Changes in Pediatric Emergency Department Visits During the COVID-19 Pandemic

This study was a 3-year single-center retrospective study from 2018 to 2020 and included children 18 years and younger who presented to the ED for either ARI or trauma at a high-volume, 343-bed freestanding children’s hospital that includes an American College of Surgeons–verified level I pediatric trauma center between March 1 and May 31 of each year. This 3-month time frame of each year was chosen to correspond with the initial pandemic peak and the safer-at-home mandate and to include months still in the respiratory season and the end of the school year for our state. The specific aim was to evaluate pediatric ED visit changes during community mitigation periods in 2020 compared to the same time periods in previous years. We did not include data from the summer months for the following reasons: (1) community mitigation measures were loosened during phased reopening, which began in June in our state; (2) schools normally close at the end of May, when the summer trauma season begins; and (3) ARIs generally peak from October to May of each year, with few cases encountered in the summer months.⁴  During the study period, all children who presented to the ED were identified by a request submitted to the analytics team at our institution. International Classification of Diseases, 10th Revision, Clinical Modification admission diagnosis codes were used to identify ARI, trauma, and the mechanism of injury (Supplemental Information). We aimed to compare total numbers and proportions of ARIs, trauma visits, and injury mechanisms during community mitigation periods in 2020 (ie, safer-at-home mandate in 2020) compared to the same time periods in previous years. All these comparisons were selected a priori. Pearson’s χ² test was used to compare proportions between categorical variables. The institutional review board approved the study.

During these 3-month periods, 6393 total pediatric ED visits occurred in 2020, compared with 11 758 and 12 138 in 2018 and 2019, respectively (Table 1). In 2020, the total number of ARI visits declined by 58%, and the frequency of ARI visits also decreased significantly (Fig 1A). In contrast, although the total number of trauma ED visits declined by 34% in 2020, the proportion of trauma ED visits significantly increased from 21% and 22% in 2018 and 2019, respectively, to 26% in 2020 (P < .001; Fig 1A). In addition, in 2020, the cumulative proportions of trauma visits relative to ARI visits increased significantly after the safer-at-home order compared to previous seasons (P < .001; Fig 1B), maintaining seasonal reciprocity between these 2 causes of pediatric ED visits. A significant increase in the number and proportion of trauma visits related to recreational vehicle activities (ie, all-terrain vehicles and motorcycles) was detected (P < .001; Fig 1C, Table 2). In contrast, the numbers and proportions of both intentional (nonaccidental trauma [NAT] or abuse, suicide, and assault or homicide) (P = .009) and animal-related injuries (P = .039) decreased in 2020 compared to previous years.

This study revealed a 50% drop in all pediatric ED visits at a comprehensive regional children’s hospital during the COVID-19 pandemic and safer-at-home mandate period compared to the same time periods in the 2 preceding years. Social distancing countermeasures aimed at mitigating the spread of SARS-CoV-2 likely contributed to the decreased circulation of other common repository viruses that share similar transmission routes with SARS-CoV-2.^5,6  Alternatively, the decrease in the total number and proportion of ARIs could be associated with changes in health care–seeking behaviors and limited access to care during the pandemic.⁷  Although our findings are consistent with reports revealing decreases in viral ARIs, including influenza, in different regions and populations during the COVID-19 pandemic,^8,9  authors of prospective studies are encouraged to elucidate the actual causes of these decreases in ARIs and further confirm the role of nonmedical interventions in containing future viral epidemics and pandemics.

The total number of pediatric trauma visits declined in 2020 during the safer-at-home mandate, possibly because of a reduction in driving, traffic, and organized after-school activities. However, this study revealed that trauma contributed to more than one-third of the total pediatric ED visits in April and May 2020, a significant increase compared to the previous 2 years. Moreover, mechanisms of injury seemed to vary from previous years too. Specifically, the total number and percentage of recreational vehicle injuries increased during 2020 during normal school months. In addition, as an American College of Surgeons–verified level I pediatric trauma center, we usually manage a large number of intentional traumas (NAT or abuse, suicide, assault or homicide),¹⁰  but this season, our data revealed, intriguingly, that the numbers of these injuries declined significantly, likely resulting from the presence of multiple caregivers in the home with increased supervision, which also plausibly explains the decreases in animal-related injuries (eg, animal bites) in our study. Contrarily, data have revealed decreases in health care and ED visits among children during the pandemic,^7,11  and the decreases in NAT- or abuse-related visits might be a reflection of decreased presentation rather than true declines, given that teachers and other school staff are often instrumental in bringing these concerns to attention in a timely manner and that closure of schools may have contributed to reduced detection and delayed presentation of NAT or abuse, which our study would not have captured given the time window chosen. Nevertheless, we do believe that multiple adults mandated to be home at the same time has contributed to a reduction in overall intentional and animal-related injuries through better supervision of young children. Although trauma negatively impacts children and their families directly, the health care system is also adversely affected during a pandemic, given the use of limited medical resources, such as protective attire and life-sustaining medical equipment. Furthermore, injury-related hospitalizations could potentially increase the risk of SARS-CoV-2 exposure to patients, families, and health care workers. Future studies are needed to confirm these findings (because such changes might require resource reallocation in pediatric ED settings) and to evaluate the need for strategies to avert mechanism-specific trauma during community mitigation periods and times of limited medical recourses during a pandemic. Because the COVID-19 pandemic is ongoing with intermittent school closures, increased parental supervision and adherence to practicing safe activities would be strongly encouraged.