key: cord-0924818-w14zz4of authors: Yamamoto, Hiroo; Morikawa, Yoshihiko; Hagiwara, Yusuke; Hataya, Hiroshi title: Pediatric emergency healthcare utilization during the COVID‐19 pandemic in Tokyo date: 2021-07-29 journal: Pediatr Int DOI: 10.1111/ped.14936 sha: 604726de9a849d2f57ba13b4065331ef285ad41c doc_id: 924818 cord_uid: w14zz4of BACKGROUND: Various public health interventions have been implemented against the COVID‐19 pandemic. We investigated herein changes in pediatric emergency healthcare utilization during the current pandemic. METHODS: Based on data on outpatient healthcare visits to one pediatric emergency department in Tokyo, Japan, the descriptive, cross‐sectional study compared the number of emergency department visits between 2020 and the previous three years. Data were extracted from the electronic triage reporting system. The primary outcome was the number of emergency department visits. The characteristics of patients by age group were also investigated. RESULTS: A 40.6% reduction in pediatric emergency healthcare utilization was observed during the study period, with the greatest decrease occurring in the number of visits for fever. However, while the number of patients with a complaint with an exogenous cause decreased, the proportion of these patients increased. Although social activities in the greater community have now almost normalized, and only a slight increase in the number of patients with fever has been reported, the number of emergency department visits remains lower than in previous years as of this writing. CONCLUSIONS: Public health interventions led to a reduction in emergency department visits, thereby allowing time to redistribute health care resources. This article is protected by copyright. All rights reserved of emergency was lifted in week 22, and most schools reopened in week 23, at which time other social activities gradually resumed. Thereafter, the number of patients with COVID-19 bottomed out at week 20 before starting to increase again in Tokyo [3] . Previous studies described which diagnoses decreased in the context of the general decline in the number of ED visits [4] [5] [6] [7] , but few studies have analyzed this topic by age group [8] while no studies on this topic have been done in Japan. Moreover, no studies have yet examined changes in the trend of ED visits after a lull in the pandemic and the resumption of social activities. Therefore, based on changes over time in the frequency of pediatric ED visits at the study center, the present study analyzed pediatric emergency healthcare utilization in the pediatric ED to assess the effect of the public health interventions implemented in response to the pandemic on ED activities and to gather insights into formulating strategies for managing future emerging disease outbreaks. This article is protected by copyright. All rights reserved 《Data collection》 eTriage (DANK NET, Tokyo, Japan), an electronic triage reporting system, was used as a database for the present study. The volume of patient visits and patient characteristics, including age, sex, date, time of visit, complaints, method of arrival (walk-in, ambulance, or helicopter), vital signs, and triage acuity level were collected and analyzed. Patients with a body temperature of 38.0℃ or higher were categorized as febrile. The main complaints were divided into 17 categories, which were then subdivided into 168 subcategories. Triage was performed by a registered nurse in accordance with a modified Japanese Triage and Acuity Scale (mod-JTAS) protocol (9) . Patients classified as 1 or 2 on mod-JTAS were considered to have a high degree of urgency. The primary outcome was the number of emergency department visits during the COVID-19 pandemic with reference to the number of patients in the past three years. The relationship between changes in the characteristics of the ED visits by age group and the implementation of public health interventions and resumption of social activities was also examined. This article is protected by copyright. All rights reserved The m-JTAS chief complaint categories are divided into 17 major categories, mainly organ-specific, and further subdivided into 170 subcategories. The subcategories of complaints were divided into those with an exogenous cause (trauma, foreign objects, environmental causes, and so on), those with an endogenous cause (fever, cough, stomachache, and so on), and others (including complaints related to mental health). The patients were divided into four groups according to age as infants (under age 1 year), preschool-aged (age 1 -6 years), elementary and junior high school-aged (age 7-15 years), and older (over age 16 years). All statistical analyses were performed using SPSS version 27.0 (IBM, Armonk, NY, USA). In total, 15,998 visits occurred during the study period (calendar weeks 1-39 in 2020), during which pediatric emergency healthcare utilization decreased 40.6% compared to the mean of the preceding period (n=26,948). In the study period, the mean patient age was 5.0 years, 41.3% of the patients were female, 11.1% arrived by ambulance or medical helicopter, and 11.7% were deemed to have a high degree of urgency. The final two characteristics changed little between the study and baseline periods (Table 1) . By week 8, the number of visits was similar to that of the previous years. School closures were implemented in week 10 at which time the number of ED visits began to decrease precipitously ( Figure 1 ). The number of COVID-19 cases in Tokyo continued to increase (3), and a state of