Pediatric Emergency Department Visits Research Articles

Diaphragmatic Ultrasound in Children With Asthma Exacerbations.

Asthma is a leading cause of pediatric emergency department visits, yet few tools exist to objectively measure asthma severity. Diaphragmatic ultrasound (DUS) is a novel method of assessing respiratory distress; however, data are lacking for children.Our primary aim was to determine if diaphragmatic excursion (DE), diaphragmatic thickening (DT), or diaphragmatic thickening fraction (TF) correlated with asthma severity as determined by the Pediatric Respiratory Assessment Measure (PRAM) score. Secondarily, we examined if these parameters correlated with need for respiratory support and evaluated interrater reliability. We conducted a prospective study of children 5-18 years presenting to a pediatric emergency department with an asthma exacerbation. Diaphragmatic ultrasound was performed by a trained pediatric emergency medicine sonologist in subcostal (DE) and midaxillary (DT). Thickening fraction was calculated from DT values as previously described in literature. To evaluate interrater reliability, a subset of subjects had DUS performed by a second sonologist. We enrolled 47 subjects for a total of 51 encounters. The mean age was 9.1 ± 3.7 years. Twenty-five (49%) had mild, 24 (47%) had moderate, and 2 (4%) had severe asthma. There was a significant difference in midaxillary DT and TF between children with mild and moderate asthma (P = 0.02; mean difference, 0.2 mm; 95% confidence interval [CI], 0.03-0.4 and P = 0.02; mean difference, 0.11 mm; 95% CI, 0.02-0.2, respectively). No difference was found in subcostal DE (P = 0.43; mean difference, 1.4 mm; 95% CI, -2.1 to 4.8). No association was found between use of positive pressure and DUS parameters. Fourteen encounters had 2 sonologists perform DUS, with strong interrater reliability found for midaxillary DT (Pearson correlation, 0.56) and poor association for subcostal DE (Pearson correlation, 0.18). In this pilot study, we conclude that DUS may be helpful in assessing severity of asthma. The midaxillary view assessment for DT and TF had the best correlation with asthma severity and the best interrater reliability. Future studies may benefit from focusing on the midaxillary view for DT and TF.

The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland.

The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilization evolved throughout the pandemic. Our objectives were to investigate the impact of the pandemic in three language regions of Switzerland by analyzing trends over time, describe regional differences, and address implications for future healthcare. We conducted a retrospective, longitudinal cohort study at three Swiss tertiary pediatric EDs (March 1st, 2018-February 28th, 2022), analyzing the numbers of ED visits (including patients` age, triage categories, and urgent vs. non-urgent cases). The impact of COVID-19 related non-pharmaceutical interventions (NPIs) on pediatric ED utilization was assessed by interrupted time series (ITS) modelling. Based on 304'438 ED visits, we found a drop of nearly 50% at the onset of NPIs, followed by a gradual recovery. This primarily affected children 0-4years, and both non-urgent and urgent cases. However, the decline in urgent visits appeared to be more pronounced in two centers compared to a third, where also hospitalization rates did not decrease significantly during the pandemic. A subgroup analysis showed a significant decrease in respiratory and gastrointestinal diseases, and an increase in the proportion of trauma patients during the pandemic. The COVID-19 pandemic had substantial effects on number and reasons for pediatric ED visits, particularly among children 0-4years. Despite equal regulatory conditions, the utilization dynamics varied markedly between the three regions, highlighting the multifactorial modification of pediatric ED utilization during the pandemic. Furthermore, future policy decisions should take regional differences into account.

Primary Care Enhanced Access Services and the Association With Nonurgent Pediatric Emergency Department Utilization and Child Opportunity Index.

This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits. We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles. We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores. Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.

A family-centered approach to social needs awareness in the pediatric emergency department

ObjectiveWe aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits. MethodsFamilies were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference. ResultsForty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone (p < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion. ConclusionsAssessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts. InnovationUse of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets.

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits.

Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year. This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region. Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020. Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.

Use of Electronic Health Record-Based Measures to Assess Quality of Care for Pediatric Agitation.

