Impact of the COVID-19 Pandemic on Child and Adolescent Psychiatric Emergencies.

OBJECTIVE: By forcing closure of schools, curtailing outpatient services, and imposing strict social distancing, the COVID-19 pandemic has abruptly affected the daily life of millions worldwide, with still unclear consequences for mental health. This study aimed to evaluate if and how child and adolescent psychiatric visits to hospital emergency departments (EDs) changed during the pandemic lockdown, which started in Italy on February 24, 2020. METHODS: We examined all ED visits by patients under 18 years of age in the 7 weeks prior to February 24, 2020, and in the subsequent 8 weeks of COVID-19 lockdown at two urban university hospitals, in Turin and Rome, Italy. ED visits during the corresponding periods of 2019 served as a comparison using Poisson regression modeling. The clinician's decision to hospitalize or discharge home the patient after the ED visit was examined as an index of clinical severity. RESULTS: During the COVID-19 lockdown, there was a 72.0% decrease in the number of all pediatric ED visits (3,395) compared with the corresponding period in 2019 (12,128), with a 46.2% decrease in psychiatric visits (50 vs 93). The mean age of psychiatric patients was higher in the COVID-19 period (15.7 vs 14.1 years). No significant changes were found in hospitalization rate or in the prevalence distribution of the primary reason for the psychiatric ED visit (suicidality, anxiety/mood disorders, agitation). CONCLUSIONS: In the first 8 weeks of the COVID-19-induced social lockdown, the number of child and adolescent psychiatric ED visits significantly decreased, with an increase in patient age. This decrease does not appear to be explained by severity-driven self-selection and might be due to a reduction in psychiatric emergencies or to the implementation of alternative ways of managing acute psychopathology.

Effectiveness of Emergent Ad Hoc Coordination Groups in Public Health Emergencies.

Whether emergent groups positively or negatively influence a disaster response remains inconclusive in the literature. We analyzed the effect of an emergent group on two interorganizational networks for information communication and resource coordination during a public health emergency response. Using the 2015 Middle East Respiratory Syndrome (MERS) Coronavirus in Korea as a study case, we identified an ad hoc entity that appeared in both networks. This emergent group, which consists of government officials and public health specialists, directed and coordinated organizations at the center of the response networks. We found that the emergent group positively contributed to efficient information communication but had no effect on the resource network's efficiency. Our interpretation is that the ad hoc entity was filling relational gaps in the information network, but was redundant in the resource network.

Volunteering experience during emergencies: Comparative analysis of a military operation and a pandemic.

The aim of this study was to investigate differences in the volunteering experience in two states of emergency in Israel: Operation Protective Edge (a military man-made emergency) and the first wave of the COVID-19 pandemic (a natural emergency). The sample included 993 volunteers, of whom 498 volunteered during Operation Protective Edge and 504 during the COVID-19 pandemic. A quantitative research design was used to investigate three aspects of the volunteering experience: motives for volunteering, satisfaction from volunteering, and commitment to volunteer. Social solidarity was the most prominent motive for volunteering in both emergencies. The level of the egoistic motives, the intrinsic satisfaction from volunteering, and long-term commitment to volunteering were higher during the COVID-19 pandemic than among the volunteers during the military operation. We used a qualitative research design to investigate the experience of special moments in volunteering. The profile of special moments experienced by the COVID-19 volunteers combined self and client experiences, whereas among Operation Protective Edge volunteers, special moments are reflected mainly in experiences related to the clients and the community.

Emergency Medical Services and Syndromic Surveillance: A Comparison With Traditional Surveillance and Effects on Timeliness.

