The COVID pandemic has affected us all in many ways. It’s fair to say that Paediatric Emergency Medicine has been changed, transformed even, over the last 18 months. We have displayed resilience and adaptability in response to the pandemic.
On this whistlestop tour, let’s look at COVID Past – how departments were affected by the first wave with restricting and the impact of lockdowns on PED attendances.
Then we’ll visit COVID present – how our work practices have changed and the impact this has had on both staff and patients.
And finally, we’ll be visited by the Ghost of COVID Future – and explore what is yet to come. What have we learnt from this pandemic? Will there be a surge in other respiratory viruses? And most importantly, how can we use lessons learnt to inform future planning and acute service delivery?
Ghosts of COVID Past
Let me take you back to a time where COVID-19 did not yet exist. When there was no “new normal”, just “normal”. When we all packed onto buses and trains and made our way to crowded offices. A time where we had never even heard of social distancing. When no one was segregated or swabbed. A time when we didn’t know where our 5km radius ended.
Let me take you back to December 2019 when an outbreak of a mysterious illness “viral pneumonia of unknown cause” was first detected in Wuhan, China. The World Health Organisation subsequently reported that Chinese authorities had determined that the outbreak was caused by a novel coronavirus. On the 11th of January 2020, the first death from this novel coronavirus was reported in China.
And very quickly, the world as we knew it, changed forever.
On the 29th of February 2020, the Health Protection Surveillance Centre confirmed the first case of coronavirus in Ireland. The patient was a man, somewhere in the east of the country. I think we can all take our minds back to that moment and remember where we were when we heard that news. And remember that we had no idea of what was yet to come.
The first death due to coronavirus in Ireland happened on the 11th of March. This was the same day that the World Health Organisation confirmed that coronavirus had reached pandemic status. The next day, Taoiseach Leo Varadkar announced that schools, colleges and childcare facilities would close until the 29th of March because of the virus. These “unprecedented actions for unprecedented times” led to a lockdown in Ireland which lasted 37 days, until May the 5th.
How did this affect paediatric emergency medicine? Were we ready?
PEDs needed to prepare to manage high-risk COVID-19 patients in an efficient and safe way, from triage to final disposition. It became apparent quite quickly that children were affected less frequently and with a much more benign disease spectrum than adults. However, we needed to adapt our departments to ensure appropriate and efficient management of patients with suspected and confirmed cases of COVID and of their families.
Pathways and protocols needed to be put in place to ensure that rapid appropriate care was provided to children with suspected COVID while avoiding delay in care of non–COVID patients.
Bressan, S., Buonsenso, D., Farrugia, R., Oostenbrink, R., Titomanlio, L., Roland, D., Nijman, R.G., Maconochie, I., Da Dalt, L., Mintegi, S. and Hachimi-Idrissi, S., 2020. Preparedness and response to Pediatric CoVID-19 in European Emergency Departments: a survey of the REPEM and PERUKI networks. Annals of emergency medicine, 76(6), pp.788-800.
This study was a cross-sectional point-prevalence survey that was developed and disseminated through the paediatric emergency medicine research networks for the UK, Ireland and across Europe. It included 102 centres from 18 countries. Results were perhaps unsurprising.
34% did not have an ED contingency plan for pandemics. 36% had never had simulations for such events. There was wide variation in PPE shown at pre-triage and for patient assessment with 62% of centres declaring PPE shortages, particularly FFP2 and N95 masks. Only 17% of EDs had negative-pressure isolation rooms. Overall, this study highlighted significant variation in paediatric EDs across Europe and identified gaps in preparedness and response to the pandemic. A lack in early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and lack of appropriate isolation facilities were identified.
Emergency Medicine is known for adaptability and departments were restructured to the best of our abilities. Dedicated COVID streams were developed, entire departments restructured, structural changes made where possible, and new waiting areas and new injury pods designed. ED staff ran departments split into zones, the nature and staffing of which could change on a daily basis depending on patient presentations.