Acute agitation during pediatric mental health emergency department (ED) visits presents safety risks to patients and staff. We previously convened multidisciplinary stakeholders who prioritized 20 proposed quality measures for pediatric acute agitation management. Our objectives were to assess feasibility of evaluating performance on these quality measures using electronic health record (EHR) data and to examine performance variation across 3 EDs. At a children's hospital and 2 nonchildren's hospitals, we assessed feasibility of evaluating quality measures for pediatric acute agitation management using structured EHR data elements. We retrospectively evaluated measure performance during ED visits by children 5 to 17 years old who presented for a mental health condition, received medication for agitation, or received physical restraints from July 2020 to June 2021. Bivariate and multivariable regression were used to examine measure performance by patient characteristics and hospital. We identified 2785 mental health ED visits, 275 visits with medication given for agitation, and 35 visits with physical restraints. Performance was feasible to measure using EHR data for 10 measures. Nine measures varied by patient characteristics, including 4.87 times higher adjusted odds (95% confidence interval 1.28-18.54) of physical restraint use among children with versus without autism spectrum disorder. Four measures varied by hospital, with physical restraint use varying from 0.5% to 3.3% of mental health ED visits across hospitals. Quality of care for pediatric acute agitation management was feasible to evaluate using EHR-derived quality measures. Variation in performance across patient characteristics and hospitals highlights opportunities to improve care quality.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study.

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Perinatal Depression Associated With Increased Pediatric Emergency Department Use And Charges In The First Year Of Life.

In New Jersey, universal screening for perinatal depression at the time of delivery has resulted in a 95percent screening rate. The widespread availability of screening data allowed me to investigate the association between perinatal depression severity and infant emergency department (ED) use and charges in the first year of life. I used birth records linked to hospital discharge records for the period 2016-19. Compared with infants who had mothers with no symptoms, infants with mothers with mild or moderate/severe depressive symptoms had significantly higher overall and nonemergent ED use, but not significantly higher emergent ED use. The positive associations between depressive symptoms and ED charges were particularly striking for infants with Medicaid, which pays for a disproportionate share of pediatric ED care in the United States. This study contributes to the evidence base linking perinatal depression screening and pediatric ED use. Opportunities may exist within Medicaid to optimize screening and referrals for perinatal depression, with potential cost-saving benefits for reducing nonemergent pediatric ED visits.

Caregiver Perspectives on the Impact of Child Life Specialists during Pediatric Emergency Department Visits

OBJECTIVESTo describe and compare caregiver perceptions of their emergency department (ED) experiences with and without child life specialist (CLS) involvement in their child’s overall care. STUDY DESIGNA descriptive cross-sectional survey of caregivers of children 0-17 years at a tertiary care pediatric ED was completed from March to August 2021. Survey themes included perceived experience and satisfaction, and impact of child life specialists. RESULTSA total of 179 caregivers completed the survey; mean age was 38.9 years (SD 8.4), and 72.6% (122/179) were mothers. Caregivers of children with CLS involvement (CLS+) ranked their overall experience (p= 0.021) and satisfaction (p= 0.009) higher than without CLS involvement (CLS -). More CLS+ caregivers ranked their experience (57.6%, 34/61) and their satisfaction (79.7%, 47/61) as excellent (5/5 Likert scale rating), compared to CLS- caregivers (37.7%, 40/115 and 56.6%, 60/115 respectively). CLS+ families were more likely to be offered non-pharmacologic interventions (e.g., iPad, sensory lights, toys) (98.4% vs 31.3%, p=0.003); they were also more likely to have a healthcare worker explore their feelings and fears (52.5% vs 27.0%, p=0.0008), help them prepare for a procedure or exam (73.8% vs 31.3%, p<0.0001), provide distraction techniques (70.5% vs 19.1%, p<0.0001), offer strategies to help coping (47.5% vs 14.8%, p<0.0001), or provide play opportunities (55.7% vs 9.6%, p<0.0001). CONCLUSIONSCLS involvement in children’s ED care is associated with higher caregiver satisfaction and experience, beyond previously reported procedural distress management. Efforts to increase availability of CLSs should be made to better family experiences in the ED.

Quantifying Multipollutant Health Impacts Using the Environmental Benefits Mapping and Analysis Program-Community Edition (BenMAP-CE): A Case Study in Atlanta, Georgia.

