Pediatric emergency department visits during the COVID-19 pandemic: a large retrospective population-based study

Abstract Background COVID-19 pandemic has stretched healthcare system capacities worldwide and deterred people from seeking medical support at Emergency Departments (ED). Nevertheless, population-based studies examining the consequences on children are lacking. Methods All ED visits from 2019 to 2020 in Veneto, Italy (4.9 million residents) were collected. Anonymized records of pediatric (≤14 years) ED visits included patient characteristics, arrival mode, triage code, clinical presentation, and discharge mode. Year-on-year variation of the main ED visit characteristics, and descriptive trends throughout the study period have been examined. Results Overall, 425,875 ED presentations were collected, 279,481 in 2019, and 146,394 in 2020 (− 48%), with a peak (− 79%) in March–April (first pandemic wave), and a second peak (below − 60%) in November–December (second pandemic wave). Burn or trauma, and fever were the two most common clinical presentations. Visits for nonurgent conditions underwent the strongest reduction during both pandemic waves, while urgent conditions reduced less sharply. ED arrival by ambulance was more common in 2020 (4.5%) than 2019 (3.5%), with a higher proportion of red triage codes (0.5%, and 0.4% respectively), and hospitalizations following ED discharge (9.1%, and 5.9% respectively). Conclusion Since the beginning of the COVID-19 pandemic, pediatric ED presentations underwent a steeper reduction than that observed for adults. Lockdown and fear of contagion in hospital-based services likely deterred parents from seeking medical support for their children. Given COVID-19 could become endemic, it is imperative that public health experts guarantee unhindered access to medical support for urgent, and less urgent health conditions, while minimizing infectious disease risks, to prevent children from suffering direct and indirect consequences of the pandemic.

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Adjacent Primary Care May Reduce Less Urgent Pediatric Emergency Department Visits

Journal of Primary Care & Community Health ◽

10.1177/2150132720926276 ◽

2020 ◽

Vol 11 ◽

pp. 215013272092627

Author(s):

Julia Ellbrant ◽

Jonas Åkeson ◽

Helena Sletten ◽

Jenny Eckner ◽

Pia Karlsland Åkeson

Keyword(s):

Primary Care ◽

Emergency Department ◽

Patient Characteristics ◽

Pediatric Emergency ◽

Emergency Department Visits ◽

University Hospital ◽

Pediatric Emergency Department ◽

Hospital Data ◽

Cross Sectional ◽

Ed Visits

Aims: Pediatric emergency department (ED) overcrowding is a challenge. This study was designed to evaluate if a hospital-integrated primary care unit (HPCU) reduces less urgent visits at a pediatric ED. Methods: This retrospective cross-sectional study was carried out at a university hospital in Sweden, where the HPCU, open outside office hours, had been integrated next to the ED. Children seeking ED care during 4-week high- and low-load study periods before (2012) and after (2015) implementation of the HPCU were included. Information on patient characteristics, ED management, and length of ED stay was obtained from hospital data registers. Results: In total, 3216 and 3074 ED patient visits were recorded in 2012 and 2015, respectively. During opening hours of the HPCU, the proportions of pediatric ED visits (28% lower; P < .001), visits in the lowest triage group (36% lower; P < .001), patients presenting with fever ( P = .001) or ear pain ( P < .001), and nonadmitted ED patients ( P = .033), were significantly lower in 2015 than in 2012, whereas the proportion of infants ≤3 months was higher in 2015 ( P < .001). Conclusions: By enabling adjacent management of less urgent pediatric patients at adequate lower levels of medical care, implementation of a HPCU outside office hours may contribute to fewer and more appropriate pediatric ED visits.

