Impact of the COVID-19 pandemic on emergency

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www.analesdepediatria.org

ORIGINAL ARTICLE

Impact of the COVID-19 pandemic on emergency

department: Early findings from a hospital in Madrid ^⋆

Miguel Ángel Molina Gutiérrez

^∗

, José Antonio Ruiz Domínguez,

Marta Bueno Barriocanal, Bego˜ na de Miguel Lavisier, Rosario López López, Julia Martín Sánchez, María de Ceano-Vivas la Calle

ServiciodeUrgenciasPediátricas,HospitalUniversitarioLaPaz,Madrid,Spain Received12May2020;accepted16June2020

KEYWORDS

Paediatricemergency medicine;

COVID-19;

Pandemics

Abstract

Introduction:SARS-CoV-2,coronavirusthatcausescoronavirus disease2019(COVID-19),was firstdetectedinSpainon31January2020.On14March2020,astateofemergencywasdeclared inSpaininabidtocontrolthespreadoftheCOVID-19pandemicinthecountry.Theaimofour studyistoanalyzetheimpactonemergencymedicineattendanceafterthenationallockdown, aswellastheclinicalpresentationandthemanagementofpatientswithsuspectedCOVID-19 inthePaediatricEmergencyDepartment.

Patientsandmethods: This retrospectiveobservational study includedchildren andadoles- centsundertheageof18,attendedinourPaediatricEmergencyDepartmentduringtheperiod March14toApril17,2020.

Results:Atotalof1666patientswereattendedduringthestudyperiod,65.4%lessthaninthe sameperiodof2019.Justoverhalf(51.2%)weremales,andmeanagewas5.4years.Intriage, 39.9%werehighprioritylevels,6.5%morethan2019.Mostfrequentreasonsforconsultationat thePaediatricEmergencyDepartmentwerefever(26.5%),respiratorysymptoms(16.1%),and trauma(15.2%).Atotalof218patients(13%)receivedadiagnosisofpossibleCOVID-19,with SARS-CoV-2infectionconfirmedin18.4%,and23.8%(52/218)werehospitalised.Atdischarge, 44%(96/218)werediagnosedwithlower,and33.9%(74/218)withupperrespiratoryinfection.

Conclusions: During the SARS-CoV-2 outbreak, the demand for urgent paediatric care decreased, withthe proportionofcases with highpriority triagelevels increasing.Most of

⋆ Please cite this article as:Molina Gutiérrez MÁ, Ruiz Domínguez JA, BuenoBarriocanal M, de Miguel Lavisier B, López López R, MartínSánchezJ,etal.ImpactodelapandemiaCOVID-19enurgencias:primeroshallazgosenunhospitaldeMadrid.AnPediatr(Barc).

2020;93:313---322.

∗Correspondingauthor.

E-mailaddress:[email protected](M.Á.MolinaGutiérrez).

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thepatientswithsuspectedormicrobiologicalconfirmationofCOVID-19hadmildrespiratory symptoms.

4.0/).

PALABRASCLAVE Medicinapediátrica deurgencias;

COVID-19;

Pandemia

ImpactodelapandemiaCOVID-19enurgencias:primeroshallazgosenunhospitalde Madrid

Resumen

Introducción:SARS-CoV-2,responsabledelaenfermedadporcoronavirus2019(COVID-19),fue detectadoporprimeravezenEspa˜nael31deenerode2020.El14demarzofuedeclarado elestadodealarmaconelobjetivodecontrolarlapandemia.Elobjetivodeesteestudioes analizarlasconsecuenciasdeestacrisissanitariasobreelpatróndedemandaasistencial,así comoelmanejoylascaracterísticasdelospacientesconsospechadeCOVID-19enelServicio deUrgenciasPediátricas.

Pacientesymétodos: Estudioretrospectivoobservacionalenni˜nosyadolescentesmenoresde 18a˜nos,atendidosennuestroServiciodeUrgenciasPediátricasduranteelperiodocomprendido desdeel14demarzohastael17deabrilde2020.

Resultados: Duranteelperiododeestudioseatendieron1.666pacientes,un65,4%menosque en elmismoperiodo de 2019. La edadmedia fuede 5,4 a˜nos y el51,2% eran varones. El 39,9%fueronclasificadosconnivelesdealtaprioridad,un6,5%másqueen2019.Losprinci- palesmotivosdeconsultafueronfiebre(26,5%),síntomasrespiratorios(16,1%)ytraumatismos (15,2%).Untotalde218pacientes(13%)fuerondiagnosticadosdeposibleCOVID-19,confirmán- doselainfecciónenel18,4%.El44%(96/218)fuerondiagnosticadosdeinfecciónrespiratoria inferioryel33,9%(74/218),superior.El23,8%(52/218)fueronhospitalizados.