Air pollution risk assessments do not generally quantify health impacts using multipollutant risk estimates, but instead use results from single-pollutant or copollutant models. Multipollutant epidemiological models account for pollutant interactions and joint effects but can be computationally complex and data intensive. Risk estimates from multipollutant studies are therefore challenging to implement in the quantification of health impacts. Our objective was to conduct a case study using a developmental multipollutant version of the Environmental Benefits Mapping and Analysis Program-Community Edition (BenMAP-CE) to estimate the health impact associated with changes in multiple air pollutants using both a single and multipollutant approach. BenMAP-CE was used to estimate the change in the number of pediatric asthma emergency department (ED) visits attributable to simulated changes in air pollution between 2011 and 2025 in Atlanta, Georgia, applying risk estimates from an epidemiological study that examined short-term single-pollutant and multipollutant (with and without first-order interactions) exposures. Analyses examined individual pollutants (i.e., ozone, fine particulate matter, carbon monoxide, nitrogen dioxide (), sulfur dioxide, and particulate matter components) and combinations of these pollutants meant to represent shared properties or predefined sources (i.e., oxidant gases, secondary pollutants, traffic, power plant, and criteria pollutants). Comparisons were made between multipollutant health impact functions (HIF) and the sum of single-pollutant HIFs for the individual pollutants that constitute the respective pollutant groups. Photochemical modeling predicted large decreases in most of the examined pollutant concentrations between 2011 and 2025 based on sector specific (i.e., source-based) estimates of growth and anticipated controls. Estimated number of avoided asthma ED visits attributable to any given multipollutant group were generally higher when using results from models that included interaction terms in comparison with those that did not. We estimated the greatest number of avoided pediatric asthma ED visits for pollutant groups that include (i. e., criteria pollutants, oxidants, and traffic pollutants). In models that accounted for interaction, year-round estimates for pollutant groups that included ranged from 27.1 [95% confidence interval (CI): 1.6, 52.7; traffic pollutants] to 55.4 (95% CI: 41.8, 69.0; oxidants) avoided pediatric asthma ED visits. Year-round results using multipollutant risk estimates with interaction were comparable to the sum of the single-pollutant results corresponding to most multipollutant groups [e.g., 52.9 (95% CI: 43.6, 62.2) for oxidants] but were notably lower than the sum of the single-pollutant results for some pollutant groups [e.g., 77.5 (95% CI: 66.0, 89.0) for traffic pollutants]. Performing a multipollutant health impact assessment is technically feasible but computationally complex. It requires time, resources, and detailed input parameters not commonly reported in air pollution epidemiological studies. Results estimated using the sum of single-pollutant models are comparable to those quantified using a multipollutant model. Although limited to a single study and location, assessing the trade-offs between a multipollutant and single-pollutant approach is warranted. https://doi.org/10.1289/EHP12969.

Assessing the Impact of the COVID-19 Pandemic on Pediatric Emergency Department Visits in Taiwan.

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted healthcare systems worldwide. To assess the effects of the pandemic on pediatric emergency department (ED) visits in Taiwan, we conducted a study to evaluate changes in pediatric ED visits during the COVID-19 pandemic. Materials and Methods: This retrospective study included pediatric patients (age ≤ 18) who visited the ED between 21 January 2019 and 30 April 2019, at three hospitals of the Cathay Health System, and compared them with a corresponding period in 2020. Basic information, including mode of arrival, triage level, disposition, chief complaints, and incidence rates, were analyzed before and during the pandemic. Results: A total of 10,116 patients, with 6009 in the pre-pandemic group and 4107 in the pandemic group, were included in this study. The mean number of daily pediatric ED visits decreased from 60.09 before the pandemic to 40.66 during the pandemic, while ambulance use increased significantly by 2.56%. The percentage of patients with high acuity triage levels (levels 1 and 2) was significantly lower during the pandemic period (0.63% and 10.18%, respectively) than the pre-pandemic period (0.7% and 10.9%, respectively). Additionally, a significantly higher proportion of patients were discharged during the pandemic period (89.36%) than during the pre-pandemic period (88.33%). The proportion of COVID-19-related complaints, such as fever and respiratory tract infections, as well as other complaints including gastrointestinal issues, trauma, and psychological problems, significantly increased during the pandemic. Conclusions: In preparation for future pandemics, we recommend increasing emergency medical service capacity, establishing a non-contagious route for obtaining chronic medication prescriptions, optimizing staff allocation in pediatric emergency departments, and increasing the number of hospital social workers for enhanced support.