OBJECTIVE: Traditional public health surveillance of nonfatal opioid overdose relies on emergency department (ED) billing data, which can be delayed substantially. We compared the timeliness of 2 new data sources for rapid drug overdose surveillance-emergency medical services (EMS) and syndromic surveillance-with ED billing data. METHODS: We used data on nonfatal opioid overdoses in Kentucky captured in EMS, syndromic surveillance, and ED billing systems during 2018-2019. We evaluated the time-series relationships between EMS and ED billing data and syndromic surveillance and ED billing data by calculating cross-correlation functions, controlling for influences of autocorrelations. A case example demonstrates the usefulness of EMS and syndromic surveillance data to monitor rapid changes in opioid overdose encounters in Kentucky during the COVID-19 epidemic. RESULTS: EMS and syndromic surveillance data showed moderate-to-strong correlation with ED billing data on a lag of 0 (r = 0.694; 95% CI, 0.579-0.782; t = 9.73; df = 101; P < .001; and r = 0.656; 95% CI, 0.530-0.754; t = 8.73; df = 101; P < .001; respectively) at the week-aggregated level. After the COVID-19 emergency declaration, EMS and syndromic surveillance time series had steep increases in April and May 2020, followed by declines from June through September 2020. The ED billing data were available for analysis 3 months after the end of a calendar quarter but closely followed the trends identified by the EMS and syndromic surveillance data. CONCLUSION: Data from EMS and syndromic surveillance systems can be reliably used to monitor nonfatal opioid overdose trends in Kentucky in near-real time to inform timely public health response.

Reduction of admissions for urgent and elective pacemaker implant during the COVID-19 outbreak in Northern Italy.

AIMS: The coronavirus disease-19 (COVID-19) outbreak has been recently associated with lower hospitalization rates for acute coronary syndromes. Aim of the study was to investigate whether a similar behaviour is observed in admissions for urgent pacemaker implant. METHODS: This retrospective study included 1315 patients from 18 hospitals in Northern Italy with a high number of COVID-19 cases. Hospitalization rates for urgent pacemaker implant were compared between the following periods: 20 February to 20 April 2020 (case period); from 1 January to 19 February 2020 (intra-year control period); from 20 February to 20 April 2019 (inter-year control period). RESULTS: The incidence rate of urgent implants was 5.0/day in the case period, 6.0/day in the intra-year control period and 5.8/day in the inter-year control period. Incidence rate in the case period was significantly lower than both the intra-year [incidence rate ratio (IRR): 0.81, 95% CI 0.67-0.99, P = 0.040] and inter-year control periods (IRR: 0.79, 95% CI 0.66-0.95, P = 0.012); this reduction was highest after the national lockdown (IRR 0.68, 95% CI 0.52-0.91, P = 0.009). The prevalence of residents in rural areas undergoing urgent pacemaker implant was lower in the case period (36%) than in both the intra-year (47%, P = 0.03) and inter-year control periods (51%, P = 0.002). Elective pacemaker implants also decreased in the case period, with the incidence rate here being 3.5/day vs. 6.4/day in the intra-year (-45%) and 6.9/day in the inter-year period (-49%). CONCLUSION: Despite severe clinical patterns, the COVID-19 outbreak has negatively affected the population presentation to Emergency Departments for bradyarrhythmias requiring urgent pacemaker implant in Northern Italy. This mainly occurred after the national lockdown and concerned patients living in rural areas.

Health knowledge, health behaviors and attitudes during pandemic emergencies: A systematic review.

BACKGROUND: People with good health knowledge present a conceptual and objective appropriation of general and specific health topics, increasing their probability to express health protection and prevention measures. The main objective of this study was to conduct a rapid systematic review about the effects of health knowledge on the adoption of health behaviors and attitudes in populations under pandemic emergencies. METHODS: A systematic review was performed according to PRISMA checklist and the Cochrane method for rapid systematic reviews. Studies searches were performed in APA PsycNet, Embase, Cochrane Library and PubMed Central. Studies published between January 2009 and June 2020 and whose primary results reported a measure of interaction between health knowledge, health attitudes and behaviors in population groups during pandemics were included. A review protocol was recorded in PROSPERO (CRD42020183347). RESULTS: Out of a total of 5791 studies identified in the databases, 13 met the inclusion criteria. The included studies contain a population of 26099 adults, grouped into cohorts of health workers, university students, clinical patients, and the general population. Health knowledge has an important influence on the adoption of health behaviors and attitudes in pandemic contexts. CONCLUSIONS: The consolidation of these preventive measures favors the consolidation of public rapid responses to infection outbreaks. Findings of this review indicate that health knowledge notably favors adoption of health behaviors and practices. Therefore, health knowledge based on clear and objective information would help them understand and adopt rapid responses to face a pandemic.

The Emergency Use Authorization of Pharmaceuticals: History and Utility During the COVID-19 Pandemic.