emergency was declared in seven prefectures, including Tokyo, on April 7 (week 15). Most schools opened in week 23, when the number of ED visits increased at the same rate as in previous years, but the total number remained lower than the baseline. This article is protected by copyright. All rights reserved Figure 2 shows the number of patients presenting to the ED with a complaint with an exogenous cause. Across all age groups, public health interventions led to a sharp decrease in the number of ED visits but an increase in the percentage of patients admitted. With the resumption of social activities, the number of ED visits again began to rise, and the number of patients approximated that at baseline after week 33 (Figures 2a, 2b) . The number of infants with a complaint with an exogenous cause was roughly the same as in the preceding years, but the proportion of infantile patients with the identical complaint increased (Figures 2c, 2d ). The number of elementary and junior high school-aged patients a complaint with an exogenous cause showed a marked decrease after the closure of schools, but their number continued to increase from week 16 and reached parity with the baseline figure by week 31 (Figure 2g ). The proportion of patients in the latter age group was roughly the same at week 31 as baseline (Figure 2h ). Figure 3 shows the number of patients presenting to the ED with fever. Across all age groups, public health intervention resulted in a sharp decrease in the number of febrile patients. Their number is again slowly increasing but remains much lower than in previous years (Figures 3a, 3b) . In previous years, the number of infants and preschool-aged patients with fever tended to increase through summer; however, this was not the case in 2020 (Figures 3c, 3e ). The number of elementary and junior high school-aged patients with fever decreased slightly after the closure of schools, but as social activities resumed, their number and overall proportion approximated the numbers in the preceding years (Figures 3g, 3h) . This article is protected by copyright. All rights reserved proportion of patients arriving by these conveyances (Figure 4a, 4b) . A similar trend was observed in patients deemed to have a high degree of urgency (Figures 4c, 4d) . While previous studies reported a decrease in the number of ED visits due to public health interventions (4-7), the present study investigated this trend in terms of patient age groups. The present study also identified trends in the number of ED visits after the resumption of social activities. In line with previous studies, a significant reduction (40.6%) in pediatric emergency healthcare utilization was observed. Three findings in particular deserve closer scrutiny. First, the number of patients with fever decreased dramatically after the public health interventions were implemented. Second, the number of primary and junior high school-aged patients with a complaint with an exogenous cause decreased, but the number of infantile and preschool-aged patients did not change compared to previous years. Third, even after the resumption of social activities, the number of ED visits has remained low. The number of patients with fever decreased most significantly after the implementation of public health interventions. Previous studies showed a decrease in complaints related to the common cold and gastroenteritis, which are infectious, but not in complaints related to urinary tract infections, which are endogenous (5) . Similarly, the national statistics for 2020 showed no decrease in the incidence of exanthema subitum, which is mainly caused by familial infections although the incidence of hand-foot-and-mouth disease or herpangina, which is common in the summer, decreased significantly (9-11). On the other hand, the number of patients except infants with a complaint with an exogenous cause decreased despite an increase in the proportion of cases. The lack of change in the number of infantile patients is likely due to the fact that accidental injuries in This article is protected by copyright. All rights reserved this age group typically occur indoors (13) , and the public health interventions therefore did not contribute to reducing the incidence of such complaints. Thus, medical resources need to be available continually to treat these patients even during a pandemic. Strictly speaking, the present study was unable to determine whether the decline in the number of patients was due to a decrease in the number of injuries and illnesses or to avoidance of hospital visits. A previous study reported that some parents avoided taking their children to the hospital from fear of contracting COVID-19 (6) . If the decline in the number of patients observed in the present study was due to avoidance of hospital visits, the number of relatively less urgent cases might be expected to have decreased to a greater degree and that of relatively more urgent cases might be expected to have increased to a greater degree; however, the present study found only a small increase in the proportion of patients with a high level of urgency or transportation via ambulance. Thus, it is likely that a smaller number of injuries and illnesses contributed more greatly to the drop in the overall number of patients than the avoidance of hospital visits. Currently, the number of ED visits is still smaller than in previous years despite the slight increase seen after the resumption of social activities. In particular, the number of patients presenting with a complaint with an exogenous cause