Conclusiones:Durante elbrote epidémico SARS-CoV-2 disminuyó la demanda de asistencia pediátricaurgente, aumentandola proporciónde casoscon nivelesdetriaje dealta prior- idad.La mayoríadelospacientescon sospechaoconfirmación microbiológica deCOVID-19 cursaronconclínicarespiratorialeve.

Introduction

An outbreak of infection by the coronavirus currently known as SARS-CoV-2, which causes coronavirus disease 2019 (COVID-19), wasfirst reported in the city of Wuhan (China) onDecember 31, 2019.On January 30,2020, the WorldHealthOrganizationdeclaredittothepublichealth emergencyofinternationalconcern,andonMarch11,the outbreakwasofficiallydeclaredapandemic.

Spainisoneofthemostaffectedcountries,andoneof theregionsmostaffectedwithinitistheAutonomousCom- munityofMadrid(ACM),consideredanareaofcommunity spread of SARS-CoV-2 since March 12. The declaration of thestateofalertbytheSpanishgovernment(RoyalDecree 463/2020 of 14 March) included population-wide confine- mentmeasurestolimitthespreadofinfection.

Asthepandemicoverwhelmedemergencycareunitsand adult inpatient wards, a restructuring of paediatric care deliverybecamenecessaryintheACM,withpaediatriccare beingdivertedandconsolidatedinto2specificfacilitiesdur- ingthe pandemic, oneof which is ourhospital. However, somehospitals inthe ACMhave continuedtoofferpaedi-

atricemergencycareservicestotheextentpossibleand,to alesserextent,paediatricinpatientcare.

The data currently available show that only 2% of affectedindividualsareagedlessthan18years.^1---3Themain symptomsarefever,drycoughandfatigue.Thereareatyp- icalpresentationswithgastrointestinalsymptomsandfew respiratorymanifestations.Althoughmostpaediatriccases aremild,therehavealsobeenseverecasesinthisagegroup, with such cases having the potential to rapidly progress to respiratory distresssyndrome, septic shock, refractory metabolic acidosis, coagulopathy and multiple-organ fail- ure,andevensomedeathshavebeenreportedinChinaand other countries. As occurs in adults,there is evidence of asymptomatic casesandthat childrenmaybe asource of transmission,astheymayshedvirusinthestoolfor more than1month.^4---8

Theaimof ourstudywastoanalyzetheimpactof the pandemicandthedeclarationofthestateofalarmbythe Spanishgovernmentonthepatternofhealthcareuse,and alsothecharacteristics of patientswithsuspectedCOVID- 19andtheirmanagementinthepaediatricemergencycare setting.

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Patients and methods

Studydesignandsample

We conducteda retrospective observationalstudy in children andadolescentsagedless than18 yearsmanagedat the paediatric emergency department (PED) of a tertiary carechildren’shospitalintheACMinthefirst35dayssince thestateofalarmwasdeclared.Wecomparedthedemand forhealthcareservices,thepresentingcomplaintsandthe distributionbyleveloftriagecomparedtothesameperiod in the previous year (2019). The diagnosis of ‘‘suspected COVID-19’’ wasbased on the judgement of the physician in charge of the patient. The study was approved by the ResearchEthicsCommitteeofourhospital.

Inclusioncriteria

• Patients aged less than 18 years, managed in our PED betweenMarch14andApril17of2019and2020.

• Patients aged more than 18 years withchronic disease followedupinourhospitalthatreceivedemergencycare inthesametimeperiods.

Exclusioncriteria

• Patients aged more than 18 yearsthat were not being followedupinourchildren’shospital.

• PatientsthatleftthePEDbeforereceivingcare.

Statisticalanalysis

We used the software IBM^® SPSS^® Statistics 20. We have expressedqualitativedataasabsoluteandrelativefrequen- ciesandquantitativedataasmeanandstandarddeviation (SD)or medianand range.Wecompared groupsusing the Studentttestandthechisquaretest.

Results

Intheperiodunderstudy,ourPEDreceived1680visits,of which1666mettheinclusioncriteria(comparedto4813in thesameperiodin 2019,therewasadecreaseof 65.4%).

