key: cord-0829315-zxlhxmsq
authors: Bressan, S.; Buonsenso, D.; Farrugia, R.; Parri, N.; Oostenbrink, R.; Titomanlio, L.; Roland, D.; Nijman, R.; Maconochie, I.; Da Dalt, L.; Mintegi, S.
title: Preparedness and response to Pediatric CoVID-19 in European Emergency Departments: a survey of the REPEM and PERUKI networks
date: 2020-05-01
journal: nan
DOI: 10.1101/2020.04.28.20075481
sha: 4e2a4b86d7a598e657d7a86149a95459db495ea6
doc_id: 829315
cord_uid: zxlhxmsq

Study objective: We aimed to describe the preparedness and response to the COVID-19 pandemic in referral EDs caring for children across Europe. Methods: We did a cross-sectional point prevalence survey, which was developed and disseminated through the pediatric emergency medicine research networks for Europe (REPEM) and the United Kingdom and Ireland (PERUKI). We included a pre-determined number of centers based on each country population: five to ten EDs for countries with > 20 million inhabitants and one to five EDs for the other countries. ED directors or named delegates completed the survey between March 20th and 21st to report practice in use one month after the outbreak in Northern Italy. We used descriptive statistics to analyse data. Results: Overall 102 centers from 18 countries completed the survey: 34% did not have an ED contingency plan for pandemics and 36% had never had simulations for such events. Wide variation on PPE items was shown for recommended PPE use at pre-triage and for patient assessment, with 62% of centers experiencing shortage in one or more PPE items. COVID-19 positive ED staff was reported in 25% of centers. Only 17% of EDs had negative pressure isolation rooms. Conclusion: We identified variability and gaps in preparedness and response to the COVID-19 epidemic across European referral EDs for children. Early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and appropriate isolation facilities emerged as key factors that should be optimized to improve preparedness and inform responses to future pandemics.

Ever since the first human cases of the novel coronavirus were reported in Wuhan, Hubei cases between countries. Although European countries greatly differ in their culture, legislation, health care systems, and territorial organization, physicians working in the frontline of pediatric emergencies strongly advocate for generalizable guidance to enhance preparedness and readiness to pandemic emergencies across the whole age spectrum, to better face COVID-19 and possible future pandemics.

Even though it has now become apparent that children are affected less frequently and with a much more benign disease spectrum than adults,5,6 appropriate management of suspected and confirmed cases and their families are essential throughout all levels of health care systems. 7, 8 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint EDs should also maintain the quality of care provided to children presenting with serious illnesses or accidents not related to the pandemic. Pathway and protocols need to be in place to ensure that rapid appropriate care is provided to suspected COVID-19 children, while avoiding delay in care of non-COVID-19 patients. 9 In addition, it will be paramount to ensure patients and staff are protected from the infection and with as little exposure as possible.10 It has also become recognised that children may present with conditions not linked to COVID-19 but some, when admitted for that condition, are found to have COVID-19 positive swabs as an incidental finding. This may be a feature with the more widespread dissemination of COVID-19 throughout the population.

Hence, we developed a structured point prevalence survey to describe the preparedness and response to the COVID-19 pandemic, including strengths and challenges, in European referral EDs for children within the REPEM and PERUKI networks. The secondary objective was to summarize the lessons learnt, which can be generalizable across countries.

