Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic

Molecular Point-of-Care Testing in the Emergency Department for Group A Streptococcus Pharyngitis : A Randomized Trial

OBJECTIVES

To compare clinical and health systems outcomes of rapid molecular testing versus throat culture recovery for the management of group A Streptococcus (GAS) pharyngitis in a pediatric emergency department (PED).

METHODS

We conducted a single-center randomized trial of children (3-17 years) presenting to a PED with suspected GAS pharyngitis. A single dual-headed throat swab was collected, and participants were randomized to 1 of 2 parallel treatment groups with 1:1 allocation: point-of-care (POC) nucleic acid amplification testing or standard throat culture. The primary outcomes were time to throat pain +/- fever resolution. Secondary outcomes included absenteeism, length of stay, return visits to care, and antibiotic prescriptions and utilization.

RESULTS

A total of 227 children were randomly assigned to culture (n = 115) or POC (n = 112) testing. Antibiotics were initiated earlier in the POC group by approximately 1 day (95% confidence interval, -0.40 to -1.58). No associated difference in time to throat pain or fever resolution was observed between groups. There was a decrease in the proportion of prescribed antibiotics in the POC group (0.35) compared with the culture group (0.79; P < 0.001). Otherwise, no significant differences in secondary outcomes were observed.

CONCLUSIONS

Establishing a POC nucleic acid amplification testing program for GAS in a PED facilitates earlier treatment and fewer antibiotic prescriptions. Although this did not translate to improved clinical and health systems outcomes in our study, it may serve as an important tool amid evolving pediatric febrile illnesses and growing antimicrobial resistance patterns.

A demographic comparison and characterization of pediatric poisoning before and after the emergence of COVID-19

BACKGROUND

To compare relative rates of pediatric poisoning before and after COVID-19, including by demographic and urban-rural status, and by agent identified, using data from one university healthcare system and children's hospital.

METHODS

Using retrospective, cross sectional design from deidentified healthcare claims data, we extracted all encounters with the ICD-10-CM for Poisoning by, Adverse effects of, and Underdosing of drugs, medicants and biological substances (T36-T50) and grouped the encounters as those after state mandates regulating activity came into effect (Post-COVID-19 (3/17/2020-3/18/2021)) Pre-COVID-19 (3/18/2019-3/17/2020). We then compared poisoning agent, age at the time of the encounter, recorded sex, race, ethnicity, rural/urban residence, and visit type using Mann-Whitney U test, chi-square test of association, incidence rates and incident rate ratios between the time periods.

FINDINGS

The sample included 1608 unique patients 0-17 years of age and 4216 encounters. We also identified IRRs >1 in nearly every demographic subgroup with the exception of Non-Hispanic Blacks. The comparison of specific drugs or medicants identified a significant decrease in poisoning by Systemic antibiotics (T36); but an increase in Hormones and their synthetic substitutes and antagonists (T38), Non opioid analgesics antipyretic and antirheumatic (T39), Psychotropic Drugs (T39) and Systemic and hematologic agents (T45).

CONCLUSION

This study identifies pediatric subgroups highly affected by pediatric poisoning during the time-period immediately after the identification of COVID-19 and characterizes the drugs commonly associated with poisonings.

APPLICATION TO PRACTICE

With a further understanding nursing has the potential to impact pediatric poisoning in the inpatient, outpatient and public health setting.

Comparison of pediatric poisoning patterns before and during the COVID-19 pandemic in South Korea

OBJECTIVE

To investigate the epidemiological changes in emergency department (ED), including changes in toxic substances and ED outcomes in pediatric and adolescent patients who visited the EDs before and during the COVID-19 pandemic.

METHODS

This cross-sectional observational study used data from the ED-based Injury In-depth Surveillance from 2017 to 2021 in South Korea (SK). The study population comprised patients aged <19 years who visited 23 EDs because of poisoning before and during the COVID-19 outbreak. We divided the study period into pre-COVID-19 (January 2017 to February 2020) and COVID-19 periods (March 2020 to December 2021).

RESULTS

In total, 5862 patients were included in the final analysis, with 3863 and 1999 in the pre-COVID-19 and COVID-19 periods, respectively. The patients' mean age increased from 8.3 ± 7.1 to 11.2 ± 6.9 years between the pre-COVID-19 and COVID-19 periods (P < 0.001), and the number of adolescents (aged 13-18 years) significantly increased during the COVID-19 period (1653 [42.8%] vs. 1252 [62.6%]; P < 0.001). The number of intentional poisoning cases increased from 1332 (34.5%) before COVID-19 to 1174 (58.7%) during COVID-19 (P < 0.001). Specifically, pharmaceutical poisoning significantly increased during the COVID-19 period (2242 [58.0%] vs. 1443 [72.2%]; P < 0.001), with central nervous system (CNS) drug poisoning being the most common type (780 [34.8%] vs. 747 [51.8%]; P < 0.001). Among the intentional poisoning cases, pharmaceutical substance use significantly increased during the COVID-19 period (1207 [90.6%] vs. 1102 [93.9%]; P = 0.007). We used Bayesian structural time series (BSTS) forecasting models to forecast the number of ED visits during COVID-19. The total number of pediatric patients with poisoning decreased during the COVID-19 pandemic. However, when using the BSTS forecasting model, the decrease in the number of patients was not significant. Furthermore, the forecasting models showed no statistically significant increase in the number of intentional pediatric poisoning cases.

CONCLUSIONS

The previous studies suggested a decrease in the total number of patients with poisoning but an increase in intentional poisoning cases during the COVID-19 pandemic. By using similar methods to those of previous studies, our results also reached the same conclusion. However, the BSTS model, which predicts real-world time series patterns, seasonal effects, and cumulative effects, shows no significant change in pediatric poisoning patterns during the COVID-19 pandemic.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Decreased incidence of urinary tract infections in febrile infants aged ≤60 days during COVID-19 pandemic

AIM

To investigate the incidence rate of urinary tract infections (UTIs) among febrile infants aged ≤60 days before, during, and after the COVID-19 pandemic.

METHODS

We conducted a retrospective study in 2 Swedish paediatric emergency departments between 2014 and 2022. We included full-term infants aged ≤60 days with fever without source. We calculated the annual incidence rate of UTI per 1000 births.

RESULTS

We included 1589 full-term infants with fever without source. In 2020, 89 infants were evaluated in the emergency department versus 203-259 in 2017-2019. In 2020, the incidence rate of UTI was 1.43 per 1000 births/year versus 2.18-2.37 in 2017-2019. The median age, sex, fever duration, and urine testing were similar between the years 2017 and 2020.

CONCLUSION

The number of febrile infants who presented to the paediatric emergency department and the incidence rate of UTIs decreased in 2020. This decrease might imply a systematic misdiagnosis of UTIs in infants with febrile viral infections. A more selective urine testing approach for febrile, previously healthy, infants should be considered to mitigate UTI misdiagnosis and its potential harmful effects.

Epidemiological changes in the pattern of children's traumatic injuries at Hong Kong emergency departments during the COVID-19 pandemic: a retrospective, single-institutional, serial and comparative study

INTRODUCTION

Trauma is the leading cause of paediatric mortality and morbidity. Stay-home regulations for coronavirus disease 2019 (COVID-19) reportedly changed trauma severity, yet data from Hong Kong were lacking. This study examined Hong Kong's spectrum of paediatric trauma and addressed knowledge gaps concerning epidemiological changes during COVID-19.

METHODS

Children with traumatic injuries who attended a tertiary trauma centre from January 2010 to March 2022 were included in this retrospective, cross-sectional study. We analysed demographic and clinical data and conducted unadjusted bivariate analyses of injury patterns before and after the pandemic.

RESULTS

In total, 725 children attended the Accident and Emergency Department due to trauma, 585 before and 140 during COVID-19. The male-to-female ratio was 1.84:1. The 90-day trauma-related mortality was 0.7%. The overall Injury Severity Score was 3.52 ± 5.95. The paediatric trauma incidence was similar before and after social-distancing policies (both 5.8 cases monthly). Gender, ISS distribution, intensive care unit stay length, and hospital stay length values were similar (p > 0.05). Trauma call activation (8.4% vs. 5.7%, p = 0.002) and road traffic accidents (10.6% vs. 5.7%, p = 0.009) significantly decreased, yet younger-patient injuries (< 10 years old; 85.7% vs. 71%, p < 0.001), burns (28% vs. 45.7%, p < 0.001), and domestic injuries (65.5% vs. 85.7%, p < 0.001) significantly increased. No significant self-harm, assault, or abuse increases were found.

CONCLUSIONS

The paediatric trauma incidences were similar before and during the pandemic. However, domestic and burn injuries significantly increased, highlighting the importance of injury prevention.

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments

OBJECTIVES

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs).

METHODS

Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use.

RESULTS

Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82).