ThePEDmanagedatotalof1429patients,withameanof 1.1visitsperpatient(range,1---7visits/patient);12.8%made 2ormorevisits.The meannumberofdailyvisitswas47.6 (range,17---76PEDvisits/day).PatientsstayedinthePEDfor ameanof3hand21min(range,10minto22hand29min) andtherateofhospitaladmissionwas15.1%.Themeanage ofpatientswas5.4years(SD,5),andthemedianwas3.7 years;51.2%weremale(Table1).Ofthetotalvisits,39.9%

wereclassifiedashighpriority(triagelevelsi-iiiofthepaedi- atricCanadiantriageandacuityscale),comparedto33.4%

in2019.

Analysisofpresentingcomplaints

As can be seen in Table 2, the most frequent presenting complaints in the period under study were the same

Table1 Generalcharacteristics(n=1666).

n(%) Age

<1month 78(4.6%)

1---3months 136(8.1%)

3---6months 86(5.1%)

6---12months 96(5.7%)

1---3years 344(20.6%)

3---5years 249(14.9%)

5---12years 443(26.5%)

12---16 186(11.1%)

>16years 48(2.8%)

Distributionofpatientsbyshift

Morning(8:00a.m.---15:00p.m.) 588(35.2%) Afternoon(15:00p.m.---21:00p.m.) 667(40%) Night(21:00p.m.---8:00a.m.) 411(24.6%) Distributionbysex

Male 854(51.2%)

Female 812(48.7%)

Distributionbytriagelevel

I 1(0.0%)

II 52(3.1%)

III 612(36.7%)

IV 953(57.2%)

V 48(2.8%)

asthe previous year,although insome casesthe percent- agecorrespondingtosome ofthemincreasedsignificantly comparedto 2019 (fever, traumatic injury, jaundice, for- eignbodyandfatigue).Ontheotherhand,gastrointestinal symptoms,cutaneous complaints in absence of fever and ophthalmologicalcomplaintswerelessfrequent.

ThemostfrequentreasonforvisitingthePEDwasfever, followedbyrespiratorysymptomsandinjuries.Weincluded abdominal pain (6.7% of visits), orofacial pain/ear-nose- throat(ENT)complaints(1.7%),genitalpain/nephrological or urological complaints (1.3%) and headache (0.8%) in the ‘‘pain’’ category of presenting complaints. The

‘‘behaviouralchanges’’categoryincludedepisodesofanx- iety or agitation (including a suicide attempt) and other complaintssuchasirritabilityorfoodrefusalininfantsand toddlers.

‘‘SuspectedCOVID’’usuallyimpliedthepresenceofmild symptomsor absenceofsymptomsinpatientswithhouse- holdcontactswithconfirmedinfection.

Analysisofdischargediagnoses

Thedischargediagnosiswasaninfectiousdiseasein48.4%

(807/1666)ofPEDvisits(Table3).Inthisgroup,54%were casesofrespiratorytractinfection(60.5%oftheupperair- way and 39.4% of the lower airway) and 20.4% of fever withoutasource.

Generalsurgicalemergencies(205/1666)andtraumatic injuries (124/1666) amounted to 19.7% of the total, with puncturewoundsandtraumaticinjuryofanextremitywith- outfracturebeing themost frequent diagnosisin each of thesecategories,respectively(Table4).

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Table2 Reasonforemergencyvisit(March14---April17).

n(%) P

2019 2020

Fever 1027(21.3%) 441(26.5%) <.001

Respiratorysymptoms 820(17%) 269(16.1%) .450

Traumaticinjury(includingburns/animalbites) 595(12.3%) 253(15.2%) <.005

Pain 706(14.6%) 227(13.6%) .275

Gastrointestinalsymptoms(excludingabdominalpain) 590(12.2%) 81(4.9%) <.001

Rash/skinlesions(withoutfever) 303(6.2%) 56(3.4%) <.001

Neurologicsymptoms(excludingheadache) 93(1.9%) 52(3.1%) <.005

Bulge/localswelling 91(1.8%) 40(2.4%) .225

Behaviouralchanges 124(2.5%) 33(2.0%) .175

Jaundice 34(0.7%) 33(2.0%) <.001

Foreignbody(anylocation) 38(0.7%) 28(1.7%) <.002

ENT(excludingcoldandENTpain) 62(1.2%) 16(1.0%) .275

SuspectedCOVID 0(0%) 14(0.8%)

Apnoea/choking/arrest/CPR/drowning 14(0.2%) 9(0.5%) .125

Devices(problems) 18(0.3%) 9(0.5%) .375

Malaise/asthenia/fatigue 10(0.2%) 9(0.5%) <.005

Nephrology(excludingdysuria) 45(0.9%) 8(0.5%) .075

Allergicreaction 22(0.4%) 7(0.4%) .825

Eye/visionproblems 71(1.4%) 6(0.4%) <.001

Poisoning/substanceexposure(accidental) 21(0.4%) 5(0.3%) .425

Infection(miscellaneous) 22(0.4%) 4(0.2%) .225

Other 107(2.2%) 66(4.0%) <.001

Total 4813 1666

Otherfrequentdiagnosticcategoriesweregastrointesti- naldiseaseandnon-infectiousrespiratorydisease(Table5).

