Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA

The COVID-19 pandemic will likely be one of the most significant clinic events for any of us in our professional lives. Reflecting backwards to early 2020, it thus far remains one of the most challenging times in my career. Working in a busy ED where how we were managing patients with COVID-19 intially, was on some days changing hour by hour. With subsequently, many people then dying on each shift. One of the notable outcomes was the disparities among different ethnic groups.

Khosla et al conducted a retrospective cohort study of adult patients tested for COVID-19 during or 14 days prior to the index ED visit in 2020. This was from 155 EDs from 27 states of the USA and included data from 26 111 patients. They found Hispanic/Latino patients had twice (aOR=2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than non-Hispanic white (NHW) patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified this effect was only observed in the early phase. Subsequent hospitalisation was more likely in Asian patients (Adjusted Odds Ratio (aOR)=3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in black and Hispanic/Latino patients in the late phase. This work suggests there is more to the impact of COVID-19 than comorbidities alone. It is likely these findings will not be a surprise to emergency medicine clinicians and will pave the way for further work looking into this.

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Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN)

This Canadian study from Rosychuk et al looked at patients returning to the ED with COVID-19 between 1 March 2020 and 31 March 2022. 39 809 patients diagnosed with COVID-19 accounted for 44 862 COVID-19-related ED visits across 47 sites in Canada. 35 468 patients (89%) had one visit (Single Visit (SV) group) and 4341 (11%) returned to the ED (Multi-visit (MV) group) within 30 days (mean 2.2, SD=0.5 ED visits). 40% of SV patients and 16% of MV patients were admitted at their first visit, and 41% of MV patients not admitted at their first ED visit were admitted on their second visit. In the MV group, the median time to return was 4 days and 49% returned within 72 hours. Factors for repeat visit included older age, pregnancy, presence of comorbidities, cancer, obesity, organ transplant, prior or current substance use, higher temperature or severe disease according to the WHO. Conversely, return was less likely for female patients and those boosted or vaccinated. This work creates the opportunity for learning and resource development for short-term follow-up options.

Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study

Working in the ED can be challenging for many reasons, making staff retention a challenge. Daniels et al conducted a qualitative study to explore difficulties in the work environment, the impact of these difficulties, and barriers to and priorities for change. Doctors, nurses and advanced care practitioners of all grades from all over UK were recruited. 33 participated, with four key themes generated. These were a ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’.

When speaking about culture of blame and negativity, people reported that the work environment often felt unsupported and toxic at times, with one participant saying: “You worry about making a mistake, and if you did make a mistake who would have your back.” This led to the next theme of untenable work environments, with significant concern and care being felt to be compromised and staff being undervalued due to poor facilities for them. On the theme of compromised leadership, participants felt the clinical leads in the ED were responsible for setting the tone, culture and behaviour in the ED, leading by example: “you lead by example as well, so if your consultant in charge is not taking a break you feel like you can’t ask to take a break. It’s the same with the nurses, if the nurse in charge is not taking a break, then a lot of the junior nurses won’t come and ask for a break because again, you’re guided by the leadership, aren’t you?” The last theme was striving for support. This encompasses the concerns raised by participants regarding well-being and staff support and the ability to access it. These themes are likely to be unsurprising to anyone reading them. Working in emergency medicine is such a rewarding job and keeping people happy and healthy, to do it is crucial.

Podcast

Finally, each month, Professor Rick Body (Deputy Editor) and I release a podcast of some of the highlights of each month’s journal. So keep your ears peeled. The podcast is available anywhere you might usually download your podcasts. Alternatively, you can find the podcast at https://emj.bmj.com.