Changes in emergency service access after spread of COVID-19 across Italy.

Editor,

The Italian National Health System is currently living through some catastrophic days, owing to the rapid spread of COVID‐19 across the country. At the time of writing, our Government has passed emergency laws (11 March 2020), with a view to preventing widespread viral infection among the population, which may well lead to an increase in the number of people requiring intensive care unit (ICU) hospital treatment. Currently, most of the northern Italian regions are close to saturation point in terms of the number of available ICU inpatient beds. Albeit dermatologic ‘true’ emergencies are a small number, many patients access our emergency services (ES) for routine diseases in order to avoid having to wait any length of time for a scheduled dermatological examination. The aim of our study is to analyse any possible changes in access to our ES by examining two different weeks before and after COVID‐19 emergency in Italy.

The first week in the pre‐COVID‐19 era was randomly selected, while the second was chosen during the actual COVID‐19 emergency. We analysed a 6‐day workload because our Unit does not operate an ES on Sundays. Diseases such as burns, drug eruption, acute urticaria–angio‐oedema and skin rash (including psoriasis and bullous autoimmune dermatitis) involving more than 10% of the body surface area, along with acute infection (bacterial or viral) were identified as real emergencies. The remaining pathologies were considered to be unjustified consultations. The week between 21 October 2019 and 26 October 2019 was identified as the pre‐COVID‐19 (no closure of the outpatients' surgeries available in our Unit for holidays or meetings). The days between 12 March 2020 and 18 March 2020 characterized the weekly activity of our emergency service during the COVID‐19 era (days in the run‐up to the Government decree‐law). In the pre‐COVID‐19 era, 106 patients accessed our emergency outpatients' room, whereas just 20 cases were examined after the emergency decree‐law. The number of unjustified accesses was 60 in pre‐COVID era, and 46 patients showed ‘true’ emergencies. Acute bacterial/viral infections on a par with diffuse skin rashes (19 cases each) were the most common problems, while eight patients accessed the ES for burns. After 11 March 2020, 19 patients referred to the ES. Five patients turned up for an unjustified consultation, while 14 showed a ‘true’ problem (four diffuse rashes, seven acute infections and three burns). See Table 1 for all the patient details.

Table 1

Principal characteristics of our patients

	Total number of access	Justified access	Non‐justified access	Median age (years)	Male	Female
Pre‐COVID	106	46	60	61	56	50
COVID	19	14	5	44	6	13

The misuse of the emergency consultation facility is a bad habit and it has been estimated that at least half of the patients do not have a ‘true’ emergency (range 49–82%), , , , , , which is confirmed by our study (60 vs. five unjustified accesses, before/after the COVID‐19 pandemic). However, emergencies still exist, even in the presence of a potentially life‐threatening virus. Patients suffering from acute myocardial infarction will refer to the ES even in the COVID‐19 era, and the same will occur in the case of dermatological emergencies. Drago et al. appropriately defined a ‘true emergency’ in dermatology as a severe dermatosis that requires immediate medical attention and an observation period lasting at least 24 h. A possible bias in our research may be due to the panic related to the COVID‐19 disease, which can explain the drop in the number of consultations (106 vs. 19, for an 81% reduction). Our data clearly show a decrease in unjustified referrals (60 vs. four, for a 93% reduction, P‐value for Fisher's exact test 0.0032) highlighting the misuse of the ES at our Unit. To conclude, a solution for select patient access to ES could be to: (i) implement the number of scheduled examinations by recruiting more dermatologists; (ii) have more outpatients accessing during the daytime, especially in afternoon (an infrequent event in Italy); and (iii) train general practitioners to recognize and diagnose the most commonly occurring dermatosis.

Funding sources: none.