key: cord-319066-jdvvegp9
authors: Bressan, Silvia; Buonsenso, Danilo; Farrugia, Ruth; Parri, Niccolo’; Oostenbrink, Rianne; Titomanlio, Luigi; Roland, Damian; Nijman, Ruud G.; Maconochie, Ian; Da Dalt, Liviana; Mintegi, Santiago
title: Preparedness and response to Pediatric CoVID-19 in European Emergency Departments: a survey of the REPEM and PERUKI networks
date: 2020-05-15
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.05.018
sha: 
doc_id: 319066
cord_uid: jdvvegp9

Abstract Study objective We aimed to describe the variability and identify gaps in preparedness and response to the COVID-19 pandemic in European EDs caring for children. Methods A cross-sectional point prevalence survey, was developed and disseminated through the pediatric emergency medicine research networks for Europe (REPEM) and the United Kingdom and Ireland (PERUKI). We aimed to include ten EDs for countries with > 20 million inhabitants and five EDs for less populated countries, unless the number of eligible EDs was below five. ED directors or their delegates completed the survey between March 20th and 21st to report practice at that time. We used descriptive statistics to analyse data. Results Overall 102 centers from 18 countries (86% response rate) completed the survey: 34% did not have an ED contingency plan for pandemics and 36% had never had simulations for such events. Wide variation on PPE items was shown for recommended PPE use at pre-triage and for patient assessment, with 62% of centers experiencing shortage in one or more PPE items, most frequently FFP2/N95 masks. Only 17% of EDs had negative pressure isolation rooms. COVID-19 positive ED staff was reported in 25% of centers. Conclusion We found variation and identified gaps in preparedness and response to the COVID-19 epidemic across European referral EDs for children. A lack in early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and appropriate isolation facilities emerged as gaps that should be optimized to improve preparedness and inform responses to future pandemics.

Ever since the first human cases of the novel coronavirus were reported in Wuhan, Hubei Province in China in December 2019, the Coronavirus Disease 2019 (COVID-19) pandemic has spread rapidly across the world. 1 The epidemic in Europe initially centerd around Northern Italy where there was a steep rise in the number of cases and case fatalities from February 20 th 2020 onwards. 2 While European countries were deciding upon or were enacting containment measures of varying degrees, the infection continued to spread across the continent with devastating impact on health systems, the economy and the society at large.

Within healthcare, it is crucial that the emergency department (ED), as the entry point to hospital care, is prepared to manage high risk COVID-19 patients in an efficient and safe way, from triage to final disposition. The ED should respond to the epidemic surge in agreement with hospital contingency plans and guidelines from local and national health authorities, 3 also learning from the experience of other countries. 4 Even though it has now become apparent that children are affected less frequently and with a much more benign disease spectrum than adults, 5, 6 appropriate management in the ED of suspected and confirmed cases and their families is essential. 7, 8 Children may present with conditions not linked to COVID-19 but some, when admitted for that condition, are found to have COVID-19 positive swabs as an incidental finding. This may be a feature with the more widespread dissemination of COVID-19 throughout the population. Besides suspected or confirmed COVID-19 patients, EDs should also maintain the quality of care provided to children presenting with serious illnesses or accidents not related to the pandemic.

Pathways and protocols need to be in place to ensure that rapid appropriate care is provided to suspected COVID-19 children, while avoiding delay in care of non-COVID-19 patients. 9 In addition, it is paramount to ensure adequate protection and minimize exposure of patients and staff to the infection. 10 However, the dialogue between European pediatric emergency physicians who liaised through their European Society and their research networks (Research in European Pediatric Emergency Medicine -REPEM and Paediatric Emergency Research in the United Kingdom and Ireland -PERUKI) [11] [12] [13] highlighted differences and challenges in ED preparedness and response between countries, as the COVID-19 pandemic unfolded throughout Europe.

Hence, we aimed to describe the preparedness and response to the COVID-19 pandemic in European referral EDs for children within the REPEM and PERUKI networks.

We hypothesised that European referral EDs for children would show variability and gaps in preparedness and response to the COVID-19 pandemic, from which lessons could be learned for the current and future pandemics.

We conducted a cross-sectional point prevalence survey. The survey was developed in English by the lead author and then underwent several rounds of review by the research team.

