Assessment of Inadequate Use of Pediatric Emergency Medical Transport Services: The Pediatric Emergency and Ambulance Critical Evaluation (PEACE) Study

Effects of Closure of the Paediatric Department of a District Hospital on Regional Care: Analysis of Patient Flows

BACKGROUND

The consequences of economization and staff shortage in the German health care system strongly affect paediatric care structures, especially in rural regions. It is not known how closures of paediatric departments influence patient flows of surrounding hospitals. Here, we investigate the quantitative effects of closure of the paediatric department of a district hospital and the subsequent opening of an alternative inpatient service on the utilisation of inpatient and outpatient care services of the two neighboring hospitals and the emergency services of the region.

METHODOLOGY

In the observation period from 2015 to 2019, patient-related data from the three hospitals in the study region as well as data from the rescue service were evaluated.

RESULTS

In the year after the paediatric department of the district hospital was closed in 2016, the total number of inpatient cases in the region decreased by 33% (2015: n=1,787; 2016: n=1,193) and then decreased by an additional 11% (2019: n=1,005). The number of outpatient cases decreased by further 8% (2015: n=6,250; 2019: n=5,770). In the last observation year, emergency services were used much more frequently than in the year before the closure (2015: n=398; 2019: n=572). This means an increase of 44%.

CONCLUSION

After the closure of the paediatric department, the total number of inpatient cases in the region fell sharply. However, actual gaps in care apparently did not arise. Before closing, the consequences for the surrounding hospitals should be assessed more precisely. Real gaps in care must be counteracted, e. g. through alternative outpatient services.

Impact of school closures on pediatric ambulance transport in Japan

BACKGROUND

After the coronavirus disease (COVID-19) pandemic, nationwide school closures were implemented in many countries. This study aimed to determine the impact of the school closures on pediatric ambulance transport, comparing the situation before and after the COVID-19 pandemic.

METHODS

This retrospective observational study was conducted using data from the Kochi-Iryo.net database. In Kochi prefecture, schools were closed from March 6 to May 24, 2020. Pediatric emergency transport during the school closure period in 2020 was compared with that in the same period in 2019 (before the COVID-19 pandemic) and in 2021 (when schools were not closed). Statistical analysis comprised χ² tests with Bonferroni adjustments for multiple testing. To adjust for patient backgrounds, we also performed multiple logistic regression analyses for numbers of pediatric ambulance transports.

RESULTS

The rate of pediatric ambulance transports was significantly lower (p = 0.008) in 2020 (276; 3.97%) than in 2019 (391; 4.87%), but there was no significant difference (p = 0.360) between 2019 (391; 4.87%) and 2021 (352; 4.56%). Multivariable analysis revealed similar trends (2019 vs. 2020: OR 0.86, 95% CI 0.73-1.00; 2019 vs. 2021: OR 0.96, 95% CI 0.82-1.11). Regarding the characteristics of pediatric ambulance transport journeys, there were no significant differences in 2019, 2020, and 2021 in terms of sex, severity, locations of ambulance stations, and disease classification.

CONCLUSIONS

There was a decrease in pediatric ambulance transportation due to the public health interventions for COVID-19, including school closures. However, this decrease was not solely due to school closures.

What factors are associated with ambulance use for non-emergency problems in children? A systematic mapping review and qualitative synthesis

OBJECTIVE

To explore what factors are associated with ambulance use for non-emergency problems in children.

METHODS

This study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature 'map', and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the 'thematic map' element. The uniting feature running through all of the identified themes was the determination of 'inappropriateness' or 'appropriateness' of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis.

RESULTS

There were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection.

CONCLUSIONS

There is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation.

PROSPERO REGISTRATION NUMBER

CRD42019160395.

