Paediatric Emergency Department Attendances Research Articles

Caregiver perceptions and experiences of paediatric emergency department attendance during the COVID-19 pandemic: A mixed-methods study.

During the early stages of the COVID-19 pandemic, concerns were raised about reduced attendance at hospitals, particularly in paediatric emergency departments, which could result in preventable poorer outcomes and late presentations among children requiring emergency care. We aimed to investigate the impact of COVID-19 on health-seeking behaviour and decision-making processes of caregivers presenting to paediatric emergency services at a National Health Service (NHS) Trust in London. We conducted a mixed-methods study (survey and semi-structured interviews) across two hospital sites between November-December 2020. Data from each study were collected concurrently followed by data comparison. Overall, 100 caregivers participated in our study; 80 completed the survey only, two completed the interview only and 18 completed both. Our quantitative study found that almost two-thirds (63%, n = 62) of caregivers attended the department within two days of their child becoming ill. Our qualitative study identified three major themes which were underpinned by concepts of trust, safety and uncertainty and were assessed in relation to the temporal nature of the pandemic and the caregivers' journey to care. We found most caregivers balanced their concerns of COVID-19 and a perceived "overwhelmed" NHS by speaking to trusted sources, predominantly general practitioners (GPs). Caregivers have adapted their health-seeking behaviour throughout the pandemic as new information and guidance have been released. We identified several factors affecting decisions to attend; some existed before the pandemic (e.g., concerns for child's health) whilst others were due to the pandemic (e.g., perceived risks of transmission when accessing healthcare services). We recommend trusted medical professionals, particularly GPs, continue to provide reassurance to caregivers to seek emergency paediatric care when required. Communicating the hospital safety procedures and the importance of early intervention to caregivers could additionally provide reassurance to those concerned about the risks of accessing the hospital environment.

Using ICD-10 diagnostic codes to identify 'missing' paediatric patients during nationwide COVID-19 lockdown in Oxfordshire, UK.

The study aims to identify ‘missing’ diagnoses amongst paediatric admissions during the UK’s first national lockdown, compared with the previous 5 years. A retrospective observational cohort study of all children (0–15 years) attending for urgent care across Oxfordshire, during the first UK lockdown in 2020, compared to matched dates in 2015–2019, across two paediatric hospitals providing secondary care, including one with tertiary services. Our outcome measures were changes in numbers of patients attending and inpatient diagnoses (using ICD-10 classification) during the first 2020 lockdown, compared with the previous 5 years, were used. We found that total Emergency Department (ED) attendances (n = 4030) and hospital admissions (n = 1416) during the first UK lockdown were reduced by 56.8% and 59.4%, respectively, compared to 2015–2019 (5-year means n = 7446.8 and n = 2491.6, respectively). Proportions of patients admitted from ED and length of stay were similar across 2015–2020. ICD-10 diagnoses in lockdown of 2020 (n = 2843) versus matched 2015–2019 dates (n = 19,946) demonstrated significantly greater neoplasm diagnoses (p = 0.0123). Of diagnoses ‘missing’ in lockdown, 80% were categorised as infectious diseases or their sequelae and 20% were non-specific pains/aches/malaise and accidental injury/poisonings.Conclusions: Pandemic public health measures significantly altered paediatric presentations. Oxfordshire hospitals had a 58% reduction in ED attendances/inpatient admissions, with ‘missing’ diagnoses predominantly infection-related illnesses. These are likely driven by a combination of the following: (1) public health infection control measures successfully reducing disease transmission, (2) parents/carers keeping mild/self-limiting disease at home, and (3) pandemic-related healthcare anxieties. Prospective studies are needed to ensure referral pathways identify vulnerable children, those with social concerns, and avoid delayed presentation. What is Known:• Significant reductions of paediatric ED attendances and inpatient admissions are reported globally, throughout national and regional lockdowns for COVID-19.• Previous studies (supplemental table 5) examined only ED diagnoses or specific inpatient diagnoses during lockdown periods, demonstrating reductions of infectious diseases, accidents/injuries, and safeguarding referrals.What is New:• Using ICD-10 coding, robustly controlling for five historical years and adopting a hypothesis-independent analysis, demonstrating 80% of ‘missing’ inpatient diagnoses during national COVID-19 lockdown were infectious diseases or its sequelae, the remainder being non-specific aches/pains/malaise and accidental injuries/poisonings.• Greater numbers of neoplasms and other specific diagnoses were detected during lockdown, including greater documentation of co-morbidities and incidental findings.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00431-021-04123-x.