The survey was distributed through the REPEM network, 12 a research collaborative consisting of Pediatric EDs (PEDs) and EDs of general hospitals with a separate pediatric section, serving as referral centers for children, and also the sites affiliated to the executive committee members of PERUKI. For each country, a country lead was identified on a volunteer basis, through the network, to disseminate the survey to centers meeting the above reported criteria. Country leads were pediatric emergency physicians or paediatricians working in the ED. We also included Israel as a European associated country, as Israel has been part of the REPEM network since its foundation. 14 To ensure balanced representativeness of participating countries and feasibility of the study, the research team, using a quota sampling method, 15 agreed to include a pre-determined number of centers based on the population of participating countries. For countries with more than 20 million inhabitants (namely Italy, France, Germany, Spain and the United Kingdom) participation of ten EDs was sought. For countries with less than 20 million inhabitants five EDs were expected to participate, unless the number of eligible EDs was less than five (i.e. Estonia: four EDs eligible; Iceland: one ED eligible; Latvia: one ED eligible; and Malta two EDs eligible). The denominator for our survey comprised 103 centers.

Country leads were to decide on the strategy to approach eligible EDs in their country. Some country leads approached more than the pre-established number of centers to ensure a 100% response rate, accounting for the possibility that some contacted centers might not respond.

By adopting this approach, some countries actually exceeded the expected number of participating centers per country. For calculation of the survey response rate the number of EDs exceeding the pre-determined expected number of participating EDs per country was not considered.

ED directors or their delegates, staff members appointed by the ED director as most suitable persons to complete the survey, completed one survey for each participating center. The survey was open on March 20 th and 21 st 2020. Survey responses were collected in REDCap, a validated online data collection system. 16 Respondents were asked to state their country of residency, but it was not mandatory to give the name of their hospital. Each country lead recorded the name of the invited and participating hospitals. Country leads communicated to the principal investigator the number of centers that completed the survey, without disclosing the hospitals' identities, ensuring the number of completed surveys per country matched the number of centers that actually completed the online survey.

Preparedness and response were defined, based on consensus of the research team, as organizational and operational actions taken by EDs to face the pandemic, including contingency plans, training, screening of suspected cases, surge capacity, availability and use of personal protective equipment, ED infection control measure, care pathways and management of suspected cases, health professionals safety and sustainability of care.

A first survey was completed by country leads to reflect the national situation of the COVID- The participating ED survey completed by each participating center focused on organizational and operational aspects of preparedness and response as reported in the above mentioned definition.

We followed STROBE guidelines for reporting of observational studies. 19

Descriptive statistics were used to analyse the data, reporting 95% confidence intervals (CI) around each point estimate. Data were analysed using Stata (version 13, StataCorp, College Station, Texas, USA).

This survey accessed clinicians via a research collaborative to assess their departmental practice and therefore did not require formal ethics review, as determined by the ethics board of the University Hospital of Padova, Italy. Consent was implied by participation.

A total of 18 countries participated in the study. Eighty-nine of the expected 103 centers, based on the pre-established number of participating centers per country, completed the survey (response rate 86%). However, some countries exceeded the number of expected participating EDs, leading to a total of 102 EDs participating to the survey ( Table 1 and Approximately one third of centers (34%) did not have an ED contingency plan for pandemics and 36% had never organized simulations for such events. The majority of centers (76%) had not experienced mass casualty disasters or pandemics during the past five years.

Nearly all institutions had established a formal ED management plan for suspected/confirmed pediatric COVID-19 cases, with daily updates in 69% of centers. Surge capacity for pediatric suspected COVID-19 cases was variable between centers at an ED, admission ward and intensive care level in terms of number of available rooms/beds ( Table 2 ). In one fifth of the institutions there was no intensive care availability for pediatric COVID-19 patients. Only admission ward surge capacity increased according to ED volume (Supplementary Figure   1 ). Adjustments implemented to best manage suspected/confirmed COVID-19 patients included cancellation of planned activity (i.e. outpatient visits, surgery or hospital admissions) in 90% or more of participating centers; reorganization of beds in other pediatric wards in 75%, and telemedicine in nearly 70%.

The distribution of responses showed variation in the timing of pre-triage set-up and training on personal protective equipment (PPE). Variation was also observed in the recommended use of PPE to be worn during pre-triage and during patient assessment. If looking at recommended mask use during pre-triage, surgical masks were used in 52% of centers, FFP2/N95 masks in 27% and FFP3/N100 masks in 8%, while during patient examination, 49% of centers used FFP2/N95 masks, 43% surgical masks and 11% FFP3/N100 masks.