The Emergency Use Authorization (EUA) originated in 2004 because of the need for emergency medical countermeasures (MCMs) against potential bioterrorist attacks. The EUA also proved useful in dealing with subsequent pandemics and has emerged as a critical regulatory pathway for therapeutics and vaccines throughout the Coronavirus Disease 2019 (COVID-19) pandemic. With the EUA process in the USA, we witnessed emergency authorizations, their expansions, as well as withdrawal of previously authorized products, which exemplifies the dynamic nature of scientific review of EUA products. EUAs proved vital for the first group of COVID-19 vaccines, including the temporary pause of one vaccine while emergency safety issues were evaluated. Although this review on the EUA is primarily focused on the USA, distinctions were made with other jurisdictions such as Europe and Canada with respect to the emergency authorizations of the vaccines. Finally, we discuss some important differences following EUA and formal new drug/vaccine application (NDA/BLA) approvals.

Impact of the COVID-19 Pandemic on Emergency Adult Surgical Patients and Surgical Services: An International Multi-center Cohort Study and Department Survey.

OBJECTIVES: The PREDICT study aimed to determine how the COVID-19 pandemic affected surgical services and surgical patients and to identify predictors of outcomes in this cohort. BACKGROUND: High mortality rates were reported for surgical patients with COVID-19 in the early stages of the pandemic. However, the indirect impact of the pandemic on this cohort is not understood, and risk predictors are yet to be identified. METHODS: PREDICT is an international longitudinal cohort study comprising surgical patients presenting to hospital between March and August 2020, conducted alongside a survey of staff redeployment and departmental restructuring. A subgroup analysis of 3176 adult emergency patients, recruited by 55 teams across 18 countries is presented. RESULTS: Among adult emergency surgical patients, all-cause in-hospital mortality (IHM) was 3.6%, compared to 15.5% for those with COVID-19. However, only 14.1% received a COVID-19 test on admission in March, increasing to 76.5% by July.Higher Clinical Frailty Scale scores (CFS >7 aOR 18.87), ASA grade above 2 (aOR 4.29), and COVID-19 infection (aOR 5.12) were independently associated with significantly increased IHM.The peak months of the first wave were independently associated with significantly higher IHM (March aOR 4.34; April aOR 4.25; May aOR 3.97), compared to non-peak months.During the study, UK operating theatre capacity decreased by a mean of 63.6% with a concomitant 27.3% reduction in surgical staffing. CONCLUSION: The first wave of the COVID-19 pandemic significantly impacted surgical patients, both directly through co-morbid infection and indirectly as shown by increasing mortality in peak months, irrespective of COVID-19 status.Higher CFS scores and ASA grades strongly predict outcomes in surgical patients and are an important risk assessment tool during the pandemic.

Methodology of emergency medical logistics for multiple epidemic areas in public health emergency.

Coronavirus disease 2019(COVID-19) has brought great disasters to humanity, and its influence continues to intensify. In response to the public health emergencies, prompt relief supplies are key to reduce the damage. This paper presents a method of emergency medical logistics to quick response to emergency epidemics. The methodology includes two recursive mechanisms: (1) the time-varying forecasting of medical relief demand according to a modified susceptible-exposed-infected- Asymptomatic- recovered (SEIAR) epidemic diffusion model, (2) the relief supplies distribution based on a multi-objective dynamic stochastic programming model. Specially, the distribution model addresses a hypothetical network of emergency medical logistics with considering emergency medical reserve centers (EMRCs), epidemic areas and e-commerce warehousing centers as the rescue points. Numerical studies are conducted. The results show that with the cooperation of different epidemic areas and e-commerce warehousing centers, the total cost is 6% lower than without considering cooperation of different epidemic areas, and 9.7% lower than without considering cooperation of e-commerce warehousing centers. Particularly, the total cost is 20% lower than without considering any cooperation. This study demonstrates the importance of cooperation in epidemic prevention, and provides the government with a new idea of emergency relief supplies dispatching, that the rescue efficiency can be improved by mutual rescue between epidemic areas in public health emergency.

Where Have All the Emergencies Gone? The Impact of the COVID-19 Pandemic on Obstetric and Gynecologic Procedures and Consults at a New York City Hospital.

