Over the last decades, ERs have known an important growth in patients’ flow. Thus, “Observatoire Regionale des Urgences Champagne - Ardennes” organization reported an increase of number of admissions to the ERs in the Champagne-Ardennes state of France of 6.43% per year from 2008 to 2013 [5].
During the outbreak of COVID-19, patients were forced to postpone regular check-ups and non-urgent clinical or surgical procedures to avoid risks of COVID-19 transmission due to the overcrowding of the ERs and of the departments. At the same time, Government imposed a total lockdown in Italy and obligated people at home, unless for proved necessities. Schools of any grade were closed and sport activities were prohibited. Our findings demonstrate that the lockdown led to 87% reduction in the overall ER pediatric patients’ flow of our Regional Trauma Hub. In normal conditions, unnecessary admissions contribute to the ER congestion with a long length of stay. Nevertheless, these issues resolved spontaneously during the pandemic. A similar decrease in ER patient’s flow was reported in Canada, Taiwan and Hong Kong during SARS epidemic (2003–2004), and it may be probably attributed to people perception of the ER as a possible source of infection. As reported by Huang et al [6], at the peak of the SARS epidemic, the reduction in daily ER visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. Moreover, this reduction persisted 3 months after the end of the epidemic. Man et al [7] displayed a significant drop in the overall ER attendance following the outbreak of SARS, in particular the trauma rate was significantly lower in 2003 than in 2002 (P = 0.03) due to the fear of virus exposure. In addition, during SARS spread, as well as during COVID-19 outbreak, most of the people preferred to avoid crowded areas; thus, recreational or sporting activities may have been less popular then before. Consequently, a change in community behavior may also explain the drop in ER admission reported in the present study.
Furthermore, Bhuvaneswari et al [8] reported that the most common age group injured at home included patients younger than 12 years and toddlers. Similarly, our study demonstrates an important reduction of patients’ age during the lockdown. As a matter of fact, we found an important reduction of patients older than 12 year old who visited the Emergency Department during the COVID-19 outbreak (41.8% in 2019 vs 22.3% in 2020) (Table 2). This finding is probably due to the fact that younger children are less aware of the risks of injury and they probably have an experimental behavior. Farrell et al[9] reported that during the SARS outbreak in 2003, ER visits declined by 21% (95% CI, 18–24%) over the 4-week study period. Conversely to what the present study shows, those authors found the greatest reduction involves both infant and toddler visits (69%; 95% CI, 58–79%) and these data did not recover the following year. This difference might be explained by the fact that our data are relative only to pediatric admissions in a Trauma Hub center specialized only in Orthopaedic surgery. Indeed, COVID-19 disease in neonates, infants and children has been reported to be significantly milder than their adult counterparts. Similarly, all the reported neonatal cases have been mild [10]. Concerning admissions to ER in our Center, no cases of COVID-19 were registered in children, whereas many adult patients diagnosed with COVID-19 were hospitalized at our Institute.
Table 2
Patients divided by age groups admitted to ED: differences between NG and PG.
|
Age (years)
|
0–2
|
2–6
|
6–12
|
> 12
|
Mean age
|
SD
|
Median age
|
|
NG (2019)
|
2.3%
|
6.5%
|
49.5%
|
41.8%
|
11.4
|
3.4
|
12
|
|
PG (2020)
|
14.6%
|
15.5%
|
47.6%
|
22.3%
|
8.6
|
4.6
|
9
|
|
NG: Non-pandemic Group
|
|
PG: Pandemic Group
|
During COVID-19 pandemic, with parks closed recent spike in purchase of home play equipment and trampolines has been registered. Consequently, the lockdown per se did not prevent all injuries [9]. Regarding the place and causes of trauma, Prakash et al [11] reported that up to 63.9% children attending ER in ordinary times sustained injuries at home, followed by road accidents (26.2%), whereas school and play areas accounted only for 8.8% of traumas. The present study demonstrated a big shift from non-domestic traumas (including both scholastic, sport and play areas injuries) to injuries occurred at home in the NG in comparison with the PG (respectively 6.8% and 34.8%). More specifically, our study showed 0% of scholastic traumas during the period of lockdown and only 10% of play areas injuries, whereas in 2019 they counted for 18.8% and 68.4% of traumas, respectively. This shift is obviously due to the banning of both open-air activities and sports performed in gyms and swimming pools. These measures led to a drop of patients presenting for non-urgent chronic reasons, sports-related injuries (sprains, contusions, dislocations) and minor road accidents. Therefore, fewer minor traumas such as sprains of knee reached our ER, as expected, and this finding explains the decreased percentages of non-urgent codes and a statistically significant tendency towards more serious triage codes in the PG. Moreover, we found that the fracture diagnosis was more frequent in the PG in comparison with the NG, confirming that only the most severe injured patients sought medical attention during the pandemic period.
The conclusions drawn from this study rely on data about an Orthopedic Trauma Hub that includes also a Pediatric Orthopedics service and may be different from the flow in other hospitals. Thus we cannot comment on the pediatric patients’ flow in the ER due to ailments other than traumas. Nevertheless, this is the first study revealing the epidemiologic effects that COVID-19 pandemic and lockdown measures had on pediatric patients’ flow in an emergency department.
Moreover, our study indirectly demonstrated that the vast majority of ER admissions in normal conditions is due to non-urgent or deferrable conditions. Thus, this evidence-based analysis is fundamental to improve the strategies of care of the National Health System, in order to better employ the available resources and to reduce overcrowding in the ER, that usually leads to long waiting time for patients and the risk of a lower standard of care.