Changes in Emergency Department Activity and the First COVID-19 Lockdown: A Cross-sectional Study.

IntroductionEmergency department (ED) attendances fell across the UK after the ‘lockdown’ introduced on 23rd March 2020 to limit the spread of coronavirus disease 2019 (COVID-19). We hypothesised that reductions would vary by patient age and disease type. We examined pre- and in-lockdown ED attendances for two COVID-19 unrelated diagnoses: one likely to be affected by lockdown measures (gastroenteritis), and one likely to be unaffected (appendicitis).MethodsWe conducted a retrospective cross-sectional study across two EDs in one London hospital Trust. We compared all adult and paediatric ED attendances, before (January 2020) and during lockdown (March/April 2020). Key patient demographics, method of arrival, and discharge location were compared. We used Systemised Nomenclature of Medicine codes to define attendances for gastroenteritis and appendicitis.ResultsED attendances fell from 1129 per day before lockdown to 584 in lockdown, 51.7% of pre-lockdown rates. In-lockdown attendances were lowest for under-18s (16.0% of pre-lockdown). The proportion of patients admitted to hospital increased from 17.3% to 24.0%, and the proportion admitted to intensive care increased fourfold. Attendances for gastroenteritis fell from 511 to 103, 20.2% of pre-lockdown rates. Attendances for appendicitis also decreased, from 144 to 41, 28.5% of pre-lockdown rates.ConclusionED attendances fell substantially following lockdown implementation. The biggest reduction was for under-18s. We observed reductions in attendances for gastroenteritis and appendicitis. This may reflect lower rates of infectious disease transmission, although the fall in appendicitis-related attendances suggests that behavioural factors were also important. Larger studies are urgently needed to understand changing patterns of ED use and access to emergency care during the coronavirus 2019 pandemic.

Paediatric emergency department dog bite attendance during the COVID-19 pandemic: an audit at a tertiary children’s hospital

BackgroundResponses to the COVID-19 pandemic include strict public health measures, such as national lockdowns. During these measures, paediatric emergency department attendances have declined and the prevalence of presenting complaints has...

Paediatric emergency department attendances during COVID-19 and SARS in Singapore

We evaluated the impact of public health measures on paediatric emergency department attendances during the COVID-19 and severe acute respiratory syndrome (SARS) outbreaks in Singapore. Between 1 January 2020 and 31 July 2020, we retrospectively reviewed paediatric emergency department attendances and admissions in a tertiary paediatric hospital in Singapore before and after a national lockdown to combat the spread of COVID-19 in Singapore. Hospital attendances and admissions were compared with data from a corresponding period in 2019 (1 January 2019 to 31 July 2019), as well as during and after the SARS outbreak (1 January 2003 to 31 December 2004). Compared with a corresponding non-outbreak period, emergency department attendances decreased in line with nationwide public health measures during the COVID-19 and SARS outbreaks (2020 and 2003 respectively), before increasing gradually following lifting of restrictions, albeit not to recorded levels before these outbreaks. During the COVID-19 outbreak, mean daily attendances decreased by 40%, from 458 per day in January-July 2019, to 274 per day in January-July 2020. The absolute number of hospital inpatient admissions decreased by 37% from January-July 2019 (19,629) to January-July 2020 (12,304). The proportion of emergency department attendances requiring admission remained similar: 20% in January-July 2019 and 21% in January-July 2020. Nationwide public health measures in Singapore have had an impact on paediatric emergency department attendances and hospital inpatient admissions. Data from this study could inform planning and resource allocation for emergency departments in Singapore and internationally.

Management of non-urgent paediatric emergency department attendances by GPs: a retrospective observational study.