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Identifying patient characteristics associated with potentially redirectable paramedic transported emergency department visits in Ontario, Canada: a population-based cohort study

BMJ Open ◽

10.1136/bmjopen-2021-054625 ◽

2021 ◽

Vol 11 (12) ◽

pp. e054625

Author(s):

Ryan P Strum ◽

Walter Tavares ◽

Andrew Worster ◽

Lauren E Griffith ◽

Andrew P Costa

Keyword(s):

Emergency Department ◽

General Practice ◽

Delphi Study ◽

Patient Characteristics ◽

Population Based ◽

Emergency Department Visits ◽

Urgent Care ◽

Main Diagnosis ◽

Ed Visits ◽

Main Intervention

ObjectiveParamedic redirection from emergency department (ED) to subacute centres may be more beneficial for some patients, though little is known about which patients are potentially appropriate. We examined whether patient characteristics were associated with ED visits when the main intervention was suitable to be performed in a subacute centre.MethodsWe conducted a retrospective observational study using the National Ambulatory Care Reporting System from 2014 to 2018 in Ontario, Canada. We included all adult patients transported by paramedics and had a main physician intervention recorded. We used results of a RAND/UCLA modified Delphi study to categorise patients into either ED or a subacute care (urgent care and/or general practice centre) based on their main intervention. An independent logistic regression model was analysed for each subacute centre.ResultsA total of 2 394 072 ED visits were included; 59% of ED interventions were categorised as ‘urgent care’, 27% ‘ED only’, 9% either ‘urgent care’ or ‘general practice’ and 5% had an intervention not previously classified. ED visits suitable for ‘general practice’ had the highest percentage of patients discharged, while ‘ED only’ had the lowest. Lower medical acuity, younger age, time of triage in evening and overnight, and discharged from ED were independently associated with both subacute centres. ‘Urgent care’ visits/interventions were associated with an ED main diagnosis of the respiratory system (OR 3.49), while ‘general practice’ visits were associated with mental health disorders (OR 9.85) and injury/poison/consequences of external causes (OR 3.38).ConclusionsThe majority of ED visits had a main intervention that could have potentially been conducted in a subacute centre. We identified characteristics and diagnostic patterns associated with ED visits when the main intervention was categorised as a subacute centre intervention. This study contributes knowledge to inform which patients are potentially appropriate for paramedic redirection.

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The impact of COVID-19 on hospital admissions and emergency department visits: A population-based study

PLoS ONE ◽

10.1371/journal.pone.0252441 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0252441

Author(s):

Elissa Rennert-May ◽

Jenine Leal ◽

Nguyen Xuan Thanh ◽

Eddy Lang ◽

Shawn Dowling ◽

...

Keyword(s):

Public Health ◽

Emergency Department ◽

Hospital Admissions ◽

Population Based ◽

Emergency Department Visits ◽

System Capacity ◽

Population Based Study ◽

Health Measures ◽

Ed Visits ◽

The Impact

Background As a result of the novel coronavirus disease 2019 (COVID-19), there have been widespread changes in healthcare access. We conducted a retrospective population-based study in Alberta, Canada (population 4.4 million), where there have been approximately 1550 hospital admissions for COVID-19, to determine the impact of COVID-19 on hospital admissions and emergency department (ED visits), following initiation of a public health emergency act on March 15, 2020. Methods We used multivariable negative binomial regression models to compare daily numbers of medical/surgical hospital admissions via the ED between March 16-September 23, 2019 (pre COVID-19) and March 16-September 23, 2020 (post COVID-19 public health measures). We compared the most frequent diagnoses for hospital admissions pre/post COVID-19 public health measures. A similar analysis was completed for numbers of daily ED visits for any reason with a particular focus on ambulatory care sensitive conditions (ACSC). Findings There was a significant reduction in both daily medical (incident rate ratio (IRR) 0.86, p<0.001) and surgical (IRR 0.82, p<0.001) admissions through the ED in Alberta post COVID-19 public health measures. There was a significant decline in daily ED visits (IRR 0.65, p<0.001) including ACSC (IRR 0.75, p<0.001). The most common medical/surgical diagnoses for hospital admissions did not vary substantially pre and post COVID-19 public health measures, though there was a significant reduction in admissions for chronic obstructive pulmonary disease and a significant increase in admissions for mental and behavioral disorders due to use of alcohol. Conclusions Despite a relatively low volume of COVID-19 hospital admissions in Alberta, there was an extensive impact on our healthcare system with fewer admissions to hospital and ED visits. This work generates hypotheses around causes for reduced hospital admissions and ED visits which warrant further investigation. As most publicly funded health systems struggle with health-system capacity routinely, understanding how these reductions can be safely sustained will be critical.

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Abstract 32: Have Choosing Wisely Recommendations Changed Diagnostic Testing Patterns for Patients With Syncope?