Impact of the COVID-19 pandemic on the Emergency Department of a tertiary children's hospital

BACKGROUND

Italy was the first country in Europe affected by COVID-19: the emergency started on February 20, 2020, culminating with national lockdown on March 11, which terminated on May 4, 2020. We describe how the pandemic affected Emergency Department (ED) accesses in a tertiary children's hospital, composed by two different pediatric centers, one located in Rome's city center and the second, Palidoro (regional COVID-19 center), in its surrounding metropolitan area, both in the Lazio region, analyzing the profile of admitted patients during the pandemic period in terms of their general characteristics (at presentation in the ED's) and urgent hospitalizations compared to prepandemic period.

METHODS

The study compare the period between the 21st of February and the 30th of April 2020, covering the three phases of the national responses (this period will be referred to as the pandemic period) with the same period of 2019 (prepandemic period). The study analyzes the number of ED visits and urgent hospitalizations and their distribution according to selected characteristics.

RESULTS

The reduction of ED visits was 56 and 62%, respectively in Rome and Palidoro centers. The higher relative decline was encountered for Diseases of Respiratory System, and for Diseases of the Nervous System and Sense Organs. A doubling of the relative frequency of hospitalizations was observed, going from 14.2 to 24.4% in Rome and from 6.4 to 10.3% in Palidoro. In terms of absolute daily numbers the decrease of urgent hospitalizations was less sharp than ED visits. For pathologies such as peritonitis, tumors or other possible life-treathening conditions we did not observe a significative increase due to delayed access.

CONCLUSIONS

In the pandemic period there was a general reduction in the number of children referred to ED, such reduction was greater in low-acuity levels. The reduction for respiratory tract infections and other communicable diseases during school closure and the national lockdown must make us reflect on the possible impact that these conditions may have on the health system, in particular the ED, at the reopening of schools. The major problem remains the fear for possible diagnostic delays in life-threatening or crippling diseases; our study doesn't demonstrate an increase in number or significant delay in some serious conditions such as tumors, peritonitis, diabetic ketoacidosis, ileo-colic intussusception and testis/ovary torsion. A continuous, deep re-organizational process step by step of the ED is nececessary in the present and upcoming pandemic situation.

Decision Support Capabilities of Telemedicine in Emergency Prehospital Care: Systematic Review

Background

Telemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation.

Objective

Our objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care.

Methods

This systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently.

Results

Out of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use; however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes.

Conclusions

The information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.

Effect of Population Lockdown on Pediatric Emergency Room Demands in the Era of COVID-19

Objectives: The aim of this study was to assess the impact of the COVID-19 pandemic and population lockdown on pediatric ED consultations. Methods: A cross-sectional study on pediatric emergency department consultations before and during the current COVID-19 pandemic (March-May 2019 vs. March-May 2020) was performed in two hospitals in the Campania region (Southern Italy) [i.e., Salerno University Hospital (Salerno) and Pediatric Regional Referral Emergency Hub "AORN Santobono-Pausillipon" (Naples)]. Results: 29,368 consecutive ED pediatric patients (13,430 females; mean age ± SD = 5.4 ± 4.7 years) were seen in March-May 2019 and 9,133 (4,494 females; mean age ± SD = 5.9 ± 4.2 years) in March-May 2020. Resuscitation/emergency and urgent care pediatric ED consultations were 1,388 (4.7%, 95% CI 4.5-4.9) in the 2019 trimester, while they were 648 (7.1%, 95% CI 6.6-7.6) in the 2020 trimester (p < 0.01). Mean pediatric ED daily consultations were 326.3 (95% CI 299.9-352.7) in the considered period of 2019 and 101.4 (95%CI 77.9-124.9) in the same period of 2020 (p < 0.001). COVID-19 nasal swabs were performed for 385 children; of those, six resulted positive and four of them were hospitalized. Conclusions: This work provides a unique snapshot of the pediatric EDs demands in the era of COVID-19. We witnessed a significant reduction of non-urgent health care demands during the pandemic but an increase of more severe urgent cases. The COVID-19 pandemic and the following lockdown unveiled the inappropriateness of the majority of pediatric ED consultations. Nevertheless, the current scenario highlighted the need for appropriate and timely clinical evaluations in the pediatric primary care to tackle late and more severe diagnoses in EDs.