has returned to the same level as in previous years. However, the proportion of them remains higher than in previous years. The number of febrile, infant or preschool-aged patients remained low, possibly as an effect of changes in behavior, such as more widespread mask use, more frequent hand hygiene practices, and the avoidance of the so-called 3C's (closed spaces, crowded places, and close-contact settings). The number of elementary and junior high school-aged patients with fever has returned to the level in previous years. Closure of schools may be more effective than the 3C's in reducing the prevalence of This article is protected by copyright. All rights reserved infectious diseases in this age group. The public health interventions, including school closures, succeeded in providing an opportunity to redistribute medical resources. In particular, isolation beds and personal protective equipment (PPE) tended to be in short supply during the pandemic. Owing to the massive reduction in the number of ED visits, procedures for dealing with COVID-19 patients and obtaining a sufficient PPE supply were able to be developed during the lull in ED activity created by the drop in visits. Children were considered a potential source of COVID-19 transmission because they are more susceptible than adults to various viral infections, such as influenza. Furthermore, this concern was magnified by the fact that children infected with COVID-19 are typically asymptomatic or have mild symptoms indistinguishable from those of the common cold (13) . Although the evidence supporting the effectiveness of school closures against the spread of COVID-19 is very scant, many countries, including Japan, implemented this measure, which was based on evidence showing that reduced social contact between students was able to interrupt the transmission of the influenza virus (14) (15) (16) . In Belgium, school closures were associated with a significant decline in the infection and mortality rates during the current pandemic (17) . On the other hand, another study reported that school closures did not contribute to controlling the epidemic, and that other social distancing measures were more important (18) . The present study did not provide a clear answer to this question because it was not concerned with addressing changes in the number of pediatric COVID cases. Of course, there are other factors involved as well, but public health interventions, including school closures, reduced the number of ED visits and were considered to have been very effective for creating time needed for the redistribution of medical resources. This finding may be useful for the further spread of COVID-19. However, their effectiveness against the transmission of COVID-19 has yet to be determined. This article is protected by copyright. All rights reserved Global epidemics caused by emerging infectious diseases will continue to be a threat by virtue of increased international travel and the greater opportunities for zoonotic transmission due to more frequent contact with wildlife brought about by climate change. It is important to evaluate the effectiveness of various interventions and to be prepared for future emerging infectious diseases. It is hoped that the findings of the present study will be useful in these ends. The present study has two limitations. First, this study was monocentric; thus, its findings may not be extrapolatable to other countries or regions. Second, our database did not include information about diagnoses or patient dispositions; changes in the frequency of individual diseases and the prognosis of patients were unable to be determined. Public health interventions, including school closures, should be effective in reducing the number of ED visits to some degree, thereby allowing time for redistributing health care resources. The findings of the present study will aid in formulating strategies for managing future emerging infectious disease outbreaks. Public health interventions are not sufficient to reduce the incidence of accidental injuries substantially, and medical resources need to be available continually for patients with these complaints even during a pandemic. We believe that further research into changes in pediatric emergency healthcare utilization are warranted. This article is protected by copyright. All rights reserved 【Acknowledgments】 We would like to thank Mr. James Robert Valera for his assistance with editing the manuscript. The authors declare no conflicts of interest. This article is protected by copyright. All rights reserved 【Figure legends】 World Health Organaization Updates on COVID-19 in Tokyo COVID-19 related reduction in pediatric emergency healthcare utilization -a concerning trend COVID-19 pandemic: Impact caused by school closure and national lockdown on pediatric visits and admissions for viral and non-viral infections, a time series analysis Delayed access or provision of care in Italy resulting from fear of COVID-19 Changes in Children's Healthcare Visits During Coronavirus Disease-2019 Pandemic in Hangzhou Pediatric Emergency Department Visits at US Children's Hospitals During the COVID-19 Pandemic Down-triage' for children with abnormal vital signs: evaluation of a new triage practice at a paediatric emergency department in Japan National Institute of Infectious Diseases HFMD) cases reported per sentinel weekly Accepted Article This article is protected by copyright. All rights reserved 11) National Institute of Infectious Diseases. 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