CONCLUSIONS

BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Routine Emergency Department Screening to Decrease Subsequent Physical Abuse

STUDY OBJECTIVE

Emergency department (ED) screening for child physical abuse has been widely implemented, with uncertain effects on child abuse identification. Our goal was to determine the effect of screening on referrals to child protective services (CPS) identifying abuse.

METHODS

We performed a retrospective cohort study of children younger than 6 years old with an ED encounter at 1 of 2 large health care systems, one of which implemented routine child abuse screening. The main outcome was initial (<2 days) or subsequent (3 to 180 days) referral to CPS identifying child abuse using linked records. We compared outcomes for the 2-year period after screening was implemented to the preperiod and nonscreening EDs using generalized estimating equations to adjust for sex, age, race/ethnicity, payor and prior ED encounters and clustered by center.

RESULTS

Of the 331,120 ED encounters, 41,589 (12.6%) occurred at screening EDs during the screening period. Screening was completed in 34,272 (82%) and was positive in 188 (0.45%). Overall, 7,623 encounters (2.3%) had a subsequent referral, of which 589 (0.2%) identified moderate or severe abuse. ED screening did not change initial (adjusted odds ratio [aOR]=1.01, 95% confidence interval [CI] 0.89 to 1.15) or subsequent referral to CPS when compared to the prescreening period (aOR=1.05, 95% CI 0.9 to 1.18) or to the nonscreening EDs (aOR=1.06, 95% CI 0.92 to 1.21).

CONCLUSION

Routine screening did not affect initial or subsequent referrals to CPS.

Oral enteral nutrition in the emergency department for children with bronchiolitis hospitalized on high flow nasal cannula

OBJECTIVES

We assessed whether initiation of oral enteral nutrition in the emergency department (ED) for patients with bronchiolitis hospitalized on humidified high flow nasal cannula (HHFNC) was associated with a shorter hospital length of stay (LOS) without an increase in return ED visits or hospital readmissions.

PATIENTS AND METHODS

This retrospective cohort study included children ≤24 months of age with bronchiolitis hospitalized to the general pediatric floor on HHFNC in two time periods: October 1, 2018 - April 30, 2019, and following implementation of a revised institutional bronchiolitis pathway that encouraged enteral nutrition initiation in the ED, October 1, 2021 - April 30, 2022. The primary outcome of interest was hospital LOS where the exposure was enteral feeding in the ED.

RESULTS

We included 391 'fed', 114 'not fed' and 304 'unknown' patients. HHFNC treatment time (25 h for 'fed' vs. 43 h for 'not fed' vs. 35 h for'unknown', p = 0.0001) and hospital LOS (39 h for 'fed' vs. 56 h for 'not fed' vs. 48 h for 'unknown', p = 0.0001) was shorter in the 'fed' group. There were no significant differences in return ED visits or hospital readmissions. Using our median LOS (45.1 h, inter-quartile range 30.2, 64.4 h) while controlling for age, sex, initial HHFNC flow rate, the respiratory oxygenation (ROX) index, viral etiology, and time period, an adjusted logistic regression analysis demonstrated that patients fed in the ED were 1.8 times more likely to have a hospital LOS of <45 h (aOR 1.88, 95% CI 1.11-3.18, p = 0.019).

CONCLUSIONS

Initiation of oral enteral nutrition in the ED for patients with bronchiolitis on HHFNC is associated with a shorter hospital LOS without an increase in return ED visits or hospital readmissions. Future prospective studies are needed to develop feeding recommendations for children with bronchiolitis receiving HHFNC support.

Coming in Hot: A quality improvement approach to improving care of febrile infants

Background and Objectives

Significant practice variation exists in managing young infants with fever. Quality improvement strategies can aid in risk stratification and standardization of best care practices, along with a reduction of unnecessary interventions. The aim of this initiative was to safely reduce unnecessary admissions, antibiotics, and lumbar punctures (LPs) by 10% in low-risk, febrile infants aged 29 to 90 days presenting to the emergency department (ED) over a 12-month period.

Methods

Using the Model for Improvement, a multidisciplinary team developed a multipronged intervention: an updated clinical decision tool (CDT), procalcitonin (PCT) adoption, education, a feedback tool, and best practice advisory (BPA) banner. Outcome measures included the proportion of low-risk infants that were admitted, received antibiotics, and had LPs. Process measures were adherence to the CDT and percentage of PCT ordered. Missed bacterial infections and return visits were balancing measures. The analysis was completed using descriptive statistics and statistical process control methods.

Results

Five hundred and sixteen patients less than 90 days of age were included in the study, with 403 patients in the 29- to 90-day old subset of primary interest. In the low-risk group, a reduction in hospital admissions from a mean of 24.1% to 12.0% and a reduction in antibiotics from a mean of 15.2% to 1.3% was achieved. The mean proportion of LPs performed decreased in the intervention period from 7.5% to 1.8%, but special cause variation was not detected. Adherence to the CDT increased from 70.4% to 90.9% and PCT was ordered in 92.3% of cases. The proportion of missed bacterial infections was 0.3% at baseline and 0.5% in the intervention period while return visits were 6.7% at baseline and 5.0% in the intervention period.

Conclusions

The implementation of a quality improvement strategy, including an updated evidence-based CDT for young infant fever incorporating PCT, safely reduced unnecessary care in low-risk, febrile infants aged 29 to 90 days in the ED.

Purpose

To develop and implement a multipronged improvement strategy including an evidence-based CDT utilizing PCT to maximize value of care delivered to well-appearing, febrile infants presenting to EDs.

Expectations of emergency patients regarding triage system knowledge upon arrival: an interpretive study

BACKGROUND

One of the most important aspects of healthcare knowledge is having a thorough understanding of the triage system which is used in emergency departments. This study aims to assess the level of awareness of Jordanian patients who visit the ED about the triage procedure.

METHODS

A descriptive, cross-sectional design was utilized in the emergency department at the biggest public hospital in Jordan. A convenience sample of a self-administrated questionnaire utilizing a Discounted Cash Flow Interview (DCF) survey was filled out.

RESULTS

A total of 726 participants were recruited with a response rate of 90.8%. The mean age of the participants was M = 38.1 (SD = 12.9), and the age of the participants varied from 18 to 89 years. More than half of the participants were male (n = 383, 52.8%) and married (n = 425, 58.5%). A significant relationship between the overall perception of knowing what a teaching hospital is and patients' educational level (X2 = 11.9, P < 0.003), current job (X2 = 25.2, P < 0.001), nationality (X2 = 7.20, P < 0.007), and family income (X2 = 15.9, P < 0.001).

CONCLUSION

More investigation is required to determine the causes of the low knowledge of the triage system. The study suggests increasing staffing levels, giving nursing staff ongoing education and training, and integrating technology and automation to reduce the load of patient care.

Adolescent Mental Health: A Focus on Psychiatric Counseling from the Emergency Room of an Italian University Hospital in the Five Years from 2019 to 2023

Recent studies have revealed increasingly worse and more complex mental health conditions in young people, which is reflected in a growing trend in emergency room (ER) visits for acute psychopathological symptoms (APSs). This phenomenon has become exacerbated in recent decades, with a peak in the post-pandemic period. To better characterize the phenomenon, we investigated the change in the rate and type of ER counseling requests provided at the Child Neuropsychiatry Unit of the University Hospital of Bari, Italy over the period between 2019 and 2023 for subjects younger than 18 years old. For this purpose, we retrospectively analyzed a total number of 1073 urgent consultation reports retrieved through the reporting computerized operating system of our hospital. The distribution of the counseling requests provided for APSs and, among these, the distribution of the numbers of APSs and of the male: female ratio were significantly different over the years, with an increasing linear trend identified for APSs (p = 3.095 × 10-7), the average number of APSs (p = 3.598 × 10-7), and female gender prevalence (p = 0.03908), as well as for the patients with a history of psychotropic drug assumption (p = 0.0006319). A significant change in the number of urgent counseling requests received for eating disorders (p = 0.0007408), depression (p = 7.92 × 10-8), somatization (p = 4.03 × 10-6), self-harm (SA) (p = 1.358 × 10-6), and non-suicidal self-injury (NSSI) (p = 8.965 × 10-6) was found, with a significant increasing trend for anxiety (p = 0.0444), depression (p = 8.06 × 10-6), somatization (p = 0.004616), SA (p = 3.998 × 10-8), and NSSI (p = 5.074 × 10-7). The findings of our study support the hypothesis of an alarming progressive worsening of the mental health of children and adolescents, with an overlapping effect of the pandemic exacerbating the process.

Global Otitis Media Incidence Changes During the COVID Pandemic: Systematic Review and Meta-Analysis

OBJECTIVE

The aim was to analyze the global impact of the COVID-19 pandemic and national lockdowns on the incidence of otitis media (OM), a common otolaryngologic disease.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

A systematic review and meta-analysis were performed using PRISMA reporting guidelines. OM incidence (measured as newly diagnosed OM cases over total patients seen over a time period), OM antibiotic prescriptions (OM cases for which antibiotics were prescribed over total OM cases), and tympanostomy tube surgeries (all tympanostomy tube surgeries over total surgical cases) were extracted. Meta-analysis of proportions and comparison of proportions were performed.