Extreme temperatures increase the risk of pediatric pneumonia: a systematic review and meta-analysis.

The impact of climate change on ambient temperatures threatens to worsen pediatric pneumonia-related outcomes considerably. This study examined the associations of temperature variation and extreme temperature with pediatric pneumonia-related events using a meta-analysis. We systematically searched PubMed, Medline, Embase, and Web of Science databases for relevant literature, and the quality of evidence was assessed. Fixed and random-effects meta-analyses were performed to calculate the pooled relative risks (RRs) of the associations with pneumonia-related events. We observed that a 1°C temperature variation increased the RR of pneumonia events by 1.06-fold (95% confidence interval (CI): 1.03-1.10). A 1°C temperature variation increased the RR by 1.10-fold of the pediatric pneumonia hospital admissions (95% CI: 1.00-1.21) and 1.06-fold of the pediatric pneumonia emergency department visits (95% CI: 1.01-1.10). Extreme cold increased the RR by 1.25-fold of the pediatric pneumonia events (95% CI: 1.07-1.45). A 1°C temperature variation increased the RR of pneumonia events in children by 1.19-fold (95% CI: 1.08-1.32), girls by 1.03-fold (95% CI: 1.02-1.05), and in temperate climate zones by 1.07-fold (95% CI: 1.03-1.11). Moreover, an increase in extreme cold increased the RR of pneumonia events in children by 2.43-fold (95% CI: 1.72-3.43), girls by 1.96-fold (95% CI: 1.29-2.98) and in temperate climate zones by 2.76-fold (95% CI: 1.71-4.47). Our study demonstrated that pediatric pneumonia events are more prevalent among children, particularly girls, and individuals residing in temperate climate zones. Climate change represents an emergent public health threat, affecting pediatric pneumonia treatment and prevention.. PROSPERO (CRD42022378610).

(O-I4) Changes in Pediatric Emergency Department Visits After Arrival of COVID-19

(O-I4) Changes in Pediatric Emergency Department Visits After Arrival of COVID-19

Drivers for low-acuity pediatric emergency department visits in two tertiary hospitals in Switzerland: a cross-sectional, questionnaire-based study

PurposeLow-acuity pediatric emergency department (PED) visits are frequent in high-income countries and have a negative impact on patient care at the individual and health system levels. Knowing what drives low-acuity PED visits is crucial to inform adaptations in health care delivery. We aimed to identify factors associated with low-acuity PED visits in Switzerland, including socioeconomic status, demographic features, and medical resources of families.MethodsWe conducted a prospective, questionnaire-based study in the PEDs of two Swiss tertiary care hospitals, Bern and Lausanne. We invited all consecutive children and their caregiver attending the PED during data collection times representative of the overall PED consultation structure (e.g. day/night, weekdays/weekends) to complete a questionnaire on demographic features, socioeconomic status, and medical resources. We collected medical and administrative data about the visit and defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed, and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.ResultsWe analysed 778 PED visits (September 2019 to July 2020). Most children visiting our PEDs had a designated primary care provider (92%), with only 6% not having seen them during the last year. Fifty-five per cent of caregivers had asked for medical advice before coming to the PED. The proportion of low-acuity visits was 58%. Low-acuity visits were associated with caregiver's difficulties paying bills (aOR 2.6, 95% CI 1.6 – 4.4), having already visited a PED in the last 6 months (aOR 1.7, 95% CI 1.1 – 2.5) but not with parental education status, nor parental country of birth, parental employment status or absence of family network.ConclusionEconomic precariousness is an important driver for low-acuity PED visits in Switzerland, a high-income country with compulsory health coverage where most children have a designated primary care provider and a regular pediatric follow-up. Primary care providers and PEDs should screen families for economic precariousness and offer anticipatory guidance and connect those in financial need to social support.

