Early unplanned return visits to pediatric emergency departments in Israel during the SARS-CoV-2 pandemic

a b s t r a c t

Introduction: During the SARS-CoV-2 pandemic there was a considerable drop in the number of visits to Pediatric Emergency Departments (PED). UnplannED return visits (URV) might represent inadequate emergency care. We assessed the impact of the pandemic on early URV to PEDs in Israel.

Methods: This multicenter cross-sectional study analyzed the 72-h URV to PEDs among patients under the age of 18 years during a one-year pandemic period (March 1st, 2020, to February 28th, 2021), and compared them with the 72-h URV of the corresponding pre-pandemic period (March 1st, 2019, to February 28th, 2020). Data was ex- tracted from Clalit Health Services (CHS), the largest public health care organization in Israel.

Results: The pandemic and pre-pandemic early URV rates were 5465 (5.1%) and 8775 (5.6%), respectively (OR = 0.90, 95% CI 0.92-0.99). The rate of return-visit admissions to hospital wards during these periods were 29.5% and 32.1%, respectively (OR = 0.83, 95% CI 0.86-0.98). The rate of return-visit admissions to ICUs during these pe- riods were 0.64% and 0.52%, respectively (OR = 1.11, 95% CI 0.67-1.62). On return-visit, 3 (0.055%) and 5 (0.057%) URV patients were declared dead on arrival during the pandemic and pre-pandemic periods, respec- tively (OR = 0.96, 95% CI 0.23-4.03). The distributions of the time interval from index visit to return visit remained consistent between the periods.

Discussion: In our study, early URV to PED’s were only mildly influenced by the SARS-CoV-2 pandemic.

(C) 2023

  1. Introduction

Pediatric Emergency Department (ED) unplannED return visits (URV) might represent inadequate emergency care [1]. Early URV has been commonly defined as a return visit to the ED within 72-h from the index visit [2]. During the severe acute respiratory syndrome coro- navirus 2 (SARS-CoV-2) pandemic, many countries declared a national lockdown with varying degrees of intensity, accompanied by a consid- erable drop in the number of visits to pediatric EDs [3]. This decrease

Abbreviations: ED, Emergency Department; ICU, Intensive Care Unit; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; URV, unplanned return visit.

* Corresponding author at: Pediatric emergency Department, Ha’Emek Medical Center, Yitzhak Rabin Boulevard 21, Afula 1834111, Israel.

E-mail addresses: [email protected] (F.A. Hanna), [email protected] (I. Shavit), [email protected] (S. Campisi-Pinto), [email protected] (G. Chayen), [email protected] (R. Jacob).

1 Dr. Abu Hanna and Dr. Shavit contributed equally.

was attributed to social distancing, school closure, transportation chal- lenges during lockdowns, fear of ED-based contagion [4] and healthcare avoidance [5]. Seeking care in non-ED sites was also suggested as a fac- tor. The decline in communicable diseases among young children dur- ing the pandemic [5] particularly during the winter [6], in conjunction with an increase in adolescent presentations due to psychological and mental stress [5] may have influenced URV as well.

The aim of this study was to assess the impact of the SARS-CoV-2

pandemic on early URV rates to pediatric EDs in Israel.

  1. Methods

This multicenter cross-sectional study analyzed early URVs to 7 Pe- diatric EDs in Israel during the first year of the SRAS-CoV-2 pandemic period (March 1, 2020, to February 28, 2021), and compared them with early URVs to pediatric EDs during the corresponding pre- pandemic period (March 1, 2019, to February 28, 2020). An early URV

0735-6757/(C) 2023

was defined as return visit to the Pediatric ED within 72-h of an index visit [2]. Patients were excluded if they were admitted to the hospital, left against medical advice, Left without being seen, or transferred to an- other facility.

Data were extracted from Clalit Health Services using the Clalit Health Services research data sharing platform. Clalit Health Services is a part of the state mandated Public insurance system and is the largest healthcare organization in Israel, providing emergency care through 7 Pediatric EDs that are geographically distributed and serve a diverse population in terms of ethnicity and socioeconomic status. These Pedaitric EDs (both regional and tertiary) visits comprise 37% of all an- nual visits of children in Israel [7].