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.11.suppl_1.32 ◽

2018 ◽

Vol 11 (suppl_1) ◽

Author(s):

Timothy Anderson ◽

Robert L Thombley ◽

Grace A Lin

Keyword(s):

Emergency Department ◽

Brain Mri ◽

Diagnostic Testing ◽

Patient Characteristics ◽

Emergency Department Visits ◽

Choosing Wisely ◽

Mixed Effect ◽

Hospital Variation ◽

Ed Visits ◽

Cardiac Testing

Background: Syncope is a common reason for emergency department visits. Guidelines suggest minimal initial workup, including history, physical exam, and ECG testing. Additional cardiac testing is recommended in only high risk patients and neuroimaging is rarely indicated. Because of the low yield of neuroimaging, in 2012, the Choosing Wisely campaign recommended against its use for syncope. Our objective was to examine trends in cardiac testing and neuroimaging of patients presenting to the ED with syncope, before and after the Choosing Wisely recommendations and to describe hospital variation in testing rates. Methods: We linked State Inpatient and Emergency Department Databases to conduct a retrospective study of all ED visits in 2009 and 2013 for 8 states reporting procedure utilization. We calculated rates of ECG, advanced cardiac testing (echocardiogram, stress testing, diagnostic catheterization) and neuroimaging (head CT, brain MRI, carotid ultrasound) for all adults with a discharge diagnosis of syncope. Differences between years were estimated using mixed effect regression modeling adjusted for patient characteristics, comorbidities, and hospital random effects. Results: We identified 287,261 ED visits for syncope in 2009 and 315,221 ED visits in 2013 from 676 hospitals. Between 2009 and 2013, adjusted rates of ECG testing increased from 81.1% of discharges to 84.3% (p<.0001). Rates of advanced cardiac testing increased from 10.3% to 12.4% (p<.0001), driven primarily by a substantial increase in the use of echocardiograms (8.3% vs 11.3%, p<.0001). Rates of neuroimaging increased from 36.0% to 42.0% (p<.0001) with increased utilization of all tests. Rates of ECG, advanced cardiac testing and neuroimaging varied significantly between hospitals in both years (Figure). The median hospital-level change in testing between years was 1.6% (IQR -3.5 to 11.2) for ECG, 1.2% (IQR -1.8 to 5.9) for advanced cardiac imaging and 4.2% (IQR -5.3 to 18.4) for neuroimaging. Conclusions: Among patients presenting to the ED with syncope, rates of both high- and low-value diagnostic testing increased between 2009 and 2013, with substantial variation between hospitals. Thus, the 2012 Choosing Wisely recommendations do not appear to have had a significant effect on testing for patients presenting with syncope.

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Emergency department visits during the 4/20 cannabis celebration

Emergency Medicine Journal ◽

10.1136/emermed-2019-208947 ◽

2019 ◽

Vol 37 (4) ◽

pp. 187-192

Author(s):

John A Staples ◽

Ketki Merchant ◽

Shannon Erdelyi ◽

Adam Lund ◽

Jeffrey R Brubacher

Keyword(s):

Emergency Department ◽

Negative Binomial ◽

Care Service ◽

Negative Binomial Regression ◽

Fold Increase ◽

Population Based ◽

Service Planning ◽

Emergency Department Visits ◽

Adjusted Relative Risk ◽

Ed Visits

BackgroundAnnual ‘4/20’ cannabis festivals occur around the world on April 20 and often feature synchronised consumption of cannabis at 4:20 pm. The relationship between these events and demand for emergency medical services has not been systematically studied.MethodsWe conducted a population-based retrospective cohort study in Vancouver, Canada, using 10 consecutive years of data (2009–2018) from six regional hospitals. The number of emergency department (ED) visits between 4:20 pm and 11:59 pm on April 20 were compared with the number of visits during identical time intervals on control days 1 week earlier and 1 week later (ie, April 13 and April 27) using negative binomial regression.ResultsA total of 3468 ED visits occurred on April 20 and 6524 ED visits occurred on control days. A non-significant increase in all-cause ED visits was observed on April 20 (adjusted relative risk: 1.06; 95% CI 1.00 to 1.12). April 20 was associated with a significant increase in ED visits among prespecified subgroups including a 5-fold increase in visits for substance misuse and a 10-fold increase in visits for intoxication. The hospital closest to the festival site experienced a clinically and statistically significant 17% (95% CI 5.1% to 29.6%) relative increase in ED visits on April 20 compared with control days.InterpretationSubstance use at annual ‘4/20’ festivals may be associated with an increase in ED visits among key subgroups and at nearby hospitals. These findings may inform harm reduction initiatives and festival medical care service planning.

