key: cord-0832504-p6rtwav3 authors: Daniels, N. F.; Ridwan, R.; Barnard, E. B.; Amanullah, T. M.; Hayhurst, C. title: A comparison of Emergency Department presentations for Medically Unexplained Symptoms in Frequent Attenders during COVID-19 date: 2020-08-31 journal: nan DOI: 10.1101/2020.08.25.20181511 sha: 76f36f09bd2553b8bbf5c05fac117ca670a5b88a doc_id: 832504 cord_uid: p6rtwav3 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). 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. 1. 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. 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. 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. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 31, 2020. . https://doi.org/10.1101/2020.08.25.20181511 doi: medRxiv preprint Since the declaration of the COVID-19 pandemic, the physical and psychological sequelae associated with SARS-CoV2 are still being discovered. The pandemic's impact on mental health has been extensively discussed in the literature, with COVID-19 related health anxiety admissions described. [1] Particularly challenging ED presentations are those in which symptoms have no identified organic aetiology, referred to as Medically Unexplained Symptoms (MUS). [2] These symptoms include non-cardiac chest pain, gastrointestinal complaints, non-epileptic seizures, functional neurology, and shortness of breath. MUS is a common presentation in frequent attenders (FA). In a previously published dataset from our hospital, 45% of FA were identified as having one or more MUS. [3] The Royal College of Emergency Medicine defines FA's as those who attend an ED five times or more in a year. The impact of MUS on patients can be debilitating, with added stressors due to stigma experienced both within society and the healthcare system. [4] Despite this, there are few data reporting rates of MUS or treatment in the ED. This issue is key for two reasons: the personal burden for patients, and the disproportionate use of allocated resources by the FA group. [5, 6] Our primary aim was to compare the proportion of FA with MUS amongst all ED attendances during the first four months of the COVID-19 pandemic compared to a control period in 2019. The secondary aim was to compare the relative frequency of MUS diagnostic categories between the two periods. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 31, 2020. FA-MUS visits were categorised into common syndromes; categories with less than ten total visits were grouped into 'other' (for example, palpitation (n=9), falls (n=6), vomiting (n=5)). The only difference observed was a significant increase in the MUS diagnosis of shortness of breath during the COVID-19 period, Table 1 . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted August 31, 2020. This study has demonstrated a significant increase in FA-MUS attendances to our ED during COVID-19, a phenomenon seen in other cases of unpredictable threats. [7] This suggests that despite the risk of attending an ED in the context of a pandemic, these symptoms are debilitating enough for the patients to deem the risk necessary. Shortness of breath was the only MUS presentation that significantly increased during COVID-19, likely secondary to pandemic related anxiety. Despite the difficulties in managing MUS patients, to the best of our knowledge, there are no studies looking at how the COVID-19 pandemic has influenced this population. Generally the default management of the MUS patient is extensive investigation to rule out physical aetiology, followed by psychiatric assessment and/or discharge. [8] However, it has been reported that early diagnosis with reassurance and an explanation regarding the mechanisms of such symptoms can help. [4] Alternatively, a stepped Psychological approach may be of benefit. [9] ED providers often report uncertainty in managing patients with MUS, prompting a need for increased knowledge so that investigations to rule out other pathology are balanced with early diagnoses and appropriate interventions. Some of these patients would be better served within primary care but this depends on ease of access and primary care clinicians being confident of MUS diagnosis and management. The high prevalence of FA in the ED is likely a symptom of the general trend of unmet needs for this diverse and vulnerable group elsewhere in the healthcare system. [10] This paper adds further evidence that the needs of these individuals with MUS are not being met, and in added stressors such as the COVID-19 pandemic, their needs are further exacerbated. The data analysis was performed retrospectively and represents a single ED, thus the results are not necessarily translatable to other centres. Additionally, due to the perceived increase in MUS patients before commencing the data extraction, reviewer bias is an important consideration. This was minimised by having two reviewers (ND and RR) extract the data from both 2019 and 2020. Whilst the total number of ED attendances reduced by almost one third during COVID-19, the proportion of all visits by FA-MUS tripled during the same period. This paper highlights the significance of the MUS experience, with patients willing to risk their safety at the peak of the pandemic. This speaks volumes of the severity of the FA-MUS patient experience, and should prompt the general healthcare system to consider how to better help this patient group. The study was conceived by CH. Data acquisition was performed by ND and RR. Data analysis was performed by EB and TA. The manuscript was drafted by ND and EB. Revisions were performed by CH and EB. All authors have contributed to and agreed the final version. How health anxiety influences responses to viral outbreaks like COVID-19: What all decision-makers, health authorities, and health care professionals need to know Medically unexplained symptoms and syndromes Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design Patients' experiences of living with medically unexplained symptoms (MUS): a qualitative study Healthcare costs incurred by patients repeatedly referred to secondary medical care with medically unexplained symptoms: a cost of illness study Frequent attendances at emergency departments in England Unforeseen consequences of terrorism: medically unexplained symptoms in a time of fear Medically unexplained physical symptoms in emergency medicine Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention Are we preaching to the choir? Where should studies on frequent users of EDs be published We thank Dr Shiraz Hashmi (Aga Khan University Hospital) for his help in organizing the data and giving statistical input.