Clinical research Covid-19/SARS-CoV-2 Changing patterns of urologic emergency visits and admissions during the COVID-19 pandemic: a retrospective, multicenter, nationwide study Pawel Rajwa1, Mikolaj Przydacz2, Wojciech Krajewski3, Blazej Kuffel4, Piotr Zapala5, Aleksandra Krzywon6, Alexander J. Cortez6, Bartosz Dybowski7, Remigiusz Stamirowski8, Marcin Jarzemski9, Rafal B. Drobot10, Pawel Stelmach11,12, Krystyna Mlynarek13, Mateusz Marcinek14, Maciej Przudzik15, Wiktor Krawczyk8, Jakub Ryszawy1, Dominik Choragwicki2, Lukasz Zapala5, Marcin Lipa10, Michal Pozniak4, Dawid Janczak11,12, Szymon Słomian13, Jan Łaszkiewicz3, Marcel Nowak14, Marcin Miszczyk16, Marek Roslan15, Michał Tkocz14, Romuald Zdrojowy3, Andrzej Potyka13, Tomasz Szydełko11,12, Tomasz Drewa4, Piotr Jarzemski9, Piotr Radziszewski5, Marcin Slojewski8, Artur Antoniewicz10, Andrzej Paradysz1, Piotr L. Chlosta2 1Department of Urology, Medical University of Silesia, Zabrze, Poland Corresponding author: 2Department of Urology, Jagiellonian University Medical College, Krakow, Poland Pawel Rajwa MD, PhD 3Department of Urology and Urological Oncology, Wroclaw Medical University, Department of Urology Wroclaw, Poland Medical University of Silesia 4Department of General and Oncological Urology, 1st University Hospital, 3-go Maja Street 14-15 Nicolaus Copernicus University, Bydgoszcz, Poland 41-800 Zabrze, Poland 5Department of General, Oncological and Functional Oncology, Medical University Phone: +48 323704454 of Warsaw, Warsaw, Poland E-mail: pawelgrajwa@gmail. 6Department of Biostatistics and Bioinformatics, Maria Skłodowska-Curie National com Research Institute of Oncology, Gliwice Branch, Gliwice, Poland 7Department of Urology, Roefler Memorial Hospital, Pruszkow, Poland 8Department of Urology and Urological Oncology, Pomeranian Medical University, Szczecin, Poland 9Department of Urology, Jan Biziel University Hospital in Bydgoszcz, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Poland 10Department of Urology and Urological Oncology, Multidisciplinary Hospital in Warsaw-Miedzylesie, Warsaw, Poland 11Clinical Department of Urology, 4th Clinical Military Hospital, Wroclaw, Poland 12Division of Oncology and Palliative Care, Faculty of Health Sciences, Wroclaw Medical University, Poland 13Urological Ward, Independent Public Health Care Unit, Voivodeship Specialised Hospital No. 3, Rybnik, Poland 14Department of Urology, FMS in Katowice, Medical University of Silesia, Katowice, Poland 15University of Warmia and Mazury, Faculty of Medicine, Department of Urology, Olsztyn, Poland 16Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland Submitted: 7 July 2020; Accepted: 28 July 2020 Online publication: 25 August 2020 Arch Med Sci 2021; 17 (5): 1262–1276 DOI: https://doi.org/10.5114/aoms.2020.98364 Copyright © 2020 Termedia & Banach Abstract Introduction: We aimed to examine the change in the number and severity of visits to the emergency departments (EDs) and subsequent admissions for urgent urologic conditions in the early stage of the coronavirus disease 2019 (COVID-19) pandemic in Poland. Material and methods: We evaluated data from 13 urologic centers in Po- land and compared the number of visits to the EDs and subsequent admis- Creative Commons licenses: This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY -NC -SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/). Changing patterns of urologic emergency visits and admissions during the COVID-19 pandemic: a retrospective, multicenter, nationwide study sions before and after the advent of COVID-19 in 2020, and before and after the escalating national restric- tions. Furthermore, data on types of urologic complaints, crucial laboratory parameters, and post-admission procedures were analyzed. Results: In total 1,696 and 2,187 urologic visits (22.45% decrease) and 387 and 439 urologic urgent admis- sions (11.85% decrease) were reported in given periods in 2020 and 2019, respectively. The year-over-year difference in daily mean visits was clear (36.1 vs. 46.5; p < 0.001). Declines were seen in all complaints but device malfunction. In 2020 daily mean visits and admissions decreased from 40.9 and 9.6 before lockdowns to 30.9 (p < 0.001) and 6.9 (p = 0.001) after severe restrictions, respectively. There was a trend towards more negative laboratory parameter profiles in 2020, with patients who visited the EDs after severe restrictions having twice as high median levels of C-reactive protein (15.39 vs. 7.84, p = 0.03). Conclusions: The observed declines in ED visits and admissions were apparent with the significant effect of national lockdowns. Our results indicate that some of the patients requiring urgent medical help