RESULTS

Of 1004 studies screened, 26 studies in 11 countries met inclusion criteria. The percentages of OM cases pre- and during-lockdown were 6.67%, 95% CI [4.68%, 8.99%], and 2.63% [2.02%, 3.31%], respectively, with an OR of 0.31 favoring during-lockdown [0.25, 0.39] (p < 0.00001). Antibiotic prescriptions per all OM episodes pre- and during-lockdown were 1.61% [0.17%, 8.46%] and 0.62% [0.07%, 3.32%], with an OR of 0.37 favoring during-lockdown ([0.35, 0.40], p < 0.00001). Tympanostomy tube surgery proportions pre- and during-lockdown were 31.64% [6.85%, 64.26%] and 29.99% [4.14%, 66.55%], with an OR of 0.94 favoring neither during- nor pre-lockdown [0.45, 2.00] (p = 0.88).

CONCLUSION

The incidence of OM decreased significantly following international lockdowns due to the COVID-19 pandemic, with antibiotic prescriptions for OM episodes showing a corresponding decrease. Despite these reductions, numbers of tympanostomy tube procedures did not change significantly. These reductions are likely due to social distancing, decreased exposure through high transmission facilities such as day cares, decreased health care utilization, and even possibly decreased air pollution. Laryngoscope, 134:2028-2037, 2024.

A Comparative Analysis of Pediatric Emergency Department Admissions Before and During the COVID-19 Pandemic

Objectives This study aims to evaluate the outbreak's impact on emergency services, with findings obtained from patients who applied to our pediatric emergency service before and during the pandemic period. Methods In this study, the Pediatric Emergency Polyclinic of Hatay Mustafa Kemal University (MKU) Department of Pediatrics was evaluated during the COVID-19 pre-pandemic period and the COVID-19 pandemic period. Demographic features, complaints, discharge situations, diagnostic groups, and diagnoses of 16,730 non-traumatic patients one month to 18 years old were compared retrospectively. Results Comparing the pre-pandemic period and the pandemic period, it was determined that there was a statistically significant difference in the average age of patients, age groups, admission hours, triage classification, complaints, and diagnoses seen. Conclusion According to the findings obtained in the study, pediatric emergency department admissions decreased significantly during the pandemic period. As a result of the pandemic measures taken, the incidence of diseases caused by infectious agents, such as respiratory tract infections, decreased. The change in pediatric emergency service habits with the pandemic highlights the importance of conducting more comprehensive epidemiological studies in terms of more efficient and effective use of pediatric emergency health services in Turkey.

Benralizumab in children with severe eosinophilic asthma: Pharmacokinetics and long-term safety (TATE study)

BACKGROUND

Benralizumab is an anti-interleukin-5 receptor α monoclonal antibody approved as an add-on maintenance treatment for patients with uncontrolled severe asthma. Prior Phase 3 studies have evaluated benralizumab in patients aged ≥12 years with severe uncontrolled asthma. The TATE study evaluated the pharmacokinetics (PK), pharmacodynamics (PD), and safety of benralizumab treatment in children.

METHODS

TATE was an open-label, Phase 3 study of benralizumab in children aged 6-11 years from the United States and Japan (plus participants aged 12-14 years from Japan) with severe eosinophilic asthma. Participants received benralizumab 10/30 mg according to weight (<35/≥35 kg). Primary endpoints included maximum serum concentration (Cmax ), clearance, half-life (t1/2 ), and blood eosinophil count. Clearance and t1/2 were derived from a population PK (popPK) analysis. Safety and tolerability were also assessed.

RESULTS

Twenty-eight children aged 6-11 years were included, with an additional two participants from Japan aged 12-14 years also included in the popPK analysis. Mean Cmax was 1901.2 and 3118.7 ng/mL in the 10 mg/<35 kg and 30 mg/≥35 kg groups, respectively. Clearance was 0.257, and mean t1/2 was 14.5 days. Near-complete depletion of blood eosinophils was shown across dose/weight groups. Exploratory efficacy analyses found numerical improvements in mean FEV1 , mean ACQ-IA, patient/clinician global impression of change, and exacerbation rates. Adverse events occurred in 22/28 (78.6%) of participants; none led to discontinuation/death.

CONCLUSION

PK, PD, and safety data support long-term benralizumab in children with severe eosinophilic asthma, and were similar to findings in adolescents and adults.

TRIAL REGISTRATION

ClinicalTrials.gov-ID: NCT04305405.

Impact of the COVID-19 Pandemic on Emergency Department Encounters in a Major Metropolitan Area

BACKGROUND

The end of 2019 marked the emergence of the COVID-19 pandemic. Public avoidance of health care facilities, including the emergency department (ED), has been noted during prior pandemics.

OBJECTIVE

This study described pandemic-related changes in adult and pediatric ED presentations, acuity, and hospitalization rates during the pandemic in a major metropolitan area.

METHODS

The study was a cross-sectional analysis of ED visits occurring before and during the pandemic. Sites collected daily ED patient census; monthly ED patient acuity, as the Emergency Severity Index (ESI) score; and disposition. Prepandemic ED visits occurring from January 1, 2019 through December 31, 2019 were compared with ED visits occurring during the pandemic from January 1, 2020 through March 31, 2021. The change in prepandemic and pandemic ED volume was found using 7-day moving average of proportions.

RESULTS

The study enrolled 83.8% of the total ED encounters. Pandemic adult and pediatric visit volume decreased to as low as 44.7% (95% CI 43.1-46.3%; p < 0.001) and 22.1% (95% CI 19.3-26.0%; p < 0.001), respectively, of prepandemic volumes. There was also a relative increase in adult and pediatric acuity (ESI level 1-3) and the admission percentage for adult (20.3% vs. 22.9%; p < 0.01) and pediatric (5.1% vs. 5.6%; p < 0.01) populations.

CONCLUSIONS

Total adult and pediatric encounters were reduced significantly across a major metropolitan area. Patient acuity and hospitalization rates were relatively increased. The development of strategies for predicting ED avoidance will be important in future pandemics.

Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022

OBJECTIVES

Boarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics.

METHODS

We performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018-02/2020), early pandemic (II, 03/2020-06/2021), COVID-19 variants (III, 07/2021-06/2022), and non-COVID respiratory viruses (IV, 07/2022-12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions.

RESULTS

Median PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report.

CONCLUSIONS

Since July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.

Assessing the Impact of the COVID-19 Pandemic on Pediatric Emergency Department Visits in Taiwan

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted healthcare systems worldwide. To assess the effects of the pandemic on pediatric emergency department (ED) visits in Taiwan, we conducted a study to evaluate changes in pediatric ED visits during the COVID-19 pandemic. Materials and Methods: This retrospective study included pediatric patients (age ≤ 18) who visited the ED between 21 January 2019 and 30 April 2019, at three hospitals of the Cathay Health System, and compared them with a corresponding period in 2020. Basic information, including mode of arrival, triage level, disposition, chief complaints, and incidence rates, were analyzed before and during the pandemic. Results: A total of 10,116 patients, with 6009 in the pre-pandemic group and 4107 in the pandemic group, were included in this study. The mean number of daily pediatric ED visits decreased from 60.09 before the pandemic to 40.66 during the pandemic, while ambulance use increased significantly by 2.56%. The percentage of patients with high acuity triage levels (levels 1 and 2) was significantly lower during the pandemic period (0.63% and 10.18%, respectively) than the pre-pandemic period (0.7% and 10.9%, respectively). Additionally, a significantly higher proportion of patients were discharged during the pandemic period (89.36%) than during the pre-pandemic period (88.33%). The proportion of COVID-19-related complaints, such as fever and respiratory tract infections, as well as other complaints including gastrointestinal issues, trauma, and psychological problems, significantly increased during the pandemic. Conclusions: In preparation for future pandemics, we recommend increasing emergency medical service capacity, establishing a non-contagious route for obtaining chronic medication prescriptions, optimizing staff allocation in pediatric emergency departments, and increasing the number of hospital social workers for enhanced support.

