key: cord-0947808-651fn050
authors: Bae, Woori; Choi, Arum; Kim, Kyunghoon; Kang, Hyun Mi; Kim, Sae Yun; Lee, Heayon; Yoo, Il Han; Yang, Eun Ae; Chun, Yoon Hong; Bin, Joong Hyun; Yoon, Jong‐seo; Lee, Sang Haak; Kim, Hyun Hee; Kim, Sukil; Jeong, Dae Chul
title: One‐year changes in the pediatric emergency department caused by prolonged COVID‐19 pandemic
date: 2021-10-04
journal: Pediatr Int
DOI: 10.1111/ped.15016
sha: 60cbb865badf31e27651da63d71116a7fb149f8b
doc_id: 947808
cord_uid: 651fn050

BACKGROUND: With the coronavirus disease 2019 (COVID‐19) pandemic lasting for more than a year, it is imperative to identify the associated changes in the use of emergency medical care for efficient operation of the PED. This study was conducted to determine the long‐term impact of the COVID‐19 pandemic on the patterns of PED visits. METHODS: This is a retrospective observational study of visits to the PED of six hospitals, between January 1, 2017, and December 31, 2020. We compared changes in the characteristics of patients before and during the COVID‐19 pandemic. RESULTS: A total of 245,022 visits were included in this analysis. After the first case of COVID‐19 was reported in Korea, we observed a significant decrease (54.2%) in PED visits compared to the annual average number of visits in the previous three years. Since then, the weekly number of PED visits decreased by 11.9 person/week (95% CI: ‐15.3 to ‐8.4, P<0.001), which included an increase of 0.21% (95% CI: 0.15% to 0.26%, P<0.001) per week in high acuity patients. From 2017 to 2020, the proportion of infectious respiratory diseases by year was 25.9%, 27.0%, 28.6%, and 16.3%, respectively, demonstrating a significant decrease in 2020 (P<0.001). CONCLUSIONS: During the COVID‐19 pandemic, the number of patient visits to PEDs continues to decline, especially among those with infectious diseases. However, the disease severity of patients has gradually increased. There has been a change in the characteristics of visits to PEDs after COVID‐19 which will require an appropriate response from a long‐term perspective.

At the end of 2019, coronavirus disease 2019 caused by severe acute respiratory 3 syndrome coronavirus 2 (SARS-CoV-2) was first reported in Wuhan, Hubei province, China. 1 

Since then, COVID-19 has rapidly spread to Europe and Asia, including Korea, with 108,822,960 5 cases in 223 countries, prompting the World Health Organization to declare a COVID-19 6 pandemic on March 11, 2020. 2 To prevent the spread of COVID-19, governments and health 7 systems around the world have imposed various rules and restrictions on daily life. In Wuhan, 8 Chinese authorities implemented non-pharmaceutical interventions, including an unprecedented 9 policy of cordon sanitaire, imposing severe restrictions on people leaving the city. 3 The United 10 States, and other local governments, also implemented social distancing measures, including bans 11 on large social gatherings; school closures; closure of entertainment venues, gyms, bars, and 12 restaurant dining areas; and shelter-in-place orders. 4 These government-led initiatives have 13 discouraged participation in community activities and changed the pattern of health care practices. 14 The first COVID-19 confirmed case in Korea was reported on January 20, 2020, and as of 15 November 30, 2020, there were 438 new cases of COVID-19, 34,201 cumulative confirmed cases, 16 and 536 cumulative COVID-19 related deaths. 5 The Korean government implemented social 17 distancing measures on March 22 2020, which included the following guidelines: cancellation of 18 meetings that include eating or sharing of food; restriction of individuals with fever or respiratory 19 symptoms from visiting work-places; avoiding physical contact with others outside of the family 20 context; social distancing of ≥2 m; frequent handwashing; encouraging individuals to work from 21 home and rely on video conferencing for meetings; and individual monitoring for fever and 22 respiratory symptoms when entering confined spaces. 6 Nevertheless, the current COVID-19 23 pandemic has lasted for a long period of more than a year, bringing about various changes in the 24 social and economic as well as the public health system and medical utilities.