Inpatient teams worked hard to ensure their complex care patients were managed in the community where at all possible, protecting these vulnerable patients and also relieving some of the capacity pressures on emergency departments.
As the weeks progressed, we all learnt to work together. We learnt from our different experiences and perspectives. And a real team-based culture was developed.
How did this affect PED attendances?
McDonnell, T., Nicholson, E., Conlon, C., Barrett, M., Cummins, F., Hensey, C. and McAuliffe, E., 2020. Assessing the impact of COVID-19 public health stages on paediatric emergency attendance. International journal of environmental research and public health, 17(18), p.6719.
McDonnell’s team looked at the impact of COVID-19 on paediatric ED attendances in Ireland. The study analysed records from five EDs and one urgent care centre in Ireland, representing approximately 48% of national annual public paediatric ED attendances. It looked at patterns of attendance.
Attendances dropped across all sites for the first three months of the pandemic by between 27% to 62%, with large reductions in injuries and viral infections as a result of social distancing and changed living conditions imposed by the public health response. Interestingly, attendances for complex chronic conditions also dropped – this is an important point. This was partly due to the huge efforts by the speciality teams to keep their patients in the community. But the other factor to consider is the possibility of avoidance behaviour”.
Were parents avoiding bringing their children to hospital?
Nicholson, E., McDonnell, T., Conlon, C., Barrett, M., Cummins, F., Hensey, C. and McAuliffe, E., 2020. Parental hesitancy and concerns around accessing Paediatric unscheduled healthcare during COVID-19: a cross-sectional survey. International Journal of Environmental Research and Public Health, 17(24), p.9264.
This study was designed to look at avoidance behaviour and level of hesitancy in parents towards accessing healthcare for their child during the pandemic and to determine any associated factors.
As a cross-sectional survey of 1044 parents of children under the age of 16 in Ireland, across all socio-economic groups, it is one of the largest studies of its type internationally, providing unique insights into parental decisions regarding accessing unscheduled healthcare.
Multinomial and logistic regression analyses were used to determine the factors that influenced avoidance and hesitancy. So, what did it show?
The decision to seek healthcare was complex. Parents weighed up information regarding their child’s need for healthcare for a non-COVID-19 related illness, the risk of their child catching COVID-19 and the government public heath advice. 34% of parents stated that their child needed healthcare during the pandemic but 22% decided against attending medical facilities to address it. Parents who were stressed were much more reluctant to access healthcare.
A proportion of the sample may have misunderstood government advice. This may have resulted in unnecessary avoidance of, or hesitancy to access, health services. This is an important take home point – public health messaging can influence emergency department attendances in a positive or a negative way.
We were all aware that this avoidance behaviour could result in delayed or even missed diagnoses of serious illnesses such as leukaemia and DKA, although evidence emerging from the UK seems not to support this.
Public health messaging must ensure parents are reassured about the accessibility and safety of paediatric healthcare services as the pandemic draws out continues.
Some of the quotes from parents when asked why they decided not to access healthcare provide insights which we, as healthcare professionals, may not have considered.
“I was worried about being judged for using a service if it wasn’t an emergency.”
“I don’t have a car and didn’t want to use public transport.”
The Ghost of COVID Present
Our work practices have changed.
Streaming of patients into COVID and non-COVID pathways has become the norm. When we consider that all children with fever / cough / vomiting / diarrhoea / recent contact / recent travel need to be isolated, you can begin to appreciate the demands this places on the capacity of the emergency department.
We enforce strict rules regarding face coverings and the presence of one parent only.
We have become proficient at donning and doffing PPE.
We have adapted many of our resuscitation guidelines to prioritize the safety of staff and ensure PPE is applied prior to any resuscitation.