did not appear at the ED or came later than they would have done before the pandemic, presenting with more severe complaints. Key words: coronavirus, COVID-19, urology, emergency, admissions, visits. Introduction In this retrospective, multicenter, nationwide study, we aim to examine the change in the num- The pandemic of coronavirus disease 2019 ber and severity of visits to the ED and subse- (COVID-19) has had a tremendous impact on quent admissions for urgent urologic conditions healthcare utilization worldwide, including dras- in the early stage of the COVID-19 pandemic in tically reduced patient care-seeking for medical Poland. We hypothesize that the number of visits emergencies unrelated to COVID-19. In China, Ita- to the ED and subsequent admissions decreased ly, the UK, and the US, initial reports suggest a de- with increased severity of reported conditions. crease in visits to emergency departments (EDs) and admissions for urgent cardiac and neurolog- Material and methods ical conditions [1–5]. In Italy and Portugal, there is also evidence of a decrease in ED visits and ad- In this retrospective, multicenter, nationwide missions for urgent urologic conditions but mostly study, we analyzed all emergency visits and ad- reported in studies of a single center or a short missions for urologic complaints at 13 urolog- duration [6–10]. ic centers in Poland. All of the EDs in the study Poland, a Central European country of 38 mil- provided 24-hour urology service. We compared lion people, had an initial peak of 475 COVID-19 (1) the number of visits to the ED and subsequent cases on April 5, 2020 and saw its healthcare infra- admissions and (2) the laboratory patterns of uro- structure generally less disrupted by the surge of logic conditions for these visits and admissions COVID-19 cases than many other countries. How- before and after the advent of COVID-19 in 2020 ever, in the early stage of the pandemic, because and before and after the state of epidemic threat healthcare resources must be preserved and noso- (initial national lockdown) in Poland on March 14, comial and community transmission must be limit- 2020, and after the most severe restrictions as ed [11], the Polish National Health Fund (obligatory implemented on March 25, 2020. The specific public insurance) and other major healthcare or- period of COVID-19 in this study was from Febru- ganizations recommended postponing routine and ary 29, 2020 to April 15, 2020 (2 weeks before to elective procedures [12, 13], and the Polish govern- 1 month after the initial national lockdown); a pre- ment introduced an initial national lockdown on COVID-19 reference period was selected as from March 14, 2020 and additional severe restrictions February 28, 2019 to April 15, 2019 (Figure 1). on March 25, 2020 [14, 15]. In detail, from March Due to heterogeneity in coding systems across 14, 2020 shopping malls, sports centers, bars, cin- institutions, we categorized urologic conditions emas, and libraries were closed. Public gatherings into eight major groups by author consensus of 50 or more people were banned. The most se- based on initial patient complaints, brief case de- vere restrictions (e.g., bans on non-essential move- scriptions, and reported the International Statisti- ments outside the home and gatherings of more cal Classification of Diseases and Related Health than two people) were applied from March 25, Problems, Tenth Revision (ICD-10) codes: renal 2020. Nevertheless, many urgent urologic condi- colic, hematuria, urinary retention, urinary tract tions, such as gross hematuria, urinary retention, infection (UTI), device (urinary drainage tube) and acute scrotum, require prompt interventions malfunction (e.g., nephrostomy tube dislocation, and if untreated can lead to serious morbidity and urinary catheter obstruction), acute scrotum, mortality. Patients with such conditions must seek trauma, and others. We additionally collected pa- care even during the COVID-19 era. tients’ demographic and laboratory data, includ- Arch Med Sci 5, August / 2021 1263 P. Rajwa, M. Przydacz, W. Krajewski, B. Kuffel, P. Zapala, A. Krzywon, A.J. Cortez, B. Dybowski, R. Stamirowski, M. Jarzemski, R.B. Drobot, P. Stelmach, K. Mlynarek, M. Marcinek, M. Przudzik, W. Krawczyk, J. Ryszawy, D. Choragwicki, L. Zapala, M. Lipa, M. Pozniak, D. Janczak, S. Słomian, J. Łaszkiewicz, M. Nowak, M. Miszczyk, M. Roslan, M. Tkocz, R. Zdrojowy, A. Potyka, T. Szydełko, T. Drewa, P. Jarzemski, P. Radziszewski, M. Slojewski, A. Antoniewicz, A. Paradysz, P.L. Chlosta 500 Visits 60 400 300 40 200 20 detection COVID-19 Admissions 100 Number of admissions and visits Number 0 0 0 4th March 10 14th March 20 25th March 30 40