Effect of Maternal Adverse Childhood Experiences (ACEs) and Maternal Resiliency on Early Childhood Outcomes on Vaccination Adherence and Emergency Department Visits

Introduction: Adverse Childhood Experiences (ACEs) are traumatic events that occurred to an individual during ages 0-17 years. The 1998 Adverse Childhood Experiences (ACE) suggested higher ACE scores contributed to negative future health outcomes. The tool is now used to screen at-risk populations for the development of chronic health conditions. Protective factors, such as resilience, were later studied and found to offset the negative health impacts of traumatic childhood events. The 7Cs questionnaire was a tool developed to measure resilience in adolescents and demonstrated better health outcomes despite the presence of higher ACE scores. This pilot study evaluated whether higher maternal ACEs would result in more frequent pediatric ED visits and less vaccination adherence and whether higher 7Cs would be protective. Methods: This IRB approved study recruited pregnant women and new mothers in a tertiary NJ urban hospital, between their second trimester and their child’s one month well visit at the pediatric clinic. All subjects completed the Adverse Childhood Events (ACEs) survey, 7Cs resilience tool, and a Maternal Health questionnaire at the time of recruitment. A review of children’s electronic medical records was conducted at 2-, 4-, 6-, and 12-months to evaluate pediatric outcomes, adherence to AAP recommended vaccine schedule and emergency department visits. Results: Total of 34 women were enrolled, their and their children’s medical and demographic data collected. There was no difference in higher ACE scores and number of ED visits for the babies (OR 0.9645 [CI 0.7643 - 1.2172]), with no effect seen with higher resilience scores and number of ED visits (OR 0.8477 [0.6192 – 1.1604]). Increase in ACE scores resulted in reduction in vaccination adherence (OR 0.3555 [CI 0.1417 – 0.8923]). Increase in resilience scores decreased vaccination adherence by 44% (OR 0.5578 [CI 0.4164 - 0.7471]). Conclusion: There was no significant relationship between ACE or resilience scores and pediatric ED visits. A higher ACE score and lower levels of resilience were associated with decreased child vaccine adherence rate. ACE scores relate to higher traumatic childhoods, suggest poorer outcomes in offspring. Women with higher ACE scores could benefit from closer interventions and resources from obstetricians, and closer follow up of their children by the pediatricians.

Effect of COVID-19 on the dynamics of pediatric emergency department visits and admissions

Objective: This study aimed to evaluate how the pandemic and social constraints have affected the number of pediatric emergency department (ED) visits and hospitalizations at the current study institution. Methods: In the pediatric emergency department of the Maternity and Children Hospital in AlAhsa, Saudi Arabia, a retrospective, single-centered, observational comparison study was carried out between January and February 2020, prior to the COVID-19 outbreak, and between January and February 2021, during the COVID-19 outbreak. Comparisons were made between dispositions, diagnoses, visit information, and demographics. Results: Compared to the same period in 2016, the COVID-19 outbreak resulted in a significant decline in ED referrals (from 16,047 to 12,608) and a decrease in hospital admission rates (from 458 to 371). During the pandemic, there was a notable drop in ED visits for respiratory symptoms, despite the fact that fever and/or respiratory symptoms were the most frequently reported symptoms both times. Among the possible causes were a decreased risk of infection spread overall as a result of isolation and self-protective measures, avoiding needless hospital stays in the absence of severe symptoms, and parental anxiety about their children being exposed to COVID-19. Conclusion: During the COVID-19 epidemic, there were major changes in patterns of care seeking. Reduced ED visits should spur attempts to understand these occurrences, encourage appropriate care seeking, and monitor for morbidity and mortality that might arise from delayed or deferred therapy.

Rates of pediatric emergency department visits vary according to neighborhood marginalization in Ottawa, Canada.

