key: cord-0912890-oy2dw9ry
authors: Masler, I.; Monroe, K. W.; Duerring, S. A.
title: 44 Trends in Pediatric Emergency Department Acuity and Trauma During the COVID-19 Pandemic
date: 2021-08-31
journal: Annals of Emergency Medicine
DOI: 10.1016/j.annemergmed.2021.07.045
sha: a294aaa572d54602c67bb88895e92163355506c3
doc_id: 912890
cord_uid: oy2dw9ry

Study Objective: SARS-CoV-2 was declared a pandemic March 11, 2020 by the WHO. Adult health care systems faced tremendous challenges in volume and acuity;however, morbidity and mortality among children is low and pediatric emergency departments (EDs) have been spared the same challenges. Treatment of SARS-CoV-2 patients and efforts to curb disease transmission affected health care delivery in the United States causing negative effects on the delivery of routine primary care, the closures of schools, the implementation of shelter-in-place orders, and the cancellation of typical activities for children. The impact of these factors and the COVID-19 epidemic on pediatric EDs has yet to be fully understood. Our study contributes by demonstrating the COVID-19 epidemic’s impact on our tertiary care pediatric ED and level 1 trauma center. Methods: This retrospective time series study was conducted in a southern state with data coming from three sources: 1. State Office of EMS 2. ED visits and admissions 3. Hospital trauma database. The hospital is a free-standing children’s hospital with an annual ED census around 75,000 prior to 2020. The hospital is the only state certified pediatric level I trauma center. Strict criteria exist for triggering trauma team activation. Four years of data were analyzed for number of patients seen, number and percent of patients admitted to a critical care unit, number and percent patients who met trauma activation criteria, and number of EMS transfers. This study was deemed exempt by the institutional review board since data were de-identified and aggregate. Data were managed using Excel™. Results: Overall volume decreased 34% from 74,513 (2019) to 48,924 (2020) in contrast to trends of volume from 2017 through 2019, which had shown a steady increase by an additional 1,100 patients per year. Annual admission rate rose from 13.4-13.9% in 2017-2019 to 18.6% in 2020. The institution saw a linear increase in combined admission rates to the intensive care and intermediate care units from a high of 23.7% (2019) to 25.4% (2020) with a corresponding decrease in admission rates to acute care floors. Rate of admission to inpatient psychiatry unit increased from an average yearly rate of 7.2-7.7% in 2017-2019 to 9.3% in 2020. The number of patients transferred via EMS to our institution from outside facilities increased 8.8% from 1,868 in 2019 to 2,034 in 2020. Trauma alert activations increased from 0.65% of total patient volume in 2019 to 1.2% in 2020 with a noticeable increase in firearm related injuries from 44 in 2019 to 66 in 2020. Conclusion: While total volumes of patients seen in our tertiary pediatric ED showed a significant decrease during the COVID-19 pandemic there were significant increases in acuity as evidenced by admission rate, admission location, and number of interfacility transfers to our pediatric emergency department. There were also significant increases in psychiatric admissions and trauma alerts.

Study Objective: SARS-CoV-2 was declared a pandemic March 11, 2020 by the WHO. Adult health care systems faced tremendous challenges in volume and acuity; however, morbidity and mortality among children is low and pediatric emergency departments (EDs) have been spared the same challenges. Treatment of SARS-CoV-2 patients and efforts to curb disease transmission affected health care delivery in the United States causing negative effects on the delivery of routine primary care, the closures of schools, the implementation of shelter-in-place orders, and the cancellation of typical activities for children. The impact of these factors and the COVID-19 epidemic on pediatric EDs has yet to be fully understood. Our study contributes by demonstrating the COVID-19 epidemic's impact on our tertiary care pediatric ED and level 1 trauma center.

Methods: This retrospective time series study was conducted in a southern state with data coming from three sources: 1. State Office of EMS 2. ED visits and admissions 3. Hospital trauma database. The hospital is a free-standing children's hospital with an annual ED census around 75,000 prior to 2020. The hospital is the only state certified pediatric level I trauma center. Strict criteria exist for triggering trauma team activation. Four years of data were analyzed for number of patients seen, number and percent of patients admitted to a critical care unit, number and percent patients who met trauma activation criteria, and number of EMS transfers. This study was deemed exempt by the institutional review board since data were de-identified and aggregate. Data were managed using Excel TM .