Child Health Needs and the Pediatric Emergency Medicine Workforce: 2020-2040

Approximately 30 million ill and injured children annually visit emergency departments (EDs) in the United States. Data suggest that patients seen in pediatric EDs by board-certified pediatric emergency medicine (PEM) physicians receive higher-quality care than those cared for by non-PEM physicians. These benefits, coupled with the continued growth in PEM since its inception in the early 1990s, have impacted child health broadly. This article is part of a Pediatrics supplement focused on predicting the future pediatric subspecialty workforce supply by drawing on the American Board of Pediatrics workforce data and a microsimulation model of the future pediatric subspecialty workforce. The article discusses the utilization of acute care services in EDs, reviews the current state of the PEM subspecialty workforce, and presents projected numbers of PEM subspecialists at the national, census region, and census division on the basis of this pediatric subspecialty workforce supply model through 2040. Implications of this model on education and training, clinical practice, policy, and future workforce research are discussed. Findings suggest that, if the current growth in the field of PEM continues on the basis of the increasing number and size of fellowship programs, even with a potential reduction in percentage of clinical time and attrition of senior physicians, the PEM workforce is anticipated to increase nationally. However, the maldistribution of PEM physicians is likely to be perpetuated with the highest concentration in New England and Mid-Atlantic regions and "PEM deserts" in less populated areas.

Unintentional pediatric poisonings before and during the COVID-19 pandemic: A population-based study

OBJECTIVES

The impact of coronavirus disease 2019 (COVID-19) on unintentional pediatric poisonings is unclear. We examined changes in emergency department (ED) visits and hospitalizations for poisonings before and during the COVID-19 pandemic. We compared changes in cannabis vs non-cannabis poisoning events given the recent legalization of cannabis in October 2018 and cannabis edibles in January 2020.

STUDY DESIGN

Interrupted time-series (ITS) analyses of changes in population-level ED visits and hospitalizations for poisonings in children aged 0-9 years in Ontario, Canada (annual population of 1.4 million children), over two time periods: pre-pandemic (January 2010-March 2020) and pandemic (April 2020-December 2021).

RESULTS

Overall, there were 28,292 ED visits and 2641 hospitalizations for unintentional poisonings. During the pandemic, poisonings per 100,000 person-years decreased by 14.6% for ED visits (40.15 pre- vs. 34.29 during) and increased by 35.9% for hospitalizations (3.48 pre- vs. 4.73 during). ED visits dropped immediately (Incidence Rate Ratio [IRR], 0.76; 95% CI, 0.70-0.82) at the onset of the pandemic, followed by a gradual return to baseline (quarterly change, IRR 1.04, 95%CI 1.03-1.06), while hospitalizations had an immediate increase (IRR 1.34; 95% CI, 1.08-1.66) and no gradual change. The only increase in poisonings was for cannabis which had a 10.7-fold for ED visits (0.45 to 4.83 per 100,000 person-years) and a 12.1-fold increase for hospitalizations (0.16 to 1.91 per 100,000 person-years). Excluding cannabis, there was no overall increase in poisoning hospitalizations.

CONCLUSIONS

The COVID-19 pandemic was not associated with increases in any type of unintentional pediatric poisonings, with the exception of cannabis poisonings. Increased cannabis poisonings may be explained by the legalization of non-medical cannabis edibles in Canada in January 2020.

Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic

IMPORTANCE

Urinary tract infection (UTI) is common in children, but the population incidence is largely unknown. Controversy surrounds the optimal diagnostic criteria and how to balance the risks of undertreatment and overtreatment. Changes in health care use during the COVID-19 pandemic created a natural experiment to examine health care use and UTI diagnosis and outcomes.

OBJECTIVES

To examine the population incidence of UTI in children and assess the changes of the COVID-19 pandemic regarding UTI diagnoses and measures of UTI severity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational cohort study used US commercial claims data from privately insured patients aged 0 to 17 years from January 1, 2016, to December 31, 2021.

EXPOSURE

Time periods included prepandemic (January 1, 2016, to February 29, 2020), early pandemic (April 1 to June 30, 2020), and midpandemic (July 1, 2020, to December 31, 2021).

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of UTI, defined as having a UTI diagnosis code with an accompanying antibiotic prescription. Balancing measures included measures of UTI severity, including hospitalizations and intensive care unit admissions. Trends were evaluated using an interrupted time-series analysis.

RESULTS

The cohort included 13 221 117 enrollees aged 0 to 17 years, with males representing 6 744 250 (51.0%) of the population. The mean incidence of UTI diagnoses was 1.300 (95% CI, 1.296-1.304) UTIs per 100 patient-years. The UTI incidence was 0.86 per 100 patient-years at age 0 to 1 year, 1.58 per 100 patient-years at 2 to 5 years, 1.24 per 100 patient-years at 6 to 11 years, and 1.37 per 100 patient-years at 12 to 17 years, and was higher in females vs males (2.48 [95% CI, 2.46-2.50] vs 0.180 [95% CI, 0.178-0.182] per 100 patient-years). Compared with prepandemic trends, UTIs decreased in the early pandemic: -33.1% (95% CI, -39.4% to -26.1%) for all children and -52.1% (95% CI, -62.1% to -39.5%) in a subgroup of infants aged 60 days or younger. However, all measures of UTI severity decreased or were not significantly different. The UTI incidence returned to near prepandemic rates (-4.3%; 95% CI, -32.0% to 34.6% for all children) after the first 3 months of the pandemic.

CONCLUSIONS AND RELEVANCE

In this cohort study, UTI diagnosis decreased during the early pandemic period without an increase in measures of disease severity, suggesting that reduced overdiagnosis and/or reduced misdiagnosis may be an explanatory factor.

An evaluation of pediatric emergency cases in the first year of the COVID-19 pandemic: A single-centre experience

AIM

Nurses responsible for the care of children in the emergency department must be aware of the case profile of the pandemic era, better prepare for developing crises, and identify preventive services. The study aims to determine the pediatric emergency cases admitted during the pandemic and compare them to those during the pre-pandemic period.

METHODS

The current study was designed as a single-center, retrospective, cross-sectional, and descriptive research. All patients aged between 0 and 18 who presented to the pediatric emergency department and had electronic patient records were included in the research population. The data were gathered over two periods: the pre-pandemic period from 2019 to 2020 and the pandemic period from 2020 to 2021. A total of 145,591 patient records were analyzed.

RESULTS

The number of admissions declined by 51.6% during the pandemic, and a noticeable difference in the reasons for emergency department visits (p = 0.001) was detected. The pandemic saw a decrease in the cases of respiratory, gastrointestinal diseases, and ear, nose, and throat problems. In contrast, there was an increase in the cases of musculoskeletal system diseases, infections, falls, traumas, and neonatal problems.

CONCLUSION

The number of pediatric emergency cases decreased significantly during the pandemic, and compared to the pre-pandemic period, some changes in these cases were observed.

PRACTICAL IMPLICATIONS

Particular attention should be given to ensuring that mothers of newborn infants receive adequate nursing care. Nurses working in the emergency department should keep their knowledge up-to-date regarding the changing health issues specific to the pandemic period.

Changes in Bronchiolitis Characteristics During the COVID-19 Pandemic: A Description of Pediatric Emergency Department Visits in a Community Hospital, 2019-2021

A retrospective, cross-sectional study of children with bronchiolitis aged 1 to 24 months during an ED visit between 2019 and 2021 was performed. Chi-square or Kruskal-Wallis was used to compare groups. The gamma coefficient was used to measure the association of variables through time. Bronchiolitis cases decreased by 75% from 2019 to 2020 and rose back to prepandemic levels by 2021. Radiographs (gamma -0.443), steroids (gamma -0.298), and bronchodilators (gamma -0.414) decreased during the study period (P < .001). Laboratory studies (gamma 0.032), viral testing (gamma 0.097), antibiotic use (gamma -0.069), and respiratory support (gamma 0.166) were unchanged. The decrease in steroids and bronchodilators was related to a clinical pathway that discouraged their use. Respiratory support remained unchanged. The COVID-19 pandemic (2019-2021) seems to have had little effect on the severity or resource utilization associated with bronchiolitis but may have unraveled a potential bronchiolitis phenotype that may have been more prominent during the pandemic.

COVID-19 and Caregiver Risk Factors for Child Maltreatment: The Pandemic in Review

The COVID-19 pandemic has fostered an environment for increased risk of child maltreatment (CM) as families experience increased psychosocial and financial burdens and spend unprecedented amounts of time together in the home. This narrative review aimed to summarize empirical findings on existing or new pandemic-related risk factors among caregivers. A combination of search terms related to CM and COVID-19 were used to identify articles published within five databases between February 2020 and July 2022. Literature searches produced 113 articles, of which 26 published across 12 countries met inclusion criteria. Four previously well-established risk factors for CM perpetration continued to persist during the pandemic, including stress, parental mental health, financial concerns, and parental substance use. Of note, inconsistent definitions and measures were used to capture these risk factors. Several additional emerging and understudied risk factors were also identified among limited articles, such as food insecurity and parental education. Findings emphasize the ongoing need for evidence-based interventions to address CM risk during the pandemic, including parent training programs. However, consolidated measures and consistent conceptualization of risk factors are needed to advance the study of CM. Going forward, practitioners and researchers should (a) strengthen the identification process for families at greatest risk for CM, and particularly those vulnerable to pandemic-related stressors; and (b) augment delivery of CM prevention strategies and evidence-based programs to fit the pandemic context.