The following variables were extracted for all returned patients: Age and sex, day of the week, time of the day and season of the year of the index and return ED visits, the time interval from index-visit to return-visit and the type of referrals to the ED. The primary outcome measure was the rate of early URV.

Odd ratios (OR) were considered statistically significant if the 95% Confidence Interval (CI) did not include 1. The statistical analysis was performed using R (version 4.1.0, R Foundation for Statistical Comput- ing). The institutional review board of Clalit Health Services approved the study without the requirement to obtain informed consent.

  1. Results

Overall, 107,201 and 156,243 patients with a mean age (standard deviation) of 6.63 (5.42) years attended the Pediatric EDs during the pandemic and pre-pandemic periods, respectively. The pandemic and pre-pandemic 72-h URV rates were 5465 (5.1%) and 8775 (5.6%), re- spectively (OR = 0.90, 95% CI 0.92-0.99; P < 0.001). Return-visit admis- sion rates to non-Intensive Care Unit (ICU) hospital wards during the pandemic and pre-pandemic periods were 29.5% and 32.1%, respec- tively (OR = 0.83, 95% CI 0.86-0.98; p = 0.001). Return-visit admission rates to ICUs during the pandemic and pre-pandemic periods were

0.64% and 0.52%, respectively (OR = 1.11, 95% CI 0.67-1.62; p =

0.434). On return-visit, 3 (0.055%) and 5 (0.057%) URV patients were declared dead on arrival during the pandemic and pre-pandemic pe- riods, respectively (OR = 0.96, 95% CI 0.23-4.03; p = 0.96). Overall, 1.3% and 1.1% of returned patients were referred to the Pediatric EDs by Emergency Medical Services during the pandemic and pre- pandemic periods, respectively (OR = 1.05, 95% CI 0.76-1.38; p < 0.001) (Table 1). The distributions of URV during the pandemic and pre-pandemic periods and the time intervals between index-visits and return-visits are presented in Fig. 1.

  1. Discussion

The main finding of our study is that early URV rates were mildly de- creased when compared with the pre-pandemic period (5.1% vs 5.6%). There were comparable rates of return-visit admissions to non-ICU and ICU wards between the two periods. Our data also show low rates of return-visit deaths in both the pre- and pandemic periods, with a mi- nority of patients being transported to the EDs by emergency medical services in both periods. Another key finding is that the distributions of index visit-to-return visit time interval were similar in both periods, as shown in Fig. 1. Taken together, our findings suggest that early URV to Pediatric EDs were only mildly influenced by the SARS-CoV-2 pandemic.

Previous studies evaluating URV rates during the pandemic period in various countries showed similar findings [8-10]. In the US, a single- center study,utilizing a 9-day cutoff for representation to the ED, re- ported decreased rates (3.55% Vs 4.83%) of pediatric URVs during the pandemic period [9]. In Canada, an observational study assessing pre-pandemic, peri-pandemic and early pandemic periods among 11 tertiary care pediatric EDs reported a 55% decrease in the number of ED revisits within 72 h during the early pandemic period [10]. A South Korean study, that evaluated URVs among seven pediatric EDs, also reported a decrease in 72-h return visits (5.1% Vs 6%) during the

Table 1

Early unplanned return visits to Pediatric Emergency Departments during the pandemic and pre-pandemic periods.

Pandemic (5465)

Pre-pandemic (8775)

OR (95% CI)

Sex, n (%)


2535 (46.4)

4099 (46.7)

0.90 (0.90-1.00)


2930 (53.6)

4676 (53.3)

0.91 (0.91-1.00)

Age, n (%)

3 days-11 months

1281 (23.4)

2113 (24.1)

0.88 (0.88-1.02)

12 months-5 years

2017 (36.9)

3586 (40.9)

0.81 (0.87-0.97)

6 years- 11 years

1075 (19.7)

1659 (18.9)

0.94 (0.90-1.05)

12 years-18 years

1092 (20)

1417 (16.1)

1.12 (0.97-1.14)

Day, n (%)


3901 (71.4)