This was a cross-sectional point prevalence study to describe the preparedness and response to the COVID-19 pandemic and to explore common themes in lessons learnt from the pediatric emergency field across Europe. The survey was developed in English by the lead author and then underwent several rounds of review by the research team. The survey was distributed through the REPEM network,12 a research collaborative consisting of Pediatric EDs (PEDs) and EDs of general hospitals with a separate pediatric section, serving as referral centers for children and also the sites affiliated to the executive committee members of PERUKI. For each European Country a country lead was identified to disseminate the survey to centers meeting the above criteria. We also included Isrel as a European associated country, as Isrel has been part of the REPEM network since its foundation.14 To ensure balanced representativeness of participating countries and feasibility of the study, the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint research team agreed to include a pre-determined number of centers based on the population of participating countries. For countries with more than 20 million inhabitants the country leads had to include five to ten EDs; for countries with less than 20 million inhabitants this was one to five EDs. We defined ED directors or named delegates as most suitable persons to complete the survey, and they were asked to complete one survey for each participating center. The survey was open on March 20th and 21st with specific instructions to respond reporting information available and practice in use on March 20th 2020. Survey responses were collected in REDCap, a validated online data collection system. 15 Respondents were asked to state their country of residency, but it was not mandatory to give the name of their hospital. Each country-lead recorded the name of the invited and participating hospitals.

Country leads communicated to the principal investigator the number of centers that completed the survey, without disclosing the hospitals' identities, ensuring the number of completed surveys per country matched the number of centers that actually completed the online survey.

A first survey was completed by country-leads to reflect the national situation of the COVID-19 pandemic as of March 20 2020. The country lead survey included questions on range of COVID-19 cases (total and pediatric) per country; the date of identification of the first COVID-19 cases in the country; and the type of containment measures enforced in their country. Data on range of confirmed cases per country, as well as deaths, were cross checked with the European center for Disease Control and worldometers websites on March 21st, to ensure complete update of data up to March 20th.16,17 The formal study survey completed by each participating center focused on organizational and operational aspects of preparedness and response including contingency plan, training, screening criteria for suspected cases, capacity, personal protective equipment, ED infection control measures and management of patients, health professionals safety and sustainability of care, resources found useful to prepare the ED for management of pediatric cases. All answers had to be provided as per practice on March 20th.

Descriptive statistics were used to analyse the data. Association between categorical variables was tested by means of chi square or Fisher exact test as appropriate.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint Data were analysed using Stata (version 13, StataCorp, College Station, Texas, USA). Pvalues were considered significant if P was less than 0·05.

This survey accessed clinicians via a research collaborative to assess their departmental practice and therefore did not require formal ethics review, as per consultation with the ethics committee of the University Hospital of Padova, Italy. Consent was implied by participation.

A total of 102 centers from 18 countries completed the survey. The survey was completed by the ED director in 48% of cases and by their delegate in 52%. The number and characteristics of participating centers and the range of COVID-19 confirmed cases per country as of March 20th is reported in Table 1 . The majority of participating EDs were tertiary-care PEDs (75%) and most centers have a pediatric yearly census > 10,000 visits per year (89%). Only few Approximately one third of centers (34%) did not have an ED contingency plan for pandemics ( Table 2) , irrespective of time interval from first COVID case, number of confirmed cases or ED setting. The majority of centers (76%) had not experienced mass casualty disasters or pandemics during the past 5 years and 36% had never had simulations . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04.28.20075481 doi: medRxiv preprint for such events. Nearly all institutions had established a formal ED management plan for suspected/confirmed pediatric COVID-19 cases by March 20th, with daily updates in 69% of centers. Surge capacity for pediatric suspected COVID-19 cases was highly variable between centers at an ED, admission ward and intensive care level and was not proportional to the ED pediatric annual census for any of these settings.

In one fifth of the institutions there was no intensive care availability for pediatric COVID-19

patients. Plans to increase capacity widely varied between centers. Establishment of a pretriage and personal protective equipment (PPE) training was also highly variable, as was the use of PPE at pre-triage and for patient assessment. Recommended PPE use for patients was more consistent across centers. Recommended duration of filtering masks use was also variable. A shortage of both basic and erosol generating protective PPE items was experienced by nearly two thirds of centers with masks being the items most frequently missing ( Table 3) .