We have learnt about new conditions. We are now skilled at the recognition of PIMS-TS, the hyperinflammatory state seen in children with exposure to SARS-CoV-2. Although it is rare, emergency clinicians still remain vigilant, and we have adapted our teaching and simulation sessions to ensure we don’t miss it.
Gilmartin, S., Barrett, M., Bennett, M., Begley, C., Chroinin, C.N., O’Toole, P. and Blackburn, C., 2021. The effect of national public health measures on the characteristics of trauma presentations to a busy paediatric emergency service in Ireland: a longitudinal observational study. Irish Journal of Medical Science (1971-), pp.1-7.
We have seen an increase in trauma presentations. As this study demonstrated, total injury attendances reduced during the initial phases of the lockdown with 17.5% and 15.6% reductions in site attendances when compared with the two previous years. This was followed by a significant increase in injury presentations, which reached a peak of 44.6% of all attendances.
Alongside this was a significant change in injury type, final disposition and device associated injury.
Wheeled recreational devices were associated with over 20% of all injuries. We have seen the effect that public health messages can have on ED attendances. This study identified potential modifiable characteristics of paediatric trauma which could be addressed by future public health strategies.
McDonnell, T., Barrett, M., McNicholas, F., Barrett, E., Conlon, C., Cummins, F., Hensey, C., McAuliffe, E. and Nicholson, E., 2021. Increased Mental Health Presentations by Children Aged 5-15 at Emergency Departments during the first 12 months of COVID-19. Irish Medical Journal, 114(5), pp.356-356.
This study looked for changes in mental health attendance at Emergency Departments by children aged five to 15 during the pandemic. It analysed mental health presentations during the first year of the pandemic and compared them with the prior year for three public paediatric EDs in Dublin.
We saw an initial decrease in mental health presentations of 26.8% for the first four months of the pandemic (303 attendance in 2020 compared to 414 in 2019). This was followed by a significant and a sustained increase of 52.4% in July and August and 45.6% in September through to December.
An Irish survey of young people conducted in late June provides some insight on the mental health of many adolescents. Mental health challenges were reported as the most common negative effect of COVID-19. These included overthinking, concern, worry, anxiety, depression and a sense of utter hopelessness. The spike in attendance prior to many schools reopening may have been due to concerns held about the imminent return to school and school safety.
The COVID-19 pandemic has caused severe disruption for CAMHS worldwide, with many children and adolescents unable to access much needed mental health supports . While many countries reported that addressing mental ill health was part of their national COVID-19 response plans, few have allocated sufficient funding to support the response . Even before COVID, emergency departmentt mental health presentations by children and young people were rising. The pandemic has only increased momentum. Long-term stressors linked to the pandemic may be leading to chronic mental health problems
Unfortunately the child and adolescent mental health services in Ireland are grossly under-resourced, with demand greatly exceeding availability. This, combined with a lack of out of hours services, has resulted in an over reliance on ED care and as we all know, inappropriate yet often unavoidable hospital admissions.
And what about the impact on our staff?
Roberts, T., Hirst, R., Sammut-Powell, C., Reynard, C., Daniels, J., Horner, D., Lyttle, M.D., Samuel, K., Graham, B., Barrett, M.J. and Foley, J., 2021. Psychological distress and trauma during the COVID-19 pandemic: survey of doctors practising anaesthesia, intensive care medicine, and emergency medicine in the United Kingdom and Republic of Ireland. British journal of anaesthesia, 127(2), pp.e78-e80.
The primary aim of this study was to assess the prevalence and degree of psychological distress and trauma in frontline doctors during the acceleration, peak and deceleration of the COVID first wave. It was a prospective online three-part longitudinal survey. 5440 doctors across EM, anaesthetics and ICU participated.
Emergency medicine staff are renowned for being highly resilient and well accustomed to facing traumatic situations, however this study clearly demonstrates that the pandemic has imposed unprecedented demands in workload intensity and personal health risk on staff.High infection rates have been reported in frontline clinicians, with over 150 fatalities in the UK by May 2020.