STUDY OBJECTIVE: The purpose of this study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical volume and emergency department (ED) consults across obstetrics-gynecology (OB-GYN) services at a New York City hospital. DESIGN: Retrospective cohort study. SETTING: Tertiary care academic medical center in New York City. PATIENTS: Women undergoing OB-GYN ED consults or surgeries between February 1, 2020 and April 15, 2020. INTERVENTIONS: March 16 institutional moratorium on elective surgeries. MEASUREMENTS AND MAIN RESULTS: The volume and types of surgeries and ED consults were compared before and after the COVID-19 moratorium. During the pandemic, the average weekly volume of ED consults and gynecology (GYN) surgeries decreased, whereas obstetric (OB) surgeries remained stable. The proportions of OB-GYN ED consults, GYN surgeries, and OB surgeries relative to all ED consults, all surgeries, and all labor and delivery patients were 1.87%, 13.8%, 54.6% in the pre-COVID-19 time frame (February 1-March 15) vs 1.53%, 21.3%, 79.7% in the COVID-19 time frame (March 16-April 15), representing no significant difference in proportions of OB-GYN ED consults (p = .464) and GYN surgeries (p = .310) before and during COVID-19, with a proportionate increase in OB surgeries (p <.002). The distribution of GYN surgical case types changed significantly during the pandemic with higher proportions of emergent surgeries for ectopic pregnancies, miscarriages, and concern for cancer (p <.001). Alternatively, the OB surgery distribution of case types remained relatively constant. CONCLUSION: This study highlights how the pandemic has affected the ways that patients in OB-GYN access and receive care. Institutional policies suspending elective surgeries during the pandemic decreased GYN surgical volume and affected the types of cases performed. This decrease was not appreciated for OB surgical volume, reflecting the nonelective and time-sensitive nature of obstetric care. A decrease in ED consults was noted during the pandemic begging the question "Where have all the emergencies gone?" Although the moratorium on elective procedures was necessary, "elective" GYN surgeries remain medically indicated to address symptoms such as pain and bleeding and to prevent serious medical sequelae such as severe anemia requiring transfusion. As we continue to battle COVID-19, we must not lose sight of those patients whose care has been deferred.

The impact of COVID-19 pandemic in stroke code activation and time from symptom onset to hospital arrival in a Portuguese comprehensive stroke centre. / El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) impacted emergency services worldwide. AIM: We aimed to evaluate COVID-19 effect on the number of stroke code activations and timings during the first two months of the pandemic. MATERIAL AND METHODS: We reviewed the stroke code database of a single comprehensive stroke centre in Portugal for the number of activations through 2019-2020. We compared the pathway timings between March and April 2020 (COVID-19 period) and the homologous months of the previous four years (pre-COVID-19 period), whilst using February as a control. RESULTS: Monthly stroke code activation rates decreased up to 34.2% during COVID-19 pandemic. Compared to the pre-COVID-19 period, we observed an increase in the time from symptom onset to emergency call, with a significant number of patients waiting more than four hours (March 20.8% vs. 6.8%, p = 0.034; April 23.8% vs. 6%, p = 0.01); as well as an increase in the time from symptom onset to hospital arrival (March: median 136 minutes [IQR 106-410] vs. 100 [IQR 64-175], p = 0.001; April: median 188 [IQR 96-394] vs. 98 [IQR 66-168], p = 0.007). No difference between both periods was found concerning in-hospital times, patient characteristics, stroke/mimic diagnosis, stroke severity, and mortality. CONCLUSION: COVID-19 related factors probably reduced healthcare services utilization, and delayed emergency calls and hospital arrival after stroke onset. These highlight the importance of health education to improve the effectiveness of medical assistance. The preservation of in-hospital times validates the feasibility of the protected stroke code protocol.