Recommended PPE use for patients was more consistent across centers with a surgical mask to be worn by patients in 82% of EDs. Recommended duration of filtering masks use was also variable. A shortage of both basic and aerosol generating protective PPE items was experienced by nearly two thirds of centers with FFP2/N95 masks being the items most frequently missing ( Table 3) . Contagion of healthcare workers was frequently reported at an institution level (69%), but less so at the ED level (25%). Only 18% of sites endorsed a periodic active surveillance of ED staff. Disposition of healthcare workers who had been in close contact with a confirmed COVID-19 case varied between centers, with approximately one third allowing staff to work while asymptomatic and one third recommending quarantine at home. Overall, ED physicians shift work had been re-arranged in nearly two thirds of centers with variable adjustments including both increase and reduction in staff, as well as different shift schemes to prevent cross-infection among staff ( Table 4) .

and reorganized patient flow to accommodate suspected cases in separate dedicated areas.

Fewer than 20% of EDs had isolation rooms with negative pressure. Most EDs performed swab testing for SARS-CoV-2 (78%). However, asymptomatic children with a history of close contact, who could be otherwise discharged, were not tested in the ED in the majority of centers (75%). At most sites suspected cases who were tested, but were fit for discharge, were sent home and swab results communicated to the family when they became available. In cases of positive test results for discharged patients, half of the centers could count on specific outpatient services to provide telephone follow-up. Most EDs experienced a substabtial reduction in pediatric presentations, by more than 50% in half of the centers ( Table 5) . Centers further into the infection spread wave more frequently reported a larger reduction in the number of pediatric presentations (Figure 2 ). Overall 46% of centers agreed (36%) or strongly agreed (10%) about the statement "My hospital was ready and prepared to handle COVID-19 at the time the outbreak started in our country" and 54% agreed (39%) or strongly agreed (15%) when the statement was referred to ED pediatric care.

The results of our study should be interpreted in the light of its limitations. Although we included a large number of European countries, our survey does not provide a pan-European perspective. However, this is the first European dataset that provides a detailed snapshot of pediatric emergency care from within the pandemic, at a more granular level than any institutional channel has been able to provide so far. While the pandemic evolves in each country and accompanying adjustments are made, a repeat focused survey will capture the dynamic progress made from an organizational and operational perspective. We arbitrarily decided, as a research team, the number of centers to be included in each country to ensure a balanced representativeness and to obtain timely completion of the survey. The participating centers represent a subset of EDs caring for children in Europe and include referral centers for children, thus our findings may not be generalisable across different settings. Although some countries exceeded the expected number of recruited centers, we were able to obtain a reasonable balance in terms of country representativeness. In addition, the objective of this survey was to explore common challenges and common learning points and not to compare responses between countries. Lastly, while the authors themselves refined questions via review processes, the survey questions did not undergo a formal content validation procedure. Given that most of the answers required fixed quantitative responses on practice in use/recommended at participating EDs, a formal content validation would have likely had limited impact on the reliability of our findings.

Our survey provides a snapshot of preparedness and response of EDs caring for children from 17 European countries and a European associated country at one month after the COVID-19 outbreak started in Northern Italy. Overall, the findings of our study show high variation in time and in level of organisational responses to COVID-19 of EDs caring for children across Europe and identified a few gaps that still need to be optimized to improve preparedness and inform responses to future pandemics. Our data show that a written and documented contingency plan was still missing in approximately one-third of centers one month after the onset of the outbreak in Europe. While the majority had not faced an epidemic or a mass casualty event in the past five years, nearly 40% had never run a simulation on how to manage such a crisis in the ED. A striking finding of our point prevalence survey was the wide variation in reported PPE use at pre-triage and for the assessment of suspected COVID-19 cases, with 62% of centers experiencing shortage in one or more PPE items. In addition, a high percentage of centers reported infection in staff members, which may affect the sustainability of care provided. From a structural perspective, the low percentage of EDs with negative pressure isolation rooms (17%) highlights opportunities for improvement, should renovation work be undertaken or new hospitals are built in the future. While participating countries were at different stages in the outbreak spread the different pace in the pandemic advancement represents an opportunity for healthcare systems to learn from each other by sharing experience and identifying areas for improvement. This may ensure a more rapid response in terms of implementation of infection prevention and control measures within healthcare in those countries that lag behind the spread wave. This is important at all levels of care within an integrated health care system, but it is paramount for frontline services such as EDs. 20 no PPE is required if preliminary screening does not involve direct patient contact. 28, 29 Nearly half of the centers reported a shortage of PPE, most often FFP2/N95 masks. PPE use should be maximized to avoid shortage of supplies, which ultimately exposes staff and the broader community to an increased transmission risk. One third of respondents stated that respirators (N95/FFP2 or FFP3/N100) are disposed of after the assessment of each suspected case. This practice may contribute to shortage of supplies, as the same respirator could be used for more than one patient, as long as it is not damaged or soiled. 29 Approximately 70% of respondents were aware of infected healthcare workers at their institution, while one fourth reported infected staff in the ED. Unfortunately, infection of healthcare workers has been reported as a major threat to the sustainability of healthcare in this pandemic. 26 In fact, the disposition of healthcare professionals who had been in close contact with a confirmed COVID-19 case varied between centers, possibly because of concerns regarding service provisions.

