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As ER Volumes Drop, Hawaii Doctors Worry People Are Delaying Care

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Hospitals across the state have noticed sharp decreases in the number of patients visiting their emergency rooms since the COVID-19 outbreak.


“Our volumes have been at least 50% of what it has been in recent months prior to the COVID situation,” said Toni Higa, Hilo Medical Center ER nurse manager.

Hilo Medical Center is not an outlier. The decline in ER patients is a national trend also seen in other Hawaii facilities.

Doctors and nurses from Pali Momi Medical Center, the Queen's Medical Center, Kaiser Permanente, and Maui Memorial Medical Center have all noted a sudden drop in ER volume.

Fear of contracting COVID-19 

Many health professionals across the state suspect the main reason for the decline in ER visits is patients’ fear of catching the coronavirus at the hospital.

“They probably see the hospital as the kind of place where they can contract the virus,” said Dr. Michael Lui, a neurologist at Pali Momi Medical Center and the president-elect of the Hawaii chapter of the American Heart Association.

“I think the initial message was don't come into the hospitals and that really was the case when we weren't sure exactly how the virus was affecting Hawaii or the rest of the world.”

However, Lui explained that hospitals have been able to adapt and have implemented strict infection control policies that have created a safe environment for patients to visit without the fear of catching COVID-19.

“Let me put it this way, if my mother had to go into the hospital for some emergency issue, I would say, go into the hospital,” he said. “Don't wait, it's actually safer to do that now.”

One medical center that had to rapidly adjust its infection control measures is Maui Memorial Medical Center. An employee infected with COVID-19 who reported to work in March caused a cluster of at least 60 health care workers and patients. The outbreak at the facility triggered criticism from the state Department of Health and an internal review of the facility's infection control policies.

“We're just continually adjusting what we're doing, just to make sure that we are making sure that our staff and employees' safety is number one at all times,” said Maui Memorial Medical Center Infection Control Director Kelly Catiel.

“Since the cluster started, I think there's just much more awareness of what's happening and much more communication that's going on within the facility.”

Maui Memorial Medical Center’s ER has also seen a drop in volumes.

“Those general medical issue patients are still out there in the community -- the patients that aren't taking their medicine, that aren't taking very good care of themselves that come in for care are not coming in for care,” Catiel said. 

“They're out there waiting at home because they're afraid of COVID, but  . . . we're here and we need to see those patients. They need to not delay care because it's just going to harm them and perhaps harm their long-term outcome because of the delay in care.”

Delaying Care

Catiel said that Maui Memorial’s head ER doctor has seen instances of community members who did not seek out immediate care for broken bones, heart attack and strokes.

Lui said those having a stroke or heart attack especially should not postpone going into the ER because speed matters.

“The longer you wait to call 911, the longer you wait to get treatment . . . the more brain cells start to die,” Lui said of a stroke. “When that happens, it can become irreversible and patients can die. The same goes for the heart, every second counts.”

Stroke symptoms include facial drooping, difficulty speaking, slurred speech, dizziness and weakness on one side of the body.

Lui said if a stroke is treated within the first three to four hours, doctors can give the patient a medication that will break through the blood clot causing the condition. Within the first 24 hours, doctors can also perform a surgical procedure to remove the clot from a blood vessel. 

When it comes to strokes and heart attacks specifically, not all hospitals have seen declines, and most of the observations have been anecdotal, not based on data.

Higa noticed a small decrease in stroke and cardiac patients at Hilo Medical Center since the COVID-19 outbreak.

However, the Queen’s Medical Center Stroke Center director, Dr. Kazuma Nakagawa, compared the number of stroke patients at the hospital between January and April of last year to this year’s numbers. He said there's been little to no change.

“It's not fair to look at March or April compared to January and February because stroke and heart attacks are a little bit seasonal, meaning that it tends to happen more in the wintertime,” he said.

“Nobody really knows why but there are multiple possibilities like anytime we have a cold or a flu or any kind of infection, that can potentially increase the risk of stroke or heart attack.” 

Doctors are still speculating

While fear of catching COVID-19 is the most common reason why doctors think people are not going to the ER right now, they suspect other reasons may be driving the decrease as well.

Dr. Jay Ishida, a Kaiser Permanente ER physician, has been told by patients that they felt guilty going to the hospital during the coronavirus outbreak.

“People were probably worried about utilizing resources and taking a bed that somebody else needs,” he said. “I've had patients mention that they feel bad taking up a bed.”

However, he also thinks people may be using telehealth options instead of going to the ER. Over half of Kaiser’s clinic visits have been virtual ones.

Lt. Gov. Josh Green, a Big Island emergency room doctor, thinks people may have developed a better understanding of what the emergency room is designed for.

“People realized that you don't go to the hospital for a small issue when there's a global pandemic. You go when there's serious things like the heart problem,” he said. 

“Over the years, I've on numerous occasions taken care of people with sort of basic issues, runny nose, ingrown toenails, rashes that aren’t emergencies . . . they're more reserved now for the serious stuff.”

However, Ishida said while doctors can speculate, there is not yet any concrete data on which patients are not using emergency rooms and why.

“We are seeing decreases in a lot of conditions that we're seeing, but that doesn't mean they're not happening,” he said, including strokes and heart attacks.  “We're wondering what's happening to those patients. Only time will tell when we get studies and data as to what happened and the outcomes of those patients.”

That’s why Dr. Rick Bruno, the Queen’s Medical Center’s chief medical officer, said that over the next few months, his hospital will be looking very closely at which patients chose to stay home and not go to the ER.

In the meantime, health care workers urge those who think they may be having a medical emergency to call 911 and not drive themselves to the hospital or delay care.


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