Pediatric Emergency Care Before and During the Late Pandemic Period: A National Perspective

Children account for approximately 30 million emergency department (ED) visits annually in the United States, of which more than 80% are treated in general EDs.1,2 Reports of the effects of the COVID-19 pandemic on pediatric emergency care have been limited to the experiences of large pediatric hospitals and have focused largely on the early stages of the pandemic when volumes decreased dramatically.3–5 The effects of the late pandemic surge on patient volumes have not been well described.We hypothesized that operational metrics typically used as a proxy for safety (leaving without care [LWC]), patient experience (door to clinician [D2C] time and length of stay [LOS]), and the proportion of low acuity nonemergency visits increased when COVID-19 and respiratory illnesses surged in 2021 as compared with a similar period in 2019. Low acuity nonemergency visits comprise more than 50% of pediatric emergency department (PED) visits, are typically discharged with ambulatory care-sensitive diagnoses, and have been associated with lower access to primary care and public insurance.6–11We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) because it is nationally representative.1 We included ED visits in patients aged up to 19 years in the 18 prepandemic months (July 2018-December 2019) and compared the visits with a similar period in July 2021 to December 2022, when a seasonal surge of respiratory illness coincided with the emergence of Delta and Omicron variants of COVID-19.4 The periods we selected represent the most comparable cohorts after the initial impact of COVID-19 on volumes in 2020. Multiple logistic regression was used to provide estimates of the effect size for each variable. Statistical significance was evaluated at α = 0.01 to account for multiple hypotheses.Table 1 shows the baseline characteristics of the 2 study groups. Table 2 displays differences in key outcome variables between the 2 periods after adjusting for confounders of age, race, sex, acuity, mental health related visits, insurance, and region. Mean LOS and the proportion of patients with a LOS more than 4 hours were higher in the late pandemic period, as was the proportion of patients with a D2C time greater than 1 hour. While the increase in LWC and mean D2C time were not statistically significant, their adjusted odds ratios suggest the same directional change from the prepandemic period.Several measures suggest increased strain on ED treatment of children in the late pandemic period. While the trends toward increased PED visit counts and LWC were not statistically significant, other operational challenges were clearly amplified in the late pandemic period, including increased LOS, acuity, and the proportion of visits with prolonged D2C time. We are not aware of any prior study examining late pandemic key performance metrics across US EDs.The point estimate for LWC in our study increased by 50% during the late pandemic surge, representing 528 564 children LWC. Our LWC rate of 3% is comparable to 2.9%-5.4% reported by a national ED staffing group12 and lower than a recent report from a large children’s hospital.13 This comparison may represent differences in efficiencies in those EDs compared with performance of a broader representation of EDs nationwide as reflected in the NHAMCS. We also observed a trend toward decreased injury-related visits, similar to a study using the pediatric health information system database, which included visits up to March 2021.5 Our data are also consistent with prior literature that suggests return visits did not increase during the pandemic.14The point estimate increase of 5% in psychiatric admissions in our study is comparable with the 8.4% increase reported in a retrospective analysis of mental health ED visits among youth with commercial insurance.15 Our results include a more representative sample covered by both commercial and noncommercial payers.Our study has several limitations. The NHAMCS is an administrative database that assigns weights to visits. Hence, many unobserved encounters and clinical details from visits may be lacking. We used operational measures as surrogates for quality and safety. The most recent information available from the NHAMCS only extends through 2022, and the data used in our analysis may not represent the current state.Our results suggest a shift toward higher acuity and longer wait times for PED visits in the late pandemic period. A detailed review of patient level data is needed to fully understand the implications of this unfavorable trend.Gia Badolato, PhD for consultation on study design.