The flow pattern of neuro-pediatric emergency visits during COVID-19 pandemic

The study's aim, protocol, and procedure were approved by the Unit of Biomedical Ethics Research Committee of XXX with reference number (324–23) on June 20, 2023. The study was conducted according to the World Medical Association Declaration of Helsinki. All revealing data was masked, and patients' privacy was ensured throughout the conduct of the study.

We retrospectively reviewed and extracted data from a single tertiary care hospital following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist [12] to analyze the flow pattern of ED visits among pediatric patients with neuro-related complaints during the prior COVID-19 pandemic. The tertiary care center is a publicly funded and owned center that serves the entire community with a bed capacity of 750 beds and up to 900 beds in an emergency setting and receives an estimated 60,000 visits annually. It has specialized units and services for neurological complaints. The data was directly extracted from the electronic hospital record system after obtaining technical and ethical clearance. Participants were filtered after applying the inclusion criteria to include pediatric patients with a neurological provisional diagnosis. The neurological provisional diagnosis included the following: seizure or epilepsy, headache or loss of consciousness, inflammation, cranial nerve palsy, neuromuscular, neoplasm, vascular, injury, and abscess. All these diagnoses were related to or affected the nervous system. Subsequently, a total of 108,000 visits were reduced to 960 patients. Patients were later divided into two groups: pre- (n = 309) and during the (n = 651) COVID-19 pandemic. As for the determination of the start of the COVID-19 pandemic, the date of the first case detected nationwide was set as the start of the pandemic. Time periods prior to that were labeled pre-pandemic. The pediatric age groups were defined by the National Institute of Child Health and Human Development as follows: (A) Neonate (birth–1 month); (B) Infancy (1 month–1 year); (C) Toddler (1–3 years); (D) Preschool (3–6 years); (E) School age (6–12 years); and (F) Adolescent (12–18 years) using the standardized labeling according to the center's clinical practice. We identified demographic characteristics, including their gender, nationalities, triage priority, provisional diagnosis, clinical outcome, chief complaint, length of stay (LOS), investigations (i.e., X-Ray, Computerized tomography scan, Magnetic resonance imaging, lab workup), and number of medications. The triage level categorization that was determined in this study was done using the Australasian Triage Scale (ATS). Furthermore, it was adopted in accordance with local standardized triage protocols and guidelines set by our center. These protocols classify patients based on how urgently they need medical care in order to ensure patient safety and effective resource allocation.

Descriptive statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA) and SmartPLS 3 to test the relationship between the variables. Quantitative variables were described using measures of central tendency. Categorical variables, on the other hand, use frequencies and percentages. A chi-square test was applied to categorical variables for comparison. One-way analysis of variance (ANOVA) and multilinear logistic regression were used to predict the difference between the data during and prior to the pandemic. All data utilized graphical presentation in the form of line charts and illustrated graphs. All P-values < 0.05 and 95% confidence intervals were considered to be statistically significant.

The study included 960 patients with a provisional neurological diagnosis, as described in the methodology section. Table 1 presents the baseline characteristics of the patients. There were 542 (56.5%) male patients in comparison to 418 (43.5%) female patients. The mean age of the patients during the admission was 5.29 ± 4.19 years. The most common age group was the school-age group (6–12 years), which comprised 279 (29.1%) of the patients. The majority of patients were triaged as “priority 1: resuscitation”. (n = 332, 34.6%), followed by “Priority 3: Urgent” (n = 331, 34.5%).

Table 2 demonstrates a comparison of different characteristics between the pre-COVID-19 pandemic and the COVID-19 pandemic.

The most common chief complaint was seizures (n = 317, 33.0%), followed by patients presenting in the post-ictal state (n = 187, 19.5%). Most patients received a provisional diagnosis of seizures/epilepsy (n = 529, 55.1%). When comparing both eras, a statistically significant difference in the most common chief complaints was observed (P = 0.005) (Table 2). However, there was no statistically significant difference in the provisional diagnosis (P = 0.232) (Table 2). Table 3 demonstrates a multinomial logistic regression that compares the pre-COVID-19 era to the time of the COVID-19 pandemic according to a specific provisional diagnosis. During the pre-COVID-19 era and after adjusting the odds ratio, statistical significance was observed for patients complaining of vascular issues (P = 0.013). Similarly, it was significant during the COVID-19 pandemic (P = 0.013). Other values were presented in Table 3.

The most common outcome was discharge (n = 558, 58.1%), followed by admission (n = 394, 41.0%). The mean length of stay was 10.56 ± 20.33 h, and the majority of the patients stayed for less than 24 h (n = 896, 93.3%) (Fig. 1). When comparing between both eras according to the outcome, a statistically significant difference was not found (P = 0.587). The mean length of stay during the pre-COVID-19 pandemic was 16.48 ± 33.53 h, in contrast to a shorter mean length of stay of 7.76 ± 7.27 h during the COVID-19 pandemic (P < 0.001) (Table 2).

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