key: cord-0827538-9sxhmx09 authors: Chaiyachati, Barbara H.; Agawu, Atu; Zorc, Joseph J.; Balamuth, Fran title: Trends in Pediatric Emergency Department Utilization after Institution of COVID-19 Mandatory Social Distancing date: 2020-07-20 journal: J Pediatr DOI: 10.1016/j.jpeds.2020.07.048 sha: faaa3d5f8c19ca447498eaa8c80228e0163a2503 doc_id: 827538 cord_uid: 9sxhmx09 nan We conducted a descriptive cross-sectional study of pediatric emergency healthcare utilization during the onset of SARS-CoV-2 pandemic after a state-wide stay-at-home order. Our study demonstrated decreased volume, increased acuity, and generally consistent chief complaints compared with the prior 3 years (2017 through 2019). Ingestions became a significantly more common chief complaint in 2020. In an effort to contain the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there have been widespread changes in daily activities and healthcare delivery to decrease viral spread. 1, 2 In addition to the intended impacts on healthcare utilization, changes in daily activities could also lead to changes in emergency healthcare utilization for complaints unrelated to SARS-CoV-2 syndromic illness . Early data have shown changes in emergency care utilization including decreased frequency of visits and disease specific changes. [3] [4] [5] [6] [7] Changing patterns of healthcare utilization could be driven by a decreased need for emergency medical care, decreased utilization of emergency medical care despite need, or shifted use within the medical system to alternative sources of urgent medical care such as telemedicine. For example, decreased travel and mobility may lead to fewer related injuries and decreased need for emergency medical care related to motor vehicle accidents. 3 Related data from California show decreased motor-vehicle crashes and injuries during the COVID-19 shelter-in-place period compared with data from the previous year. 8 There have been multiple reports of decreased care for acute myocardial infarction (MI) in adults with concern that delayed or missed presentation may result in long-term morbidity. 4, 6 Data from pediatric providers have demonstrated that approximately 1 in 3 presentations for emergency medical care was perceived to be delayed. 9 Finally, telemedicine care has been brought to the forefront during the global pandemic response. 10 Children have a lower likelihood of direct infection with SARS-CoV-2, and thus less need for related emergency medical care, compared with adults. 11 Changes in other healthcare interactions, including routine pediatric care has been as demonstrated by decreased immunization rates per the U.S. Centers for Disease Control (CDC). 12 Analysis from Chinese outpatient pediatric care also revealed decreased overall outpatient healthcare with notable declines in multiple infectious complaints. 13 Alternatively, social isolation measures may expose children to different risks. For example, available data have shown a large increase in national calls to poison control centers, including a persistent percentage of child exposures, and a threefold increase in dog bites at one large pediatric hospital. 14, 15 Understanding patient or caregiver stated concerns at the point of emergency medical care access can be a useful reflection of community sense of health emergencies beyond provider determined diagnoses. Data support discordance between chief complaint and diagnosis codes. 16, 17 Additionally, triaged acuity at presentation to ED can give insight to use of emergency medical care for high versus low-acuity issues. In pre-pandemic times, a substantial volume of pediatric ED utilization was related to low-acuity needs. 18 Drivers of low-acuity ED utilization include perceived and real barriers in access to other sources of medical care, parental health literacy, and perceptions in quality of care differences. [18] [19] [20] [21] Overall shifts in acuity trends at presentation may give additional insight to community sense of health emergencies -as well as outline areas of focus for assessment of delayed emergent medical care that may result in morbidity and mortality. We sought to characterize the early impact of social distancing measures by describing the volume, acuity and distribution of presenting complaints in a high-volume urban, tertiary pediatric emergency department. A descriptive, cross-sectional study of emergency department (ED) visits to a tertiary urban children's hospital comparing 2020 to the same date range during three prior years (2017 through 2019). Visits were excluded if patients left without being seen, were transferred to another institution, left against medical advice, or were older than 21 years (n=446). We included data per visit and did not restrict to unique patients served during the study period. We abstracted data from the institution's electronic medical record (EMR) including demographic variables, chief complaint, triage acuity at presentation, and disposition from ED. Demographic variables included age, sex, race, ethnicity, and insurance carrier. Insurance carrier was classified as private or public including Medicaid or local state providers. Chief complaint and acuity are recorded during triage by a standardized process. Chief complaint is categorized according to an institutional standard. 22 Acuity is determined per Emergency Service Index (ESI) triage levels on scale of 1 (critical) to 5 (non-urgent) based upon anticipated resource use and patient factors such as medical history, age and vital signs. 