A comparison of Emergency Department presentations for Medically Unexplained Symptoms in Frequent Attenders during COVID-19

Background

Medically Unexplained Symptoms (MUS) refer to symptoms with no identified organic aetiology, and are amongst the most challenging for patients and Emergency Department (ED) staff. Providers working in our ED perceived an increase in severity and frequency of these types of presentations during the COVID-19 pandemic.

Methods

A retrospective list of frequent attenders (FA) presenting five or more times to the ED between two 122-day periods were examined: 01 Mar to 30 Jun 2019 (Control) and 2020 (COVID-19). The FA group were then examined to identify patients presenting with MUS (FA-MUS). Data were analysed in Prism; presented as n(%), % (95% confidence interval (95%CI) – Wilson/Brown method). Proportions were compared with a two-tailed Fisher’s exact test. A Baptista-Pike odds ratio was used to estimate magnitude and precision.

Results

The total number of ED attendances during the control period was n=42,785 which reduced to n=28,806 in the COVID-19 period, a decrease of 32.7%. The control FA cohort had n=44 FA-MUS patients with 149 ED visits. This increased to n=65 FA-MUS patients with 267 visits during COVID-19, p=0.44. There was a significant increase in the proportion of all ED visits that were FA-MUS: 0.3% (control) compared to 0.9% (COVID-19); OR 2.7, p<0.001. There was a significant increase in shortness of breath amongst MUS during the COVID-19 pandemic relative to the control period (p<0.01), with no significant difference in any other MUS category.

Conclusion

Whilst the total number of ED attendances reduced by almost one third during COVID-19, the actual number of all visits by frequent attenders with MUS increased and the proportion of attendances by these tripled during the same period. This presents an increasing challenge to ED clinicians who may feel underprepared to manage these patients effectively.

What is already known

• Medically Unexplained Symptoms (MUS) are those that have no identified organic aetiology - they are amongst the most challenging presentations for patients and Emergency Department (ED) staff.

• During times of stress and uncertainty, frequent attenders (FA) appear to be disproportionately affected by MUS. However, there are few data examining the impact of COVID-19 on the FA population.

What this paper adds

• There was a significant increase in the proportion of all ED visits by FAs during the first four months of the COVID-19 pandemic.

• There was a significant increase in the proportion of all ED visits by FAs with MUS during the first four months of the COVID-19 pandemic.

• The proportion of MUS presentations that were ‘shortness of breath’ was significantly higher in the COVID-19 period compared to the control period. There were no other proportional differences observed in MUS categories.