Determine the frequency of 16 high-risk conditions and associated complications in a Michigan state-wide network of academic and community EDs (MiPEM) during the COVID-19 pandemic

1. Impact of COVID-19 on High-risk Conditions
and Associated Complications in a
Statewide Pediatric Emergency Network
Courtney Mangus, MD
Barsan Research Conference
April 13, 2022

2. Disclosures
No disclosures or
conflicts of
interest to report

3. Background
The COVID-19 pandemic has
affected emergency
department (ED) patient
volumes and the
epidemiology of ED visits
Early reports suggested a
potential increase in
diagnostic delays and
complications of common
pediatric conditions
(appendicitis, DKA)
The impact of the pandemic
on the frequency and
complications of certain
high-risk conditions is
unknown
Snapiri et al. Aca Paediatr. 2020; Rabbone et al. Diabetes
Care 2020; Dżygało et al. Pediatr Endocrinol Diabetes

4. Objective
Determine the frequency of 16 high-risk conditions and
associated complications in a Michigan state-wide network of
academic and community EDs (MiPEM) during the COVID-19
pandemic

5. Methods
CROSS-SECTIONAL
STUDY
PEDIATRIC (AGE 0-21
YEARS) ED VISITS
5 MICHIGAN HEALTH
SYSTEMS COMPRISING
13 EDS
PRE-PANDEMIC (3/1/19-3/10/20)
AND PANDEMIC (3/11/20-3/31/21)
PERIODS

6. Methods - Data Variables
- Patient demographics
- Chief complaint
- Emergency severity index (ESI) triage level
- Mode of arrival
- Disposition
- Procedure codes
- Encounter ICD-10 diagnosis codes

7. Methods - High-Risk Conditions
Appendicitis
Intussusception
Meningitis
Encephalitis
Compartment
syndrome
Diabetic
ketoacidosis
Ectopic
pregnancy
Empyema
Mastoiditis Myocarditis
Stroke
Orbital
cellulitis
Ovarian, testicular
torsion
Sepsis Septic arthritis

9. Methods - Statistical analysis
Hypothesis tests were assessed for significance using
chi-squared and Fisher’s exact tests at a two-tailed
alpha of 0.05

10. Results
309,500
151,745
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
Pre-Pandemic (3/1/19-3/10/20) Pandemic (3/11/20-3/31/21)
Pandemic pediatric ED visits were
lower in number
Volume (visits)

11. Results
5.24
91.96
0.22
2.58
7.55
88.64
0.43
3.38
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Ambulance/Medical
flight
Personal
vehicle/walk-in
Other* Unknown
Pandemic pediatric ED visits were higher
in acuity (EMS/Med Flight Arrival)
Pre-Pandemic Pandemic
Mode
of
arrival
percentage
p= <0.001 *police, fire department

12. Results
0.66
13.90
44.77
35.00
4.99
0.67
0.95
17.45
47.23
29.71
4.13
0.54
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
50.00
1 2 3 4 5 Unknown
Pandemic pediatric ED visits were higher
in acuity (ESI Levels 1-3)
Pre-Pandemic Pandemic
Acuity
percentage
p= <0.001 * n=326,552; 4/5 hospital systems reporting

13. Results
7.76
0.02
89.73
0.26 2.12 0.11
10.24
0.05
85.36
0.28
3.33
0.74
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Pandemic pediatric ED visits were higher
in acuity (ED deaths and Admit/Obs)
Pre-Pandemic Pandemic
Disposition
percentage
p= <0.001 * Transfer or send to another location/facility, Elected to go to urgent care, nurse only

14. Results
High-Risk
Condition
Pre-pandemic Pandemic P value
Appendicitis 701 (0.23%) 741 (0.49%) <0.001
Bacterial
Meningitis
27 (0.01%) 26 (0.02%) 0.012
Diabetic
Ketoacidosis
589 (0.19%) 849 (0.56%) <0.001
Intussusception 127 (0.04%) 91 (0.06%) <0.001
Myocarditis 7 (0.00%) 11 (0.01%) 0.02
Ovarian Torsion 43 (0.01%) 36 (0.02%) 0.017
Sepsis 315 (0.10%) 216 (0.14%) <0.001
Septic Arthritis 38 (0.01%) 30 (0.02%) 0.049
Stroke 16 (0.01%) 24 (0.02%) <0.001
Testicular
Torsion
102 (0.03%) 130 (0.09%) <0.001
The proportion of patients presenting with select high-risk
conditions was higher in the pandemic period compared to
pre-pandemic

15. Results
Cases with
Complication
Pre-pandemic Pandemic P value
Appendicitis 183/701 (26.1%) 207/741 (27.9%) 0.43
Bacterial
Meningitis
9/27 (33.3%) 15/26 (57.7%) 0.075
Compartment
Syndrome
3/11 (27.3%) 2/8 (25.0%) 1
Diabetic
Ketoacidosis
84/589 (14.3%) 117/849 (13.8%) 0.796
Ectopic
Pregnancy
4/31 (12.9%) 1/25 (4.0%) 0.367
Empyema 9/19 (47.4%) 7/16 (43.8%) 1
Encephalitis 3/11 (27.3%) 7/10 (70%) 0.086
Intussusception 3/127 (2.4%) 2/91 (2.2%) 1
The frequency of patients presenting with complications of
high-risk conditions was not statistically different in the
pandemic period compared to pre-pandemic

16. Results
Cases with
Complication
Pre-pandemic Pandemic P value
Mastoiditis 5/70 (7.1%) 2/22 (9.1%) 0.671
Myocarditis 2/7 (28.6%) 4/11 (36.4%) 1
Orbital Cellulitis 2/14 (14.3%) 3/12 (25.0%) 0.635
Ovarian Torsion 6/43 (14.0%) 0/36 (0%) 0.029
Sepsis 64/315 (20.3%) 39/216 (18.1%) 0.517
Septic Arthritis 5/38 (13.2%) 3/30 (10.0%) 1
Stroke 4/16 (25%) 8/24 (33.3%) 0.729
Testicular Torsion 1/102 (0.98%) 0/130 (0.0%) 0.44
The frequency of patients presenting with complications of
high-risk conditions was not statistically different in the
pandemic period compared to pre-pandemic

17. Conclusions
Pandemic ED visits were lower
in volume but higher in acuity
compared to pre-pandemic
visits
Despite a higher proportion of
ED visits due to high-risk
conditions, there was no
increase in complications,
suggesting minimal impact of
the pandemic in outcomes of
pediatric ED visits

18. Collaborators
Michigan Pediatric Emergency Medicine (MiPEM) Network
• Sarah Parker, Prashant Mahajan – University of Michigan
• Amy DeLaroche – Children’s Hospital of Michigan
• Stephen Gunnink, Erica Michiels – Helen DeVos Children’s Hospital
• Julia Hays, Gerard Heath – Henry Ford Hospital
• Courtney Mangus – Hurley Medical Center, University of Michigan

19. Special Thanks
• Corey Powell
• Elizabeth Duffy
• Sarah Parker