Background
A novel coronavirus belonging to beta-coronavirus genera (named as 2019-nCoV by World Health Organization [WHO]) was identified as the causative agent associated with a cluster of cases of pneumonia detected in Wuhan City by Chinese authorities on 7 January [
1,
2]. On January 2, 2020, the first 2 cases, two Chinese tourists, were identified in Italy; on January 30, 2020, WHO re-evaluated the potential effects of 2019-nCoV infection in global public health, and declared this epidemic as a “Public Health Emergency of International Concern (PHEIC)”. Since the discovery of 2019-nCoV, the virus has been rapidly spreading all over the word [
3,
4]. Infected children might appear asymptomatic or have mild clinical manifestations: fever, dry cough, and fatigue, and few have upper respiratory symptoms including nasal congestion and running nose; some patients presented with gastrointestinal symptoms including abdominal discomfort, nausea, vomiting, abdominal pain, and diarrhea [
5‐
8]. However, cases of major systemic inflammation (Kawasaki-Like Hyperinflammatory Syndrome) have been reported in children infected with coronavirus [
9]. A study that involved a cohort of 100 Italian children younger than 18 years of age (
The Coronavirus Infection in Pediatric Emergency Departments, CONFIDENCE) who were assessed between March 3 and March 27 in 17 Pediatric Emergency Departments (PED) (median age 3,3 years) observed that common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%). A total of 54 children (54%) had a temperature of at least 37.6 °C and 12 (12%) appeared ill, and 38 children (38%) were admitted to the hospital; 20 of them had moderate or severe disease (19 and 1 respectively) [
10]. Another study that involved 102 centers from 18 countries found a wide variation on personal protective equipment (PPE) use at pre
-triage and for patient assessment [
11]. Preparation strategies for managing this pandemic have been needed all over the world and in all the hospitals. Reallocation of resources in the management of this crisis implied careful planning, the interruption of scheduled hospitalizations, and the training of health workers. Strict adherence to infection control such as PEE and disinfection are the keys to contain the transmission of the disease. In particular, the key interventions of the PED for the management of this pandemic have been different. Mandatory hospitalization in isolation wards for all suspected cases presenting to the PED and the segregation of PED into high-risk, intermediate-risk, and low-risk areas are crucial elements for reduction the possible rate of infection [
12].
The provision of qualified PPE to health care workers plays an essential role in
preventing occupational exposure and infection. US Centers for Disease Control and Prevention for COVID-19 infection control of healthcare personnel recommended gloves, gowns, respiratory protection, and eye protection as standardized PPE [
13].
The Italian society of pediatric emergency-urgency (SIMEUP) brings together various professional figures who manage children in the acute care setting, belonging to both general and pediatric hospitals. During the COVID-19 epidemic in Italy, the SIMEUP promoted a national survey aiming to evaluate the impact of COVID-19 on the clinical acute pediatric practice and the strategies activated at the hospital level for the management, infectious containment and reorganization of the work in the acute care pediatric setting during this pandemic.
Discussion
According to the Statistical Yearbook of the National Health System (published in 2019), in Italy there were 518 public hospital structures, 414 with a General Emergency Room (79.9%) and 90 with a Pediatric Emergency Room (17.5%) The survey was attended by 94 hospitals representing all the Italian regions (with the exception of the autonomous province of Trento) [
14]. The results of the study suggest how the Italian PEDs have promptly taken action to manage the pandemic with standardized pathways and protocols.
World literature data shows that one of the most important actions that have been activated to manage the emergency from coronavirus has been to take urgent actions to reorganize health services and protect health workers to take care of patients with COVID-19 in safety and save lives. The COVID-19 outbreak has highlighted a gap between infectious disease healthcare and epidemiologist advice for preventing the spread of the disease versus the actions taken by the state authorities that in many cases have been too late and inadequate [
15].
