The outbreak of pneumonia, which began in Wuhan, China and the cause of which was initially unknown, has been ongoing since December 2019. The novel severe acute respiratory coronavirus-2 disease, identified by the WHO as COVID-19, is caused by a new coronavirus, officially named as SARS-CoV-2. Although many people have had mild coronavirus infection, the outbreak of two betacoronaviruses, namely the severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV) have caused thousands of cases in the past twenty years, with 10% mortality rate for SARS-CoV and 37% for MERS-CoV.^1,2

The disease caused by the novel coronavirus, subsequently named SARS-CoV-2, that first appeared China in late 2019 and did not previously infect humans was named COVID-19.³ It was confirmed that SARS-CoV-2 transmits from human to human.⁴

This disease, which first appeared in Wuhan city, Hubei Province, China, spread to the vast majority of the world within months, and was declared a pandemic by the World Health Organization on March 12^th, 2020.⁵

The first case of COVID-19 in Turkey was on 10/03/2020.⁶ COVID-19 cases spread throughout Turkey in a short time. As of 04/08/2020, Sakarya province is ranked 5^th in the number of cases, following Istanbul, Izmir, Ankara, and Kocaeli in Turkey.

Emergency department admissions account for the vast majority of hospital admissions in Turkey. When we look at the data on hospital admissions of the Ministry of Health of the Republic of Turkey, it is seen that the most patient examinations are performed in the emergency services department (25.97%).⁷

Sakarya University Training and Research Hospital adult emergency department has a Green Room where non-emergency patients are examined, a Trauma Room where trauma emergencies are examined, and a Yellow Room where non-trauma emergency patients are examined. Pediatric age group traumas are also admitted to the adult emergency department trauma room. Between 20/03/2020 and 01/06/2020, Sakarya University Training and Research Hospital was declared as a pandemic hospital. After this date, the hospital began to accept only COVID-19 patients and those suspected of the disease. As of this date, elective surgery operations were stopped, outpatient clinics were closed, patients in the services were discharged or referred, and intensive care was organized to serve COVID-19 patients. The adult emergency department started to serve only the patients who had been diagnosed with COVID-19 or were COVID-19 suspects. Patients with stable condition and the patients who were not suspected of COVID-19 were referred to other hospitals. This study aims to reveal how government measures taken in the COVID-19 pandemic affected admissions to the emergency department and the impact of establishing a pandemic hospital in the management of the epidemic.

This study was carried out in accordance with the permit dated 10/04/2020 and numbered 24404279-420.01 of the Chief Physician of Sakarya University Training and Research Hospital. Patients admitted to Sakarya University Training and Research Hospital adult emergency department between the dates 20/03/2018-03/04/2018, 20/03/2019-03/04/2019 and 20/03/2020-03/04/2020 were included in the study. Sakarya University Training and Research Hospital serves as a tertiary health care provider, all major branches are available. It serves a population of about 1 million people and accepts patients with referrals from other hospitals in the province. From the date of the first patients diagnosed with COVID-19 in Sakarya province, 15-day emergency admissions were investigated, and these data were compared with patient data for the same period in 2018 and 2019. Patients' admission areas according to emergency department triage were also analyzed as part of our study.

The triage was carried out as follows (Ministry of Health, 2013):

·Category 1 (red): Patients in this category are taken to the resuscitation room for an immediate intervention.

·Category 2 (yellow): Patients in this category are taken to the emergency examination room and intervened within one hour at the latest.

·Category 3 (green): Patients in this category are taken to the emergency examination room and intervened within two hours at the latest.

·Category 4 (black): This category is for the patients who have died. A death card is filled for the patients with this condition, and attached to the patient's big toe and the body is sent to the morgue by on-duty staff.

Data of the patients admitted to adult emergency department between these dates were retrospectively investigated. The data obtained were analyzed using SPSS 21 statistical software package (IMB Corp., USA). The Chi-square test was used to evaluate the independent variables, and the results with p<0.05 were considered significant. Patients under the age of 18 and patients admitted to outpatient clinics were not included in the study.

A total of 36,341 patients, of which 15,048 between 20/03/2018 and 03/04/2018, 15,048 between 20/03/2019 and 03/04/2019, and 6,245 between 20/03/2020-03/04/2020, were admitted to the Sakarya University Training and Research Hospital adult emergency department. Of the patients, 16,588 were female and 19,753 were male. The average age of the patients was 39.49 years and the mean value was 37 years. Looking at the gender distributions of patients by year, a statistically significant difference was found in both total and male-female genders compared to 2018 and 2019. Of all patients, 15,048 (41.4%) admitted in 2018, 15048 (41.4%) in 2019, while this number was limited to 6245 (17.2%) in the same period in 2020. In addition to a significant decrease in the total number of admissions, there is a further decrease in the admission of female patients. Distribution rates and numbers of patients by gender are shown in Table 1.

