INTRODUCTION

Coronavirus disease-19 (COVID-19) first appeared in Wuhan, China at the end of 2019¹. The World Health Organization declared an international public health emergency on January 30, 2020. On March 11, 2020, the novel Severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) outbreak was officially identified as a pandemic². Schools were closed on March 16, 2020 and shelter-in-place was ordered for those whose birth dates were on or after January 1, 2000 on April 3, 2020 in Turkey.

Following lockdown decisions taken to prevent spread of COVID-19 epidemic all over the world, most of routine and elective procedures, especially emergency department (ED) service, have been interrupted in many hospitals. Triage units were created in EDs and reorganized to separate suspected COVID-19 cases from other emergency cases^3,4. At the onset of COVID-19 outbreak, just before lockdown was implemented, a sudden decline in the number of patients with non-COVID-19 complaints was reported in EDs of different countries^5-9. It was determined that this decrease in ED admissions was primarily in very urgent patients with high morbidity and mortality. These patients, who needed urgent intervention, were not admitted to EDs and were waited at home for a long time. Also, decreases were observed in admissions of children who were expected to continue their admission to EDs due to acute exacerbations of underlying problems such as neurological, endocrinological and oncological diseases or surgical reasons^7,8,10. Initially, decrease in the number of patients in EDs was welcomed worldwide to allocate more space and time to COVID-19 patients, but the continuance of decrease in admissions began to raise concerns. Decrease in admissions to hospitals and EDs may have various probable negative effects on child health. Children with various metabolic, neurological, hematological, immunological, and syndromic diseases and accordingly using devices such as tracheostomy cannula, ventriculoperitoneal shunt, home-ventilator, nebulizer, and non-invasive mechanical ventilator, and those who have special needs such as percutaneous endoscopic gastrostomy and urinary and venous catheter are potentially at higher risk of more serious illness than healthy children due to lack of access to healthcare.

There are various reasons and different alternative solution methods for the decrease in emergency admissions. Concerns about being infected with SARS-CoV-2 at hospitals, high number of patients, overcrowded waiting areas and insufficient personal protective equipment for medical staff were reported as the reasons for decrease in the number of emergency admissions^8,11,12. The fact that patients and their families delay or stop seeking treatment for emergencies will pose a significant risk in terms of preventable causes of morbidity and mortality in the future. One of unclear situations of COVID-19 epidemic is uncertainty regarding the management of patients not admitted to ED or hospitals. During pandemics, it is necessary to plan how to help patients who are not admitted to ED due to the concern of transmission of causative disease. Examining changes in the admission features of emergent and non-emergent patients will help arrangements to be made in this regard.

Therefore, we aimed to evaluate the change by comparing number of patients admitted to pediatric ED in the same period of the previous year, distribution characteristics of diseases, rates of hospitalization, and follow-up status with the period at the onset of the pandemic.

MATERIALS AND METHODS

Separated areas for evaluation and inpatient follow-up were created at our hospital for suspected or positive COVID-19 patients and for other patients in the light of current guidelines. In this sense, it was thought that anxiety and fear of patients and their families would be alleviated and number of admissions to ED would not be affected.

During COVID-19 pandemic, 4943 patients aged 0-18 years who were admitted to Pediatric ED between March 10^th and April 10^th of 2019 and in the same days of 2020 were included in our study. A retrospective, observational study was conducted by taking medical data such as demographic and epidemiological characteristics, admission date and time, emergency status, history of comorbid disease, diagnosis, and hospitalization status from the hospital’s electronic records. The percentage of change in information such as ED visits, patient characteristics and diagnoses for 2020 was calculated and compared to that for 2019. Interactions between each factor and overall variation in ED visits were assessed. Patients were divided into specific groups according to systems and diagnoses. According to the follow-up status, ward, intensive care unit and pediatric emergency follow-ups were accepted as hospital admissions. Diseases were evaluated individually or by categorization.

As the exclusion criteria for the study, cases in which there was a problem in reaching the data to be used in the study were determined.

The primary purpose of this study is to determine the effects of this pandemics on EDs, Its secondary purpose is to develop an ED procedure for the pandemic and other future pandemics.

