyspnea (22% vs 11%, p = 0.02), and/or nausea or vomiting (22% vs 11%, p = 0.02), but more patients in 2019 presented with cough (7% vs 17%, p = 0.025). None of the patients tested positive for SARS-CoV-2. There was no statistically significant difference between the study periods in hospitalization rate (44% vs 37%, p = 0.32), LOS (60 vs 64 hrs, p = 0.73), admission to the ICU (3% vs 2.5%, p = 1.0) or step-down unit (0% vs 1%, p = 1.0), or death (0% vs 1%, p = 1.0). There was a difference in ED re-presentation within 7 days of the index visit (14% vs 47%, p &lt; 0.001), but no difference in rate of readmission within 7 days (9% vs 15%, p = 0.225).
Discussion: Although fewer patients with SCD presented for acute care in 2020, there was no significant difference in objective metrics, including admission rates, LOS, readmissions, and disease-specific complications. The decrease in ED return visits in 2020 may reflect patients' concerns regarding exposure to SARS-CoV-2 while in the ED. Our data demonstrate that although fewer patients with SCD presented for acute care utilization, they did not appear to be sicker. The data support more frequent management of uncomplicated pain crises outside of the ED, through optimization of outpatient services including infusion centers and telehealth. The advent of new care delivery models as a result of the Covid-19 pandemic may have a positive impact on frequency of ED utilization for patients with SCD.

Disclosures
No relevant conflicts of interest to declare.