23 We reviewed the complete list of chief complaints (n=231) in the dataset. We collapsed rare presenting chief complaints into clinically synonymous common categories by author consensus, for example, combining ingestions and poisonings (Table 1 ; available at www.jpeds.com). We included the top 20 complaints for each time period which resulted in 21 total complaints. We assessed visit count by week during the first 16 weeks of the calendar year during four consecutive years (2017 through 2020) to evaluate the impact of social distancing and official stay-at-home orders on ED volume. We then reviewed additional elements of visits within 30 days after a statewide stay-at-home order was issued (3/23/2020 through 4/21/2020) compared with the same date range during the three prior years (2017 through 2019). We described demographic characteristics associated with emergency department visits. We assessed acuity at presentation overall between the two time periods as well as by chief complaint. We described disposition from the emergency department as admission or discharge. Admission to the intensive care unit was defined as admission from the emergency department directly to any intensive care unit including general, neonatal, and cardiac. We compared data from 2017 through 2019 with that from 2020 using standard parametric and non-parametric descriptive tests. We set level for statistical significance at 0.0016 per Bonferroni correction for family-wise error. This study was determined to not represent human subjects research by the institutional review board at Children's Hospital of Philadelphia. We observed similar weekly numbers of ED visits for all 4 years through week 10 of 2020, when there was a rapid decrease in ED visits concurrent with local documentation of SARS-CoV-2 ( Figure; available at www.jpeds.com). In the 30-day window following the stay at home order in 2020 and the same time period in 2017 through 2019, there were 29,496 ED visits ( Table 2 ). Of these, 2,948 were in 2020, and 26,548 were in 2017 through 2019). The mean (±SD) number of daily visits was lower in 2020 (95 ± 16 v 286 ± 42, P < .001). The distribution of patient race was significantly different (p<0.001), including a smaller proportion of African American patients (53.9% vs 58.7%) in 2020 compared with the baseline study period (Table II) . The distribution of insurance categories also changed (p<0.001) with a decrease in public insurance (52.3% vs 56.4%). The proportion of patients categorized as high acuity (Emergency Service Index, ESI triage level 1, 2, or 3) 23 was higher in 2020 (59.4% vs 49.6%, p<0.001). Similarly, the proportions of patients admitted both overall (22.4% vs 18.5%, p<0.001), and to the ICU (2.8% vs 1.7%, p<0.001; Table 2 ) were higher in 2020. By chief complaint, trauma, fever, and abdominal pain had higher proportions of high acuity presentations in 2020 ( Table 3) . The most common chief complaints were similar in 2020 compared with the baseline period and the top 20 complaints included over 80% of visits in both periods (82.0% in 2020, 83.1% in baseline). Consistent with the decreased volume overall, count of patient visits for most chief complaints are decreased compared with the average counts per year during the baseline period. Notably, ingestion was a top 20 complaint only for 2020 and the number of ingestions in 2020 was higher than the average number of ingestions per year in the comparison period (31 vs 25 ± 6, Table 3 ). Visits to a tertiary care pediatric emergency department declined dramatically in line with local impact of the COVID-19 pandemic and subsequent to a statewide stay-at-home order. In the 30 days following a statewide stay-at-home order, the mean number of daily visits to a tertiary urban care emergency department were significantly lower compared with the same time period in the previous 3 years. An initial decline in visit volume started just prior to the state-wide stayat home order which may represent voluntary self-isolation prior to the mandatory order. The proportion of high acuity patients increased in 2020 as measured by ESI triage level, hospital admission rate, and ICU admission rate. The most common chief complaint categories were consistent between the time periods with notable exception of ingestion, which entered the top 20 list for 2020. The prominence of ingestions is notable as potential preventable harm experienced by children during the COVID-19 pandemic. This result is consistent with data from the CDC about poison control call volumes 14 though we are unable to clarify ingestion category or intent within our data. Additionally, although absolute numbers declined, other potentially preventable chief complaints, trauma and foreign body, increased in relative frequency in 2020. These data, in addition to literature report of increased rate of dog bites, 15 support the hypothesis that children's shifted environments following stay-at-home orders present different threats to child health, may place children at new, modifiable risk, and identifies an important area of public health education and intervention. A primary source of decreased ED visit volume was fewer low-acuity visits. It is likely that low-acuity visits were influenced by hesitancy to seek medical care in the context of a pandemic. For low-acuity use of emergency medical services, this may be appropriate. We are unable to clarify high-volume pediatric equivalents to adult MI that would have similar morbidity impact of delayed emergency healthcare. 4, 6 Our study has several limitations. First, chief complaint scripts are less widely standardized across hospitals which limits generalizability. 24 Second, our study does not capture data beyond the first 30 days of the pandemic. Initial patterns may not be reflective of persistent risks. Overall, these results suggest that children may be exposed to preventable harm during enforced social distancing and that overall utilization of emergency medical care was significantly reduced. Continued evaluation of trends in healthcare utilization has implications for healthcare service delivery planning, and individual clinicians, particularly around the future trajectory of the SARS-CoV-2 pandemic. Finally, healthcare providers need to partner with community and public health organizations to ensure that families receive timely safety and anticipatory education during times of decreased contact with the healthcare system. Specifically, public health education reiterating child-proofing against ingestions and trauma prevention is warranted to address modifiable risks facing children in shifted care environments. 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Emergency Severity Index (ESI): A Triage Tool for Emergency Departments A system for grouping presenting complaints: the pediatric emergency reason for visit clusters We thank Cynthia Mollen and Jeremy Buck for their assistance with data acquisition. Bolded values statistically significant per Bonferonni family-wise error correction (p<0.0016).