TITLE: El impacto de la pandemia de COVID-19 en la activación del Código Ictus y en el tiempo desde el inicio de los síntomas hasta la llegada al hospital en un centro de ictus portugués.Introducción. La enfermedad por coronavirus 2019 (COVID-19) provocó un considerable impacto mundial en los servicios de emergencia. Objetivo. Se pretende evaluar el efecto de la COVID-19 sobre el número y los tiempos de activaciones del Código Ictus en el comienzo de la pandemia. Material y métodos. Se revisó la base de datos del Código Ictus de un centro de ictus de Portugal entre 2016 y 2020. Se compararon los tiempos de activación entre marzo y abril de 2020 (período COVID-19) y los meses homólogos de los cuatro años anteriores, mientras que se utilizó febrero como control. Resultados. Las tasas mensuales de activación disminuyeron hasta el 34,2% durante la pandemia. En comparación con el período previo, se observó un aumento del tiempo desde los síntomas hasta la llamada de emergencia, con un aumento de pacientes que esperaron más de cuatro horas (marzo: 20,8 frente a 6,8%, p = 0,034; abril: 23,8 frente a 6%, p = 0,01) y del tiempo desde los síntomas hasta la llegada al hospital ­marzo: mediana de 136 minutos (rango intercuartílico [RIC]: 106-410) frente a 100 (RIC: 64-175), p = 0,001; abril: mediana de 188 (RIC: 96-394) frente a 98 (RIC: 66-168), p = 0,007­. No hubo diferencias en los tiempos de internamiento, las características de los pacientes, el diagnóstico de ictus/stroke mimics, la gravedad del ictus o la mortalidad. Conclusión. Los factores relacionados con la COVID-19 redujeron la utilización de los servicios sanitarios y retrasaron las llamadas de emergencia y el tiempo de llegada al hospital. Esto demuestra la importancia de la educación sanitaria para mejorar la eficacia de la asistencia médica.

Do surgical emergencies stay at home? Observations from the first United States Coronavirus epicenter.

BACKGROUND: During the coronavirus disease 2019 pandemic, New York instituted a statewide stay-at-home mandate to lower viral transmission. While public health guidelines advised continued provision of timely care for patients, disruption of safety-net health care and public fear have been proposed to be related to indirect deaths because of delays in presentation. We hypothesized that admissions for emergency general surgery (EGS) diagnoses would decrease during the pandemic and that mortality for these patients would increase. METHODS: A multicenter observational study comparing EGS admissions from January to May 2020 to 2018 and 2019 across 11 NYC hospitals in the largest public health care system in the United States was performed. Emergency general surgery diagnoses were defined using International Classification Diseases, Tenth Revision, codes and grouped into seven common diagnosis categories: appendicitis, cholecystitis, small/large bowel, peptic ulcer disease, groin hernia, ventral hernia, and necrotizing soft tissue infection. Baseline demographics were compared including age, race/ethnicity, and payor status. Outcomes included coronavirus disease (COVID) status and mortality. RESULTS: A total of 1,376 patients were admitted for EGS diagnoses from January to May 2020, a decrease compared with both 2018 (1,789) and 2019 (1,668) (p < 0.0001). This drop was most notable after the stay-at-home mandate (March 22, 2020; week 12). From March to May 2020, 3.3%, 19.2%, and 6.0% of EGS admissions were incidentally COVID positive, respectively. Mortality increased in March to May 2020 compared with 2019 (2.2% vs. 0.7%); this difference was statistically significant between April 2020 and April 2019 (4.1% vs. 0.9%, p = 0.045). CONCLUSION: Supporting our hypothesis, the coronavirus disease 2019 pandemic and subsequent stay-at-home mandate resulted in decreased EGS admissions between March and May 2020 compared with prior years. During this time, there was also a statistically significant increase in mortality, which peaked at the height of COVID infection rates in our population. LEVEL OF EVIDENCE: Epidemiological, level IV.

Emergency department visits for emergent conditions among older adults during the COVID-19 pandemic.

BACKGROUND/OBJECTIVE: Emergency department (ED) visits have declined while excess mortality, not attributable to COVID-19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID-19 pandemic for older adults. DESIGN: Retrospective, observational study. SETTING: Observational analysis of ED sites enrolled in a national clinical quality registry. PARTICIPANTS: One hundred and sixty-four ED sites in 33 states from January 1, 2019 to November 15, 2020. MAIN OUTCOME AND MEASURES: We measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post-early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre-pandemic period. We report incident rate ratios to summarize changes in visit incidence. RESULTS: For AMI, stroke, and sepsis, the older (75-84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post-early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75-84) and oldest old (85+ years). CONCLUSIONS: The decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time-sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID-19 era among older adults.