6257 (71.3)

0.90 (0.92-0.99)


1564 (28.6)

2518 (28.7)

0.90 (0.89-1.02)

Shift. n(%)

Morning (07:00-15:00)

3125 (57.2)

4892 (55.7)

0.93 (0.92-1.01)

Afternoon (15:01-23:00)

1908 (34.9)

3140 (35.8)

0.88 (0.89-1.00)

Night (23:01-06:59)

432 (7.9)

743 (8.5)

0.85 (0.83-1.05)

Season, n(%)

Fall (September-November)

1535 (28)

2390 (27.2)

0.93 (0.91-1.04)

Winter (December-February)

1304 (23.9)

2444 (27.9)

0.77 (0.84-0.96)

Spring (March-May)

1178 (21.6)

1921 (21.9)

0.89 (0.88-1.02)

Summer (June-August)

1448 (26.5)

2020 (23)

1.04 (0.95-1.09)

Type of referral to the ED, n(%) Primary care physician

2372 (43.4)

3855 (43.9)

0.89 (0.90-1.00)

Caregivers’ decision to seek care

1953 (35.7)

2857 (32.6)

0.99 (0.94-1.06)


73 (1.3)

101 (1.1)

1.05 (0.76-1.38)

CHS call center

220 (4.1)

427 (4.9)

0.75 (0.75-1.04)


847 (15.5)

1535 (17.5)

0.80 (0.84-0.99)

OR = Odds Ration; EMS = Emergency Medical Service; ED = Emergency Department; CHS = Clalit Health Services; Weekday – Sunday, Monday, Tuesday, Wednesday, Thursday; Weekend – Friday, Saturday; All at index visit.

* Referral by a community nurse, community police, school nurse, and community welfare services.

Image of Fig. 1

Fig. 1. Distribution of PED-URV (%) during the pandemic (n = 5465) and pre-pandemic (n = 8775) periods in relation to the time interval between index-visit and return-visit (hours). PED-URV = Pediatric Emergency Department unplanned return visits. Hrs = hours.

SARS-CoV-2 pandemic [8]. Overall, these findings corroborate our re- sults, suggesting that the SARS-CoV-2 pandemic yielded a mild reduc- tion in URV rates to pediatric EDs.

We found that a peak in Pediatric ED URV around 24 h from the index visit. Our findings support previously reported rate of 50% re- turn visits within 1.4 days [11]. This finding may suggest that certain factors that contribute to return visits may not be influenced by the pandemic. Furthermore, this highlights the importance of providing effective follow-up care for patients within the first 24 h after their initial presentation.

Our study has several limitations. As a retrospective database analy- sis, detailed information on ED diagnosis, particularly in the eight death cases, was not readily available. Additionally, the study was unable to confirm whether the patients revisited the ED for the same symptom or diagnosis as those reported in their index visits. Given the higher rate of unplanned return visits within 24 h and the relatively large study cohort, it is unlikely that this scenario constitutes a significant percentage of unplanned return visits.

It should also be noted that the study only analyzed 37% of the total annual pediatric ED visits in Israel and did not include patients who sought care at private emergency facilities, or at EDs outside Clalit Health Services network. Although about 13% of return visits are to EDs other than the original ED [12], patients insured by the Clalit Health Services are usually referred to a Clalit Health Services hospital. Additionally, the study did not assess late returns to the ED. We chose a 72-h cutoff because it is the most frequently utilized in the literature to date [9]. Lastly, since healthcare systems vary greatly across countries, the findings of this study may not be generalizable to other populations.


The authors did not receive support from any organization for the submitted work.

Authors’ contributions

Drs Abu Hanna and Jacob had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Abu Hanna, Chayen, Jacob. Acqui- sition, analysis, or interpretation of data: Abu Hanna, Shavit, Campisi- Pinto, Jacob. Drafting of the manuscript: Abu Hanna, Campisi-Pinto, Jacob. Critical revision of the manuscript for important intellectual con- tent: Shavit, Campisi-Pinto, Chayen, Jacob. Statistical analysis: Campisi- Pinto. Administrative, technical, or material support: Abu Hanna, Chayen. Supervision: Jacob.

