Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study

Abstract

Background: During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses.

Methods and findings: Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems.

Conclusions: Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell.

Trial registration: ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258.

Fig 1. Timelines of first phase of COVID-19 pandemic in participating countries.

Timelines of the introduction of national infection prevention measures (“Response measures”), as well as dates for the first and first 100 cases of SARS-CoV-2 for each of the countries participating in the EPISODES study. The black circle depicts the date of the highest 14-day cumulative rate of new SARS-CoV-2 cases per 100,000, with the size reflecting the actual case rate. COVID-19, Coronavirus Disease 2019; EPISODES, Epidemiology, severity and outcomes of children presenting to emergency departments across Europe during the SARS-CoV-2 pandemic; SARS-CoV-2, Severe Acute Respiratory Syndrome Coronavirus 2.

Fig 2. Observed versus predicted ED attendances (%).

The observed versus predicted number of children presenting to EDs in countries across Europe in the weeks following February 2, 2020 until May 11, 2020, for all sites combined. The color and the size of the dots reflect the actual number of ED attendances for each site and for each time window. The line connects the mean of the observed vs. predicted point estimates for each of the individual sites for each time window.

Fig 3. Observed versus predicted hospital admissions for patients attending the ED (%).

The observed versus predicted number of children admitted to hospital from the ED in countries across Europe in the weeks following February 2, 2020 until May 11, 2020, for all sites combined. The color and the size of the dots reflect the actual number of ED attendances for each site and for each time window. The line connects the mean of the observed vs. predicted point estimates for each of the individual sites for each time window.

Fig 4. Hospital admissions, intensive care admissions, and deaths in the ED for the period January–April over a 3-year period.

Percentages of total ED attendances (left) and absolute numbers (right) of children admitted to hospital (top), PICUs (middle), or died in the ED (bottom); comparing the 28-day mean numbers for the months of January–April for 2018 vs. 2019 vs. 2020. ED, emergency department; PICU, pediatric intensive care unit.

Fig 5. Selected clinical diagnoses in the ED for the period January–April over a 3-year period.

Percentages of total ED attendances (left) and absolute numbers (right) of children with diagnosis of (A) common communicable diseases (tonsillitis, otitis media, LRTI, GI infections), (B) minor injuries and surgical presentations (radius fracture, minor head injury, appendicitis, intussusception, volvulus and malrotation (combined group), testicular torsion,), and (C) mental health issues and diabetic ketoacidosis; comparing the 28-day mean numbers for the months of January–April for 2018 vs. 2019 vs. 2020. ED, emergency department; GI, gastrointestinal; LRTI, lower respiratory tract infection.

Fig 6. Observed versus predicted number of selected diagnoses (%).

The observed versus predicted numbers of 8 selected diagnoses for all sites combined, for the period following February 2, 2020 until May 4, 2020. The error bars indicate the 80% prediction intervals.