manner. This is in contrast to barriers related to structural limitations and constraints affecting the organization of ED patient flow and isolation capacity, which may be difficult to overcome in a short time frame. Infection control measures were more consistently reported in the survey, including re-arrangement of ED patient flow, changing of staff work shift to optimize resource utilization, reduction in the number of care givers allowed with the child and home quarantine for confirmed COVID-19 pediatric cases fit for discharge.

Another interesting finding from our survey is the substantial reduction in pediatric ED presentations during the pandemic. Centers from countries with a longer time since first case experienced higher reductions in the number of ED presentations. Parents' fear of contagion in a healthcare environment, improved hygiene measures, reduced community transmission of communicable diseases, reduced opportunities to sustain injuries owing to the strict containment measures enforced by governments, and reduction in stress-related functional diseases may be the reasons underlying this phenomenon. Reports from previous epidemics also showed an overall decrease in PED attendances. 30, 31 The MERS outbreak had resulted in a significantly higher proportion of high acuity ED pediatric presentations and an increase in delayed presentations. 9, 32 Despite its limitations, the provision of a timely report on preparedness and response in pediatric emergency care during the pandemic is useful to inform practice and policymakers to properly reorganize health systems while the crisis is still evolving. It provides an accurate objective historical dataset from which lessons can be learned for the future, including for adult EDs. The collaboration of the REPEM and PERUKI European networks was instrumental to ensure wide representation of European countries and timely completion of this multinational point prevalence survey. The data provided highlight the importance of European multinational research collaborations to provide the best care to children in the frontline.

In summary, we identified variability and gaps in preparedness and response to the COVID- Not reported ED=Emergency Department; PED= Pediatric Emergency Department; UK= United Kingdom § number of eligible EDs was less than the pre-determined number of five expected participating centers for countries with a population of less than 20 million inhabitants * referral ED for children # Malta: general referral ED seeing children; Portugal: 2 secondary-care PED in a hospital for adults and children; Spain: secondary-care PED in a hospital for adults and children; Sweden: secondary-care PED for medical conditions. A secondary-care PED provides specialist care upon referral by primary care, pre-hospital emergency services or other smaller hospitals, but does not include highly specialized medical care, which may involve advanced and complex procedures and treatments performed by medical specialists in a tertiary-care state-of-the-art facility. ** Belgium: 3 centers did not know; Germany: 2 centers did not know; Switzerland: 1 center did not know; UK: 1 center did not know He/she must be tested and in the meantime be in quarantine He/she must be tested and in the meantime can work with a surgical mask He/she must be placed in quarantine without being tested If he/she has no symptoms, can continue to work without being tested Other Don't know 31 16 Both parents/caregivers are allowed to be with the child Only one parent/caregiver is allowed to be with the child There are no rules that establish the number of caregivers allowed in the ED 13 86 3 13% 84% 3%

8-20% 76-90% 1-8% What is the patient flow for a suspected COVID-19 in your ED/PED after pre-triage? Patient is taken directly to an isolation room, with negative pressure Patient is taken directly to an isolation room, but with no negative pressure Patient is taken directly in a usual visit room Patient waits in the usual waiting room Patient waits in a dedicated waiting room for suspected COVID-19 Other 68-84% 15-30% 0.1-5% If you perform a nasal/pharyngeal swab for SARS-CoV-2 in the ED/PED to a clinically stable child (who would not otherwise require admission) I must keep the child in a dedicated isolation room until I receive the swab result I can discharge the child home and I communicate the family the result when available I have to admit the child to a regular pediatric ward until I receive the swab result Children who do not need admission are not tested for SARS-CoV-2 in my ED Other   6  78  2  15  1   6%  76%  2%  15%  1% 3-12% 67-83% 0.5-7% 9-23% 0.1-5% If your only criterion for suspected COVID-19 is close contact with a confirmed COVID-19 case and the child is otherwise asymptomatic and well, do you test/will you test the child in the ED/PED for SARS-CoV-2?

No, they are discharged home for isolation ( 

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The authors would like to acknowledge all the respondents to the survey and who gave permission for their names to be included in the acknowledgment section of this paper: