Numerous studies have demonstrated a significant decrease in ED visits across almost all age groups during the early phase of the pandemic [7]. However, contrary to the increased proportion of adults visiting the ED, from 60.5% to 65.2% [8], our research revealed a decreased proportion and number of pediatric ED visits across all Cathay Health System hospitals during the pandemic season. Several factors, such as school closures, social distancing policies, and media influence, could have contributed to the decline in total pediatric ED visits [9, 10]. This phenomenon is particularly evident among vulnerable populations, such as pediatric patients, as parents and caregivers are often hesitant to bring their children to the hospital due to fear of COVID-19 infection during ED visits.
Based on our research, we identified several impacts of the COVID-19 pandemic on our pediatric emergency department (PED). We noted a decrease in the number of children arriving being held or walking, whereas the percentage of ambulance use increased from 3.41% to 5.97%. Additionally, the percentage of patients with low triage acuity levels (levels 3 to 5) was higher during the pandemic period (89.19 %) than during the pre-pandemic period (88.4 %). This may explain the increased proportion of pediatric patients who were discharged during the pandemic period (88.33% to 89.36%). Furthermore, we observed a decrease in the percentage of admissions, from 10.65% to 9.89%. However, we also noted an increased percentage of ambulance use during the pandemic period, indicating that parents tended to call for emergency medical attention for their children, even for mild symptoms, because of the fear of infection.
In contrast to our study, research from the United States of America reported a decrease in PED visits and an increase in admission rates during the early phase of the pandemic period [11]. Similarly, a study from Finland revealed a decline in the number of EMS missions within the first two months after the first COVID-19 cases in the study area [12]. The contradictory results from the two studies may be due to differences in local healthcare-seeking behaviors. Taiwanese people have access to convenient medical resources but may be afraid of severe disease complications, especially given the sensationalized news on COVID-19 on social media. Parents may be anxious about their children's health but hesitant to take them to hospital. Consequently, they may opt to call an ambulance, even for minor illnesses. If the doctor's examination reveals no significant health issues, they may opt for medication instead of hospitalization.
Second, our study revealed a similar percentage of pediatric trauma cases during the pre-pandemic and pandemic periods (23.31% and 23.62%, respectively). However, two other studies have reported a decrease in the percentage of pediatric trauma cases during the pandemic period, which may be associated with reduced social activities and traffic mobility due to the implementation of the "stay-at-home" policy [13, 14]. However, further studies are required to confirm these findings.
Third, life-threatening chief complaints, including altered mental status and cardiac arrest, had IRR of 3.08 and 5.00, respectively. Our results are consistent with those of similar studies conducted in other countries (England and Singapore), which revealed an increased incidence of out-of-hospital cardiac arrest and worse outcomes during the pandemic. [15,16] Additionally, we observed an increase in the IRRs of chief complaints of shortness of breath, hypertension, and glycemic problems (1.28, 16.33, and 5.4, respectively). A prospective multicenter study reported that children with COVID-19 have significantly higher systolic and diastolic blood pressures than healthy children. [17] Moreover, a study from India found that glycemic control in type 1 diabetes mellitus patients worsened during the pandemic period, although the study mainly focused on adults. [18] Pediatric patients with asthma and acute exacerbation often present to the ED with the chief complaint of wheezing (indicated by shortness of breath). [19] Long-term medication, such as bronchodilators, antihypertensive drugs, insulin, and oral antidiabetic agents, are necessary to control these chronic diseases. During the pandemic, obtaining these long-term medications may have been difficult due to lockdown policies, reduced outpatient appointments at local clinics or hospitals, and the fear of infection. Therefore, during a pandemic, it is crucial to prepare more backup, long-term medications for the public or increase online pharmacy services for medication pickup.
An interesting finding of our study was the decreased percentage of chief complaints related to headaches and convulsions. A significant proportion of headaches in children are caused by fever, which can be associated with upper respiratory tract infections. Additionally, febrile seizures are a common cause of pediatric convulsions [20]. According to our research, the percentage of chief pediatric complaints of fever and upper respiratory tract infections decreased during the pandemic period, which may be attributed to the lockdown strategy and health education policies, such as mask-wearing and improved hygiene practices. This finding is consistent with a study from Saudi Arabia, which also found a decrease in visits for common neurological conditions, such as headache and seizures, during the pandemic period [21].
Finally, although not statistically significant, an increased proportion of children presenting with social problems was noted during the pandemic compared with the pre-pandemic period in our study. The "stay-at-home" policy during the pandemic period may have led to an increase in domestic violence [22], as the home is often an unsafe place for these victims. Additionally, the rates of suicidal ideation and attempts were higher during the pandemic season [23]. These results are consistent with those of other studies and we assume that the quarantine policy may have caused people to experience more pressure and anxiety. Therefore, more social workers should be recruited in the ED in response to these circumstances.
Limitation
Our study has several limitations. First, this was a retrospective study that relied on EMR data from 2019 to 2020, which may have resulted in some missing data. Second, all three hospitals included in the study are located in northern Taiwan, which may limit the generalizability of our findings to other regions of the country. Third, the number of patients in certain subgroups of chief pediatric complaints was small, which may limit the generalizability of our findings to the pandemic period. Lastly, although all triage nurses underwent formal training, they may have assigned different emergency severity indexes (ESIs) to different patients according to their preferences.