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Assessing appropriateness of pediatric emergency department visits: is it even possible?

CJEM ◽

10.1017/cem.2019.473 ◽

2020 ◽

Vol 22 (5) ◽

pp. 661-664

Author(s):

Jessica E. Paul ◽

Katie Y. Zhu ◽

Garth D. Meckler ◽

David K. Park ◽

Quynh Doan

Keyword(s):

Emergency Department ◽

Clinical Decision Making ◽

Clinical Decision ◽

Pediatric Emergency ◽

Risk Tolerance ◽

Emergency Department Visits ◽

Ed Overcrowding ◽

Ed Visits ◽

Return Visits ◽

Clinician Judgment

ABSTRACTObjectivesNumerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit.MethodsWe conducted a retrospective cohort study comparing 3 clinicians’ determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm.ResultsA total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss’ Kappa of 0.30 (0.17–0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%).ConclusionsAlthough an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.

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Resident loneliness, social isolation and unplanned emergency department visits from supportive living facilities: a population-based study in Alberta, Canada

BMC Geriatrics ◽

10.1186/s12877-021-02718-5 ◽

2022 ◽

Vol 22 (1) ◽

Author(s):

Stephanie A. Chamberlain ◽

Susan E. Bronskill ◽

Zoe Hsu ◽

Erik Youngson ◽

Andrea Gruneir

Keyword(s):

Emergency Department ◽

Health Service ◽

Social Isolation ◽

Service Use ◽

Population Based ◽

Emergency Department Visits ◽

Health Service Use ◽

Care Providers ◽

Ed Visits ◽

Socially Isolated

Abstract Background Supportive living (SL) facilities are intended to provide a residential care setting in a less restrictive and more cost-effective way than nursing homes (NH). SL residents with poor social relationships may be at risk for increased health service use. We describe the demographic and health service use patterns of lonely and socially isolated SL residents and to quantify associations between loneliness and social isolation on unplanned emergency department (ED) visits. Methods We conducted a retrospective cohort study using population-based linked health administrative data from Alberta, Canada. All SL residents aged 18 to 105 years who had at least one Resident Assessment Instrument-Home Care (RAI-HC) assessment between April 1, 2013 and March 31, 2018 were observed. Loneliness and social isolation were measured as a resident indicating that he/she feels lonely and if the resident had neither a primary nor secondary caregiver, respectively. Health service use in the 1 year following assessment included unplanned ED visits, hospital admissions, admission to higher levels of SL, admission to NH and death. Multivariable Cox proportional hazard models examined the association between loneliness and social isolation on the time to first unplanned ED visit. Results We identified 18,191 individuals living in Alberta SL facilities. The prevalence of loneliness was 18% (n = 3238), social isolation was 4% (n = 713). Lonely residents had the greatest overall health service use. Risk of unplanned ED visit increased with loneliness (aHR = 1.10, 95% CI: 1.04–1.15) but did not increase with social isolation (aHR = 0.95, 95% CI: 0.84–1.06). Conclusions Lonely residents had a different demographic profile (older, female, cognitively impaired) from socially isolated residents and were more likely to experience an unplanned ED visit. Our findings suggest the need to develop interventions to assist SL care providers with how to identify and address social factors to reduce risk of unplanned ED visits.

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Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders

American Journal on Intellectual and Developmental Disabilities ◽

10.1352/1944-7558-124.3.206 ◽

2019 ◽

Vol 124 (3) ◽

pp. 206-219 ◽

Cited By ~ 1

Author(s):

Anna Durbin ◽

Robert Balogh ◽

Elizabeth Lin ◽

Andrew S. Wilton ◽

Avra Selick ◽

...