Therewasonecaseofsuspectedsexualabuse.

CasesofsuspectedCOVID-19

Thedailyincidenceofsuspected/confirmedcasesofCOVID- 19inourPEDthroughoutthestudyperiodfollowedsimilar trendsto thoseobserved inthe ACMoverall (Fig.1). The temporal trend in the cumulative number of new cases wasconsistent withtheoverall trendinthe ACM(Fig.2), althoughfromweek2intheperiodunderstudytherewasa slowingdowninthenumberofconfirmedcasesinthePED (althoughnotinthenumberofsuspectedcases).

Fig. 3 presents a flowchart of the patients with a discharge diagnosis of infectious disease and suspected COVID-19.Atotalof218patients(13%)receivedadiagnosis ofpossibleCOVID-19.Wedidnotfindsignificantdifferences inthesexdistributionofthisgroupcomparedtotherestof thesample(52.3%malevs.51.2%male;P=.770).Thissubset ofpatientswasslightlyolder,withameanageof6.7years (SD,5.3)yearscomparedto5.2years(SD,4.9)(P<.001).

The most frequent discharge diagnosis was lower respiratory tractinfection (96/218; 44%), followed by upper respiratory tract infection (74/218; 33.9%), fever without a source (25/218; 11.4%), cutaneous manifestations associatedwithsuspected COVID-19,usually chilblain-like lesionsindistallocations(9/218;4.1%)andKawasakidisease (1/218;0.4%).Therestofcases(13/218;5.9%)corresponded

toasymptomaticpatientsreferredtotheemergencydepart- mentforCOVID-19screening(Table6).

Apolymerasechainreaction(PCR)testfordetectionof SARS-CoV-2inpharyngeal exudatesampleswasperformed in 180/218 patients (82.6%), which turned out positive in 40/180(22.2%).In11patients(6.1%)theresultsofPCRtest- ingwere inconclusive.The meanage ofthe patientswith apositive PCRtest was6.5years(SD,5.9;range,18days to17years),withapredominanceofmalepatients(67.5%).

Wedidnotfindsignificantdifferencesinage(P=.780)orsex (P=.101)comparedtothegroupofwithnegativePCRresults (weexcludedcaseswithinconclusivePCRresultsfromthis comparison).

PositivePCRresultsforCOVID-19weremostfrequentin the group of patients with a diagnosis of upper or lower respiratorytractinfection,althoughconsideringtheactual proportionofpositiveresultsineachdiagnosticgroup,the groupwiththehighestpositivityratecorrespondedtothe patientswithfeverwithoutasource(7/25;28%),followed by patients withupperrespiratory tractinfection (18/74;

24.3%) andpatients withlowerrespiratory tractinfection (14/96;14.5%)(Table6).TherewerenoPCR-positivecases amongpatientswithsuggestive cutaneousmanifestations, andaboyaged5.8yearsthatwaseventuallygivenadiag- nosisofKawasakidiseasealsotestednegative.

The frequency ofhospital admissionin patients witha possibleCOVID-19diagnosis was23.8%.Themostfrequent diagnosisatadmissionwaslowerrespiratorytractinfection (57.6%);inthisgroup,therewereonly4caseswithaposi- tivePCRtestresult,allofwhichoccurredinpatientsinwho

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Table 3 Discharge diagnoses: infectious disease (n=807/1666).

n(%) Respiratorytractinfection 436/807(54%)

Upper 264/436(60.5%)

Lower 172/436(39.4%)

Fever 165/807(20.4%)

Withoutasource 158/165(95.7%)

Occultbacteraemia/sepsis 7/165(4.2%)

ENTinfection 62/807(7.6%)

Acuteotitismedia 24/62(38.7%)

Viralpharyngotonsillitis 25/62(40.3%) Streptococcalpharyngotonsillitis 4/62(6.4%)

Mastoiditis 2/62(3.2%)

Other 7/62(11.2%)

Skin/softtissueinfection 52/807(6.4%)

Adenitis 16/52(30.7%)

Nonspecificviralexanthema 13/52(25%)

Cellulitis 5/52(9.6%)

Abscess 7/52(13.4%)

SkinlesionscompatiblewithCOVID-19 9/52(17.3%)

