The Effect of COVID-19 on United States Pediatric Emergency Departments and Its Impact on Trainees

Abstract

Introduction: The purpose of this study was to quantify the effects of the coronavirus disease 2019 (COVID-19) pandemic on pediatric emergency departments (PED) across the United States (US), specifically its impact on trainee clinical education as well as patient volume, admission rates, and staffing models. Methods: We conducted a cross-sectional study of US PEDs, targeting PED clinical leaders via a web-based questionnaire. The survey was sent via three national pediatric emergency medicine distribution lists, with several follow-up reminders. Results: There were 46 questionnaires included, completed by PED directors from 25 states. Forty-two sites provided PED volume and admission data for the early pandemic (March-July 2020) and a pre-pandemic comparison period (March-July 2019). Mean PED volume decreased >32% for each studied month, with a maximum mean reduction of 63.6% (April 2020). Mean percentage of pediatric admissions over baseline also peaked in April 2020 at 38.5% and remained 16.4% above baseline by July 2020. During the study period, 33 (71.1%) sites had decreased clinician staffing at some point. Only three sites (6.7%) reported decreased faculty protected time. All PEDs reported staffing changes, including decreased mid-level use, increased on-call staff, movement of staff between the PED and other units, and added tele-visit shifts. Twenty-six sites (56.5%) raised their patient age cutoff; median was 25 years (interquartile ratio 25-28). Of 44 sites hosting medical trainees, 37 (84.1%) reported a decrease in number of trainees or elimination altogether. Thirty (68.2%) sites had restrictions on patient care provision by trainees: 28 (63.6%) affected medical students, 12 (27.3%) affected residents, and two (4.5%) impacted fellows. Fifteen sites (34.1%) had restrictions on procedures performed by medical students (29.5%), residents (20.5%), or fellows (4.5%). Conclusion: This study highlights the marked impact of the COVID-19 pandemic on US PEDs, noting decreased patient volumes, increased admission rates, and alterations in staffing models. During the early pandemic, educational restrictions for trainees in the PED setting disproportionately affected medical students over residents, with fellows’ experience largely preserved. Our findings quantify the magnitude of these impacts on trainee pediatric clinical exposure during this period.

Review of pediatric emergency care and the COVID‐19 pandemic

“…23 Additionally, at some institutions, pediatric-trained staff (physicians, nurses, respiratory therapists, etc) were given temporary change in delineation of privileges to expand scope of practice and were redeployed to care for adults as part of the disaster response, or were transitioned to providing telehealth services. 15,16,24 Non-emergency medicine trainees (medical students, residents, and fellows) who were originally assigned to work within the PED experienced restrictions on patient care provision and procedures, were reassigned to care for adults, or away from the ED altogether. 15 These measures initially helped to maximize hospital staffing in locations of increased infection risk and minimized exposure within the pediatric ED, with a tradeoff of impact on trainee learning about emergency pediatrics and overall decreased trainee exposure to more typical pediatric illness and injury.…”

“…13,15 In academic centers, this effort to preserve PPE impacted the training of medical students and residents. 16 Additionally, several PEDs began using a phone or tablet in order to obtain history and provide updates to patients and their families without physically being inside the examination room. 13 Protocols for airway management and resuscitations were amended to minimize ED staff exposure to aerosolizing procedures.…”

“…15 These measures initially helped to maximize hospital staffing in locations of increased infection risk and minimized exposure within the pediatric ED, with a tradeoff of impact on trainee learning about emergency pediatrics and overall decreased trainee exposure to more typical pediatric illness and injury. 16 Additionally, emergency medicine trainees may have been reassigned and/or had decreased exposure to pediatric illness and injury due to change in pediatric emergency volumes. The impact of this decrease in exposure to pediatric emergency medicine on trainee education and preparedness to care for children after residency is unknown.…”

“…From an equipment standpoint, to preserve limited available PPE 14 and to minimize infectious exposure by ED staff, some PEDs reduced the number of staff directly interacting with patients under investigation for COVID‐19 to one non‐trainee provider 13,15 . In academic centers, this effort to preserve PPE impacted the training of medical students and residents 16 . Additionally, several PEDs began using a phone or tablet in order to obtain history and provide updates to patients and their families without physically being inside the examination room 13 .…”

“…Non‐emergency medicine trainees (medical students, residents, and fellows) who were originally assigned to work within the PED experienced restrictions on patient care provision and procedures, were reassigned to care for adults, or away from the ED altogether 15 . These measures initially helped to maximize hospital staffing in locations of increased infection risk and minimized exposure within the pediatric ED, with a tradeoff of impact on trainee learning about emergency pediatrics and overall decreased trainee exposure to more typical pediatric illness and injury 16 . Additionally, emergency medicine trainees may have been reassigned and/or had decreased exposure to pediatric illness and injury due to change in pediatric emergency volumes.…”