Contagion of healthcare workers was frequently reported at an institution level (69%), but less so at the ED level (25%). Only 18% of sites endorsed a periodic active surveillance of ED staff. Disposition of healthcare workers who had been in close contact with a confirmed COVID-19 case varied between centers, with approximately one third allowing staff to work while asymptomatic and one third recommending quarantine at home. Overall, ED physicians shift work had been re-arranged in nearly two thirds of centers with variable adjustments including both increase and reduction in staff, as well as different shift schemes to prevent cross-infection among staff (Table 4) .

EDs limited caregivers/parents presence to only one person in the majority of centers (84%) and reorganized patient flow to accommodate suspected cases in separate dedicated areas.

Fewer than 20% of EDs had isolation rooms with negative pressure. While most EDs performed swab testing for SARS-CoV-2 (78%), there was wide variability on how the test was performed. However, in the majority of centers (75%), asymptomatic children with a history of close contact, who could be otherwise discharged, were not tested in the ED. At most sites suspected cases who were tested, but were fit for discharge, were sent home and swab results communicated to the family when they became available. In cases of positive test results in discharged patients, half of the centers could count on specific outpatient services to provide telephone follow-up. Most EDs experienced a significant reduction in pediatric presentations, by more than 50% in half of the centers ( Table 5) . A longer time since first case was significantly associated with a larger reduction in the number of presentations (p=0.003; Figure 1 ).

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint Local/national health authority documents, hospital policy/infectious disease expertise and websites of international organizations, and published article from China received the higher rating scores as useful sources to inform preparedness and management of pediatric COVID-19 ( Figure 2S ). Overall 46% of centers agreed (36%) or strongly agreed (10%) about the statement "My hospital was ready and prepared to handle COVID-19 at the time the outbreak started in our country" and 54% agreed (39%) or strongly agreed (15%) when the statement was referred to ED pediatric care.

The results of our study should be interpreted in the light of its limitations. Although we included a large number of European countries, our survey does not provide a pan-European perspective. However, this is the first European dataset that provides a detailed snapshot of pediatric emergency care from within the pandemic, at a more granular level than any institutional channel has been able to provide so far. While the pandemic evolves in each country and accompanying adjustments are made, a repeat focused survey will capture the dynamic progress made from an organizational and operational perspective. We arbitrarily decided, as a research team, the number of centers to be included in each country to ensure a balanced representativeness and to obtain timely completion of the survey. The participating centers represent a subset of EDs caring for children in Europe and include referral centers for children, thus our findings may not be generalisable across different settings. Although some countries exceeded the expected number of recruited centers, we were able to obtain a reasonable balance in terms of country representativeness. In addition, the objective of this survey was to explore common challenges and generalizable learning points and not to compare responses between countries.

Our survey provides a snapshot of preparedness and response of EDs caring for children from 17 European countries and a European associated country at one month after the COVID-19 outbreak started in Northern Italy. Overall, the findings of our study show high variation in time and in level of organisational responses to COVID-19 of EDs caring for children across Europe. While participating countries were at different stages in the outbreak spread the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint different pace in the pandemic advancement represents an opportunity for healthcare systems to learn from each other. This may ensure a more rapid response in terms of implementation of infection prevention and control measures within healthcare in those countries that lag behind the spread wave. This is important at all levels of care within an integrated health care system, but it is paramount for frontline services such as EDs. 18 Implementation of appropriate PPE use can be easily done and should occur in a timely manner. This is in contrast to barriers related to structural limitations and constraints affecting the organization of ED patient flow and isolation capacity, which may be difficult to overcome in a short time frame. Infection control measures were more consistently reported in the survey, including re-arrangement of ED patient flow, changing of staff work shift to optimize resource utilization, reduction in the number of care givers allowed with the child and home quarantine for confirmed COVID-19 pediatric cases fit for discharge.

Another interesting finding from our survey is the substantial reduction in pediatric ED presentations during the pandemic, which greatly helped centers with more limited isolation capacity better manage suspected COVID-19 cases. Centers from countries with a longer time since first case experienced higher reductions in the number of ED presentations.