Other 2/52(3.8%)

Urinarytractinfection 30/807(3.7%)

Afebrile 16/30(53.3%)

Febrile 14/30(46.6%)

Gastrointestinalinfection 28/807(3.4%) Acutegastroenteritis 28/28(100%)

Genitalinfection 7/807(0.8%)

Balanitis 3/7(42.8%)

Vulvovaginitis 4/7(57.1%)

Otherdiagnosis 27/807(3.3%)

Mononucleosis 6/27(22.2%)

Kawasakidisease 1/27(3.7%)

Meningitis 2/27(22.2%)

COVID-19screening 13/27(48.1%)

Other 5/27(18.5%)

thechestradiographevincedthepresenceoflungconsoli- dation.Thehighestpercentageofconfirmedpositivecases wasfound in patients admitted witha diagnosis of upper respiratorytractinfection(6/10;60%).Thepatientsadmit- tedwithfeverwithoutsourceandapositivePCRtestwere 4patients agedless than2months(meanage, 31.5days;

range,18---52days)andafemaleadolescentaged13years admittedwithfeverof14days’duration.Ofallhospitalised patients,17.3%(7withlowerrespiratorytractinfectionand 1withanupperrespiratorytractinfection)hadrespiratory difficulty or hypoxaemia (SatO2<92%). The PCR test was positiveinonly2ofthesepatients.

Discussion

ThedeclarationofthestateofalarmbytheSpanishgovern- ment combinedwiththe imposedmeasures of population confinementandtheperceptionofriskofhealthcareusers have led toa significant drop in the demand for care in

Table 4 Discharge diagnoses: surgical conditions and trauma(n=329/1666).

n(%)

Surgicalconditions 205/329(62.3%)

Puncturewound 105/205(51.2%)

Acuteappendicitis 28/205(13.6%)

Burns 27/205(13.1%)

Foreignbodyingastrointestinal tract

12/205(5.8%)

Animalbite 6/205(2.9%)

Ovariantorsion 4/205(1.9%)

Other 23/205(11.2%)

Trauma 124/329(37.6%)

Traumaticinjuryofextremities withoutfracture

54/124(43.5%)

Upperextremities 38/54(70.3%)

Lowerextremities 13/54(24%)

Polytrauma 3/54(5.5%)

Traumaticinjuryofextremities withfracture

30/124(24.1%)

Upperextremities 21/30(70%)

Lowerextremities 9/30(30%)

Headtrauma 26/124(20.9%)

Withskullfracture 5/26(19.2%)

Traumaticinjuryinotherlocations 7/124(5.6%)

Thoracic 2/7(28.5%)

Lumbar 1/7(14.2%)

Facial 4/7(57.1%)

our PED compared to 2019, despite the consolidation of paediatricemergencycareservicesinalimitednumberof hospitals. The suspension of in-person schooling at every level of education in the ACM and the mild presentation ofCOVID-19inchildren⁶havealsocontributedsignificantly tothedeclineinthevolumeofpaediatricemergencyvisits observedsincethebeginningofthispublichealthcrisis.

At the same time, in line with other European countries,^9---11 we observed an increase in the complexity of emergency visits, as we found that compared to the sametimeperiodin 2019,therewasagreater proportion ofpatientswhose triagelevelonarrivaltothePEDwasin thehigh-priorityrange.

Thepresentingcomplaintsinthestudyperiodcontinued tobetheusualreasonsforvisitingthePED,withfever,res- piratorycomplaintsandaccidentalinjuriesatthetopofthe list.^12,13 In this sense, we ought to highlight that despite confinementtothehome(duringthestudyperiod,children couldnotleave thehomeexceptincase ofdemonstrated need),traumaticinjuriescontinuedtorankthird,onceagain confirmingthatthehomeisafrequentsettingofaccidents inchildren.^14,15

Thelowdiseaseactivityinpaediatricpatients,withmild ornon-existentsymptoms, posedachallenge totheearly detectionofpossible casesat thetimeof triage. Thus,it wasnecessary toexercisestandard precautionswithmost patients, treating all of them as potential cases, which involved a significant allocation of time and resources.¹⁶ The initial ignorance of the disease, the scarcity of data on paediatric cases, which did not suffice to determine

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Table5 Dischargediagnosesotherthaninfectiousdisease (n=530/1666).

n(%)

Gastrointestinaldisease 135/530(25.4%) Abdominalpainwithoutalarming

signs

55/135(40.7%)

Nonspecificvomiting 29/135(21.4%)

Gastro-oesophagealreflux 14/135(10.3%) Gastrointestinalhaemorrhage 11/135(8.1%)

Constipation 9/135(6.6%)

Suspectedcow’smilkprotein allergy

7/135(5.1%)

Other 10/135(7.4%)

Non-infectiousrespiratoryillness 55/530(10.3%)

Acutebronchospasm 54/55(98.1%)

Spontaneouspneumomediastinum 1/55(1.8%)

Neurologicdisease 46/530(8.6%)

Afebrileseizures 23/46(50%)

Headachewithnoalarmingsigns 7/46(15.2%)

Febrileseizures 5/46(10.8%)

Shuntmalfunction 4/46(8.6%)

Other 7/46(15.2%)

Skindisease 27/530(5%)

Non-infectiousENTdisease 21/530(3.9%) Foreignbodyinnose/ear 11/21(52.3%)

Otorrhagia/eartrauma 2/21(9.5%)

Epistaxis 4/21(19%)

Other 4/21(19%)

Cardiovasculardisease 16/530(3%)

Syncope 8/16(50%)

Arrythmia 4/16(25%)

Heartfailure 2/16(12.5%)

Other 2/16(12.5%)

Maxillofacialpathology 16/530(3%)

Rheumaticdisease 14/530(2.6%)

Nontraumaticlimping 7/14(50%)

Schönlein-Henochpurpura 2/14(14.2%)

Other 5/14(35.7%)

Ophthalmologicaldisease 12/530(2.2%)

Genitourinarydisease 9/530(1.6%)

Blooddisorderorcancer 8/530(1.5%)

Mentalillness 6/530(1.1%)

Endocrinedisease 4/530(0.7%)

Onsetofdiabetes 3/4(75%)

Metabolicdecompensationin diabeticpatient

1/4(25%)

Gynaecologicaldisease 3/530(0.5%)

Other 158/530(29.8%)

Non-emergencymedicalsituation 46/158(29.1%) Neonatalhyperbilirubinemia 31/158(19.6%) Non-traumaticchestpain 12/158(7.5%)

Allergy/anaphylaxis 12/158(7.5%)

Poisoning 5/158(3.1%)

Other 52/158(32.9%)

howtomanagepaediatric patients withcomplexdisease, immunosuppression,etc.,andtheadditionaltimerequired to protect the health care staff arefactors that unques- tionablycontributedtoincreasingthemeandurationofthe stay in the emergencyroom(in the case of ourPED, 13%

greatercomparedtothesameperiodinthepreviousyear).

Hadtherenotbeenadeclineinthevolumeofpatientsman- agedinthedepartment,thedurationofthestaymayhave increasedevenmore, whichcouldhave hada deleterious impactonthequalityofcare.

Wesharetheconcernexpressedbyotherauthors¹⁷about thereluctanceofsomeparentsandcaregiverstoseekhealth care, probably motivated by a fear of exposure to coronavirus and by the current limitations in the access to primarycareservices,asthismayresultindelayeddiagno- sisofpotentiallyseverediseases(peritonitis,ketoacidosis, pyelonephritis).^9---11 In thisregard, someauthorshave also reportedanincreaseincasesofchildabuseandneglect;in ourcaseseries,therewasonly1documentedcaseofchild sexualabuse.¹⁸

Asfor the temporaldistribution ofCOVID-19 diagnoses in ourPED, Figs.1 and2 evince thesimilartrends in the cumulative case number and in the number of new sus- pectedandPCR-confirmedcasesinourPEDandintheoverall ACM.Apossibleinterpretationisthatinfectioninthepae- diatric population hasoccurred in parallel to infection in the adult population, with transmissions occurring in the household,asschoolswereshutdownonMarch11,3days beforethedeclarationofthestateofalarm.Performanceof population-basedstudieswithserologicaltestingcouldhelp confirmhouseholdtransmissionofinfection,which,onthe otherhand,isaverylikelyphenomenon.

AlthoughinoursamplechildrenwithasuspectedCOVID- 19diagnosis weresignificantlyolder comparedtotherest ofthepatientsinthesample,theywereyoungercompared totheagereportedinthestudybyDongetal.(medianof7 yearsinsuspectedcasesand10yearsinconfirmedcases)⁶or bytheCentersforDiseaseControlandPrevention(CDC)of theUnitedStates.¹⁹Incontrast,incomparisontootherstud- iesinneighbouringregions,patientswithsuspectedCOVID inoursamplewereslightlyoldercomparedtothecasesin theCONFIDENCEstudycarriedoutinItaliaor tothecases in30 healthcarefacilities intheACMinthefirst2weeks of March2020 reportedbyTagarro etal.(3 yearsinboth cases).^1,20

