key: cord-0767779-j9p6zd86 authors: Rusconi, Franca; Di Fabrizio, Valeria; Puglia, Monia; Sica, Michela; De Santis, Rita; Masi, Stefano; Gagliardi, Luigi title: Delayed presentation of children to the emergency department during the first wave of COVID‐19 pandemic in Italy: Area‐based cohort study date: 2021-07-08 journal: Acta Paediatr DOI: 10.1111/apa.16019 sha: ddfb84d4c18275f66e438dcd2e3abb05f078134f doc_id: 767779 cord_uid: j9p6zd86 AIM: To ascertain a delay in attendances to the emergency department (ED) during 2020 lockdown. METHODS: Area‐based cohort study on paediatric (0‐15 years) attendances resulting in hospital admission in Tuscany, Italy, in February‐May 2020, and the corresponding periods in 2018‐19. We analysed times from symptom onset to arrival, the odds of arriving late (>90th centile of time) and paediatricians’ judgements of a late presentation by logistic models. RESULTS: As expected, ED attendance fell sharply (−62%) in 2020 vs 2018‐19. As for cases studied (455 in 2020 and 1161 in 2018–19), we documented a delay in arrival to the ED in 2020 versus 2018–19 for several groups of diagnoses, namely gastroenteritis, sepsis, wounds, burns and infections overall. Time to presentation over 90th centile was also higher in 2020 (odds ratio, OR: 1.44; 95% confidence interval: 1.00, 2.06), as were paediatricians’ judgements of a late arrival (18.9% of cases in 2020 vs. 13.4% in 2018‐19; OR: 1.58; 1.14, 2.19) CONCLUSION: In a population‐based cohort, delayed attendances to ED ascertained both subjectively and objectively convey the message to families and to paediatricians to seek hospital care in case of severe or unremitting symptoms and not to wait longer than they normally would. of reluctance to visit the hospital for fear of contracting SARS-CoV-2. [5] [6] [7] The issue of possible delayed presentations to the ED has been addressed also more systematically. In a survey performed at the end of April 2020 in United Kingdom and Ireland, 8 paediatricians witnessed delayed presentation (from 14% to 47% of all presentations in different regions) during the two previous weeks. On the contrary, a two-week prospective survey in seven hospitals in United Kingdom and Ireland 9 found that parents reported a delay in ED attendance, that is waiting longer than they normally would, or were concerned about going to the ED only in 3.8% of cases. Both surveys 8, 9 were based on the opinion of individual paediatricians and/or parents, and there were no baseline data for comparison. With regard to surgical diseases, data on appendiceal complications as a proxy of delay in attendance to hospital for abdominal pain have been analysed in several countries during the pandemic in comparison with previous years [10] [11] [12] [13] [14] [15] . Delayed presentation to ED as a 'secondary' effect of the pandemic could notably be different in different countries due to a combination of public health organisation and family environment, and also needs to be confirmed in more structured surveys. We therefore aimed to ascertain in a systematic way whether the reduction of the number of attendances to all ED settings that care for children in Tuscany, a region of Central Italy, during the first phase of the pandemic was accompanied by a delay in presentation for selected diseases. The possible delay was studied assessing physicians' judgement but also evaluating time elapsed from the first symptoms to the presentation to the ED during a 3 and half month's period of 2020-during national lockdown-compared to the same period in the years 2018-19. We did a population-based analysis on all paediatric (0-15 years old) ED presentations in the Tuscany region in the period 1 January-31 December 2020, and in 2018-2019. We then examined paediatric attendances in the period of the first wave of SARS-CoV-2 pandemic (17 February-31 May 2020) in ED with >5000 paediatric attendances/ year, open 24/7 and with full-time coverage by a paediatrician. As we aimed at studying a possible late attendance of more severe cases only, we restricted the study to ED presentations with the highest priority codes at triage (scores 1 to 3 of a 5-level modified Emergency Severity Index), 16 who were subsequently admitted to the paediatric ward or to a short-term observation ward for at least 24 hours. Among the discharge diagnoses classified according to the International Classification of Diseases, 9th revision coding systems (ICD-9), we excluded diagnoses with a very low prevalence (<4 inthe studied period), those with symptoms not additionally classified as diseases (e. g. fever, vomiting), fractures (very unlikely to arrive late at the hospital) and diseases possibly related to SARS-CoV-2 (e.g. pneumonia and bronchitis), though we included bronchiolitis and acute respiratory failure. We studied ED attendances with the same characteristics in the corresponding period of years 2018 and 2019: two cases belonging to the same group of ICD-9 discharge codes selected for 2020. ED admissions data are derived from administrative data of the Regional Health Service (RFC106). For each ED attendance, the data were made available on a web form to a paediatrician of the hospital that had the patient in charge, who accessed the forms by means of personal ID and password. Physicians checked the data of each patient provided on the web form, which included the patient's age and sex, date and time of visit, ICD-9 diagnosis. In addition, the paediatrician reported on the web form the following data taken from the hospital case reporting system: time elapsed from symptom onset to presentation to the hospital (expressed in hours up to the first 24, expressed in days up to 15 days and censored at > 15 days) and judgement on the presence of a delayed presentation to the ED (yes, no, not sure). Two meetings were held with the participating paediatricians to explain the study. Before analyses, the data were reviewed by two paediatricians (LG, FR) and the paediatricians of each hospital and discordances on time to arrival were resolved by consensus. After collecting the data, we grouped the diagnoses in 18 mutually exclusive, clinically meaningful groups that also differed for expected times to arrival to the ED (Table S1 ). To quantify a possible delay in presentation to the hospital, we used 3 variables: 1. Time to presentation to ED, in hours/days as recorded in the hospital reporting system and described above. Given the highly positive skewed distribution of times to presentation, we compared them between years by using Wilcoxon or log-rank tests. 