In the early days of the COVID-19 pandemic, there were reports that individuals were reluctant 26 to visit hospitals leading to fewer visits to the pediatric emergency departments (PED). Foreign 27 studies report that the number of patients visiting PEDs for about one to two months after COIVD- 28 19 pandemic decreased by 50-88%. [7] [8] [9] In Korea, there are reports that the number of patients 29 visiting PEDs for about two to three months after the COVID-19 pandemic decreased by 58-30 77%. 10, 11 The above studies report changes over a short period after the COVID-19 pandemic.

Korea's public medical system and medical operations are constantly changing owing to this 32 long-term prevalence of COVID-19 pandemic. In addition, the overcrowding of PEDs on account Accepted Article of seasonal and other epidemic diseases is evolving due to the COVID-19 pandemic. 47 We included patients <18 years of age. Those who attended the PED for issuance of a certificate 48 or were discharged from the PED with R-codes, indicating symptoms or signs as diagnosis, were 49 excluded. Cases with missing data during the intake process were excluded. Diagnoses were made Statistical analysis 73 We evaluated differences in age, sex, acuity of health condition, mode of arrival, and discharge 74 between the years of comparison using a chi-squared test. We used segmented regression analysis 75 to confirm the regression model for the change in the weekly number of patients visiting the PED.

As seasonal variation exists in the trend of PED visits, the data were adjusted for seasonality. We 77 also applied the same analysis to the number of visits for infectious diseases and infectious 78 respiratory diseases, as well as to the proportion of high acuity patients.

All analyses were performed using R version 4.0.0 (R Foundation for Statistical Computing, 80 Vienna, Austria), with the probability level for significance set at a P-value <0.05. 

From January 2017 to December 2020, 257,835 patients attended the PED of the six hospitals.

Among these, 1,923 cases who visited the PED for issuance of a certificate and 9,484 cases who 89 were discharged from the PED with R-codes, indicating symptoms or signs as diagnosis, were 

This article is protected by copyright. All rights reserved 97 study group are summarized in Table 1 . years. [16] [17] [18] However, as the data used in these studies were based on a single institution, the results The limitations should be acknowledged. First, this was a retrospective study that extracted data 219 from the electronic medical records of each of the six participating hospitals. Case-mix due to 220 differences in each hospital may exist, and as a result, sampling bias or information bias may 221 occur. However, since the six hospitals cover areas where more than 50% of the total population 222 reside, the above limitations may be reduced. Second, since the data of this study were provided 223 anonymously, the possibility that information for the same patient might be included more than 224 once cannot be excluded. These are inherent limitations of de-identified datasets and are not Accepted Article specific to this study.

The strength of our study is our use of a large data set from six hospitals during the one-year 227 COVID-19 pandemic. Since data were obtained from six hospitals in metropolitan areas and 228 provinces in Korea, regional deviations in the results of this study could be reduced. We consider 229 our findings to be reliable as our analysis included 245,000 data entries, providing a comparison of 230 the characteristics of visits to the PED for three years before and about one year after the onset of 231 COVID-19 pandemic, controlling for known seasonal variation in PED visits. Our study revealed that the number of patients visiting the PED continued to decline during the 235 COVID-19 pandemic. We also identified a specific decrease in visits related to infectious diseases, 236 especially infectious respiratory diseases, accounting for a large proportion of the decrease in 237 overall PED visits. However, we did note a gradual increase in the acuity of patients who did visit 238 the PED after January week 4, 2020. Therefore, as the COVID-19 pandemic persists, there is a 239 need to implement longer-term measures for the appropriate allocation of human and material 

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Table1. Characteristics of Patients in the Pediatric Emergency Department

NA: Not applicable, KTAS: Korean Triage and Acuity Scale

All rights reserved Table 2. Diagnoses of patients visiting the pediatric emergency department

Non-infectious diseases

All authors have no potential conflicts of interest to disclose.

Bae WR, Kim 

This article is protected by copyright. All rights reserved