Although in our sample there was a slight predomi- nance of male patients in the cases with confirmed by a SARS-CoV-2 PCR test, we did not find statistically significant differences in the sex distribution of this subset comparedtotherestof thesample,whichwasconsistent withpreviouslypublishedcaseseriesinChinaortheUnited States.^6,19

ConsistentwiththecaseseriesoftheWuhanChildren’s Hospital,²¹ the most frequent diagnosis in the emergency department was lower respiratory tract infection (pneumonia, bronchiolitis),followed by upper respiratory tract infection,withthe2combinedamountingtonearly80%of suspectedCOVID-19cases.Thatis,theevidencecontinues to showthat most symptomatic patients have respiratory symptoms.

Althoughtherecentliteratureincludesreportsofcuta- neousinvolvementassociatedwithinfectionbycoronavirus

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3.600 3.300 3.000 2.700 2.400 2.100 1.800 1.500 1.200 900 600 300

18 16 14 12 10 8 6

2 4

0

Daily new cases of COVID-19

Total in the ACM Suspected in PED Confirmed (PCR+) in PED

Day 14 (March) Day 17 (March)

Day 30 (March) Day 31 (March)Da

y 1 (Apr il)

Da y 2 (Apr

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Da y 3 (Apr

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Da y 4 (Apr

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Da y 5 (Apr

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Da y 6 (Apr

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Da y 7 (Apr

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Da y 8 (Apr

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Da y 9 (Apr

il)

Day 10 (Apr il)

Day 11 (Apr il)

Day 12 (Apr il)

Day 13 (Apr il)

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Figure1 Dailynumber ofnew cases ofCOVID-19(suspected andconfirmed by PRC)diagnosedatthe paediatricemergency departmentandcorrelationtothereporteddailyconfirmedcasesintheAutonomousCommunityofMadrid(ACM)inthefirst35 daysfollowingthedeclarationofthestateofalarm.Sourceofdatafor theACM:Spanish MinistryofHealth,SocialWelfareand Equality.

aswellascasescompatiblewithKawasakidisease,wewere unabletofindacausalrelationshipinpatientsinoursam- plethatpresentedwiththesesymptoms,asmicrobiological testsinthesepatientswerenegative.

The positivity rate for the PCR test for SARS-CoV-2 in oursample(22%)wassimilartotheratesreportedinother studies(34%in thecaseseriesinChinapublishedbyDong et al.⁶), although it is important to take into account the limited sensitivities reported for the different tests available (65%---77%) in making interpretations about the actual prevalence of infection in patients with suspected COVID-19.²²

Inourseries,23.8%ofpatientswithsuspectedCOVID-19 wereadmittedtohospital.Inafourthofthesepatients,the suspectedinfectionbySARS-CoV-2wasconfirmedbyapos- itivePCRtest,asubsetthatamountedto35%ofthetotal patientsthathadapositivePCRresult.This percentageis strikinglylower comparedtothe percentagesreportedby Parri etal.in Italy²⁰ and Tagarroetal. inSpain¹ (inboth

cases,60%ofcaseswithapositivetestwerehospitalised).

Thisdifferencemaybeexplainedby,inthecaseofthefor- merstudy,because25%ofthepatientswereadmittedtobe quarantinedwhilebeingasymptomatic,somethingthatwas notdone inourhospital,andinthecase ofSpanishstudy, becauseinourhospital,inadherencewiththedirectivesof theACM,wetestedpatientsthatrequiredadmissionforany reasonorpatientswithcomorbiditiesthatwereatgreater riskforcomplications.Sinceourhospitalservesaconsider- ablenumberofcomplexpatientswithmanycomorbidities, manyofthemunderwentPCRtestingforSARS-CoV-2aspart ofamorethoroughfollowup,buttheyweredischargedhome iftheydidnothaveanyclinicalmanifestationsthatjustified admission.

