holidays deadlyThe winter holiday season is a busy time in most EDs. Colder weather, respiratory infections, and many factors contribute to this. However Christmas Day and New Year’s Day in particular are two of the deadliest days of the year. Missed medications due to travel, delayed presentations because of a desire to stay home for family gatherings, increased stress, alcohol and substance abuse, travel, and drunk driving, are just a few of the things that can contribute to morbidity and mortality in patients of all ages, and particularly in older adults. If you are working this holiday season, here is a glimpse of what you can expect.

As emergency physicians, in one sense, we never know what a day at work will bring. Anyone with any problem could walk in or roll through the ambulance bays. On the other hand, we have a good sense of what we will probably see on any given day. We can expect to see patients with abdominal pain, chest pain, back pain, headaches, dyspnea, falls, MVCs, etc. Over the holidays, we can also expect certain trends in patient presentations, as well as overall visits and mortality. In general there are more ED visits over the holiday season (late December and early January) than average. Only part of this is because most primary care physicians’ offices are closed. In an Australian study, ED visits increased by 9% over the holiday season. 39% of the ‘extra’ visits were patients who could potentially have been seen by a primary care physician had offices been open.1 We can also expect higher mortality, more cardiac deaths, heart failure visits, alcohol-related MVCs, intoxication, and psychaitric visits. So as you prepare to work your shifts over the holidays, keep the following trends in mind.

Overall Mortality

There are seasonal variations in mortality in the U.S. Mortality is lowest from June to September, and peaks during the winter months. On top of this, there are also distinct mortality spikes on Christmas and New Year’s Day, with more people dying in the ED or being pronounced dead on arrival (DOA) than would be expected, even taking into account the general holiday and seasonal swells.2 The cause of the excess holiday mortality is likely multi-factorial.

Cardiac Death

The winter season in general is associated with higher mortality and cardiac deaths, which may be related to seasonal pulmonary infections in part. However, this does not explain the discrete peaks around Christmas and New Year’s Day. Dec 25th, 26th, and Jan 1st consistently have the highest rate of cardiac deaths than any other days of the year.3 Heart failure visits also increase over the holidays.4 Many possible reasons have been suggested, but there is little compelling evidence for any one cause.4 Suggestions include:

  • Patients travelling may have forgotten their medications, or may be less adherent in taking them during the holidays.
  • Patients may have more dietary indiscretion over the holidays, with more salt or alcohol intake. This could lead to decompensation of heart failure or worse hypertension.
  • Stress during the holidays due to family relations or financial concerns could contribute to cardiac mortality.
  • ED overcrowding during the holidays could lead to delays in provision of acute care needs for certain patients, leading to higher ED decedents (although evidence for this has been inconclusive).
  • Patients may avoid coming into the ED out of a desire to stay home or with family for as long as possible.

Psychiatric Illness

The holidays can be difficult for patients who suffer from depression. They may feel their loneliness or the loss of loved ones more acutely over the holidays. Suicide rates are generally slightly lower on Christmas and New Year’s Day while homicide rates are slightly higher than average, as is the case with most national holidays.5 However, after Christmas there is typically a surge in the number of patients visiting EDs for psychatric-related illness.6 The reasons are also likely complex and multi-factorial. The increase in psychiatric patients, who can often spend many hours to days awaiting psychiatric evaluation and placement can put a strain on EDs that are already at capacity. Knowing that you can expect patients with psychiatric needs, it may be possible to streamline your systems of care in advance as much as possible, with standing labs, or expedited procedures to facilitate getting patients the care they need.

Geriatrics Pearl: Depression is common in older adults, with prevalence rates of 1-2% in community dwelling older adults, but 30-40% in nursing home residents and those with major neurocognitive impairment (dementia).7 Older patients with suicidal ideation who attempt suicide are at much higher risk of completion of the suicide. The attempt:completion ratio is 8:1 in the general population but 2:1 in older adults.