BackgroundNon-urgent emergency department (ED) attendances are common among children. Primary care management may not only be more clinically appropriate, but may also improve patient experience and be more cost-effective.AimTo determine the impact on admissions, waiting times, antibiotic prescribing, and treatment costs of integrating a GP into a paediatric ED.Design and settingRetrospective cohort study explored non-urgent ED presentations in a paediatric ED in north-west England.MethodFrom 1 October 2015 to 30 September 2017, a GP was situated in the ED from 2.00 pm until 10.00 pm, 7 days a week. All children triaged as ‘green’ using the Manchester Triage System (non-urgent) were considered to be ‘GP appropriate’. In cases of GP non-availability, children considered non-urgent were managed by ED staff. Clinical and operational outcomes, as well as the healthcare costs of children managed by GPs and ED staff across the same timeframe over a 2-year period were compared.ResultsOf 115 000 children attending the ED over the study period, a complete set of data were available for 13 099 categorised as ‘GP appropriate’; of these, 8404 (64.2%) were managed by GPs and 4695 (35.8%) by ED staff. Median duration of ED stay was 39 min (interquartile range [IQR] 16–108 min) in the GP group and 165 min (IQR 104–222 min) in the ED group (P<0.001). Children in the GP group were less likely to be admitted as inpatients (odds ratio [OR] 0.16; 95% confidence interval [CI] = 0.13 to 0.20) and less likely to wait >4 hours before being admitted or discharged (OR 0.11; 95% CI = 0.08 to 0.13), but were more likely to receive antibiotics (OR 1.42; 95% CI = 1.27 to 1.58). Treatment costs were 18.4% lower in the group managed by the GP (P<0.0001).ConclusionGiven the rising demand for children’s emergency services, GP in ED care models may improve the management of non-urgent ED presentations. However, further research that incorporates causative study designs is required.

Assessing the Impact of COVID-19 Public Health Stages on Paediatric Emergency Attendance.

This study outlines the impact of COVID-19 on paediatric emergency department (ED) utilisation and assesses the extent of healthcare avoidance during each stage of the public health response strategy. Records from five EDs and one urgent care centre in Ireland, representing approximately 48% of national annual public paediatric ED attendances, are analysed to determine changes in characteristics of attendance during the three month period following the first reported COVID-19 case in Ireland, with reference to specific national public health stages. ED attendance reduced by 27–62% across all categories of diagnosis in the Delay phase and remained significantly below prior year levels as the country began Phase One of Reopening, with an incident rate ratio (IRR) of 0.58. The decrease was predominantly attributable to reduced attendance for injury and viral/viral induced conditions resulting from changed living conditions imposed by the public health response. However, attendance for complex chronic conditions also reduced and had yet to return to pre-COVID levels as reopening began. Attendances referred by general practitioners (GPs) dropped by 13 percentage points in the Delay phase and remained at that level. While changes in living conditions explain much of the decrease in overall attendance and in GP referrals, reduced attendance for complex chronic conditions may indicate avoidance behaviour and continued surveillance is necessary.

Italian COVID-19 epidemic: effects on paediatric emergency attendance—a survey in the Emilia Romagna region

ObjectiveTo evaluate the effect of the COVID-19 epidemic on paediatric emergency department (ED) attendance in a region of Northern Italy.MethodsA survey was proposed to six out of nine paediatric EDs...

National rotavirus vaccination programme implementation and gastroenteritis presentations: the paediatric emergency medicine perspective.

Throughout the developed world, the introduction of rotavirus vaccination has led to reductions in the incidence and severity of acute gastroenteritis (AGE) in young children and consequently to reductions in paediatric emergency department (PED) attendances with AGE. Rotavirus vaccination was added to the Irish National Immunisation Schedule in November 2016. To assess the impact of vaccine introduction on citywide PED attendances and hospital admissions with all-cause AGE during rotavirus season. In an observational study, a retrospective search was performed of electronic records in three independent PEDs in Dublin. Weekly presentations and admissions with AGE in the first 30weeks (gastroenteritis season) of the years 2012-2018 were counted and stratified by age. Median weekly presentations in 2017-2018, 126 (interquartile range (IQR) 103-165) were significantly lower than in 2012-2016, 160 (IQR 128-214) (p < 0.001). A reduction in presentations was seen across the three hospitals and in those aged less than 5years. In one PED,median admissions in 2017-2018 were 10 (IQR 7-13) in comparison with nine (IQR 7-13) in 2012-2016, (p = 0.463). The emergency department AGE presentations to hospital ward admission rate was 6.7:1. A reduction in PED presentations with AGE is demonstrated post-rotavirus vaccine introduction into the Irish National Immunisation Schedule. No significant change in paediatric hospital admissions was demonstrated.