Effects of the coronavirus disease outbreak on the development of neurological disorders in children: A comparison of the incidence of febrile seizure and epilepsy using an interrupted time-series approach

BACKGROUND

With the outbreak of COVID-19, school closures and quarantines following social distancing have brought significant changes to children's lifestyles. Therefore, we aimed to compare the population-adjusted incidence of febrile seizures(FS) and epilepsy before and after the COVID-19 outbreak in Korea and to assess the effects of the COVID-19 outbreak on the incidence by region and age group.

METHODS

A retrospective cohort study was conducted using nationwide claims data and covid data from January 2019 to December 2020. The incidence of diseases and difference in incidence before (Jan 20 to Dec 30, 2019) and after (Jan 20 to Dec 30, 2020) the COVID-19 outbreak was measured using rate ratio. An Interrupted time series analysis was used to identify the effect of COVID-19 on trends of FS and epilepsy. Subgroup analysis by age, sex, insurance, and risk of coronavirus by area were conducted.

RESULTS

Following the onset of the pandemic, the number of newly diagnosed FS cases decreased sharply by 69 % (24,182 to 7238), whereas the incidence of epilepsy, increased to 1.02 times (30,286-29,312), when adjusted in proportion to the population. Notably, a greater decrease in the incidence of FS were found in the regions with high-risk of coronavirus. A result of segmented regression analysis proved the decrease was significant and made immediately after the pandemic started(p < 0.001). In contrast to the incidence of FS, that of epilepsy did not exhibit a significant month-to-month change during the baseline period, immediately after the pandemic started, and during the pandemic.

CONCLUSIONS

The COVID-19 outbreak and resulting social distancing measures reduced the incidence of febrile seizure immediately rather than gradually. Unlike in the case of acute febrile seizure, the COVID-19 pandemic had no effect on the incidence of chronic epilepsy.

Parents' perspective on pediatric emergency department visits for low-acuity conditions before and during the COVID-19 pandemic: a cross-sectional bicentric study

OBJECTIVES

The primary objective of this study was to describe and compare the motivation of parents/guardians to bring children with low-acuity conditions to a tertiary-care pediatric emergency department (ED) versus a clinic before and after the pandemic. The secondary objectives were to describe and compare the demographic and clinical characteristics of the population studied and the impact of the pandemic on their access to primary care services.

METHODS

This is a cross-sectional study based on a survey administered to parents/guardians of patients presenting with low-acuity conditions at one of two EDs.

RESULTS

The respondents numbered 659. Children were brought to a pediatric ED generally because of the perceived urgency of the condition, the presumed resource availability in the pediatric ED and the unavailability of the primary care physician. However, most respondents (n = 438, 66.5%) indicated preference for a clinic. More respondents before than during the pandemic reported they had been unable to find a doctor outside the ED (48.6% before COVID vs 26.8% during COVID, p < 0.001) but patients during the pandemic were less likely to seek care in a primary care practice or walk-in clinic (30.0% during COVID vs 48.6% before COVID, p < 0.001). In addition, the number of respondents presenting with symptoms of infection decreased by more than half after the pandemic began while the proportion of musculoskeletal and psychiatric complaints doubled.

CONCLUSION

Although the pandemic has altered the landscape of presenting complaints and pediatric healthcare-seeking behaviors, most respondents indicated they would prefer to receive care in a clinic. This finding contradicts the view that most pediatric ED visits for low-acuity conditions are by choice rather than perceived necessity. Prioritizing improved access to primary care resources would better address the preferences and expectations of parents/guardians.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic

BACKGROUND

Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic.

METHODS

This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020.

RESULTS

The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019.

CONCLUSIONS

The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

ED Visits for Schizophrenia Spectrum Disorders During the COVID-19 Pandemic at 5 Campus Health Systems

Importance

Although substantial research has reported grave population-level psychiatric sequelae of the COVID-19 pandemic, evidence pertaining to temporal changes in schizophrenia spectrum disorders in the US following the pandemic remains limited.

Objective

To examine the monthly patterns of emergency department (ED) visits for schizophrenia spectrum disorders after the onset of the COVID-19 pandemic.

Design, Setting, and Participants

This observational cohort study used time-series analyses to examine whether monthly counts of ED visits for schizophrenia spectrum disorders across 5 University of California (UC) campus health systems increased beyond expected levels during the COVID-19 pandemic. Data included ED visits reported by the 5 UC campuses from 2016 to 2021. Participants included persons who accessed UC Health System EDs had a diagnosis of a psychiatric condition. Data analysis was performed from March to June 2023.

Exposures

The exposures were binary indicators of initial (March to May 2020) and extended (March to December 2020) phases of the COVID-19 pandemic.

Main Outcomes and Measures

The primary outcome was monthly counts of ED visits for schizophrenia spectrum disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes, categorized within Clinical Classification Software groups, were used to identify ED visits for schizophrenia spectrum disorders and all other psychiatric ED visits, from the University of California Health Data Warehouse database, from January 2016 to December 2021. Time-series analyses controlled for autocorrelation, seasonality, and concurrent trends in ED visits for all other psychiatric conditions.

Results

The study data comprised a total of 377 872 psychiatric ED visits, with 37 815 visits for schizophrenia spectrum disorders. The prepandemic monthly mean (SD) number of ED visits for schizophrenia spectrum disorders was 519.9 (38.1), which increased to 558.4 (47.6) following the onset of the COVID-19 pandemic. Results from time series analyses, controlling for monthly counts of ED visits for all other psychiatric conditions, indicated 70.5 additional ED visits (95% CI, 11.7-129.3 additional visits; P = .02) for schizophrenia spectrum disorders at 1 month and 74.9 additional visits (95% CI, 24.0-126.0 visits; P = .005) at 3 months following the initial phase of the COVID-19 pandemic in California.

Conclusions and Relevance

This study found a 15% increase in ED visits for schizophrenia spectrum disorders within 3 months after the initial phase of the pandemic in California across 5 UC campus health systems, underscoring the importance of social policies related to future emergency preparedness and the need to strengthen mental health care systems.

The Impact of the COVID-19 Shelter-in-Place Order on Traumatic Brain Injuries in San Francisco, California

BACKGROUND

In response to the COVID-19 pandemic, San Francisco, California issued a shelter-in-place (SIP) order in March 2020, during which emergency physicians noted a drop in trauma cases, as well as a change in traditional mechanisms of trauma.

OBJECTIVES

Our objective was to determine the epidemiology of traumatic brain injury (TBI) pre- and post-COVID-19 SIP.

METHODS

We reviewed the electronic medical record of the only trauma center in the city of San Francisco, to determine the number of and characteristics of patients with a diagnosis of head injury presenting to the emergency department between December 16, 2019 and June 16, 2020. Using chi-squared and Fisher's exact tests when appropriate, we compared pre- and post- COVID-19 lockdown epidemiology.

RESULTS

There were 1246 TBI-related visits during the 6-month study period. Bi-weekly TBI cases decreased by 36.64% 2 weeks after the COVID-19 SIP and then increased to near baseline levels by June 2020. TBI patients during SIP were older (mean age: 53.3 years pre-SIP vs. 58.2 post-SIP; p < 0.001), more likely to be male (odds ratio 1.43, 95% confidence interval 1.14-1.81), and less likely to be 17 or younger (8.9% vs. 0.5%, pre- to post-SIP respectively, p = 0.003). Patients were less likely to be Hispanic (27.2% vs. 21.7% pre- to post-SIP, respectively, p = 0.029). The proportion of TBI visits attributable to cycling accidents increased (14.1% to 52.7%, p < 0.001), whereas those attributable to pedestrians involved in road traffic accidents decreased (37.2% to 12.7%, p = 0.003).

CONCLUSIONS

Understanding the changing epidemiology of TBI during the COVID-19 pandemic can aid in immediate and future disaster resource planning.

Hospital Admissions for Abusive Head Trauma Before and During the COVID-19 Pandemic

Importance

Several studies have demonstrated a decrease in the occurrence of child abuse in the US since the start of the COVID-19 pandemic. This finding has generated concern for missed cases due to the initial lockdowns and lack of childcare resources. Determining the association of the pandemic on hospitalizations for severe forms of abuse is essential to focus preventive efforts.

Objective

To examine trends in abusive head trauma (AHT) before and during the COVID-19 pandemic.

Design, Setting, and Participants

Retrospective, multicenter, repeated cross-sectional study, conducted January 1, 2016, through April 30, 2022, with data from tertiary care children's hospitals and contributors to the Pediatric Health Information System. Data were obtained for 2380 hospitalizations of children younger than 5 years with International Classification of Diseases, Tenth Revision, Clinical Modification codes for both abuse and head trauma.

Main Outcomes and Measures

Monthly hospitalizations were analyzed using interrupted time-series analysis. Hospitalization severity (eg, intensive care unit stay) and clinical characteristics (subdural hemorrhages and retinal hemorrhages) were compared before and after the start of the pandemic.

