Deaths due to delayed presentation to the hospital from fear of contracting COVID-19 during lockdown period: a tertiary care center experience

ABSTRACT

Background: Sudden rise in COVID-19 cases in March 2020 due to spread of pandemic led to immediate lockdown order in many states and cities across the USA. Everyone had to stay home to stop the spread of the virus. We investigated all deaths in our hospital during lockdown period and assessed how many presented and died from non-COVID-19-related illness. Among those deaths, we assessed how many presented late due to excessive fear of catching coronavirus in the hospital and succumbed to the same illness due to very late presentation.

Methods: We retrospectively reviewed charts of every patient who expired in the hospital in a 45-day period, March–April 2020.

Results: Three of 107 (2.8%) deaths during lockdown period in this hospital were clearly attributable to delayed presentation arising specifically from fear of coming to the hospital. All three died from non-COVID-19-related illnesses.

Conclusions: Authors hereby propose enhanced efforts in the direction to alleviate unnecessary fear among public even during lockdown. People should be encouraged to continue to access health care for serious/fatal medical conditions regardless of the pandemic.

KEYWORDS:

• COVID-19
• lockdown
• non-COVID mortality
• stay-home

1. Introduction

During the pandemic of COVID-19, many states of the USA including Illinois issued stay-at-home order for public, to limit the transmission of the virus. The message from health-care officials was to practice ‘social distancing,’ and avoid close human contact. Everyone including patients with mild symptoms of COVID-19 were encouraged to self-quarantine at home until recovery. As an unintended consequence, patients with non-COVID illnesses, such as stroke or myocardial infarction, presented late to the health-care facilities due to fear of contracting COVID-19 [1]. This added significantly higher morbidity which otherwise in pre-COVID era would have been preventable. In this study, we aim to look at the impact of stay-at-home order on the occurrence of excess deaths due to non-COVID-19 illnesses, specifically resulting from delay in seeking care due to excessive fear of contracting coronavirus inside the hospital, at our tertiary care center in Peoria, Illinois.

2. Methods

We studied retrospectively all adult patients >18 years who died at the OSF SFMC hospital in Peoria, Illinois, between 15 March and 30 April 2020. The study was approved by UICOMP institutional board review (1606397-1). Requirement of consent was waived by the IRB as the study only involved reviewing charts of already deceased patients. Physician investigators reviewed electronic medical record (EMR) of each deceased patient. The variables obtained were cause of death, comorbidities, microbiology, radiology, pathology, COVID-19 test, and autopsy results. Patients who died from COVID-19-related causes were excluded. EMR notes were assessed for clear documentation of patients or families’ reluctance in coming to the hospital due to fear of catching the virus and whether that led to delayed treatment and death due to that delay. Another independent investigator reviewed to confirm or refute the original conclusion on any chart that met the criteria. If doubt existed after the second opinion, those charts were not counted positive. However, inadequate documentation regarding fear and inadequate documentation regarding delay in seeking care could result in underestimation.

3. Results

A total of 107 deceased patients were identified who met the inclusion criteria. The minimum and maximum age was 24 years and 93 years, respectively. The mean age was 69.56 years. Among the patients, 44.9% were females and 55.1% were males. Fifty-two percent (56/107) died within 24 h of arrival to ED and 86% (92/107) died within 7 days of admission to the hospital. Mean number of chronic illnesses were 4.64, and 77% patients had three or more chronic illnesses. Most common causes of death in this group were septic shock, respiratory failure, and cardiac arrest. Three cases, 2.8% (3/107) of non-COVID deaths, were identified where clear documentation of delay in seeking care was present. Characteristics of these three patients are described in Table 1. Cases where recorded entry in EMR was not documented distinctly or delay in seeking care documentation were ambiguous– those cases were not counted as positive.

Table 1. Characteristics of three patients who delayed presenting to a health-care facility due to fear of contractingCOVID-19 in the hospital

	Age/Sex (M/F)	Number of comorbidities	Etiology of death based on microbiology, pathology, and radiological findings	COVID testing results (P/N)	Time of onset of symptoms prior to arrival	Was death preventable if presented early
1	37/F	2	Cardiac arrest due to septic shock and polymicrobial bacteremia	Negative	14 days	Yes
2	56/F	7	Cardiac and respiratory arrest due to late presentation of aspiration pneumonia	Negative	9 days	Yes
3	86/F	4	Cardiac arrest due to late presentation of ST-elevation MI	Not done	2 days	Yes

These deaths were preventable if they presented earlier and timely intervention was instituted at the OSF SFMC hospital, Peoria, Illinois.

4. Discussion

High-impact pandemic such as COVID-19 has instilled fear in the public, which is amplified by images on media displaying cramped hospitals and helpless physicians [1,2]. Such panic results in behavior of extreme avoidance of risk. This behavior has costed more lives from preventable conditions in addition to actual coronavirus deaths[3].

Our data provide objective evidence of panic our communities were dealing with. Analysis of mortality data in 45 days, in the largest hospital in a midsize town in Illinois, with a population of approximately hundred thousand, revealed 2.8% of the deaths were clearly related to delay in presentation. Fifty-two percent died within 24 h of arrival as compared to national average of 24% in pre-COVID era, suggesting delay in presentation is rampant [4]. Authors hereby suggest a twofold message to the public – ‘Stay home to save lives but if you need medical care you should seek assistance immediately.’ ‘Hospitals are continuing to provide excellent care while instituting strong precautionary measures to avoid the spread of COVID-19 within the facility.’ Public should be made aware, by health-care officials and news media, of mitigation efforts implemented by hospitals such as isolating COVID units and excellent hygiene techniques.

Limitations of our study is that it is retrospective, single center and lacks control. Another limitation could be inadequate documentation. History gathering and chart documentation are operator-dependent activities where incomplete documentation could lead to underestimation of total deaths due to fear of corona. To note, delay in seeking care could have also resulted from lockdown order itself, inhibiting the public activity. However, this was not assessed in our study. To our knowledge, this study is the first to report an objective increase in non-COVID mortality in COVID lockdown era.

5. Conclusions

Lockdown is an excellent measure to reduce new COVID infections and deaths. Upon chart review, we found 3 of 107 deaths during lockdown period. These patients intentionally delayed care due to fear of getting COVID-19 and died due to late presentation. Our study thus emphasizes the unintentional and unfavorable consequence of the lockdown message.

Author contribution

Concept and design: SB and MR

Acquisition, analysis, or interpretation of data: All authors

Drafting of the manuscript: All authors

Critical revision of the manuscript for important intellectual content: All authors

Administrative, technical, or material support: SB

Supervision: SB

Compliance with ethical standards

The study was retrospective cross-sectional data analysis from deceased patients. IRB approval obtained from UICOMP Peoria IRB under IRBNET ID: 1606397-1

Disclosure statement

No potential conflict of interest was reported by the author(s).