Results: Overall volume decreased 34% from 74,513 (2019) to 48,924 (2020) in contrast to trends of volume from 2017 through 2019, which had shown a steady increase by an additional 1,100 patients per year. Annual admission rate rose from 13.4-13.9% in 2017-2019 to 18.6% in 2020. The institution saw a linear increase in combined admission rates to the intensive care and intermediate care units from a high of 23.7% (2019) to 25.4% (2020) with a corresponding decrease in admission rates to acute care floors. Rate of admission to inpatient psychiatry unit increased from an average yearly rate of 7.2-7.7% in 2017-2019 to 9.3% in 2020. The number of patients transferred via EMS to our institution from outside facilities increased 8.8% from 1,868 in 2019 to 2,034 in 2020. Trauma alert activations increased from 0.65% of total patient volume in 2019 to 1.2% in 2020 with a noticeable increase in firearm related injuries from 44 in 2019 to 66 in 2020.

Study Objectives: The outbreak of the COVID-19 pandemic has led to the rapid adoption of novel telemedicine programs within the emergency department (ED) to minimize provider exposure and conserve personal protective equipment (PPE). In this study, we sought to assess how the adoption of telemedicine in the ED impacted both the timeliness of interventions and the order patterns for patients with chest pain.

Methods: A single-center, retrospective, propensity score matched study was designed for patients presenting with chest pain (n ¼ 1608). The study period was defined between April 1st, 2020, and September 30th, 2020. Patients who received telemedicine were propensity score matched based on age, sex, ED disposition, insurance status, and evaluation/management level to patients who did not receive telemedicine. Three specific time-based quality metrics were compared for all ECG, troponin I, and aspirin orders within the two groups: arrival to order and arrival to result (or administration for aspirin). In addition, the frequency of the five most frequent lab, imaging, and medication orders were compared.

Results: 455 patients who received telemedicine were matched to 455 similar patients without telemedicine with standardized mean difference < 0.1 for all matched covariates. Telemedicine was associated with longer time to first ECG (5.0 minutes for controls, 8.0 minutes for telemedicine cohort, p-value <0.001), time to ECG result (12 minutes vs 18 minutes, p-value <0.001), and time to troponin result (104 minutes vs 123 minutes, p-value < 0.001). Generally, while patients receiving telemedicine had more tests ordered compared to controls, no group received a statistically significant higher proportion of lab, imaging, or medication orders compared to the controls.

Conclusions: For patients presented with chest pain in the ED, there were small but significant differences in time-based metrics (door-to-ECG, time-to-troponin) between telemedicine and controls. While the effect size of these differences is small, it is known that increased door-to-ECG times are associated with slower downstream intervention such as door-to-balloon time. Based on analysis of laboratory, imaging, and medication order patterns, telemedicine does not appear to significantly affect the clinical workup patients received. This study is an important objective assessment of the impact that telemedicine has upon the quality of care delivered to patients and can guide future telemedicine implementation after the COVID-19 pandemic.

However, the association between key clinical variables and a patient's downstream clinical course is incompletely understood. We sought to fill this knowledge gap in order to inform emergency management of the COVID-19 patient

Demographic, clinical, radiographic and laboratory variables were collected from electronic health records using a combination of manual chart review and electronic data extraction. We used multivariate logistic regression to examine the association between patient characteristics and two primary outcomes: (1) hospitalization from the index visit; and (2) critical illness, defined as either death or a requirement for respiratory support of high flow nasal cannula, non-rebreather mask, non-invasive ventilation or mechanical ventilation within 21 days. Results: Among 801 study-eligible patients, 28% were 65 years of age, 47% were female and 24% were non-Hispanic white. 393 patients (49%) were hospitalized and 161 (20%) had critical illness. Adjusted statistically significant predictors (p<0.05) of initial hospitalization included abnormal pulmonary auscultation, elevated blood urea nitrogen (BUN), measured fever, and abnormal respiratory vital signs (respiratory rate, oxygen saturation). Independent predictors (p<0.05) of critical illness included a history of hypertension, abnormal chest x-ray, elevated neutrophil-to-lymphocyte ratio, elevated BUN, measured fever, and abnormal respiratory vital signs (Table). Conclusion: In this large