Ethics approval

This study was performed in line with the principles of the Declara- tion of Helsinki. The institutional review board of Clalit Health Services approved the study without the requirement to obtain informed consent. No. EMC- 091-21.

CRediT authorship contribution statement

Firas Abu Hanna: Writing – original draft, Project administration, Methodology, Investigation, Conceptualization. Itai Shavit: Writing – review & editing, Methodology, Investigation. Salvatore Campisi- Pinto: Methodology, Formal analysis, Data curation, Conceptualization. Gilad Chayen: Writing – review & editing, Methodology, Investigation. Ron Jacob: Writing – review & editing, Supervision, Methodology, Conceptualization.

Declaration of Competing Interest

The authors have no relevant financial or non-financial interests to disclose.


  1. Nunez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency depart- ment: an outcome of Medical errors? Qual Saf Health Care [Internet]. 2006 Apr;15

(2):102. [cited 2022 Oct 1]. Available from: /pmc/articles/PMC2464826/.

  1. Reiser O, Diamand R, Shavit I. Early unplanned return visits to a pediatric emergency department in Israel. Pediatr Int. 2019 Nov;61(11):1081-5.
  2. Kruizinga MD, Peeters D, van Veen M, van Houten M, Wieringa J, Noordzij JG, et al. The impact of lockdown on pediatric ED visits and hospital admissions during the Covid19 pandemic: a multicenter analysis and review of the literature. Eur J Pediatr [Internet]. 2021 Jul 1;180(7):2271-9. [cited 2022 Oct 1]. Available from: https://
  3. Pines JM, Zocchi MS, Black BS, Carlson JN, Celedon P, Moghtaderi A, et al. Character- izing pediatric emergency department visits during the COVID-19 pandemic. Am J Emerg Med [Internet]. 2021 Mar 1;41:201. [cited 2022 Sep 17]. Available from:


  1. DeLaroche AM, Rodean J, Aronson PL, Fleegler EW, Florin TA, Goyal M, et al. Pediatric emergency department visits at US children’s hospitals during the COVID-19 pan- demic. Pediatr Int. 2021 Apr 1;147(4) [cited 2022 Sep 17]. Available from: https://
  2. Angoulvant F, Ouldali N, Yang DD, Filser M, Gajdos V, Rybak A, et al. Coronavirus dis- ease 2019 pandemic: impact caused by school closure and national lockdown on

pediatric visits and admissions for viral and nonviral infections-a time series analy- sis. Clin Infect Dis an Off Publ Infect Dis Soc Am. 2021 Jan;72(2):319-22.

  1. Emergency Medicine Visits in Israel 2020 [Internet]. 2021 [cited 2022 Sep 11]. p. 1-156. Available from: info_emergency_2020.pdf
  2. Namgung M, Lee DH, Bae SJ, Chung HS, Park JY, Kim K, et al. A comparison of emer- gency department revisit rates of pediatric patients between Pre-COVID-19 and COVID-19 periods. Child (Basel, Switzerland). 2022;9(7):1-12.
  3. Thompson GS, Olympia RP. Patterns in emergency department unscheduled return visits during the COVID-19 pandemic. Am J Emerg Med [Internet]. 2022 Aug 1;58: 126-30. [cited 2022 Nov 2]. Available from: 679655/.
  4. Finkelstein Y, Maguire B, Zemek R, Osmanlliu E, Kam AJ, Dixon A, et al. Effect of the COVID-19 pandemic on patient volumes, acuity, and outcomes in pediatric emer- gency departments: a nationwide study. Pediatr Emerg Care. 2021 Aug;37(8): 427-34.
  5. Rising KL, Victor TW, Hollander JE, Carr BG. Patient returns to the emergency depart- ment: the time-to-return curve. Acad Emerg Med [Internet]. 2014;21(8):864-71. [cited 2022 Nov 2]. Available from:
  6. Meyer-Macaulay CB, Truong M, Meckler GD, Doan QH. Return visits to the pediatric emergency department: a multicentre retrospective cohort study. CJEM. 2018 Jul;20 (4):578-85.