Keyword(s):

Developmental Disabilities ◽

Psychiatric Disorders ◽

Population Based ◽

Emergency Department Visits ◽

Intellectual And Developmental Disabilities ◽

Hospital Emergency ◽

Population Based Study ◽

Ed Visits ◽

Short Time ◽

Hospital Emergency Departments

Abstract Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.

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Level of Acuity in Pediatric Patients with Recurrent Emergency Department Visits

Journal of Hospital Administration ◽

10.5430/jha.v1n2p1 ◽

2012 ◽

Vol 1 (2) ◽

pp. 1

Author(s):

Ilene Claudius ◽

Chun Nok Lam

Keyword(s):

Emergency Department ◽

Pediatric Patients ◽

Pediatric Emergency ◽

Emergency Department Visits ◽

Pediatric Emergency Department ◽

Group Comparison ◽

Intravenous Fluid Therapy ◽

Ed Visits ◽

And Performance ◽

Critical Intervention

Introduction: Recurrent ED utilizers account for a substantial proportion of ED visits, yet little data exists on children with multiple visits. The objective of this study was to compare the need for interventions and triage acuity of recurrent utilizers of a pediatric emergency department to that of non-recurrent utilizers. Methods: This is a retrospective analysis of children presenting to a pediatric emergency department. Children were classified as recurrent utilizers if they had 4 or more visits to the ED per year and non-recurrent utilizers if they had less than 4 visits. Data was collected and inter-group comparison performed on critical interventions received (admission, consultation, intravenous fluid therapy, observation, and performance of procedures), all interventions received (including critical interventions as well as laboratories, radiographs, and medications), and triage acuity for the index visit. Results: Two-hundred thirty patients were included, of whom, 15% were classified as recurrent utilizers. This group had significantly lower rates of requiring a critical intervention (8.6% vs. 51.4%, p=.001), lower rates of any intervention (51.4% vs. 74.4%, p=.007), and less urgent triage acuity (3.3 vs. 3.1, p=.029). Conclusions: Recurrent utilizers of the pediatric emergency department had significantly lower need for intervention and less urgent mean triage acuity when compared with non-recurrent utilizers.

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Do patient-reported symptoms predict for emergency department visits? A population-based analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.6039 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 6039-6039

Author(s):

Lisa Catherine Barbera ◽

Clare Atzema ◽

Rinku Sutradhar ◽

Hsien Seow ◽

Doris Howell ◽

...

Keyword(s):

Emergency Department ◽

Cancer Patients ◽

Symptom Assessment ◽

Well Being ◽

Population Based ◽

Emergency Department Visits ◽

Assessment System ◽

Patient Reported ◽

Symptom Scores ◽

Ed Visits

6039 Background: Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System (ESAS) has been routinely used to assess symptoms in cancer patients in both ambulatory and home-care settings. The purpose of this study was to determine the relationship between individual patient symptoms, and their severity, with the likelihood of an emergency department (ED) visit. Methods: The cohort includes all cancer patients in Ontario who completed an ESAS assessment between January 2007 and March 2009. We linked multiple provincial health databases to describe the cohort and determine if an ED visit occurred within 7 days of the patient’s first ESAS. Multivariate logistic regression was used to determine the association between symptom scores (absent: score 0; mild: 1-3; moderate: 4-7; severe: 8-10) and the likelihood of an ED visit. Results: The cohort included 45,118 unique patients whose first assessment contributes to the study. 3.8% (n=1732) had an ED visit. The patients with ED visits were more likely to be men, to have lung or gastro-intestinal cancer, to have had recent radio or chemotherapy, and to have a shorter survival. The proportion of patients with ED visits increased from 2% to 10-12% as individual symptom scores increased from 0 to 10. Anxiety and depression were not associated with ED visits in the model, regardless of severity. Pain, nausea, drowsiness, appetite and shortness of breath with moderate or severe scores were associated with ED visits. Tiredness and wellbeing were the only symptoms to show a significant association for mild, moderate and severe scores. A well being score of 7-10 (reference score=0) had the highest odds ratio of 1.8 (95% CI 1.4-2.3). Conclusions: Worsening symptoms clearly contribute to ED visits. While specific symptoms like pain are obvious targets for management in the outpatient setting, constitutional symptoms like wellbeing or fatigue are associated with even higher odds. Though difficult to manage, such symptoms also warrant detailed assessment in order to optimize patient outcomes.

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