Statistical Analysis

Analyses were made with Statistical Package for the Social Sciences 26.0 (for macOS) program. The normal distribution of data was evaluated using the Kolmogorov-Smirnov test. In descriptive statistics, categorical data were presented as numbers and percentages and non-categorical data were presented as median (25-75 percentile) because they were not normally distributed. In analytical statistics, the chi-square test and Fisher’s exact test were used. Type-1 error (a) was accepted as 5%.

This study was approved by İstanbul University, İstanbul Medical Faculty Medical Ethics Committee (approval date: 15/02/2020, decision number: 10).

RESULTS

The median age of 4943 patients admitted to the pediatric ED in both time periods were 5.0 years (2-10). Of the children, 45.9% (n=2270) were girls. A total of 24.5% of the children (n=1211) had comorbid diseases. Respectively, 80.7% (n=3989) of the admissions were in 2019 and 19.3% (n=954) were in 2020. There was a 76% reduction in the number of admissions within years. While the rate of admissions to the pediatric ED under the age of 5 years was 39% (n=372) in 2020, it was 43.6% (n=1739) in 2019, which was significantly important (p=0.010). When evaluated according to the days when they were admitted to the hospital, it was found that 28% of the patients were admitted at the weekend in 2019 and 23.7% in 2020. Weekend admissions in 2019 were significantly higher compared to those in 2020 (p=0.007). In comparison of admission time to hospital by years, it was found that there was a significant difference in terms of admission rates in three different time periods (p=0.021). In subgroup analysis, it was determined that the difference between these groups originated from 00:00-07:59 hours and that there were more admissions in these hours in 2020 compared to 2019.

The rate of comorbid diseases among those admitted to the pediatric ED was 23.7% in 2019, while it was 27.9% in 2020 and this difference was statistically significant (p=0.007). The rate of patients who were considered as priority emergencies was 10.6% in 2019 and 17.9% in 2020, and this difference was significant (p<0.001). While the rate of patients requiring service admission was 5.2% in 2019, this rate was 13.8% in 2020, which was significantly different (p<0.001).

While the rate of intensive care unit admissions was 0.5% (n=5) in 2020, it was found to be 0.3% (n=13) in 2019, and there was no statistical difference (p=0.369). In 2020, COVID-19 polymerase chain reaction test was positive in 21 (2.2%) cases (Table 1). When the admission rates of cases such as seizures, pneumonia, acute appendicitis, invagination, metabolic decompensation, drug intoxication and toxic substance intake were examined by years, no significant difference was found. When the rates of asthma attack, foreign body aspiration and severe anemia were evaluated by years, admissions in 2020 were found to be significantly higher (p<0.001, p<0.001, p=0.022) (Table 2).

Patients admitted to pediatric ED were divided into specific groups according to their diagnoses and evaluated according to years. The patient’s pathologies who were followed up in neurology, endocrinology, hematology-oncology and neonatal units and home accidents were found to be significantly higher in 2020 (p=0.037, p=0.002, p<0.001, p=0.040, p<0.001, respectively). Dermatological diseases such as urticaria, respiratory tract diseases such as upper respiratory tract infection and gastrointestinal system pathologies such as acute gastroenteritis were significantly lower in 2020 (p=0.003, p<0.001, p=0.002, respectively). Although a statistical evaluation could not be made in the diagnosis of headache-dizziness considered within neurological pathologies, a significant decrease was observed in 2020 compared to 2019. While the rate of palpitations among the diagnoses evaluated within the cardiological pathologies increased significantly in 2020, the rate of chest pain cases decreased significantly. It was noted that the percentages of acute bronchiolitis and asthma attack diagnosis evaluated within respiratory tract pathology increased significantly in 2020 compared to 2019. Although there was no case of intoxication with cologne/disinfectants in 2019, the increased percentage of intoxication cases in 2020 drew attention. When the diagnoses in the Hematology/Oncology group were evaluated, a significant decrease was observed in the percentage of bleeding cases due to factor deficiency in addition to febrile neutropenia cases in 2020 compared to 2019 (Table 3).

