On the basis of the primary results of this study, certain demographics and hospitalization features of patients admitted to the investigated PICU changed during the early major outbreak. Our PICU was not set up to receive confirmed COVID-19 cases during the entire COVID-19 outbreak in 2020. The most notable variation was that the PICU admission number showed a visible decline in comparison to that in pre-epidemic years. A similar phenomenon was observed in a study in Northern Italy, in which unplanned and medical PICU admissions markedly decreased during the COVID-19 outbreak .
We found that the number of PICU admissions due to emergency and outpatient visits decreased synchronously in 2020. It has been reported that the total number of emergency department (ED) visits during the early pandemic period in the U.S. was 42% lower than that during the same period in 2019 . This suggests a relationship between the decline in the number of PICU admissions due to emergencies and the reduction in ED visits during the COVID-19 outbreak in 2020. Nonetheless, data on admissions to the emergency department in our hospital were lacking. The proportion of admissions to the PICU due to emergency increased in 2020 compared to in pre-epidemic years, but the proportion of PICU admissions via outpatient visits decreased. In contrast, the proportion of PICU admissions via outpatient visits increased significantly in 2021 compared to that in 2020. Furthermore, the percentage of admissions from other provinces decreased in 2020 versus 2019 but increased in 2021 versus 2020. Numerous factors can explain these findings. One reason assumes that at the beginning of last year's outbreak, fear of being infected by SARS-CoV-2 was at an all-time high. People tended to seek medical attention only in cases of emergency while subjectively postponing nonemergency care-seeking behavior. The fact that fear of epidemics significantly influenced people’s health care-seeking behavior was expounded during the SARS epidemic in 2003 . Similarly, it has been reported that access to or provision of care was delayed in Italy, possibly due to fear of COVID-19, in 2020 . During the early major outbreak in mainland China in 2020, there was no obvious short-term shortage of medical resources outside the central epidemic area. However, widespread implementation of forced administrative controls impacted people's health care-seeking behavior. This may have influence, either through direct restrictions or through the indirect effect of reducing out-of-home activities, on patient demographic characteristics in the PICU during the same period. Strict traffic controls across the country restricted ecdemic residents from seeking medical care off-site, resulting in a relatively higher proportion of local patients in the Chengdu region. It is therefore possible that intervention measures such as social distancing or home quarantine rather than spread of COVID-19 itself influenced the public’s healthcare service choice.
We found that the median LOS in the PICU and the median LOS in the hospital were longer in 2020 than in 2019. At the same time, the proportion of hospital outcomes with unauthorized discharge was greatest in 2020 compared with those in the other three years. Unauthorized discharge means that after adequate communication with medical staff, family members understood that although discontinuing aggressive medical interventions may accelerate a patient's deterioration, they sought to abandon treatment voluntarily. Clinically, unauthorized discharges are often initiated by patient's families when they subjectively recognize that the patient is more likely to have a poor outcome. Therefore, the increase in the proportion of unauthorized discharges may be explained by the assumption that patients admitted to the PICU in 2020 were more severely ill and required longer intensive care treatment. These factors resulted in an increase in unauthorized discharges due to the family’s lack of confidence in the patient's recovery. Therefore, the actual mortality rate may be higher than the in-hospital mortality rate because the prognosis of patients who were discharged unauthorizedly is usually poor.
With regard to the distribution of primary diagnoses, the proportion of PICU admissions with a primary diagnosis of malignancy or neoplasms of uncertain behavior was highest in 2020 compared to the other three years. In fact, parents generally are not able to identify malignant tumors and might seek medical care on their own initiative. Therefore, the reasons for the highest proportion of patients with malignancy or neoplasms are more likely to be medical related. For instance, there might be an increase in referrals to tertiary hospitals for further treatment after diagnosis at local hospitals. In addition, pediatric surgeons of the tertiary hospital prioritized admission of patients requiring early treatment during the outbreak and postponed that of patients with slow-progress diseases, leading to an increase in the proportion of malignant tumor cases.
To date, there are still small-scale outbreaks of COVID-19 occurring occasionally in some areas of China. This pandemic has impacted many aspects of society, including the healthcare system. Our study appears to show that the COVID-19 pandemic is still affecting daily work in the PICU. Although it is difficult to specify the endpoint of the unprecedented plague, the formation of an immune barrier with increased vaccination rates may theoretically help relieve the need for masking sooner [17, 18]. In interpreting these results, some limitations should be taken into account. Considering the limitations of single-center research, some results of our study may not be applicable to other geographic regions. Additionally, this study was a retrospective analysis, and a small amount of data was missing. Nevertheless, our study focuses on the PICU, which did not admit COVID-19 patients outside the epicenter during the early major outbreak in China and has received little attention in previous studies.