This study looked at both psychological distress and post-traumatic stress amongst clinicians.
The results are quite stark.
The prevalence of psychological distress was 44.7% (n=1334) during the acceleration, 36.9% (n=1098) at peak and 31.5% (n=918) at the deceleration phase.
The prevalence of probable post-traumatic stress disorder was 12.6% (n=343) at peak and 10.1% (n=276) at deceleration.
Worry of family infection was the factor most strongly associated with both distress and trauma.
We must not under-estimate the psychological impact of the pandemic on our staff. It has huge implications for staff motivation and morale as well as recruitment and retention. We have worked tirelessly without reprieve and are now facing into another winter. Staff wellbeing must be prioritised.
Ghosts of COVID Yet to Come
Much like Scrooge, we must learn from the lessons that the pandemic has taught us. What do we anticipate our future challenges to be?
There used to be consistent seasonal peaks in infection and hospitalisation due to bronchiolitis. Cases would generally start to rise in September, peaking in November/December, and falling to summer levels by April (Ed. note: in the Northern Hemisphere). As such, when lockdown measures were implemented during the early spring of 2020, the RSV season was already in recession in the Northern hemisphere and no clear impact was seen on RSV disease burden. Studies from Southern Hemisphere demonstrated delayed peaks of bronchiolitis and higher case rates with different age distributions. Both observational and modelling studies suggested that RSV would arise out of season in the Northern hemisphere and may have a greater clinical impact. And we are already seeing this in our department.
Williams, T.C., Lyttle, M.D., Cunningham, S., Sinha, I., Swann, O.V., Maxwell-Hodkinson, A. and Roland, D., 2021. Study Pre-protocol for “BronchStart-The Impact of the COVID-19 Pandemic on the Timing, Age and Severity of Respiratory Syncytial Virus (RSV) Emergency Presentations; a Multi-Centre Prospective Observational Cohort Study”. Wellcome Open Research, 6(120), p.120.
BronchStart is a multi-centre prospective observational cohort study which uses the PERUKI Network to report real time cases of RSV infection in children aged under two years. Forty-five centres are gathering initial data on age, clinical features on presentation and co-morbidities. Each case is being followed up at seven days to identify treatment, viral diagnosis and outcome. Information is being released on a weekly basis and used to support clinical decision making.
Studies like this are extremely important for future planning for acute service delivery.
And so here we are, planning for the future.
What have we learnt?
Disaster preparedness must be a fundamental component of a hospital’s major emergency plan. We haven’t discussed that fact that in Ireland we endured a cyber-attack amid the pandemic but needless to say, we weren’t prepared for that either! Disaster preparedness must be a priority going forwards.
We have seen how public health guidance can directly influence ED attendances. We must use this knowledge in future campaigns such as helmet safety, and fire safety and to promote the management of certain conditions in primary care.
Early in the pandemic, we saw the direct impact of in-house medical teams putting additional supports in place to manage children with complex medical needs. This resulted in a reduction in ED attendances and hospital admissions. Now that we are in winter and are already seeing record numbers of attendances, we must emphasise the importance of these additional supports.
We must work to ensure that the interface between primary and secondary care is not exclusively through ED – we must look at developing real alternatives to ED attendances such as rapid access outpatients, opportunities for telephone consultations with GPs, enhanced communication with parents.
We must all work together to ensure our most vulnerable children are cared for.
The global EM COVID 19 response has demonstrated the adaptability and resilience of our specialty. But the pandemic has had a significant psychological impact on children, parents and staff. We must remain cognisant of this going forwards.
We need to learn from the Ghosts of COVID past and use our findings to be better prepared for the future.
A special thank you to Associate Professor Michael Barrett and Dr Carol Blackburn, PEM consultants at CHI at Crumlin for their contributions and support in preparing A COVID Christmas Carol
