Paediatric Emergency Injury Presentations During the COVID-19 Pandemic in Regional Victoria, Australia: A Silver Lining?

Abstract

Background/Objectives: The COVID-19 pandemic caused a widespread shift to remote work, significantly altering child supervision. In Australia, prolonged lockdowns created unique conditions where many parents were working from home while simultaneously caring for children. This study aimed to investigate potential changes in the epidemiology of paediatric injury-related presentations to emergency health services among children in Southwest Victoria, Australia, during the COVID-19 pandemic. Methods: A retrospective cross-sectional study was conducted using deidentified emergency presentation data from ten health services in regional Victoria for children aged 0–14 years between 2018 and 2023. Injury data were analysed across three timeframes (Pre-COVID, COVID, Post-COVID). Chi-squared tests assessed differences in injury presentations by age, gender, and service type. Significance was determined at p < 0.05. Results: A total of 21,072 child injury-related presentations occurred. Males accounted for 57.6% of presentations, with the 10–14 age group comprising 39.8% of cases. During lockdown, injury presentations increased among 0–4-year-old females (from 30.2% to 32.0%), likely reflecting reduced supervision as parents juggled work-from-home responsibilities. Conversely, rates declined among older children, particularly 10–14-year-olds, potentially due to reduced participation in sports and outdoor activities. More than half of all cases (59.1%) were presented to Victorian Emergency Minimum Dataset (VEMD)-reporting emergency departments. Conclusions: The shift to working from home during the pandemic had a measurable impact on childhood injury patterns, particularly among younger children. These findings highlight the importance of considering parental work and childcare arrangements in injury prevention strategies and highlight the benefits of additional regional data to provide a more accurate picture of regional health service use.

1. Introduction

The last five years have seen a major shift in the way people work, with parents, particularly mothers, more frequently actively caring for their children whilst working from home [1]. The COVID-19 pandemic had an unprecedented impact on modern society and human health [2], with the impacts of the virus directly felt at the time through substantial infection related morbidity and mortality [3], and highly restrictive public health measures intended to control the spread of the virus [4]. Indirectly, these measures had a profound social impact that radically changed our daily lives.

While the COVID-19 pandemic initially accelerated the transition, the broader adoption of work-from-home arrangements has persisted beyond the immediate crisis. These changes have redefined workplace norms and reshaped daily family life and social dynamics [5]. This widespread shift to remote work was not only a long-term trend but also deeply shaped by the unique and often intense public health responses seen in different regions. In Australia, and particularly in the state of Victoria, these responses created a distinct context in which the realities of working from home, parenting, and public health intersected in unprecedented ways [6].

The Australian Government successfully controlled COVID-19 throughout 2020, with the first COVID-19 social distancing restrictions—lockdowns—imposed in late March. Towards the end of May these restrictions were eased as the “first wave” of Australia’s COVID-19 cases declined. The state of Victoria experienced a unique spike in cases in late June culminating in a “second wave”. The Victorian government reinstated and tightened social restrictions. Despite a lack of scientific evidence on the effectiveness of these measures in the initial phases of the pandemic, Victoria experienced what would become one of the longest and strictest, lasting more than 100 days [5,7].

During the height of Victoria’s second-wave, social restrictions included: school closures, a limit on the distance allowed from one’s home, night-time curfews and controlling the movement of people between metropolitan and surrounding regional areas [8]. Together these restrictions meant that most parents and almost all children stayed home. Subsequently, opportunities for parental supervision were, in theory, heightened, traffic on the roads was significantly reduced, and participation in competitive sport was ceased [5,8]. In combination, these initiatives could typically be expected to offer a perfect panacea for childhood injury. On the other hand, the central tenet of these restrictions saw children spending more time at home, where the majority of the injuries to Australian children occur [9,10]; whilst under the supervision of parents experiencing a perfect storm of psychological stressors on the family unit, juggling work and home responsibilities, and reduced access to support services [5,11].

Reports of paediatric injury pattern during the COVID-19 pandemic are conflicting within the international literature [12,13,14,15,16], with discordance between findings complicated by differences in lockdown procedures, population adherence, as well as methodological differences [5,13]. This is further complicated in the context of children residing in non-metropolitan, i.e., regional and rural, areas. Firstly, children and families in rural and regional areas experienced differing regulations when compared to their metropolitan counterparts, with residents of metropolitan areas experiencing more severe public health controls including movement restrictions and school closures [4,13]. Secondly, various authors define rurality and regionality in different ways during the COVID-19 pandemic [12]. In combination, these complexities diminish the generalisability of their findings. Despite this, the one consistent finding within international literature is children in rural or regional areas have been shown to have increases in the number of visits to Emergency Departments (EDs) for severe injury during the COVID-19 pandemic [12,17].