Results

We identified 2380 hospitalizations due to AHT (median age, 140 [IQR, 75.0-325.5] days) from 45 hospitals. The mean (SD) monthly incidence of AHT was 34.3 (5.8) before the COVID-19 pandemic compared with 25.6 (4.2) during COVID-19 (a 25.4% decrease). When the pre-COVID-19 and during COVID-19 periods were compared, there were no significant differences in severity or clinical characteristics. On interrupted time-series analysis, there was a significant decrease in the number of monthly hospitalizations (-8.1; 95% CI, -12.41 to -3.72; P < .001) in the first month of the pandemic. In the subgroup of children younger than 1 year, there was a significant decrease in monthly hospitalizations at the onset of the pandemic (-8.2; 95% CI, -12.02 to -4.43; P < .001) followed by a significant temporal increase across the COVID-19 period (P = .01).

Conclusions and Relevance

The findings of this cross-sectional study suggest there was a significant decrease in monthly hospitalizations for AHT following the start of the pandemic in March 2020. Although there was no corresponding increase in hospitalization severity, the decrease during the pandemic may have been transient, as monthly hospitalizations for children younger than 1 year increased significantly over time during COVID-19, after the initial decrease.

Management of Pediatric Foreign Body Injuries during the COVID-19 Pandemic: Results of an International Survey

The COVID-19 pandemic has had direct and indirect effects on daily life. In hospitals, the impact of the pandemic was observed in the diagnostic and therapeutic workflow. In this work, we explored potential changes in activities related to the treatment of foreign body injuries (FBIs) in children and the behavioral habits of physicians during the first wave of the pandemic. An online survey was conducted among physicians of the Susy Safe network. The survey comprised items related to respondent information, reference center characteristics, the treatment of FBIs during the COVID-19 pandemic, and a modified COVID-19 Anxiety Scale (CAS). The survey was distributed among the Susy Safe project international network surveillance registry for FBIs. A total of 58 physicians responded to the survey, including 18 (32%) from Europe and 16 (28%) from South America. The respondents indicated that the estimated number of aspirated foreign bodies during the pandemic was lower than or the same as that before the pandemic (43, 74%), and the same was observed for ingested foreign bodies (43, 74%). In univariable logistic regression, no single predictor was associated with a delay in routine care for children or an increasing tendency of medical personnel to avoid procedures. The workflow of physicians involved in the management of FBIs in children has not changed drastically during the COVID-19 pandemic, especially in emergency departments.

High-Risk Markers and Infection Rates in Febrile Infants Aged 29 to 60 Days Presenting to an Emergency Department During the COVID-19 Pandemic

OBJECTIVES

There was an overall decline in pediatric emergency department visits during the COVID-19 pandemic. Caregivers are educated to bring febrile neonates promptly to the emergency department; however, for infants aged 29 to 60 days, there may not be the same urgency especially during a pandemic. There may have been a resultant change in the clinical and laboratory high-risk markers and infection rates in this patient population during the pandemic.

METHODS

This was a single-center retrospective cohort study of infants aged 29 to 60 days presenting to the emergency department of an urban tertiary care children's hospital because of fever (>38°C) between March 11 and December 31, 2020, compared with those presenting in the same period during the 3 prior years (2017 through 2019). Patients were categorized as having high-risk criteria on a predetermined definition of ill appearance, white blood cell count, and urinalysis based on our hospital's evidence-based pathway. Information on infection type was also collected.

RESULTS

A total of 251 patients were included in the final analysis. Comparison of the prepandemic and pandemic cohorts showed a significant increase in the proportion of patients with urinary tract infections ( P = 0.017) and bacteremia ( P = 0.02) and those presenting with high-risk white blood cell count ( P = 0.028) and urinalysis ( P = 0.034). There was no significant difference in patient demographics or in high-risk ill appearance ( P = 0.208).

CONCLUSIONS

This study demonstrates a significant increase in the rates of urinary tract infection and bacteremia in addition to the objective markers used to risk-stratify febrile infants aged 29 to 60 days. This supports the need for attentiveness in evaluating these febrile infants in the emergency department.

The changing virology and trends in resource utilization for bronchiolitis since COVID-19

BACKGROUND

Bronchiolitis is a viral respiratory illness most commonly caused by respiratory syncytial virus (RSV). COVID-19 disrupted typical patterns of viral transmission. Our study aimed to compare low value care for bronchiolitis in a tertiary emergency department (ED) in the United States from March 2017 to March 2022.

METHODS

This was a descriptive cohort study through a retrospective chart review from 2017 to 2022 analyzing ED visits for bronchiolitis including disposition, disease severity, chest radiographs, albuterol, and high flow nasal cannula usage. A year was a 12-month period from March to February.

RESULTS

From 2017 to 2020, there were over 2000 ED visits for bronchiolitis per year (3.1% of all ED visits), which decreased to 450 visits for bronchiolitis (1%) in 2020-2021. Human rhino/enterovirus was the most common virus detected (92%) at that time, and admission rates, albuterol, high flow nasal cannula, and chest radiographs were all higher. The summer of 2021 had the highest visits across the 5-study years with a return to previous rates of resource utilization.

CONCLUSIONS

Bronchiolitis ED visits due to RSV dramatically reduced during the first year of the COVID-19 pandemic in 2020, with over 80% reduction in bronchiolitis visits from 2018 to 2019. While all ED visits fell in 2020, the proportion of visits due to bronchiolitis also decreased. There was an increase in lower value care during the rhinovirus dominant, low census period. As restrictions lifted in 2021, there was a large resurgence of RSV in the atypical summer months with a return of previous rates of resource utilization.

Critical Revisits Among Children After Emergency Department Discharge

STUDY OBJECTIVE

Identifying higher risk groups could reveal ways to prevent critical emergency department (ED) revisits. The study objectives were to determine the rate of critical ED revisits among children discharged from the ED and to identify factors associated with critical revisits.

METHODS

We performed a retrospective study using the Healthcare Cost and Utilization Project State ED Databases (SEDD) and the State Inpatient Databases (SID). We included data from 6 states from 2014 through 2017. Critical ED revisit was defined as either ICU admission or death within 3 days of the initial ED discharge. We included all patients younger than 21 years. The main outcome was the rate of critical ED revisit. We also determined the relative risk (RR) of a critical ED revisit for the most common index ED visit diagnoses. We used negative binomial regression to calculate incidence rate ratios (IRR) of a critical ED visit by pediatric volume and complex chronic conditions.

RESULTS

A total of 16.3 million children were discharged from an ED over the 4-year study period. There were 18,704 (0.1%) critical ED revisits, 180 (0.00001%) of whom died. Asthma (RR 2.24, 95% confidence interval [CI] [2.11 to 2.38) had the highest relative risk of a critical revisit among all ED diagnoses. Adjusting for hospital volume and patient age, patients with complex chronic conditions were also more likely to have a critical ED revisit (IRR 11.03, 95% CI, 7.76 to 15.67).

CONCLUSIONS

Critical revisits after ED discharge were uncommon among children in our study sample, with revisits resulting in patient death within 3 days of an ED discharge being rare. Given the short time interval between ED discharges, however, future research should focus on understanding higher risk patients among those with asthma and a history of complex chronic conditions.

Inter-hospital Variation in COVID-19 Era Pediatric Hospitalizations by Age Group and Diagnosis

BACKGROUND

Mitigation strategies and public responses to coronavirus disease 2019 (COVID-19) varied geographically and may have differentially affected burden of pediatric disease and hospitalization practices. We aimed to quantify hospital-specific variation in hospitalizations during the COVID-19 era.

METHODS

Using Pediatric Health Information Systems data from 44 Children's Hospitals, this retrospective multicenter analysis compared hospitalizations of children (1 day-17 years) from the COVID-19 era (March 1, 2020-June 30, 2021) to prepandemic (January 1, 2017-December 31, 2019). Variation in the magnitude of hospital-specific decline between eras was determined using coefficients of variation (CV). Spearman's test was used to assess correlation of variation with community and hospital factors.

RESULTS

The COVID-19 era decline in hospitalizations varied between hospitals (CV 0.41) and was moderately correlated with declines in respiratory infection hospitalizations (r = 0.69, P < .001). There was no correlation with community or hospital factors. COVID-19 era changes in hospitalizations for mental health conditions varied widely between centers (CV 2.58). Overall, 22.7% of hospitals saw increased admissions for adolescents, and 29.5% saw increases for newborns 1 to 14 days, representing significant center-specific variation (CV 2.30 for adolescents and 1.98 for newborns).

CONCLUSIONS

Pandemic-era change in hospitalizations varied across institutions, partially because of hospital-specific changes in respiratory infections. Residual variation exists for mental health conditions and in groups least likely to be admitted for respiratory infections, suggesting that noninfectious conditions may be differentially and uniquely affected by local policies and hospital-specific practices enacted during the COVID-19 era.