During this period, 19,270 patients were admitted to the Green Room, 8,312 patients to the trauma room, and 8,759 patients to the Yellow Room. A statistically significant difference was found in the distribution of the departments in which patients were admitted by year. In 2020, admissions to the trauma room decreased to 8,312 people (13%) compared to previous years. However, in 2020, although the number of patients examined in the Yellow Room has decreased, it is seen that their ratio has increased to 33.4%. Distribution of patients by examination rooms and years is presented in Table 2.

There was a statistically significant difference in the distribution of patients over the years according to age groups (p<0.05). There was a big decline in patient admissions especially in the 0-18 age group in 2020. After that, admissions of patients over the age of 65 also decreased to 17.9% (Table 3).

Table 4 shows the distribution of the nationalities of patients admitted to the adult emergency department by year. Apart from the Turkish nationals, the most admissions were made by the citizens of Iraq, Syria and Afghanistan, respectively. A statistically significant difference was observed in adult emergency department admissions of foreign nationals by year in 2020. While there was a decrease in admissions of all foreign nationals, the biggest decrease compared to 2019 is observed in Iranian and Iraqi citizens. In 2020, the most admitted foreign nationals were Syrians.

A statistically significant difference was found in the distribution of emergency department admission hours by year. Especially between 17:00 and 24:00, the decline in admissions was noticeable.

Sakarya University Training and Research Hospital emergency department is the department with the highest number of patients compared to other branches. There are limited numbers of studies in the literature on the impact of COVID-19 disease on the number of admissions to emergency departments. As of 20/03/2020, Sakarya University Training and Research Hospital has been declared as a pandemic hospital. It was planned to serve only COVID-19 patients. From this date, trauma patients arriving by ambulance were directed to other hospitals, and stable outpatients were referred to other hospitals. Those patients who were not diagnosed with COVID-19 or not suspected of the disease started to be distributed to other hospitals. Therefore, the number of patients admitted to the emergency department decreased significantly between 20/03/2020 and 03/04/2020 compared to the same period in 2018 and 2019. There is a noticeable decrease especially in female patients and foreign nationals. The lockdown measure for people over the age of 65 as of 21/03/2020 can be considered to have an effect on the decrease in the number of admissions of this age group. However, looking at the age group distribution of the admitted patients, the rates of 11.5%, 14.5%, 14.3%, in the last three years respectively, shows that the proportion of patients over the age of 65 was maintained.

Sakarya University Training and Research Hospital adult emergency department serves trauma patients in the pediatric age group. It can be stated that the admission rates under the age 18 decreased to 5.8%, which were 11.3% and 11.5% in the same period in 2018-2019, due to the effect of measures such as closing schools for break, and closing public parks and gardens as of March 16^th, 2020, closing bars, discos, etc. where alcohol is consumed as of March 15^th, 2020, and referring trauma patients arriving by ambulance to other hospitals.

There was a significant decrease in the number of foreign nationals admitted to the adult emergency department of Sakarya University Training and Research Hospital. Measures such as closing the land border between Turkey and Iran on February 23^rd, 2020, and stopping all Iranian flights on February 26^th, 2020, stopping Iraqi flights on February 29^th, 2020, closing the Iraqi land border on March 1^st, 2020, and canceling all foreign flights as of March 28^th, 2020 can be said to have had an effect on this decrease. Among the foreign nationals who make the most emergency admissions, Syrians rank first, although the number of admissions has decreased, maybe due to their presence as a resident in Turkey under temporary protection, rather than tourism.

When we look at the admission rates to emergency outpatient clinics of patients, it is observed that the admission rates to the Green Room were similar compared to previous years. The Green room is an area for simple symptoms of non-emergency outpatients. Although the number of admissions to this room has decreased due to the fact that patients admitted with suspected COVID-19 mostly have simple symptoms, such as cough, fever, fatigue, it is observed that the admission rate was maintained in the last three years by 53.4%, 52.7%, and 53.0%, respectively. In the Yellow Room, which is for the patients admitted with more severe complaints, the overall number of admissions has decreased, but their proportion in total admissions has increased in years, by 22.2%, 22.8%, and 31.9%. It is understood that this increase may be relatively high as a result of a decrease in both the number and proportion of admissions to the trauma room.

COVID-19 has required some hospitals to be reorganized to reduce the risk of transmission to other patients and to increase the ability to fight against this disease. In hospitals that serve COVID-19 patients, there may be a decrease in patient admissions to emergency departments compared to previous years. Measures taken to combat COVID-19, such as closing the borders, isolation measures, travel bans, the closure of some commercial entities, can lead to a decrease in the number and rates of emergency department admissions in countries with busy emergency services, as in Turkey.

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