To determine the association between neighborhood marginalization and rates of pediatric ED visits in Ottawa, Ontario. Secondary objectives investigated if the association between neighborhood marginalization and rates varied by year, acuity, and distance to hospital. We calculated rates of pediatric ED visits per 1000 person-years for census dissemination areas within 100km of the Children's Hospital of Eastern Ontario for patients < 18years old from January 2018 through December 2020. The 2016 Ontario Marginalization Index categorized neighborhoods along quintiles of residential instability, material deprivation, ethnic concentration, and dependency. Generalized mixed-effects models determined the incidence rate ratios of pediatric ED visits for each quintile of marginalization; multivariate models were used to control for year of presentation and distance to hospital. Analysis was repeated for low versus high acuity ED visits. There were 154,146 ED visits from patients in 2055 census dissemination areas within 100km of CHEO from 2018 to 2020. After controlling for year and distance from hospital in multivariate analyses, there were higher rates of pediatric ED visits for dissemination areas with high residential instability, high material deprivation, and low ethnic concentration. These findings did not change according to visit acuity. Neighborhood residential instability and material deprivation should be considered when locating alternatives to emergency care.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic

BackgroundInjuries, the leading cause of death in children 1–17 years old, are often preventable. Injury patterns are impacted by changes in the child’s environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic.MethodsThis multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00–T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020.ResultsThe study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (− 4.9%) and overexertion (− 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019.ConclusionsThe proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Emergency Department Usage Patterns Among Pediatric Victims of Gun Violence and Physical Assault.

Violent injuries are a common reason for pediatric emergency department (ED) visits, with gun violence being the leading cause of violent death among children. The objective of this study was to assess for patterns of pediatric ED usage that are associated with future ED visits for violent injuries. This case-control study included youths aged 6 to 19 years who presented to a pediatric ED over a 3-year period due to a physical assault (PA) or their first known gunshot wound (GSW). We compared them with age-, race-, and sex-matched youths presenting for nonviolent medical complaints. All previous ED visits were coded as (1) injuries due to a previous PA, (2) mental/behavioral health visits, (3) sexual/reproductive health visits, (4) sexual assault, or (5) concerns for child abuse. We used multivariate logistic regression to identify patterns of previous ED usage associated with future ED visits for injuries related to PA and/or GSW. The PA and GSW groups used the ED for previous PAs, mental/behavioral health, sexual/reproductive health, sexual assault, and/or child abuse concerns on average 4 to 8 times as often as the control group. Previous ED visits for mental/behavioral health (odds ratio [OR] 5), sexual/reproductive health (OR 3), sexual assault (OR 9), and prior PA (OR 8) were predictive of a future ED visit for PA. Male sex (OR 6) and previous ED visits for PA (OR 5) were predictive of a future ED visit for GSW. Two percent of the PA group and 9% of the GSW group returned to the ED with a subsequent GSW in the following 16 to 40 months. Emergency department visits due to interpersonal violence, mental/behavioral health, sexual/reproductive health, and sexual assault are associated with recurrent ED visits for violent injuries. Awareness of patterns of ED usage may aid in identifying patients at high risk for violence and increase opportunities for preventative interventions.

Parents' perspective on pediatric emergency department visits for low-acuity conditions before and during the COVID-19 pandemic: a cross-sectional bicentric study.

The primary objective of this study was to describe and compare the motivation of parents/guardians to bring children with low-acuity conditions to a tertiary-care pediatric emergency department (ED) versus a clinic before and after the pandemic. The secondary objectives were to describe and compare the demographic and clinical characteristics of the population studied and the impact of the pandemic on their access to primary care services. This is a cross-sectional study based on a survey administered to parents/guardians of patients presenting with low-acuity conditions at one of two EDs. The respondents numbered 659. Children were brought to a pediatric ED generally because of the perceived urgency of the condition, the presumed resource availability in the pediatric ED and the unavailability of the primary care physician. However, most respondents (n = 438, 66.5%) indicated preference for a clinic. More respondents before than during the pandemic reported they had been unable to find a doctor outside the ED (48.6% before COVID vs 26.8% during COVID, p < 0.001) but patients during the pandemic were less likely to seek care in a primary care practice or walk-in clinic (30.0% during COVID vs 48.6% before COVID, p < 0.001). In addition, the number of respondents presenting with symptoms of infection decreased by more than half after the pandemic began while the proportion of musculoskeletal and psychiatric complaints doubled. Although the pandemic has altered the landscape of presenting complaints and pediatric healthcare-seeking behaviors, most respondents indicated they would prefer to receive care in a clinic. This finding contradicts the view that most pediatric ED visits for low-acuity conditions are by choice rather than perceived necessity. Prioritizing improved access to primary care resources would better address the preferences and expectations of parents/guardians.