DISCUSSION

Our data showed that there was a significant decrease of 76% in emergency admissions during COVID-19 pandemic compared to the same period last year. Although it was reported that admissions to ED in emergencies with high mortality were reduced by half in adults, it was observed in our study that there was no decrease in admissions for priority red.

Some studies have reported a decrease in ED admissions at the onset of the COVID-19 pandemic before lockdown has just started^6,7,13,14. The number of admissions to the pediatric ED at weekends decreased significantly in 2020 compared to 2019. The curfew, which was only admitted at the weekends during the lockdown, might have caused this situation. When admission hours to the ED for children were observed, it was determined that the number of admissions increased significantly from 12.00 am to 08.00 am in 2020 compared to 2019. The fact that there were more admissions at these hours in 2020 might indicate that patients were admitted to the hospital without waiting in case of complaints or they might think that they would be exposed to less crowding in ED at specified hours. In a study examining the admissions to the pediatric ED, it was shown that there were more admissions on the weekend throughout the whole time and a striking decrease was observed in the number of daily admissions during the pandemic period¹⁵.

Studies in adults have reported unexpected and disproportionate decreases in emergency admissions with high morbidity and mortality, such as cerebrovascular events, stroke, and myocardial infarction^7,13. There are also studies that have reported an increase in morbidity and mortality in pediatric patients due to delay in admission of critically ill patients to EDs^8,15. In our study, there were 5 (0.5%) patients hospitalized in intensive care unit and no fatalities occurred.

Despite the decrease in hospital admissions during the pandemic, the rate of cases considered as priority emergencies was found to be statistically higher compared to the previous year. Considering the increase in the rates of priority emergencies and the rate of hospitalized patients, it was thought that critical patients continued to be admitted to EDs despite the pandemic and it might be concluded that a sufficient number of experienced healthcare workers should be organized in EDs for these patients.

Angoulvant et al¹⁶. reported that there was more than 70% decline in acute gastroenteritis, common cold, acute bronchiolitis and acute otitis media complaints in pediatric ED admissions. In our study, the rate of admissions in 2020 due to diseases with high morbidity and mortality such as asthma attack, foreign body intake and severe anemia were found to be significantly higher than in 2019. Foreign body intake might have increased due to having to spend more time at home. It was thought that the increase in asthma attack admissions was due to the increase in awareness of families to cough and respiratory distress symptoms related to COVID-19. The reason for the increase in severe anemia might be the result of deterioration and delayed follow-up of chronic diseases.

It has been reported that the percentage of hospital admissions increased in pediatric patients due to diseases with high morbidity and mortality, and patients in need of urgent medical care were admitted to pediatric ED without causing a significant delay during lockdown⁹. In our data, no significant change was found in cases of seizures, pneumonia, acute appendicitis, drug intoxication, invagination, decompensation of metabolic diseases and toxic substance intake by years. Unlike adults, families brought their children to pediatric ED because they thought that these diseases, which have high morbidity and mortality, could not be cured at home.

While analyzing the results of our study, the patients were divided into specific groups according to their systems and diagnoses, and neurological, endocrinological, hematological-oncological and neonatal diseases and home accidents were found to be significantly higher in 2020 compared to 2019. In a study, it was reported that there was an increase in the rate of neoplastic diseases from 5.6% to 14.9% and a decrease in the rate of perinatal pathologies and cardio-circulatory system diseases from 22.5% to 8.1% and from 5.6% to 0%, respectively¹⁵. It was thought that families did not prefer to stay at home even during the pandemic, since the diseases belonging to these diagnostic groups are the diseases with more serious complaints. It was found that there was an increase in home accidents depending on the length of time that children stayed at home. It was concluded that the rate of serious illnesses in the number of emergency admissions increased due to the decrease in the number of ED admissions for non-urgent diseases.

The number of dermatological, respiratory diseases and gastrointestinal system pathologies decreased significantly compared to previous year. For the diseases of these diagnostic groups with milder complaints, families might have preferred home follow-up and treatment or the frequency of getting ill might have decreased as a result of home isolation. While the rates of headache, dizziness and chest pain decreased in 2020, rate of palpitation increased. The complaint of palpitation might have increased due to anxiety arising from the pandemic. The fact that patients and their families wanted to be followed up at home for a while, instead of coming to ED, might have been effective in the decrease of admissions with subjective complaints such as headache and chest pain. In 2020, we did not have any critical patient who was lately admitted to our pediatric ED due to complaints such as headache and chest pain. It was reported in a study conducted in pediatric patients that there were significant decreases in respiratory tract infection symptoms such as fever, respiratory distress, cough, sore throat, earache, headache and symptoms related to functional syndromes such as dizziness and chest pain and a decrease in injuries following lockdown⁹.

