Archives of Academic Emergency Medicine. 2021; 9(1): e28 https://doi.org/10.22037/aaem.v9i1.1167 LE T T E R TO ED I TO R Emergency Department and Overcrowding During COVID-19 Outbreak; a Letter to Editor Jean-Baptiste Bouillon-Minois1,2∗, Julien Raconnat1, Maelys Clinchamps3, Jeannot Schmidt1,2, Frédéric Dutheil2,3 1. Emergency Medicine, CHU Clermont-Ferrand, Université Clermont Auvergne, F–63000 Clermont–Ferrand, France. 2. CNRS, LaPSCo, Physiological and Psychosocial Stress, F–63000 Clermont–Ferrand, France. 3. Preventive and Occupational Medicine, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France. Received: January 2021; Accepted: February 2021; Published online: 25 March 2021 Cite this article as: Bouillon-Minois J-B, Raconnat J, Clinchamps M, Schmidt J, Dutheil F. Emergency Department and Overcrowding During COVID-19 Outbreak; a Letter to Editor. Arch Acad Emerg Med. 2021; 9(1): e28. Dear Editor, Emergency Physicians (EPs) work under extreme stress con- ditions (1). Overcrowding – defined as hospital beds not be- ing available for several patients who need one – has been a significant public health problem for more than a decade and is the consequence of the increase in health care demand and the decrease in bed spaces and number of staff (2). These parameters increase stress at work, which leads EPs to ex- perience significant stress consequences, a feeling of dimin- ished skills, and loss of time control (3). Many studies are interested in the overcrowding problem, like a recent study by Tangkulpanich et al. who found the predictive factors of revisiting in 48 hours (4). Since the end of 2019, because of COVID-19, people were re- quired to stay at home to prevent the spread of COVID-19 and the overflow of emergency and intensive care units. But in some places, there was no overflow, and a massive decrease, up to 50%, was observed in admission rate (5). In the ru- ral area of Puy-de-Dôme – 653 742 inhabitants with a den- sity of 82 inhabitants/km2 – only 335 patients had a positive test, with 30 deaths by July 1s t , 2020. In the emergency de- partment of Clermont-Ferrand – the principal city of Puy-de- Dôme –, there were 57 177 admissions in 2019 – i.e., a mean of 157 per day. Of those 57 177 emergency department admis- sions, 38 809 were discharged, and 18 368 (i.e., 50 per day) were hospitalized. But even if the hospital provided 21 851 available beds annually (60 per day), EPs spent 152 days on overcrowding. ∗Corresponding Author: Jean-Baptiste Bouillon-Minois; University Hospital of Clermont-Ferrand (CHU), Emergency Department, 58 rue Montalembert, 63000 Clermont-Ferrand, France. Tel: +33 (0)6 74 36 04 23, Fax: +33 (0)4 73 27 46 49, Email: jbb.bouillon@gmail.com. Contrary to 2019, the year 2020 offered a massive decrease in the admission rate, with a maximum of 204 beds available on April 3rd, 2020. During the French COVID-19 lockdown be- tween March 17t h and May 11t h , there were no overcrowded days (55 days). As soon as the global lockdown ended, the emergency department was overcrowded again (Figure 1). Moreover, despite the cooling period of lockdown with a large number of beds available and few patients needing to be ad- mitted, the year 2020 seemed harder than 2019. Indeed, 75 days out of the initial 185 days of the year (40.5%) were over- crowded in 2020, similar to 2019 with 79/185 overcrowding days (43%) during the first half of the year (Table 1). If we remove the 55 days of the COVID-19 lockdown, the percent- age of overcrowded days rise up to about 58% in 2020. Al- though in-hospital mortality and hospital length of stay are correlated with the size of emergency department boarding (6), the number of hospitalization beds in France decreased from 468 000 in 2003 to 408 in 2015. In the same period, the number of admissions in the emer- gency departments increased from 15.5 million to 21 million per year in France. Furthermore, emergency departments are identified as high-risk settings for medical errors and adverse events (7), concerning up to 10% of admissions. At the same time, several complaints are growing by approximately 1% per year, which may involve a rise of complementary inves- tigations