key: cord-0985778-9bcploh4
authors: Dean, Preston; Zhang, Yin; Frey, Mary; Shah, Ashish; Edmunds, Katherine; Boyd, Stephanie; Schwartz, Hamilton; Frey, Theresa; Stalets, Erika; Schaffzin, Joshua; Vukovic, Adam A.; Reeves, Scott; Masur, Tonya; Kerrey, Benjamin
title: The impact of public health interventions on critical illness in the pediatric emergency department during the SARS‐CoV‐2 pandemic
date: 2020-08-10
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12220
sha: 4defa0047a470eaa0fdcb03a9d06359a97cbddc0
doc_id: 985778
cord_uid: 9bcploh4

STUDY OBJECTIVE: The impact of public health interventions during the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic on critical illness in children has not been studied. We seek to determine the impact of SARS‐CoV‐2 related public health interventions on emergency healthcare utilization and frequency of critical illness in children. METHODS: This was an interrupted time series analysis conducted at a single tertiary pediatric emergency department (PED). All patients evaluated by a provider from December 31 through May 14 of 6 consecutive years (2015‐2020) were included. Total patient visits (ED and urgent care), shock trauma suite (STS) volume, and measures of critical illness were compared between the SARS‐CoV‐2 period (December 31, 2019 to May 14, 2020) and the same period for the previous 5 years combined. A segmented regression model was used to explore differences in the 3 outcomes between the study and control period. RESULTS: Total visits, STS volume, and volume of critical illness were all significantly lower during the SARS‐CoV‐2 period. During the height of public health interventions, per day there were 151 fewer total visits and 7 fewer patients evaluated in the STS. The odds of having a 24‐hour period without a single critical patient were >5 times higher. Trends appeared to start before the statewide shelter‐in‐place order and lasted for at least 8 weeks. CONCLUSIONS: In a metropolitan area without significant SARS‐CoV‐2 seeding, the pandemic was associated with a marked reduction in PED visits for critical pediatric illness.

On March 11, 2020, the World Health Organization declared the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic. 1 As of July 17, SARS-CoV-2 has infected >14 million worldwide and caused at least 600,000 deaths, 2 with significant burden placed on healthcare systems in communities with substantial viral seeding. [3] [4] [5] Without a vaccine or definitive treatment, non-pharmacologic public health interventions are the foundation for lowering viral transmission rates and slowing disease spread. 6 In previous pandemics, public health interventions have been credited with slower spread and fewer deaths. 7, 8 Early studies examining the impact of these interventions during the SARS-CoV-2 outbreak suggest that they result in lower viral transmission rates and improved disease control. 9-12

Recently published studies have shown marked reductions in both adult and pediatric patient volumes during the SARS-CoV-2 pandemic. [13] [14] [15] [16] [17] [18] [19] In children, patient volume decreases have been seen in multiple settings of health care, including outpatient and emergency department settings. [13] [14] [15] [16] [17] [18] Additionally, multiple studies have evaluated changes in specific illness and injury patterns in children presenting for care during the pandemic. 14, 17, 18 Despite the growing body of evidence for a reduction of ED visits in children, 13, [15] [16] [17] 20, 21 no published study has focused on changes in critical illness presenting to the pediatric emergency department (PED). Moreover, the impact of public health interventions on the timing of changes in critical illness and injury patterns in children has not been studied. When compared to non-critically ill or injured patients, critically ill and injured patients are more likely to suffer morbidity and mortality and require more departmental resources during their care. Understanding critical illness presentation patterns during the SARS-CoV-2 pandemic can help guide planning and resource allocation during both the ongoing pandemic as well as future pandemics.

The SARS-CoV-2 pandemic offers a unique opportunity to study the effects of public health interventions, both on the disease of interest and more broadly. This study addresses the literature gap through an interrupted time-series analysis of ED and urgent care visits to a regional pediatric referral center. The study objective is to describe the impact of public health interventions during the SARS-CoV-2 pandemic on critical illness presenting to the PED.

This was a retrospective, observational study of patient visits to the ED and urgent care at Cincinnati Children's Hospital Medical Center.

The ED is the major regional pediatric emergency care provider and the only pediatric referral center. The ED and associated urgent care have ≈100,000 combined patient visits per year. The catchment area has over 2 million people, drawing from 8 counties in 3 states.

Critically ill or injured patients are evaluated in the ED's shock trauma suite (STS). Pediatric emergency nurses triage patients to the STS using a combination of the Emergency Severity Index (version 4), specific trauma criteria, and nursing discretion. 22 Boardcertified/eligible pediatric emergency physicians lead designated medical and trauma teams.

The study protocol was approved by our institutional review board.

The current report is written to be consistent with published guidelines for reporting the results of observational studies (STrengthening the Reporting of OBservational studies in Epidemiology). 23

All patients who presented to the ED or urgent care from December 31 through May 14 across 6 consecutive years (2015-2020) were eligible for inclusion. Patients who left without being seen by a physician or nurse practitioner were excluded. Eligible visits were identified using our institution's electronic health record (EHR).