Blame it on the alcohol

Not surprisingly, there are more visits for intoxication over the holidays, particularly on New Year’s Eve and New Year’s Day. We can expect to see visits for intoxication, as well as alcohol related trauma and MVCs, alcohol related metabolic derangements, or alcohol related cardiac problems.8 Deaths due to alcohol intoxication are also higher than average during the holidays.9 “Holiday heart syndrome” is a term coined in 1978 to describe cardiac dysrhythmias (particularly atrial fibrillation) in patients without underlying cardiac disease, brought on by acute alcohol ingestion (binge drinking).10

Geriatric Pearl: Alcohol misuse is often not considered in older patients, but is common (around 15% of ED patients, and under-recognized (see my Alcohol and Older Patients post for more info). So particularly during the holidays, keep it in mind as a possible source of altered mental status and contributor to MVCs or falls.

Motor Vehicle Collisions

The percentage of MVC fatalities that are alcohol related are higher over Christmas and New Year’s.11 Looking at data from 1982-1990, New Year’s Day sees more alcohol-related traffic mortalities than any other holiday.12 In 1990, 50% of traffic fatalities were alcohol-related, compared with 62% for New Year’s Day.


Take Home Points

As we prepare for our shifts during the holiday season, we never know exactly what we will see, but we can expect to see more cardiac deaths, more heart failure, more MVCs, more psychiatric, and alcohol related visits. Most places of business, including outpatient offices, shut down during the holidays, but the bright red “Emergency” sign stays lit outside our hospitals, so that when someone becomes sick or injured, we will be there to take care of them.

Happy Holidays!


Image 1

Zheng W, Muscatello D, Chan A. Deck the halls with rows of trolleys…emergency departments are busiest over the Christmas holiday period. Med J Aust. 2007;187(11-12):630-633. [PubMed]
Phillips D, Barker G, Brewer K. Christmas and New Year as risk factors for death. Soc Sci Med. 2010;71(8):1463-1471. [PubMed]
Phillips D, Jarvinen J, Abramson I, Phillips R. Cardiac mortality is higher around Christmas and New Year’s than at any other time: the holidays as a risk factor for death. Circulation. 2004;110(25):3781-3788. [PubMed]
Reedman L, Allegra J, Cochrane D. Increases in heart failure visits after Christmas and New Year’s Day. Congest Heart Fail. 2008;14(6):307-309. [PubMed]
Bridges F. Rates of homicide and suicide on major national holidays. Psychol Rep. 2004;94(2):723-724. [PubMed]
Halpern S, Doraiswamy P, Tupler L, Holland J, Ford S, Ellinwood E. Emergency department patterns in psychiatric visits during the holiday season. Ann Emerg Med. 1994;24(5):939-943. [PubMed]
Kaplan M, Adamek M, Calderon A. Managing depressed and suicidal geriatric patients: differences among primary care physicians. Gerontologist. 1999;39(4):417-425. [PubMed]
Lloyd B, Matthews S, Livingston M, Jayasekara H, Smith K. Alcohol intoxication in the context of major public holidays, sporting and social events: a time-series analysis in Melbourne, Australia, 2000-2009. Addiction. 2013;108(4):701-709. [PubMed]
Mäkelä P, Martikainen P, Nihtilä E. Temporal variation in deaths related to alcohol intoxication and drinking. Int J Epidemiol. 2005;34(4):765-771. [PubMed]
Tonelo D, Providência R, Gonçalves L. Holiday heart syndrome revisited after 34 years. Arq Bras Cardiol. 2013;101(2):183-189. [PubMed]
Centers for. Alcohol-related traffic fatalities during Christmas and New Year holidays–United States, 1978-1984. MMWR Morb Mortal Wkly Rep. 1985;34(49):737-738. [PubMed]
From the Centers for Disease Control. Annual and New Year’s Day alcohol-related traffic fatalities–United States, 1982-1990. JAMA. 1992;267(2):214-215. [PubMed]
Christina Shenvi, MD PhD
Associate Professor
University of North Carolina
Christina Shenvi, MD PhD


Emergency Medicine and Geriatrics trained, Educator, Professional nerd, mother of 4, excited about #educationaltheory, #MedEd, #EM, #Geriatrics, #FOAMed.
Christina Shenvi, MD PhD

Latest posts by Christina Shenvi, MD PhD (see all)