53 Piloting patch – providing assessment and treatment for children at home – and piecing together what works

AimsPATCH is a pilot acute community children’s nurse led service delivering assessment and treatment for children at home who are moderately unwell and might otherwise be admitted to hospital or...

Comparison of two European paediatric emergency departments: does primary care organisation influence emergency attendance?

BackroundTo compare paediatric Emergency Department (ED) attendances and admission outcomes in two European hospitals with different paediatric primary care set-up.MethodsThis is a retrospective prevalence study comparing all paediatric ED attendances during calendar years 2013 in two EDs with similar catchment area: one in Italy (Trieste) where paediatric primary care is provided by office paediatricians, the other, in the UK (Cambridge), where paediatric primary care is provided by general practitioners. Data on reason for presentation, discharge diagnosis and admission rate were collected and sub-group analysis for specific age groups (<1 year, 1–4 years, 5–15 years) was performed.ResultsOver 12 months, 20.331 children (0–15 years old) were seen in Cambridge and 18.646 in Trieste, with a very similar age distribution in both centres, except for the youngest age group: the percentage of infants seen in comparison with the total number of children attending ED was 1/3 higher in England than in Italy (15.4% vs 11.4%). The reasons for attendance were similar: under 1 year of age, the chief complaints were fever, breathing difficulties and gastrointestinal problems while in the older age groups trauma represented the commonest reason. Among discharge diagnoses, no differences were found between the two hospitals, except for faltering growth and “well child”, more frequently diagnosed in English children under 5 years. The proportion of admissions was three times higher in Cambridge (14.1% vs 4.8%) with most children being admitted for infectious diseases.ConclusionsED attendances in infants are more common in a primary care setting provided by general practicioner and, moreover, admission rates in all age groups are 1/3 reduced by primary care based paediatricians. Due to the methodological limits of this study, it isn't possible to evaluate whether these results depend only on paediatric primary care set-up or be determined by other confounding factors. New studies are needed to confirm this preliminary evidence.

Can paediatric early warning scores (PEWS) be used to guide the need for hospital admission and predict significant illness in children presenting to the emergency department? An assessment of PEWS diagnostic accuracy using sensitivity and specificity

ObjectivesDesigned to detect early deterioration of the hospitalised child, paediatric early warning scores (PEWS) validity in the emergency department (ED) is less validated. We aimed to evaluate sensitivity and specificity...

G107(P) The development of a consultant paediatrician phone-line for general practitioners

<h3>Aims</h3> Ambulatory paediatric services have changed significantly over the last year at our hospital. One of these changes has been the development of a consultant-manned phone line, whereby general practitioners (GPs) can speak directly to a consultant paediatrician between 0800–2300 on weekdays and 0800–2000 at weekends. The aim was to optimise patient care by facilitating timely communication with the most appropriate hospital based paediatrician. This enables acutely unwell children and outpatient referrals to be directed appropriately, reducing paediatric emergency department (PED) attendances and it also serves to strengthen links between primary and secondary care. <h3>Methods</h3> Activity data for the first five months was analysed. The consultants complete a proforma for each phone call with a predefined data set. This includes the general demographics of the caller and the patient in question, as well as information about the outcomes of calls. <h3>Results</h3> 167 calls from GPs have been taken since the phone-line began and 59 of these have been recorded onto proformas. 29% were from GPs asking for management advice and potential referral of outpatient problems, whereas 68% were from GPs asking about the acute management of an unwell child in the GP surgery. There were a variety of different outcomes from the calls, directing the unwell child to the most appropriate practitioner (Figure 1). Consultants taking the phone calls recorded that 33 ED attendances and 2 admissions had been prevented following calls from GPs. <h3>Conclusion</h3> The phone-line has been very successful, reducing PED attendances and improving pathways of outpatient referrals. Not only does this service comply with ‘Facing the Future’ standards, as it is consultant delivered and available at times of peak activity, but it is also in accordance with the NHS Mandate, keeping children out of hospital, in the community wherever possible. The service is in its infancy, but thus far has been instrumental in the development of ambulatory paediatric services at our hospital. It provides excellent quality of care for local children and enhances our links with local GPs.