Assessing timeline delays associated with utilization of ultrasound diagnostics in paediatric acute scrotum, pre and per COVID-19 pandemic

INTRODUCTION

Acute scrotum is a common presentation in the pediatric population and can indicate serious conditions such as testicular torsion, in which quick diagnosis and treatment is crucial for increasing the chances of a favorable outcome. During the COVID-19 pandemic, even patients with serious conditions, had delayed presentations and in-hospital management, resulting in worse outcomes.

OBJECTIVE

The aim of the study was to evaluate the safety of ultrasound in diagnosing pediatric acute scrotum and to identify delays from onset of symptoms until surgical exploration. Additionally, we wanted to gauge the impact of COVID-19 pandemic on delay and outcome.

METHODS

Medical records of patients aged 1-16 years seen with acute scrotum at the authors' University Hospital from 2017 to 2020 were reviewed, and 438 patients in 467 individual visits were included. Information on demographics, symptoms, ultrasound results, outcome, and time courses were retrieved and analyzed with regards to outcome and the presence COVID-19.

RESULTS

We did not find the use of ultrasound to increase the risk of orchiectomy (OR 2.259 (0.387-13.195)), however patients undergoing ultrasound had a significantly longer pre-hospital ischemia time, and therefore an increased orchiectomy rate. Delay between referral and presentation was the greatest predictor of orchiectomy in testicular torsion (OR 1.031 (1.003-1.060)), while in-hospital delay did not increase the risk of orchiectomy (OR 0.998 (0.992-1.004)). Time courses and outcome did not significantly differ before- and during the COVID-19 pandemic.

DISCUSSION

The primary contributor to ischemic time in testicular torsion was pre-hospital delay, and neither in-hospital delay nor the delay incurred by use of ultrasound affected the outcome. This might be explained by timely in-hospital management and ultrasound only being used selectively in patients with a lower clinical suspicion of testicular torsion and in those with prolonged symptom duration. During the COVID-19 pandemic, pre- and in-hospital delay as well as outcome did not differ significantly from pre-pandemic measures, which indicates that parents felt safe approaching the healthcare system, and resources were sufficient to handle this patient group in spite of an ongoing pandemic. The current study is limited by its retrospective design, and relatively small group of testicular torsion patients.

CONCLUSION

We found ultrasound to be safe in diagnosing pediatric acute scrotum. Furthermore, it can be inferred that measures aimed at reducing pre-hospital delay could potentially increase the salvage rate in testicular torsion. We did not find COVID-19 to affect either outcome or time to treatment in testicular torsion.

Electronic health records identify timely trends in childhood mental health conditions

BACKGROUND

Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research.

METHODS

In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms.

RESULTS

The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories.

CONCLUSIONS

These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.

The impact of COVID-19 pandemic on revisits to emergency department

AIM

This study presents the impact of COVID-19 on revisits to the emergency department comparing revisit rates and characteristics between the pre-COVID-19 and COVID-19 periods.

METHODS

This multi-center retrospective study included patients over 18 years of age who visited emergency departments during the pre-COVID-19 period and the COVID-19 pandemic. The revisit rates were analyzed according to five age groups; 18-34, 35-49, 50-64, 65-79, and ≥ 80 years, and three revisit time intervals; 3, 9, and 30 days. Also, we compared the diagnosis and disposition at revisit between the study periods.

RESULTS

The revisit rates increased with age in both study periods and the revisit rates among all age groups were higher in the COVID-19 period. The proportion of infectious and respiratory diseases decreased during the COVID-19 period. The ICU admission rate and mortality at the revisit among patients aged ≥ 80 years were lower in the COVID-19 period than in the pre-COVID-19 period.

CONCLUSION

The revisit rates increased with age in both study periods and there were several changes in the diagnosis and disposition at the revisit in the COVID-19 period.

Comparison of Trauma and Burn Evaluations in a Pediatric Emergency Department During Pre, Early and Late COVID-19 Pandemic

BACKGROUND

Pediatric trauma epidemiology altered during early COVID-19 pandemic period but the impact of the ongoing pandemic is unknown.

OBJECTIVES

To compare pediatric trauma epidemiology between the pre, early and late pandemic periods and to evaluate the association of race and ethnicity on injury severity during the pandemic.

METHODS

We performed a retrospective study of trauma consults for an injury/burn in children ≤16 years between January 1, 2019 and December 31, 2021. Study period was categorized into pre (January 1, 2019-February 28, 2020), early (March 1, 2020-December 31, 2020), and late (January 1, 2021-December 31, 2021) pandemic. Demographics, etiology, injury/burn severity, interventions and outcomes were noted.

RESULTS

A total of 4940 patients underwent trauma evaluation. Compared to pre-pandemic, trauma evaluations for injuries and burns increased during both the early (RR: 2.13, 95% CI: 1.6-2.82 and RR: 2.24, 95% CI: 1.39-3.63, respectively) and late pandemic periods (RR: 1.42, 95% CI: 1.09-1.86 and RR: 2.44, 95% CI: 1.55-3.83, respectively). Severe injuries, hospital admissions, operations and death were higher in the early pandemic but reverted to pre-pandemic levels during late pandemic. Non-Hispanic Blacks had an approximately 40% increase in mean ISS during both pandemic periods though they had lower odds of severe injury during both pandemic periods.

CONCLUSIONS

Trauma evaluations for injuries and burns increased during the pandemic periods. There was a significant association of race and ethnicity with injury severity which varied with pandemic periods.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Emergency Department Use by Young Adults With Chronic Illness Before and During the COVID-19 Pandemic

INTRODUCTION

There was a significant decrease in emergency department encounters during the COVID-19 pandemic. Our large urban emergency department observed decreased encounters and admissions by youths with chronic health conditions. This study aimed to compare the frequency of emergency department encounters for certain young adults before the pandemic and during the COVID-19 pandemic.

METHODS

A retrospective cohort study using medical records of patients ages 20 to 26 years from October 2018 to September 2019 and February 2020 to February 2021. Files set for inclusion were those with a primary diagnosis of human immunodeficiency virus, diabetes mellitus, epilepsy, cerebral palsy, sickle cell disease, asthma, and certain psychiatric disorders for potentially preventable health events.

RESULTS

We included 1203 total encounters (853 before the pandemic and 350 during the pandemic), with the total number of subjects included in the study 568 (293 before the pandemic to 239 during the pandemic). During the pandemic, young adults with mental health conditions (53.1%) accounted for most encounters. Encounters requiring hospital admissions increased from 27.4% to 52.5% during the pandemic, primarily among patients with diabetes (41.8% vs 61.1%) and mental health conditions (50% vs 73.3%).

DISCUSSION

The number of young adults with certain chronic health conditions decreased during COVID-19, with encounters for subjects with mental health conditions increasing significantly. The proportion of admissions increased during the pandemic with increases for subjects with mental health disorders and diabetes. The number of frequent users decreased during COVID-19. Future research is needed to understand better the causes for these disparities in young adults with chronic conditions who use the emergency department as a source of care.

Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline

BACKGROUND

Left without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended.

OBJECTIVE

We assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS.

METHODS

We performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively.

RESULTS

Mean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am.

CONCLUSIONS

LWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.

Psychiatric Boarding Patterns Among Publicly Insured Youths Evaluated by Mobile Crisis Teams Before and During the COVID-19 Pandemic

Importance

Psychiatric boarding occurs when patients needing intensive psychiatric services who are already under clinical supervision experience delays in their admission to psychiatric facilities. Initial reports have suggested that the US had a psychiatric boarding crisis during the COVID-19 pandemic; however, little is known about the consequences of this crisis for publicly insured youths.

Objective

To estimate pandemic-associated changes in psychiatric boarding rates and discharge modalities for people aged 4 to 20 years who accessed psychiatric emergency services (PES) through a mobile crisis team (MCT) evaluation and were covered by Medicaid or health safety net programs.

Design, Setting, and Participants

This retrospective cross-sectional study used data from the MCT encounters of a multichannel PES program in Massachusetts. A total of 7625 MCT-initiated PES encounters with publicly insured youths who lived in Massachusetts between January 1, 2018, and August 31, 2021, were assessed.

Main Outcomes and Measures

Encounter-level outcomes (psychiatric boarding status, repeat visits, and discharge disposition) during a prepandemic period (January 1, 2018, to March 9, 2020) were compared with outcomes during a pandemic period (March 10, 2020, to August 31, 2021). Descriptive statistics and multivariate regression analysis were used.