The hospital preparedness for epidemics and pandemics of COVID-19 has taught us several lessons, which deviate from the classical safety and protection protocols for healthcare personnel those who remain on the frontline, fighting against the further spread and tirelessly treating those who are diseased [
15]. Due to a lack of sufficient awareness of the COVID-19 in the early stages of the epidemic, some healthcare workers (HCWs) have been infected [
16].
Following the Chinese model, containment measures to reduce the risk of COVID-19 in Italy have been promptly activated and implemented [
17]. Due to the necessity to set up emergency management protocols for the prevention and control novel coronavirus (2019-nCoV) infection spread, various hospitals have completely reorganized their work and space. As highlighted in our work, almost all Italian hospitals have defined specific pathways for pediatric cases of COVID-19, with the creation of dedicated pre-triage structures, sometimes only for children (30%).
Numerous pediatric departments, both in Italy and in the rest of the world, had to initiate a series of structural and organizational changes to manage this pandemic. For example, the American pediatric response to the COVID-19 pandemic implemented change in 4 domains: physical space, clinical services, staffing models, and leadership. The goal was to continue to provide outstanding and safe pediatric care while at the same time supporting the adult emergency COVID-19 crisis [
18].
To prevent the spread of COVID-19 to healthcare workers, additional infection control measures were implemented. Mask fitting exercises and PPE training was provided to all healthcare personnel. The most important PPE includes an N95 mask, eye protection with goggles or an eye shield, gown, and gloves [
19].
The type and amount of PPE that should be used when treating a patient with COVID19 varies based on clinical job and setting [
20]. For HCWs providing direct inpatient care for patients with COVID-19, a medical mask, gown, gloves, and eye protection in the form of goggles or a face shield should be used. If aerosol-generating procedures are being performed, healthcare workers should also wear an apron and use an N95 respirator in the place of a surgical mask [
21]. All these indications have been respected in all pediatric departments in our nation; as can be seen in Table
1, there has been an increase in the use of PPE after the pandemic in all HCWs.
This data, especially in the early stages of the pandemic, inevitably led, as emerged in our work, to a significant difficulty in the procurement of PPE.
All these structural changes in hospitals, and the increase in the use of PPE, inevitably had a major economic impact. Tassa Tan-Torres et al. have recently published a study on the expected economic needs for an adequate response to covid-19. They conclude that the costs of a response to COVID-19 in the healthcare sector will increase considerably, particularly if transmission increases, but putting in place early and comprehensive measures to limit the further spread of the virus will conserve resourced and support the response [
22].
Finally, another important fact that emerges from our investigation was the reduction of pediatric emergency visits hospitalizations across the nation. Our results show a reduction of approximately 70% for both visits to pediatric emergency departments and in the number of hospitalizations. However, as highlighted in another study, given the reduction rate in the number of accesses, the children were referred to the ED more frequently by physicians or the out-of-hospital emergency system, and for reasons that were more frequently urgent [
23]. The substantial decreases in pediatric care access in Italy might reflect the scarcity of available resources due to pandemic-related redistribution, or reticence on the part of parents and caregivers to risk exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in a health-care setting, in addition to lower rates of acute infections and trauma [
24]. There is a need to prevent delays in accessing hospital care and to increase the provision of high-quality coordinated care by health-care providers.
Both of these aspects should be considered as part of the overall public health impact of the COVID-19 pandemic, as evident in other epidemics [
25] and must be adequately monitored. Both the general population and health-care workers need clear guidance and information. Specifically, parents should be made fully aware that the risks of delayed access to hospital care for emergency conditions can be much higher than those posed by COVID-19.
The authors acknowledge the non-uniformity and selection bias limitations associated with non-random convenience sampling in surveys, while recognizing the generalizability and internal and external validity of the survey approach.
The sample size is relatively low and there is likely to be variability in the practices observed between different health professionals, hospitals, and regions with varying prevalence. However, we believe that the results obtained may be explanatory of the real situation in which the PED lived during the first months of the COVID 19 pandemic wave.
Acknowledgements
SIMEUP research group.