G26(P) Gaps in provision of community paediatric primary dental healthcare: a review of the burden of disease presenting to Emergency Departments

Background and objectivesIn Greater Manchester, children generally have poorer dental health compared to England as a whole. There is some evidence that emergency departments are increasingly being used as provider...

Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium

The nonurgent use of the emergency department (ED) for pediatric patients is an increasing problem facing healthcare systems worldwide. To evaluate the magnitude of the phenomenon and to identify associated factors, an observational prospective survey was performed including all patients (<15 years) attending the ED in 12 Belgian hospitals during 2 weeks in autumn 2010. Use of ED was considered appropriate if at least one of the following criteria was met: child referred by doctor or police, brought by ambulance, in need for short stay, technical examination or orthopedic treatment, in-patient admission, or death. Among the 3,117 children, attending ED, 39.9 % (1,244) of visits were considered inappropriate. Five factors were significantly associated with inappropriate use: age of child, distance to ED, having a registered family doctor, out-of-hours visit, and geographic region. The adjusted odds ratio and 95 % confidence intervals are respectively-1.7 (1.3-2.0), 1.7 (1.3-2.2), 1.5 (1.1-2.2), 1.5 (1.2-1.9), and 0.6 (0.5-0.8). Almost 40 % of all paediatric ED attendances did not require hospital expertise. The risk of an inappropriate use of ED by pediatrician patients is predominantly associated with organizational and cultural factors. Access, equity, quality of care, and medical human resources availability have to be taken into account to design financially sustainable model of care for those patients. Furthermore, future research is needed to explain reasons why parents visit ED rather than using of primary-care services.

PMO-077 Home enteral tube feeding (HETF): a case burden for the paediatric emergency department (PED)?

IntroductionThe contribution of HETF issues to PED workload is poorly understood. We aimed to evaluate PED attendance records of children receiving HETF (rates, presenting complaints and outcomes). We also aimed...

Sledging is still a seasonal source of serious injury in Scottish children

In 2002 it was highlighted that sledging results in serious injuries in the paediatric population and safety recommendations were made. The aim of this study was to re-examine the number, severity and aetiology of sledging-related trauma. This was a retrospective study performed in the Paediatric Emergency Department (PED) of the Royal Aberdeen Children's Hospital (RACH) during two periods totalling 12 days, when there was continuous snow ground cover. Records of all attendances were scrutinized to identify patients with sledging injuries. The nature, mechanism and severity of injury, and subsequent management were then analysed. Of 403 PED attendances, 45 (11%) were sledging related with 16 (36%) fractures and 13 (29%) head injuries. Eight patients (18%) were admitted to hospital and three (7%) required an operation. Collision with a stationary object was the most common reason for injury (51%), followed by the adoption of a dangerous sledging position or use of a stationary jump. No patients were wearing a helmet. In conclusion, there has been little change in the epidemiology and aetiology of paediatric sledging injuries since 2002. Work is needed to inform parents of the previously recommended safety measures that could reduce the morbidity of this activity without detracting from the enjoyment.

027 Paediatric emergency department attendances between 2000 and 2009: trends in a large UK Children's Hospital

Objectives and BackgroundThere has been an increase in UK demand for emergency department services. This may be attributed to changes in public behaviour or the availability of out of hours...

Unscheduled re-attendances to a paediatric Emergency Department: an audit

IntroductionUnscheduled re-attendances (UR) continue to pose a problem to the Paediatric Emergency Department (PED) and there is paucity of research on this topic. 5% of PED attendances are UR.1 Although...

Management of limb fractures in children under 1 year of age in a dedicated paediatric emergency department

Background:The recognition of possible non-accidental injury (NAI) in children is an area of ongoing concern for all emergency departments. Limb fractures in non-mobile children should alert clinicians to consider NAI...