Data were collected from the EHR using 2 approaches. We used a single EHR query to collect data on total patient visits. We collected STS-specific data, including measures of critical illness, from an existing internal database of all STS encounters. A pediatric emergency nurse has maintained the STS database since 2015, using automated EHR daily reports and supplemented by manual EHR review.

The STS database is used for quality assurance and peer review activities, and we have a track record of successful research using this approach.

The main outcomes were (1) total patient visits, (2) STS volume, and (3) critical illness volume. All 

We first tabulated all data and generated standard descriptive statistics, including for each outcome. We report medians and interquartile We selected the 5 time periods a priori, based on the specific dates' theoretical public health relevance (to patient volumes). 16 ically ill pediatric patients. These findings provide valuable perspectives to inform regional pandemic preparedness.

For all 3 outcomes, we conducted robust interrupted time series analyses with segmented regression, 25, 26 to assess differences between the pandemic and control groups. We used scatter plots and smooth curves of the time series to examine potential trends and dispersion. We assumed the intervention effects on the primary outcome would be non-linear and eventually reach a plateau. An exponential decay model was then built to evaluate decay rates in each outcome after the initiation of local public health interventions.

For total patient visits and STS volume, we used linear mixed modeling. We calculated the differences in mean total patient visits and STS volume (daily), with corresponding 95% confidence interval (CI), for each of the 5 periods. We included terms for time period, intervention group, and period-by-group interaction as fixed effects. For the random effect, we used a first-order auto-regression correlation structure to account for autocorrelation by inclusion seasonality and For critical illness volume, we conducted zero-inflated Poisson mixed effects modeling to assess differences in daily volume between the pandemic and control groups. 27 As the frequency of zero daily critical illness visits was common, we calculated the odds of zero daily critical illness visits in the pandemic versus the control group for each of the 5 periods. P values <0.05 were considered statistically significant.

All analyses were performed with SAS Version 9.4 (SAS Institute, Cary, NC, USA). Patient characteristics for the 2 study groups are provided in Table 1 . Patient age and sex were similar between the pandemic and control groups. In both groups, approximately two thirds of STS evaluations were medical (non-trauma evaluations).

During the pandemic, total patient visits were unchanged in periods Daily STS volume during the pandemic generally mirrored the decrease in total patient visits ( Figure 3 , Table 2 ). During the height of local public health interventions, there were 7 fewer patients evaluated in the STS per day than in the previous 5 years. Following the initiation of local public health interventions, STS volume had a daily decay rate of −9.9% (95% CI −18.9%, −0.85%) (Figure 4 ).

Critical illness volumes during the pandemic were similar in periods 1-3 ( Figure 5 ). During period 4, the first 6 weeks after public school closings and the shelter-in-place order, the odds of having a 24hour period without a single critically ill patient were 5.5 higher during the pandemic (95% CI 2.6, 11.7; Table 2 ). During period 5, critical illness volumes were similar between the pandemic and control groups.

Our study should be interpreted in light of 2 main limitations. First, this was a single-center study, limiting generalizability. Ohio's state- A second important limitation is that we measured visits and not the actual incidence of illness or injury. We believe that a large percentage of the drop in total visits was for conditions that might be addressed by phone or telehealth visits. Our institution, like many others throughout the country, put an increased emphasis on telehealth visits during the mandated shelter-in-place order. As noted, however, we believe caregivers seeking alternatives to ED care does not explain all, or even most, of the drop in STS volume; we believe the drop in patients with critical illness visits is not explainable by an increase in alternative visits.

The with a probable reduction in both organized and unorganized recreational activities, likely contributed to decreased rates of critical traumatic injuries. 32 We did not collect data on diagnostic category or chief complaint, so we cannot state definitively which specific forms of critical illness were after infection control measures were implemented. 33 Our findings suggest that factors other than public awareness and official orders triggered the initial decrease in healthcare utilization. We speculate that these factors may include the intensity or specific type of media coverage, high morbidity and mortality rates in early hot spots, and caregivers' perceptions about the level of personal risk of disease exposure. 15, 34 Our findings provide additional epidemiologic evidence of how nonpharmacologic public health interventions likely affect the typical pattern of infectious diseases and traumatic injuries in a community. It will be vital to follow healthcare utilization rates and critical illness volumes during and after public health interventions are relaxed. In a state still experiencing significant numbers of new cases daily, the impact of less stringent public health interventions remains to be seen. 2 In summary, public health interventions in a metropolitan area without significant community seeding of SARS-CoV-2 led to profound and persistent decreases in PED utilization, including for critical illness and injury. The latter change likely represents a decreased incidence of more serious conditions, possibly from an indirect effect of social distancing and shelter-in-place orders on the typical pattern of non-SARS-CoV-2 infectious diseases and traumatic injuries in children. The current pandemic presents a unique opportunity for epidemiologic investigations such as ours that can influence planning and resource allocation in future pandemics and inform future epidemiologic studies.

The authors sincerely thank Holly Lynd for her assistance with data extraction. We thank the leadership of the Division of Emergency

Medicine and Cincinnati Children's Hospital Medical Center, for their efforts during the pandemic and their support on this project. Finally, we thank our colleagues, at Cincinnati Children's and elsewhere, for

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