Alberto Arrighini, MD8, Maria Antonietta Barbieri, MD9, Claudia Bondone10, MD, Silvia Bressan, MD11, Vincenza Corsi, MD12, Massimo Chiossi, MD13, Elisabetta Cortis, MD14, Laura Crespin,MD15, Antonio Cualbu, MD12, Liviana Da Dalt, Phd11, Valeria De Donno, MD16, Maria De Filippo, MD3, Antonella Di Stefano, MD17, Pasquale Ferrante, MD18, Battista Guidi, MD19, Adima Lamborghini, MD20, Marcello Lanari, PhD21, Cristina Malorgio, MD22, Sergio Manieri, MD23, Stefano Masi, MD24, Susanna Masiero, MD11, Beatrice Messini, MD14, Maria Pia Mirauda, MD23, Anna Maria Musolino, MD9, Rosaria Nigro, MD25, Giuseppe Parisi, MD26, Niccolò Parri, MD24, Massimo Pettoello-Mantovani, PhD27, Flavio Quarantiello, MD28, Eduardo Ponticiello, MD29, Stefano Romero, MD30, Salvatore Savasta, MD31, Eurilla Sequi, MD31, Debora M.L. Simonetti, MD33, Eleonora Tappi, MD34, Antonio Francesco Urbino10, MD, Patrizia Vianelli, MD35, Tiziana Zangardi, MD10.
Affiliations.
8 Pediatric Emergency Department, Presidio Ospedale dei Bambini, A.O. Spedali Civili, Brescia, Italy.
9 Pediatric Emergency Department, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.
10 Department of Pediatric Emergency, Regina Margherita Children’s Hospital - A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy.
11 Division of Pediatric Emergency Medicine, Department of Women’s and Children’s Health, University of Padova, Italy.
12 Department of Pediatrics, San Francesco Hospital of Nuoro, Italy.
13 Department of Pediatrics and Neonatology, Hospital of Lavagna, Italy.
14 Paediatric Unit, San Giovanni Battista Hospital of Foligno, Italy.
15 Department of Pediatrics, Valle del Serchio Hospital, Italy.
16 Department of Pediatrics, S. Croce e Carle Hospital of Cuneo, Italy.
17 Department of Pediatrics, Cannizzaro Hospital of Catania, Italy.
18 Department of Pediatrics and Neonatology, “L Bonomo” Hospital of Andria, ASL BT, Italy.
19 Paediatric Unit, AUSL of Modena, Pavullo nel Frignano, Italy.
20 Department of Pediatrics, Asl di Teramo, Italy.
21 Pediatric Emergency Department, S. Orsola Hospital, Bologna, Italy.
22 Department of pediatrics and neonatology, Valduce Hospital, Como, Italy.
23 Department of Pediatrics, San Carlo Hospital, Potenza, Italy.
24 Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children’s Hospital, Florence, Italy.
25 Department of Pediatrics, Iannelli Hospital of Cetraro, Italy.
26 Department of Pediatrics, Anna Rizzoli Hospital, Ischia Island, ASL Naples 2 Nord, Italy.
27 Department of Pediatrics, Scientific Institute “Casa Sollievo della Sofferenza”, University of Foggia, Foggia, Italy.
28 Department of Pediatric and Adolescent Medicine, A.O San Pio, Benevento, Italy.
29 Pediatric Emergency Department, Santobono-Pausilipon Hospital, Napoli, Italy.
30 Department of pediatrics, San Pietro Fatebenefratelli Hospital, Roma, Italy.
31 Pediatric Unit, Senior Hospital of Crema, Italy.
32 Department of Neonatology, “Nostra Signora Bonaria” San Gavino Monreale, Italy.
33 Pediatric Unit, “A. Cardarelli” Hospital. ASREM- Campobasso,Italy.
34 Department of Pediatric, “S.Croce e Carle” Hospital of Cuneo, Italy.
35 Department of Pediatric, Salesi Hospital of Ancona, Italy.