While the number of patients with important diseases, who can be treated, decreased in other studies⁵, the decrease in the number of admissions for non-serious complaints was more remarkable¹⁷. In our study, the number of patients with upper respiratory tract infections in the common but non-emergency category of the pediatric ED in the respiratory tract disease group decreased. The admission rate of patients diagnosed with acute bronchiolitis and asthma attacks increased in 2020 compared to 2019. It was thought that this situation was caused by the awareness of families for COVID-19-like symptoms such as fever, cough and respiratory distress. When the diagnoses in the hematology-oncology group were examined, it was observed that the percentage of admission decreased in 2020 compared to 2019 in cases of bleeding disorders due to factor deficiency and febrile neutropenia. It was thought that the decrease in the rate of patients presenting with bleeding due to factor deficiency may be due to the decrease in trauma exposure as a result of home isolation period. It was predicted that the decrease in the rate of patients with febrile neutropenia may be the effect of protection from infectious agents due to home isolation during the pandemic period.

The rate of hospitalization of patients admitted to the pediatric emergency in 2020 was significantly higher than in 2019. This situation made us think that unlike adults during the pandemic, pediatric patients were admitted to the pediatric ED in cases with more serious complaints and hospitalization indications and that mild complaints might also be followed at home with different methods by their own means. However, there was no statistical difference between the intensive care unit hospitalization rates of the patients who were admitted by years. It was thought that the patients were brought to ED before they became sufficiently severe to require intensive care. It has been reported that hospitalization rates have been increased in studies^15,18. The increase in hospitalization in our findings is consistent with the literature.

The rate of patients with comorbid diseases in 2020 was statistically higher compared to 2019. Since these patients were followed up due to chronic diseases, they knew that the disruptions in outpatient services and acute exacerbations due to chronic diseases could rapidly worsen during the pandemic period, so they came to ED for routine examinations, follow-up and nasogastric tube replacement. Severe illness or death was not observed among our patients with comorbid diseases.

While there was no case of intoxication with cologne or disinfectants in 2019, a high rate of 40% of intoxication cases with cologne or disinfectants was observed in 2020. It may be considered that colognes and disinfectants were in more accessible areas during the pandemic. In a study, a lack of information has been found on keeping hand disinfectants out of the reach of children¹⁹. During the COVID-19 pandemic, it has been reported that search for information about hand sanitizers has increased in the National Poison Center²⁰. It has been thought that the increase in intoxication cases were due to rise of disinfectant usage and their presence in areas that children could reach.

Study Limitations

The limitation of the study is that it was single centered and cross-sectional study. The first strength of our study is that it covered the first period of the lockdown, where significant changes took place. The second is that demographic factors in ED admissions, the characteristics of admission to the ED, their diagnoses, the severity of the diseases, and their comorbidities were examined on the basis of both diseases and systems. In addition, potential risk factors for future pandemics were also evaluated.

CONCLUSION

Prolongation of the COVID-19 outbreak or future pandemics may lead to a generalized inadequacy of health care for children. We think that the results of our study can enable physicians to quickly manage emergency diagnosis and treatment processes in pediatric EDs during the lockdown admission as a result of the onset of another new pandemic or the continuation of the existing one.

Ethics

Ethics Committee Approval: This study was approved by İstanbul University, İstanbul Medical Faculty Medical Ethics Committee (approval date: 15/02/2020, decision number: 10).

Informed Consent: Retrospective study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: M.U., R.Y., S.G., Concept: M.U., R.Y., S.G., Design: M.U., R.Y., S.G., Data Collection or Processing: R.Y., S.G., Analysis or Interpretation: M.U., R.Y., Literature Search: R.Y., S.G., Writing: M.U., R.Y., S.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.