Rate of Pediatric Appendiceal Perforation at a Children’s Hospital During the COVID-19 Pandemic Compared With the Previous Year

This cross-sectional study assesses the rate of appendiceal perforations during the COVID-19 pandemic at a children’s hospital during10-week periods in 2020 vs 2019.

We noted an increased incidence of perforated appendicitis coinciding with the closure of Virginia public schools on March 16, 2020, and sought to determine whether a true difference existed.

Methods
As part of a quality improvement initiative to alert our community to the dangers of delayed medical care, we assessed the percentage of acute and perforated appendicitis in children younger than 18 years. The study period covered 10 weeks between March 16 and June 7, 2020, at the pediatric emergency department in Inova Children's Hospital in Northern Virginia. We compared this rate with the same period 1 year earlier. The final diagnosis of appendicitis and the presence of perforation was determined by the operative report. Data were collected using the electronic medical record (Epic; Epic Systems Corporation). We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. The office of research at INOVA Health System determined this review to be exempt from the need for study approval or patient informed consent because it was conducted as an institutional quality improvement project.
Nominal outcomes were analyzed using either Fisher exact or χ 2 tests. Continuous outcomes were analyzed using a 2-tailed unpaired t test. The α level was set at 0.05 for all comparisons. Data were analyzed using online GraphPad, version 7.0 software (GraphPad Software).
The median patient age in 2019 was 11 years (IQR, 9-14 years), 44 (63%) were boys, and 33 (47%) were White individuals. This change in the number of cases between 2020 and 2019 represents a 20% absolute increase in the incidence of perforated appendicitis (P = .009).
During the COVID-19 study period, 8 children (9%) presented with a pelvic abscess that required initial medical management before delayed interval appendectomy. No patient required medical management in the 2019 control period (Table).
Patient volumes in the emergency department were also decreased during the pandemic, from a mean of 144 patients per day (95% CI, 136%-152%) to 65 patients per day, reflecting a 55% decrease (95% CI, 39%-90%); P < .001). However, there was a nonsignificant increase in the admission rate of 16.4% over the 10-week study period compared with a baseline admission rate of 10.5% in 2019 (P = .07).

Discussion
Although studies in the adult literature and case series in the pediatric literature have reported delays in medical care attributable to COVID-19, we report a statistically significant increased rate of appendiceal perforation during this pandemic. [2][3][4][5][6] Over the 3 months studied, parents displayed visible signs of anxiety when in the emergency department and openly expressed reluctance to visit the hospital for fear of contracting COVID-19.
Unlike their adult counterparts, pediatric patients do not commonly experience medical conditions with a high risk of mortality. However, medical conditions do exist for which delayed diagnosis and management can lead to a significant increase in morbidity, prolonged hospitalization, and increased financial expense. In this cross-sectional study, appendiceal perforation also resulted in pelvic abscess, bowel obstruction, and sepsis.
This was a single institutional cohort, and generalizability to other settings may be limited.
Although the reduction in "unnecessary" emergency care may be welcomed by some, broad avoidance of the emergency department may lead to increased morbidity and mortality in both children and adults.