The SARS-CoV-2 pandemic led to a reduction in ED visits across the country in both the adult and pediatric populations. In line with recent studies, this institution saw significantly decreased patient volumes in 2020 compared to each previous year (Palinkas et al. 2021; Bartsch et al. 2020; Pines et al. 2020). Overall patient volumes sharply decreased starting in February 2020 and reached the lowest numbers in March with volumes remaining below the pre-pandemic levels throughout the year. Stay-at-home quarantine and social distancing orders likely contributed to the decreases in patient volumes seen in the early stages of the pandemic, while a surge in primary care telehealth medicine visits may have kept volumes low as the state began to ease its social distancing guidelines in the later months of 2020. Our study adds to the growing body of research that illustrates the opportunities that ED providers have for education on injury prevention because injury numbers remained stable despite a global pandemic, as well as the implications for appropriate ED staffing.
Despite the decrease in overall patient volumes, the acuity of patients seen in the ED remained high, as shown by the markedly increased rate of admission to the hospital. The peak admission rates occurred in the months immediately following the start of the pandemic (March 2020) and the yearly admission rate for 2020 was elevated compared to previous years. Particularly, the admission rates to the intensive care and step-down care units were elevated in 2020 compared to 2019 with a corresponding reduction in the acute care floor admission rates. Recent studies also demonstrate the decrease in lower acuity visits that typically compose a majority of the volume of patient seen in the pediatric emergency department, there is still little data that exists currently that demonstrates the substantial increase in high acuity patients admitted to the hospital that required intensive level care (Bartsch et al. 2020; Pines et al. 2020; Even et al. 2020). The decrease in low acuity visits possibly represents hesitancy from caregivers to seek medical attention once stay-at-home orders were issued in March of 2020. Further correlations can be seen between the reduction in face-to-face interactions and close contacts of school-aged children and the reduction in the incidence of communicable diseases especially with respiratory viruses. Additionally, other studies note an increase in telemedicine visits, specifically for routine check-ups and typical sick visits, which could have contributed to the decreases seen in lower acuity visits.
Looking specifically at injury-related ED visits, there was an overall decrease in injury numbers; however, the number of trauma alert activations rose, indicating that the types of injuries that were seen during 2020 required more intensive care and medical resources. The Covid-19 pandemic seemed to have varied effects on specific injury types and trauma activations that presented to the ED. Notably, there was an increase in the number of MVC- and firearm-related trauma activations consistent with other recent literature (Bartsch et al. 2020; Chaiyachati et al. 2020). These trends represent an important area of public health that can be addressed to emphasize education and policies to reduce modifiable risk factors that contribute to these types of traumas. During the pandemic, ED physicians have been in a unique position to play a larger role in providing anticipatory guidance due to decreased availability of health care during times of limited contact with primary healthcare providers who usually address risk factors that help prevent injuries and traumas such as firearm and MVC-related events.
It is worth noting that there was an increase in the percentage of ED visits for psychiatric reasons and the number of inpatient psychiatry admissions in 2020 compared to previous years. While this trend has been seen in the adult populations, there have been few studies that illustrate the same phenomenon in the pediatric population (Bartsch et al. 2020). Notably, our study demonstrates a predictable seasonality to psychiatry admissions, with peak admission numbers during the winter months and the lowest admission numbers occurring during the summer months. During 2020, our peak admission numbers were shifted to the months immediately following the institution of the statewide stay-at-home orders and remained overall elevated through the remainder of the calendar year. This correlation suggests that the social distancing and disruption of the normal school year may have negatively impacted children and adolescent’s mental health.
Limitations
Data were obtained from one institution over a 4 year period. This may not be generalizable to other institutions; however, it seems to be consistent with other reported findings. Additionally, initial data analysis began in the middle of 2021, so this study is limited to the pre-pandemic and early pandemic effects on the institution. Future directions for this study will include updated ED numbers from 2021 to assess how the surges of Covid variants affected the trends noted here. Because this analysis is limited to pediatric ED data, patients may have sought care elsewhere such as urgent cares or even adult EDs. This is less likely because we are the only Level 1 pediatric trauma center in the state, though our trauma data may actually underestimate the statewide trends because pediatric patients are evaluated in other institutions. Likewise it is unlikely to be a significant factor for the critically ill patients as our institution serves as the tertiary referral center for critically ill patients for the state.
Conclusions
The results from this study suggest that the overall use of our pediatric emergency department was significantly reduced; however, this trend was largely due to the reduction in the high volumes of lower acuity ED visits. The acuity of the ED visits increased as evidenced by the increase in critical care admissions, EMS transfers, and trauma activation rates in 2020 compared to previous years. Additionally, the increase in psychiatric-related ED visits and hospital admissions highlights the ongoing need for available resources that deliver primary mental health care especially as the delivery of outpatient health care is shifting toward more telemedicine. These trends argue for the importance of maintaining adequate medical resources and appropriate staffing in pediatric EDs to meet the needs of the increased percentage of higher acuity visits, as well as the psychiatric-related visits that require considerable resources specifically ED beds for boarding and additional medical staff for safety. This study demonstrates that preventable injuries are a constant public health concern in the pediatric population and highlight the need to continue focusing our efforts on injury prevention, despite a worldwide pandemic.