2. For each diagnostic group, time to presentation was recoded to create a variable identifying cases whose time was above the 90 th • This population-based study reported a simultaneous reduction of emergency department attendance and a delayed presentation during the first wave of the pandemic. • The delay was demonstrated both based on paediatricians' judgements and on time elapsed from symptoms to presentation, in comparison with the previous 2 years. • We found a delay for sepsis, gastroenteritis, wounds and burns and, when considered together, additional infections including mastoiditis, cellulitis, urinary tract infections and bronchiolitis. centile for each diagnostic group, taking the value of yes (>90th centile) or no. We performed a multivariable analysis using logistic models, estimating odds of outcome adjusted for the following covariates: hospitals and diagnostic groups. The choice of covariates was done based on the observation that median time of arrival was substantially different in different diagnostic groups and on the knowledge of the distribution of hospitals in the Tuscany Region, with a few hospitals covering larger areas than others. Thus, a later arrival is presented as a higher odds, and the corresponding contrast between years-2020 vs 2018-2019-yields a higher odds ratio (OR) in case of later arrival in 2020. 3. The paediatricians' judgement of late arrival: a binary variable where answers 'no' and 'not sure' were grouped together and analysed with a logistic model to estimate OR. As data were collected within hospitals, observations are not independent. To take into account this structure of data in multivariable analysis, we carried out conditional logistic models (for time >90th centile and paediatriciansa judgements of late arrivals). To estimate the degree of clustering on hospitals, we used randomeffects logistic models. Owing to correlated errors, robust standard errors estimation was always used. 17 Finally, we looked at possible deleterious delays in appendicitis arrivals by analysing the rate of appendiceal perforation over all appendicitis who underwent a surgical procedure, based only on hospital discharge records of the same hospitals from 17 February to 31 May 2020 and corresponding periods of 2018-2019. All statistical analysis was carried out with Stata version 15 (Stata Corp, College Station, USA). All the data, including those on the web forms, were provided by the Regional Health Agency of Tuscany, which is a branch of the Regional Health Service, and were de-identified. No ethical permission was therefore required according to Regional law. We found substantial decreases in paediatric ED patient vol- This area-based cohort study in Tuscany confirmed that during the first wave of the pandemic, the number of ED presentations fell briskly. It also confirmed that children were brought to the hospital 25th centile 50th centile 75th centile 90th centile 2020 431 2 12 48 96 2018-19 1082 2 10 24 72 Note: p = 0.34, Two-sample Wilcoxon rank-sum test. *Time from symptom onset to presentation. our findings on infections is that during the pandemic, as in-person visits by general paediatric practitioners were reduced, common antibiotics for upper respiratory infections were used more freely, for example in case of fever. This might have resulted in infections not cured either because sustained by bacteria possibly not responsive to antibiotics commonly used for respiratory infections (i.e. amoxicillin in case of urinary tract infections or sepsis) or because of viral pathogenesis (i.e. gastroenteritis and bronchiolitis). We did not observe a delayed presentation in cases of diabetes, which was instead reported in a paper on five large hospitals in Italy 5 and in a survey done in the United Kingdom and Ireland. 8 However, in both studies paediatricians had witnessed a delay in presentation to the ED, with no objective measurements and, above all, no comparison with previous years. Surgical emergencies (appendicitis, testicular or other abdominal organ torsion) also did not arrive substantially later during the pandemic, though time from symptom onset to presentation to the emergency department was longer in 2020 versus previous years. An additional analysis restricted to cases of appendicitis who underwent surgery showed a tendency to a larger percentage of appendiceal perforation in 2020 incomparison with the two previous years. Our results confirmed previous ones obtained in most [10] [11] [12] [13] [14] but not all 15 countries in Europe, Israel, USA and China of an increase, sometimes a borderline/not significant one, in complications rates for appendicitis during pandemic which has been attributed to late presentations. Our data, that point to a possible increased reluctance of parents in seeking hospital care during the COVID-19 outbreak, are consistent with those reported in a few studies in adults. Admissions for acute myocardial infarction were substantially reduced in Italy in 2020 vs 2019, and for patients admitted, a delay was documented for time from symptom onset to coronary angiography and for time from first medical contact to coronary revascularisation. 18 These findings have been confirmed in other countries. 19 The strength of our study lies in the area-based ascertainment of cases from a whole Italian Region (Tuscany), in the comparison with earlier years, and in the evaluation of a possible delay based not only on physicians' judgement but also on time elapsed from first symptoms to presentation. We focussed on ED attendances presenting with higher acuity (as evidenced by a triage code in the 3 most acute categories on a 5-point scale) yielding a hospital admission of at least 24 h. We a priori selected a number of conditions that could have presented a delay in ED presentation, excluding rare conditions that could not be adequately compared across years, fractures (that we deemed improbable that were not taken to hospital on time) and presentations without a definite diagnosis (e.g. fever and vomiting). As a limitation, we cannot demonstrate how much the reported delays were associated with harm to children, though delayed presentations for medical and surgical conditions which require fast assessment and treatment like sepsis or acute respiratory failure or testicular torsion were probably accompanied by a more severe and prolonged course of the disease. On the other hand, a retrospective national cohort study in Scotland suggested that a reduction in paediatric emergency care utilisation was not associated with evidence of severe harm. 20 In conclusion, our study demonstrates a delayed hospital care seeking for several paediatric conditions during the COVID-19 pandemic in a population-based retrospective survey. Based on these findings, the message to both families and paediatricians is to seek hospital care in case of severe or unremitting symptoms and not to wait longer than they normally would. 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