The most frequent reason for hospital admission in patients with suspected COVID-19 was lower respiratory tractinfection.Only2ofthepatientswithconfirmedCOVID- 19 met the criteria for severe disease proposed by Dong et al.,⁶ which amounted to 5% of all confirmed cases, a

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Cumulative number of cases of COVID-19

52.500 47.500 42.500 37.500 32.500 27.500 22.500 17.500 12.500 7.500 2.500 250 225 200 175 150 125 100 75 50 25 0

Day 14 (March)

Day 30 (March)Day 1 (Apr il)

Day 3 (Apr il)

Day 5 (Apr il)

Day 7 (Apr il)

Day 9 (Apr il)

Day 11 (Apr il)

Day 13 (Apr il)

Day 15 (Apr il)

Day 16 (March)

Total in the ACM Suspected in PED Confirmed (PCR+) in PED

Figure2 CumulativefrequencyofnewCOVID-19cases(suspectedandconfirmedbyPCR)diagnosedatthepaediatricemergency departmentandcorrelationtothereportedcumulativenumberofconfirmedcasesintheAutonomousCommunityofMadrid(ACM) inthefirst35daysfollowingthedeclarationofthestateofalarm.SourceofdatafortheACM:SpanishMinistryofHealth,Social WelfareandEquality.

percentagethatwasidenticaltotheonereportedbythese authors.Halfofthepatientsadmittedwithfeverwithouta sourcehadapositiveSARS-CoV-2PCRtestresult.Ofthese 10patients,6wereagedlessthan1monthandanotherless than3months,whichmayhavemotivated theiradmission despitehavingmildcasesofdiseasebasedonthedefinition ofDongetal.

There are severallimitations tothis study. Firstly,the reorganizationofemergencycareintheACM, withreduc- tionsoracompleteshutdownofpaediatricservicesinmany hospitals,makesitdifficulttointerprettheactualimpactof thepandemiconthedemandforpaediatricemergencycare inthedepartment.Anothersignificantlimitationisthatwe wereunabletoperformasubsequentfollowup withaddi- tionalmicrobiologicaltests(repeatPCRSARS-CoV-2testor antibodytest)inpatientswithsuspectedCOVID-19andneg-

ativeresultsofthePCRtestperformedinthePED.Onthe other hand, given the policies concerning microbiological testingintheearlyweeksoftheoutbreak,itispossiblethat some patients with low clinical suspicionfor COVID-19 or thatdidnotmetthecriteriaforadmissionweredischarged fromthePEDwithalternativediagnosesandwerenotinves- tigatedaspossiblecasesofCOVID-19.Forthesamereason, wewereunabletoanalyzetheprevalenceofasymptomatic carriage of SARS-CoV-2 in patients that consulted due to closecontactwithcasesof infectioninthehouseholdand otherreasons.

Conclusions

The SARS-CoV-2 pandemic has led to a decrease in the demand for paediatric emergencycare in our population,

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1680 visits

14 excluded 1666 included

non-infectious disease, 895

infectious disease, 807

Upper airway (n = 264)

Suspected

COVID-19 (n = 74)

(n = 18)

(n = 96) (n = 25)

(n = 7)

(n = 9) (n = 14)

(n = 1) (n = 14)

SARS-CoV-2 PCR+

Lower airway (n = 172)

Fever without source (n = 165)

ENT infection (n = 62)

Skin lesions (n = 52)

Genito- urinary (n = 37)

Other (n = 37) Gastro-

intestinal (n = 28)

Figure3 Flowchartofpatientswithadischargediagnosisofinfectiousdiseaseandofsuspected/confirmedCOVID-19.

Table6 DescriptionofcasesdiagnosedaspossibleCOVID-19(n=218).

Total,n(%) PCR+,n(%)

Dischargediagnosis

Lowerrespiratorytractinfection 96/218(44%) 14/96(14.5%)

Pneumonia 45/96(46.8%) 9/45(20%)

Other 51/96(53.1%) 5/51(9.8%)

Upperrespiratorytractinfection 74/218(33.9%) 18/74(24.3%)

Feverwithoutasource 25/218(11.5%) 7/25(28%)

SkinlesionssuggestiveofCOVID-19 9/218(4.1%) 0/9(0%)

Kawasakidisease 1/218(0.5%) 0/1(0%)

ScreeningforCOVID-19 13/218(6%) 1/13(7.6%)

Reasonforadmission

Lowerrespiratorytractinfection 30/52(57.6%) 4/30(13.3%)

Pneumonia 17/30(56.6%) 4/17(23.5%)

Feverwithoutasource 10/52(19.2%) 5/10(50%)

Upperrespiratorytractinfection 10/52(19.2%) 6/10(60%)

SkinlesionssuggestiveofCOVID-19 1/52(1.9%) 0/1(0%)

Kawasakidisease 1/52(1.9%) 0/1(0%)

accompaniedbyanincreaseintheproportionofcasescor- respondingtoahightriagelevel.

Most paediatric patients with suspected or confirmed COVID-19 presented with respiratory symptoms, usually mild,orfeverwithoutasource.

Conflicts of interest

Theauthorshavenoconflictsofinteresttodeclare.

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Impact of the COVID-19 pandemic on emergency

ORIGINAL ARTICLE