Introduction
The Emergency Department acts as a gateway to the health and social care system for many children, while also providing critical care when other services are overburdened. As the COVID-19 pandemic progressed across the globe, changes in patterns of paediatric attendances at the ED indicated the pandemic was impacting children’s access to healthcare. A substantial reduction in paediatric emergency care utilization followed public health measures aimed at halting the spread of the virus, including school closures and restrictions on movement and social interactions. This has raised concerns regarding potential delays in seeking healthcare [
1,
2], and increased rates of morbidity and mortality due to delayed presentations have been reported [
3‐
5]. In Italy, paediatric presentations reduced by 73–88% compared to the previous two years [
5], while in Ireland paediatric attendances fell by 46% between March and May 2020, compared to the same period in 2019 and 2018 [
6]. Some studies have examined the scale of delayed presentations [
7,
8], with one study finding that 32% of paediatricians working in EDs and Paediatric Assessment Units in Ireland and the UK observed delayed presentations during the initial phase of the pandemic [
8]. Lower attendance rates have been attributed to reduced infectious diseases and injuries due to public health measures implemented. Furthermore, parental hesitancy to attend hospitals due to fear of COVID-19 and a misinterpretation of public health messaging may have also contributed to reduced presentations [
9].
The COVID-19 pandemic has psychosocial implications for children, who may be affected in multifaceted ways on an individual, familial and community level [
10], with evidence suggesting that quarantine conditions have adversely impacted children’s mental health [
11]. The disruption to educational, social and recreational activities removed children from peer networks and social interaction, which may cultivate social isolation [
12]. The disruption of schools and community services, often a safety net for children, may further leave children vulnerable, particularly those at heightened risk of neglect [
1]. Furthermore, children with pre-existing behavioural conditions, such as autism, and those who rely on specialist or community delivered health services, may be disproportionally affected by not having their needs met [
11,
13].
Health care systems have rapidly implemented protocols, redeployed staff and redistributed resources to create adequate capacity to deal with the expected surge in demand [
14,
15]. As children are by and large asymptomatic and mortality rare [
16], the pandemic is manifesting as a logistical, rather than clinical, challenge for PEDs [
1,
14]. EDs often act as a point of entry for hospitals, therefore a robust and rapid response is crucial to ensure appropriate management of patients and infection control [
2,
14]. As the pandemic progressed, it was expected to present additional challenges to healthcare systems due to the onset of the winter season, as well as schools remaining open in some jurisdictions. Moreover, in contrast to the first wave of COVID-19, health systems are trying to maintain facilitation of routine non-COVID-19 care. Documenting the response of PEDs to the pandemic can provide learning for health systems and policymakers for future healthcare planning and policy [
14].
A number of studies have documented the changes to paediatric emergency healthcare, however to the best of our knowledge, no qualitative study has been undertaken to examine and contextualise these changes further. Furthermore, there is limited understanding as to how PEDs and the staff working there have adapted the provision of care during COVID-19. This qualitative study will provide rich data from the perspective of multidisciplinary frontline staff delivering care to paediatric patients in the ED in order to apprehend the already documented changes in presentations, as well as to understand the experience of working under the restructured health system in paediatric ED’s in Ireland.
Methods
This study is part of a wider project looking at paediatric emergency healthcare utilization during COVID-19 in Ireland [
17]. The main aim of this qualitative study was to utilize the perspective of ED staff to 1) understand changes to paediatric emergency healthcare utilization 2) understand the experiences of working within the restructured health system from the perspective of frontline staff. Qualitative methodology was chosen as it elicits rich data and detailed insights of the phenomenon at hand [
18].
Recruitment
Frontline emergency medicine staff working in four hospitals in total: two paediatric EDs and two mixed adult/paediatric EDs were recruited through convenience sampling. Their contact information was provided to the researcher, who in turn provided them with further information on the study and obtained written consent.
Data Collection & Analysis
Interviews were carried out by one researcher (CC) remotely through phone or video call between August and October 2020. Eighteen potential participants were identified, three of whom were ineligible as they did not work in an ED during COVID-19. The interviews were semi-structured, conducted in line with an interview schedule developed with input from research collaborators working in clinical settings (see supplementary material). Interviews were recorded and transcribed into Microsoft Word.
Thematic Analysis (TA) was utilized, which is a widely used, flexible method and provides researchers with a systematic process to identify and analyse themes to create an analytical narrative of the data collected using NVivo™ software [
19]. This began with familiarisation, followed by a recursive coding process as outlined by Braun and Clarke (2012). One researcher (CC) carried out the analysis, with 40% of interviews double coded (GO’D) to ensure consistency and methodological rigor in the interpretation of the data. Initial codes were generated, followed by clustering and collapsing codes to create theoretical themes. A reviewing process, involving discussion with all authors, was then carried out to ensure the themes represented patterned and shared meaning with relevance to the research question at hand [
19].