Results

Among 7625 MCT-initiated PES encounters, the mean (SD) age of publicly insured youths was 13.6 (3.7) years; most youths identified as male (3656 [47.9%]), were of Black race (2725 [35.7%]) or Hispanic ethnicity (2708 [35.5%]), and spoke English (6941 [91.0%]). During the pandemic period, the mean monthly boarding encounter rate was 25.3 percentage points higher than the prepandemic period. After adjustment for covariates, the odds of an encounter resulting in boarding doubled during the pandemic (adjusted odds ratio [AOR], 2.03; 95% CI, 1.82-2.26; P < .001), and boarding youths were 64% less likely to be discharged to inpatient psychiatric care (AOR, 0.36; 95% CI, 0.31-0.43; P < .001). Publicly insured youths who boarded during the pandemic had significantly higher rates of 30-day readmissions (incidence rate ratio, 2.17; 95% CI, 1.88-2.50; P < .001). Boarding encounters during the pandemic were significantly less likely to end in discharge to inpatient psychiatric units (AOR, 0.36; 95% CI, 0.31-0.43; P < .001) or community-based acute treatment facilities (AOR, 0.70; 95% CI, 0.55-0.90; P = .005).

Conclusions and Relevance

In this cross-sectional study, publicly insured youths were more likely to experience psychiatric boarding during the COVID-19 pandemic and, if boarding, were less likely to transfer to a 24-hour level of care. These findings suggest that psychiatric service programs for youths were not prepared to support the levels of acuity and demand that emerged from the pandemic.

Development of a Model to Identify Febrile Children at Low Risk for Multisystem Inflammatory Syndrome

OBJECTIVES

The case definition for multisystem inflammatory syndrome in children (MIS-C) is broad and encompasses symptoms and signs commonly seen in children with fever. Our aim was to identify clinical predictors that, independently or in combination, identify febrile children presenting to the emergency department (ED) as low risk for MIS-C.

METHODS

We conducted a retrospective single-center study of otherwise healthy children 2 months to 20 years of age presenting to the ED with fever and who had a laboratory evaluation for MIS-C between April 15, 2020, and October 31, 2020. We excluded children with a diagnosis of Kawasaki disease. Our outcome was an MIS-C diagnosis defined by the Centers for Disease Control and Prevention criteria. We conducted multivariable logistic regression analyses to identify variables independently associated with MIS-C.

RESULTS

Thirty-three patients with and 128 patients without MIS-C were analyzed. Of those with MIS-C, 16 of 33 (48.5%) had hypotension for age, signs of hypoperfusion, or required ionotropic support. Four variables were independently associated with the presence of MIS-C; known or suspected SARS CoV-2 exposure (adjusted odds ratio [aOR], 4.0; 95% confidence interval [CI], 1.4-11.9) and the following 3 symptoms and signs: abdominal pain on history (aOR, 4.8; 95% CI, 1.7-15.0), conjunctival injection (aOR, 15.2; 95% CI, 5.4-48.1), and rash involving the palms or soles (aOR, 12.2; 95% CI, 2.4-69.4). Children were at low risk of MIS-C if none of the 3 symptoms or signs were present (sensitivity 87.9% [95% CI, 71.8-96.6]; specificity 62.5% [53.5-70.9], negative predictive value 95.2% [88.3-98.7]). Of the 4 MIS-C patients without any of these 3 factors, 2 were ill-appearing in the ED and the other 2 had no cardiovascular involvement during their clinical course.

CONCLUSIONS

A combination of 3 clinical symptoms and signs had moderate to high sensitivity and high negative predictive value for identifying febrile children at low risk of MIS-C. If validated, these factors could aid clinicians in determining the need to obtain or forego an MIS-C laboratory evaluation during SARS-CoV-2 prevalent periods in febrile children.

The impact of a novel policy for pediatric mental health patients in the emergency department

OBJECTIVES

Pediatric mental health presentations continue to increase across the US. These patients often board for significant periods of time and may require more resources than other acute non-mental health patients. This has important implications for the overall function of the emergency department (ED) as well as care of all ED patients.

METHODS

This study evaluated a policy developed to allow for inpatient hospital admission when 30% of the ED was occupied by boarding patients at a tertiary care children's hospital.

RESULTS

We found an increase in the number of patients for whom this policy applied, and increased days/month this policy was executed over time. There was an increase in the average ED LOS and left without being seen rate during this time which we hypothesize would have been higher without this policy.

CONCLUSIONS

A hospital policy allowing mental health patients to be admitted to the inpatient hospital once stabilized has the potential to improve ED flow and functionality.

Visits to Alberta Emergency Departments for Child Mental Health Concerns During the COVID-19 Pandemic: An Examination of Visit Trends in Relation to School Closures and Reopenings

OBJECTIVE

We examined emergency department (ED) mental health visit trends by children in relation to periods of school closure and reopening during the COVID-19 pandemic in Alberta, Canada.

METHODS

Mental health visits by school-aged children (5 to <18 years) were extracted from the Emergency Department Information System, a province-wide database, from March 11, 2020, to November 30, 2021 (pandemic period; n = 18,997) and March 1, 2019, to March 10, 2020 (1-year, prepandemic comparator period; n = 11,540). We calculated age-specific visit rates and compared rate differences between periods of school closure (March 15-June 30, 2020; November 30, 2020-January 10, 2021; April 22-June 30, 2021) and reopening (September 4-November 29, 2020; January 11-April 21, 2021; September 3-November 30, 2021) to matched prepandemic periods. We used a ratio of relative risk to examine the risk of a visit during closures versus reopenings.

RESULTS

The cohort included 11,540 prepandemic visits and 18,997 pandemic visits. Compared with prepandemic periods, ED visit rates increased across all ages during the first (+85.53%; 95% confidence interval [CI], 73.68% to 100.41%) and third (+19.92%; 95% CI, 13.28% to 26.95%) school closures, and decreased during the second closure (-15.37%; 95% CI, -22.22% to -7.92%). During school reopenings, visit rates decreased across all ages during the first reopening (-9.30%; 95% CI, -13.94% to -4.41%) and increased during the third reopening (+13.59%; 95% CI, 8.13% to 19.34%); rates did not change significantly during the second reopening (2.54%; 95% CI, -3.45% to 8.90%). The risk of a visit during school closure versus reopening was only higher for the first closure with 2.06 times the risk (95% CI, 1.88 to 2.25).

CONCLUSIONS

Emergency department mental health visit rates were highest during the first school closure of the COVID-19 pandemic, and the risk of a visit during this closure period was twice compared with when schools first reopened.

Changing patterns of infectious diseases in children during the COVID-19 pandemic

Each infectious disease has had its own epidemic pattern and seasonality for decades. However, public health mitigation measures during the coronavirus disease 2019 (COVID-19) pandemic have resulted in changing epidemic patterns of infectious diseases. Stringent measures resulted in low incidences of various infectious diseases during the outbreak of COVID-19, including influenza, respiratory syncytial virus, pneumococcus, enterovirus, and parainfluenza. Owing to the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and subsequent immunity development, decreasing virulence of SARS-CoV-2, and worldwide immunization against SARS-CoV-2 in children beyond 6 months of age, mitigation measures are lifted country by country. Consequently, the immunity debt to infectious respiratory viruses other than SARS-CoV-2 contributed to the "off-season," "see-saw," and "upsurge" patterns of various infectious diseases in children. Moreover, apart from the persistence of SARS-CoV-2, the coexistence of other circulating viruses or bacterial outbreaks may lead to twindemics or tripledemics during the following years. Therefore, it is necessary to maintain hand hygiene and immunization policies against various pathogens to alleviate the ongoing impact of infectious diseases on children.

Virtual Reality to Assess Resident Recognition of Impending Respiratory Failure During COVID-19

OBJECTIVES

To assess the performance of pediatric residents in recognizing a decompensating patient with impending respiratory failure and appropriately escalating care using a virtual reality (VR) simulated case of an infant with bronchiolitis after an extended period of decreased clinical volumes during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Sixty-two pediatric residents at a single academic pediatric referral center engaged in a 30-minute VR simulation on respiratory failure in a 3-month-old admitted to the pediatric hospital medicine service with bronchiolitis. This occurred in a socially distant manner across the Zoom platform during the COVID-19 pandemic (January-April 2021). Residents were assessed on their ability to (1) recognize altered mental status (AMS), (2) designate clinical status as "(impending) respiratory failure," and (3) escalate care. Statistical differences between and across postgraduate year (PGY) levels were examined using χ2 or Fisher's exact test, followed by pairwise comparison and posthoc multiple testing using the Hochberg test.

RESULTS

Among all residents, 53% successfully recognized AMS, 16% identified respiratory failure, and 23% escalated care. No significant differences were seen across PGY levels for recognizing AMS or identifying respiratory failure. PGY3+ residents were more likely to escalate care than PGY2 residents (P = .05).

CONCLUSIONS

In the setting of an extended period with decreased clinical volumes during the COVID-19 pandemic, pediatric residents across all PGY levels demonstrated challenges with identifying (impending) respiratory failure and appropriately escalating care during VR simulations. Though limited, VR simulation may serve as a safe adjunct for clinical training and assessment during times of decreased clinical exposure.