Parents' fear of contagion in a healthcare environment, improved hygiene measures, reduced community transmission of communicable diseases, reduced opportunities to sustain injuries owing to the strict containment measures enforced by governments, and reduction in stressrelated functional diseases may be the reasons underlying this phenomenon. Reports from . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. . https://doi.org/10.1101/2020.04. 28.20075481 doi: medRxiv preprint Author contributions: Silvia Bressan: Conceived the study, designed the study, obtained, analysed and interpreted the data, wrote the initial draft of the paper, gave final approval to be published, and agreed to be accountable for all aspects of the work. Santiago Mintegi: Conceived the study, designed the study, interpreted the data, critically revised the draft of the paper, gave final approval to be published, and agreed to be accountable for all aspects of the work. Danilo Buonsenso designed the draft of the survey. Danilo Buonsenso, Niccolo' Parri, Ruth Farrugia, Ruud Nijman, Rianne Oostenbink, Luigi Titomanlio, Ian Maconochie, Damian Roland and Liviana Da Dalt: Designed the study, contributed to the interpretation of the data, drafted or revised it critically, gave final approval to be published, and agreed to be accountable for all aspects of the work.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 1, 2020. Number of centers  7  5  3  15  13  1  4  6  11  1  2  2  2  5  9  3  6 7 ED Setting -Tertiary care PED of standalone hospital -Tertiary care PED in a hospital for adults and children -Referral general ED with pediatric section * -Other # Not reported ED=Emergency Department; PED= Pediatric Emergency Department; UK= United Kingdom * referral ED for children # Malta: general referral ED seeing children; Portugal: 2 secondary-care PED in a hospital for adults and children; Spain: secondary-care PED in a hospital for adults and children; Sweden: secondary-care PED for medical conditions ** Belgium: 3 centers did not know; Germany: 2 centers did not know; Switzerland: 1 center did not know; UK: 1 center did not know p=0·314 and p=0·689 respectively on Chi square test) # stratification by ED pediatric annual census did not show any significant difference in distribution (p=0·195; p=0·208 and p=0·229 respectively on Fisher's exact test) In your Institution, if a healthcare worker has been in contact (without personal protection devices) with a confirmed case of COVID-19

He/she must be tested and in the meantime be in quarantine He/she must be tested and in the meantime can work with a surgical mask He/she must be placed in quarantine without being tested If he/she has no symptoms, can continue to work without being tested Other Don't know Both parents/caregivers are allowed to be with the child Only one parent/caregiver is allowed to be with the child There are no rules that establish the number of caregivers allowed in the ED 13 86 3 13% 84% 3% What is the patient flow for a suspected COVID-19 in your ED/PED after pre-triage? Patient is taken directly to an isolation room, with negative pressure Patient is taken directly to an isolation room, but with no negative pressure Patient is taken directly in a usual visit room Patient waits in the usual waiting room Patient waits in a dedicated waiting room for suspected COVID-19 Other No up to 25% up to 50% more than 50%

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Impact of Middle East respiratory syndrome outbreak on the use of emergency medical resources in febrile patients

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The authors would like to acknowledge all the respondents to the survey and who gave permission for their names to be included in the acknowledgment section of this paper.

The nasal swab only The pharyngeal swab only Both (nasopharyngeal swab) with one swab stick and one tube (first pharynx first and then nose) Both (nasopharyngeal swab) with two separate swab sticks in two separate tubes Don't know 23 17 41 20 1 22% 17% 40% 20% 1% If you perform a nasal/pharyngeal swab for SARS-CoV-2 in the ED/PED to a clinically stable child (who would not otherwise require admission) I must keep the child in a dedicated isolation room until I receive the swab result I can discharge the child home and I communicate the family the result when available I have to admit the child to a regular pediatric ward until I receive the swab result Children who do not need admission are not tested for SARS-CoV-2 in my ED Other