Ethics
Ethical approval was obtained from the COVID-19 National Research Ethics Committee (NREC) in Ireland (ref: 20-NREC-COV-034).
Discussion
This qualitative study aimed to outline the experiences of frontline staff delivering care in order to gain further insight into the trends of paediatric presentations to the ED during COVID-19, and the work practice adaptations introduced in the ED in the response to the pandemic. The findings contextualise the reduced use of emergency care during the initial months of the pandemic, and provide evidence to suggest concerns regarding contracting COVID-19 and misinterpretation of public health messaging may have contributed to delayed presentations by paediatric presentations at the ED. A rise in attendances for mental health reasons was identified by clinicians, suggesting psychosocial implications for children. Disruptions to healthcare delivered in the community resulted in unmet healthcare needs for some children, and the suspension of schools and community support services removed a safety net for vulnerable children at risk of neglect. This study also identifies a number of structural and operational changes undertaken to increase isolation capacity in EDs, with streaming and zoning crucial to this process. This had staffing and spatial implications, and with attendances rising, concerns were raised about the ability of EDs to maintain current infection control standards, particularly during the winter season. A number of innovative initiatives to deliver care were highlighted, and quality and safety challenges around communication identified. Finally, working on the frontline in the midst of a pandemic created uncertainty and anxiety, significantly impacted staff wellbeing and rapport.
The cases of delayed presentations outlined by clinicians supports the findings of previous studies [
5,
7,
8] and this study provides further insight into this phenomenon, highlighting the impact of parental hesitancy to attend the ED due to COVID-19 [
9]. Public health messaging clearly impacted parents faced with making decisions around seeking care for children, thus clear and uncomplicated communication is essential [
9]. The positive reaction to infection control measures displayed by parents suggests that a public communication strategy, clearly outlining the measures in place at the ED, can help to combat fears and reassure parents to continue to present [
7]. While it is more difficult to adequately assess the extent of avoidance of emergency healthcare, it is vital that children with complex needs can continue to access appropriate healthcare. Future studies should investigate the impact of the pandemic on this particular cohort and their families.
Difficulty in accessing primary and community services, including GPs, public health nurses, mental health and other community health services may be further exasperating parents’ ability to access care for their children. Moreover, the reduction or suspension of educational, social and other community services and activities such as sports and youth outreach programmes, also raised issues around child protection for vulnerable children [
8,
12], as illustrated by the findings of this study. The pandemic likely exacerbated existing economic and health inequities, further impacting marginalised children [
20] and vulnerable children may have been at risk of
“slipping through the net”. The impact of lockdown may also have been felt more keenly by children with disabilities and chronic health conditions, whose families rely on support services and specialist schools [
13,
21]. It is imperative that both short- and long-term support measures and contingency plans are implemented to prevent and alleviate the negative effects on these children [
22].
Widespread disruption to mental health services, including repurposing of staff and facilities, has been identified at a time when they may be needed more than ever [
23]. The conditions of imposed “lockdowns” may be having a negative effect on children’s mental health [
11], and as identified in this study and elsewhere [
24], this is manifesting in rising psychosocial presentations at the ED, which may not be the most appropriate pathway to mental health care. As the pandemic continues to progress, policy makers and service providers must ensure the continued provision of essential health and social services, including targeted responses for those with existing conditions.
The implications of COVID-19 for PEDs were largely logistical. The scale of this pandemic has not been faced before in the western European context. A survey highlighted that planning and simulated responses were not carried out in over a third of PEDs across Europe, and guidelines that may be widely applicable across health systems to prepare and respond rapidly and effectively to the COVID-19 pandemic have been called for by those working in PEDs [
14]. This study also highlighted the impact of resource poor services, particularly in relation to staffing levels and spatial limitations, which will progressively worsen during the winter season, bringing further logistical and clinical challenges [
25], which must be considered in operational planning for further COVID-19 surges [
26] and future public health crises. Strategies to lessen the burden on EDs through public health measures, strengthened access to primary care services, and other ways to deliver care must be enacted if children’s healthcare needs are going to be sufficiently met. Finally, those working in paediatric EDs have been somewhat overlooked due to the lesser clinical impact of COVID-19 on children, and this study also provides evidence to suggest the impact on staff is considerable and should be examined further.
Strengths and limitations
This study provides rich insight from frontline staff working in Ireland, however as the results are consistent with previous studies carried out in other countries [
7,
8,
14] they may be applicable in other contexts. The multidisciplinary nature of the clinicians included in this study reflects a wide range of experiences. The findings are based on frontline staff’s perception of parents’ health seeking behaviour, and future research could further understand in this area. Data collection occurred at one point of time, after the first and most challenging wave when health services were largely unprepared for the pandemic.
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