Emergency Department presentations from quarantine hotels in Sydney, Australia, during the COVID-19 outbreak – an analysis of clinical patterns and outcomes

Introduction

In response to the Coronavirus (COVID-19) global pandemic, a Public Health Order was enacted in March 2020 requiring all those returning or arriving from overseas to quarantine for fourteen days in Australia.¹ To manage this process and minimise the risk of community transmission in New South Wales, all people returning from overseas from March 2020 were accommodated in around 30 temporarily repurposed hotels located in inner Sydney and the Central Business District. Those with identified acute or ongoing healthcare needs through were referred to the Royal Prince Alfred (RPA) Virtual Hospital, including those who tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) virus, and housed in 3 Special Health Accommodation hotels to allow for remote monitoring of symptoms and signs through the RPA Virtual Hospital model of care.² An analysis of characteristics of these patients will inform the ongoing public health and hospital response to COVID-19 and ensure a patient-centred approach to health services provided to this vulnerable population during isolation.

Methods

We performed a retrospective study on Emergency Department (ED) presentation types for patients referred from all Special Health Accommodation hotels, during the period of June to September 2020. Through abstraction of electronic medical records, we analysed ED clinical characteristics and outcomes of interest including diagnosis categories, comorbidities, and ED length of stay (time from arrival to actual departure date and time). Wilcoxon rank sum tests were used to compare median ED length of stay between cases associated with mental health and other diagnosis groups. Approval for this study was obtained from the Sydney Local Health District Research Ethics Committee (X20-0365 & 2020/ETH02007).

Results

Between June and September 2020, total of 2774 people were registered to be accommodated in Special Health Accommodation hotels. Of these, 461 (16.61%) presented to ED during this period at least once (total of 542 ED presentations). Thirteen patients (2.82%) were diagnosed with COVID-19 and none of these required monitoring in intensive care. The most common ED diagnosis categories (Table 1 - available in PDF) were mental health conditions (102, 18.8%) and cardiovascular complaints (84, 15.5%). Of mental health presentations, anxiety (43, 42%), suicidal ideation (24, 23%) and acute psychosis (11, 11%) were the most common (Figure 1 - available in PDF). The median length of stay for mental health presentations was longer at 543 minutes (interquartile range, IQR 372-788) compared to non-mental health presentations (433 minutes IQR 302-598) (p<0.001). These were also associated with higher triage acuity and higher proportion of pre-existing mental health conditions compared to non-mental health presentations (63.7% versus 11.1% p<0.001).

Discussion and Conclusion

The COVID-19 pandemic continues to have significant direct and indirect health care consequences globally. Some of the most important of these include impacts on mental health.³ The proportion of mental health presentations reported in this cohort was 18%, some five times higher than general ED presentations.^4,5 Whilst quarantine has proven to be a vital public health measure to curb the spread of SARS-CoV2, it is not without the potential for direct and indirect physical and psychological harms.⁶ This was the first Australian report demonstrating the impact of mental health during hotel quarantine and highlights the need for increased psychological supports and other services to be made available for people entering quarantine in other jurisdictions.⁷ In this study, all patients who presented to ED with mental health problems were routinely followed up by psychologists through the RPA Virtual Hospital. Finally, prolonged length of stay in ED (median length of stay over 9 hours) likely compounded any psychological stress in patients presenting with mental health problems. Only 15.9% of patients were admitted or discharged within the required 4 hours. A prospective study is currently underway by these authors to better understand the psychological impacts of hotel quarantine as the COVID-19 pandemic response evolves in 2021. ​​​​​​

References

1. NSW Ministry of Health. Public Health (COVID-19 Quarantine) Order 2020. https://www.health.nsw.gov.au/Infectious/covid-19/Pages/public-health-orders.aspx.
2. Hutchings O, Dearing C, Jagers D, et al. Virtual health care for community management of patients with COVID-19. medRxiv 2020. doi: https://doi.org/10.1101/2020.05.11.20082396 [Preprint]
3. Pfefferbaum B, North CS. Mental Health and the Covid-19 Pandemic.  N Engl J Med 2020; 383: 510-512.
4. Australian Institute of Health and Welfare 2020. Mental health Services in Australia. Canberra: AIHW.  https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/hospital-emergency-services
5. Perera J, Wand T, Bein KJ et al. Presentations to NSW emergency departments with self‐harm, suicidal ideation, or intentional poisoning, 2010–2014. Med. J. Aust 2018; 208: 348–353.
6. Nussbaumer-Streit B, Mayr V, Dobrescu AI, et al. Quarantine alone or in combination with other public health measures to control COVID‐19: a rapid review. Cochrane Database Syst Rev 2020; 8: CD013574. doi: 10.1002/14651858.CD013574
7. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence.  Lancet 2020; 395: 912-920.