by fear of missing a diagnosis, increasing the time spent in emergency departments, and the stress of both pa- tients and physicians (8). Interestingly, during the French COVID-19 lockdown, one author reported 32% decrease in transitory ischemic attacks, 64% in unstable angina, 42% in appendicitis, and 36% in seizures. However, we demon- strated that although the number of admissions hugely de- creased (nearly by half ) during the lockdown, the mean num- ber of patients needing hospitalization during the first half of This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem J-B. Bouillon-Minois et al. 2 the year stayed similar (around 50 per day). Lastly, although the lockdown was not so problematic for emergency depart- ments, the following months were a challenging period. Dur- ing the French lockdown, planned surgery and medical con- sultations were canceled as much as possible and every sur- geon, every staff member – emergency physician or not – was prepared to fight against COVID. But afterwards they wanted to reschedule the canceled surgeries and canceled meetings, and there were not more beds available for patients from emergency departments in hospitals. The months after the lockdown were tricky as the number of patients to hospital- ize started to rise again, without downstream beds. 1. Conclusion Contrary to the common opinion, the COVID-19 lockdown was not the most terrible period for EPs. It even appeared that the lockdown could be considered the gold standard for patient care in emergency departments, without any prob- lem to find a bed for those needing to be hospitalized. 2. Declarations 2.1. Acknowledgment To Dominique Romain, for her daily work. 2.2. Conflicts of interest The authors of this work declare no conflict of interest. 2.3. Funding support Not applicable. 2.4. Authors’ contributions JBBM performed the statistics and wrote the manuscript. JR created the database and performed the extraction of all data. MC created the figure and the table. JS supervised the creation of the database and review the manuscript. FD wrote the manuscript and performed statistics. References 1. Dutheil F, Boudet G, Perrier C, Lac G, Ouchchane L, Chamoux A, et al. JOBSTRESS study: comparison of heart rate variability in emergency physicians working a 24- hour shift or a 14-hour night shift—a randomized trial. Int J Cardiol. 2012;158(2):322-5. 2. Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M. Overcrowding in emergency department: an international issue. Internal and emergency medicine. 2015;10(2):171-5. 3. Lindeberg SI, Rosvall M, Choi B, Canivet C, Isacsson S- O, Karasek R, et al. Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women. European journal of public health. 2011;21(2):190-6. 4. Tangkulpanich P, Yuksen C, Kongchok W, Jenpanitpong C. Clinical Predictors of Emergency Department Revis- its within 48 Hours of Discharge; a Case Control Study. Archives of Academic Emergency Medicine. 2021;9(1). 5. Bouillon-Minois J-B, Schmidt J, Dutheil F. SARS-CoV-2 pandemic and emergency medicine: The worst is yet to come. The American Journal of Emergency Medicine. 2020. 6. Singer AJ, Thode Jr HC, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Academic Emergency Medicine. 2011;18(12):1324-9. 7. Freund Y, Goulet H, Leblanc J, Bokobza J, Ray P, Maig- nan M, et al. Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial. JAMA internal medicine. 2018;178(6):812-9. 8. Heath I. Role of fear in overdiagnosis and overtreat- ment—an essay by Iona Heath. Bmj. 2014;349. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e28 Table 1: Number of hospitalizations needed and beds available per day and overcrowded days during first six months of the years 2019 and 2020 Variables 2019 (185 days) 2020 (185 days) p value Hospitalizations/day 51.0 ± 10.8 47.0 ± 10.1 <0.001 Beds available/day 59.0 ± 27.1 69.0 ± 46.6 <0.01 Overcrowded (days) 79 (42.7) 75 (40.5) 0.32 Data are presented as mean ± standard deviation of number (%). Figure 1: Overcrowding in the Emergency Department of Clermont-Ferrand between January 1s t and June 30t h 2020. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Conclusion Declarations References