In a metropolitan Victorian context, Palmer and Teague [5] identified a 40% increase in the number of children admitted to The Royal Children’s Hospital Melbourne (RCH) having sustained an injury at home across the COVID-19 lockdown period when compared to previous years. However, as highlighted by Peck et al. [18], the reporting of emergency data to the state government is incomplete. Presentations that occur at EDs in larger or well-resourced health services, such as RCH, are captured by the Victorian Emergency Minimum Dataset (VEMD). The VEMD, however, does not include emergency presentation data from Urgent Care Centers (UCC), that provide urgent or critical access services at less-resourced health facilities. This data, designated as non-Victorian Emergency Minimum Dataset (non-VEMD), is not routinely captured or reported to the state government and yet represents at least 35% of all state-wide emergency data [19,20,21]. The Rural Acute Hospital Data Register (RAHDaR) was developed to capture both VEMD and non-VEMD data [22] and in so doing offers a nuanced and more complete understanding of these presentations, particularly for those residing in regional and rural areas where UCCs are situated.

Previous papers utilising RAHDaR data have examined other identified aspects of childhood injury such as socioeconomic status (SES) and geographical location [18,19]. The aim of this study was to investigate potential changes in the epidemiology of paediatric injury-related presentations to emergency health services, both ED and UCC, among children aged 0–14 years in South West Victoria, Australia, during the COVID-19 pandemic. Particular attention was given to how the widespread shift to working from home for many parents may have influenced patterns of childhood injury. While the findings are specific to South West Victoria, they may offer insights relevant to other rural and regional settings with similar demographic and public health characteristics.

2. Materials and Methods

Using a retrospective cross-sectional research design, the study collected deidentified injury (both intentional and un-intentional) presentation data over a six-year period from 1 January 2018 to 31 December 2023 for children aged 0 to 14 years, where age groups were predetermined by standardised government agencies and also used in VEMD reporting [23]. All paediatric emergency presentation events across the six-year period were collected through RAHDaR [22], collating data from the 10 participating healthcare services across six Local Government Areas (LGAs) in South West Victoria that provide emergency or urgent care. Emergency presentation data based on the Victorian Emergency Minimum Dataset (VEMD V.25 for 2020–2021) [24], where the principal diagnosis was indicated to be injury-related (ICD-10 AM: S00-T78) [25], were extracted for analysis.

Injury presentation data included gender, age, residential postcode, time and date of arrival and departure, departure status (admitted, transferred, death, or discharged), and primary diagnosis. It must be noted that children may have presented multiple times for the same injury, potentially resulting in several episodes of care across different facilities. To avoid duplication, data beyond the initial presentation were excluded in cases where repeat visits were suspected, which were identified through triangulation of gender, postcode, age, and diagnosis, or when a child was transferred between institutions. Data were aggregated across the region into VEMD (ED) and non-VEMD (UCC) to avoid potential identification of specific presentations, particularly at smaller rural sites. In addition, due to small numbers (n = 4) that may identify individual children, any child reported to be non-binary was excluded from analysis.

Data were classified by general 2-year blocks (Pre-COVID, COVID, Post-COVID) and also aligned with individual lockdown (stay-at-home orders) dates during the COVID-19 pandemic, specifically from 20 March 2020 to 21 October 2021 (denoted as Lockdown, Non-Lockdown). Over this two-year period, a total of 262 days were spent under lockdown restrictions [26]. These lockdown periods were then aligned with and mapped to the same calendar dates in the pre-COVID (2018–2019) and post-COVID (2022–2023) periods. This comparative approach was designed to assess whether temporal differences in paediatric injury presentations were associated with the presence or absence of lockdowns. By matching the same dates across different time periods, the analysis controlled for seasonal and temporal confounders, allowing for a clearer understanding of the specific impact of the lockdowns. The rationale for this approach was to determine whether differences in injury presentations were uniquely associated with lockdown periods, or if similar patterns occurred in the absence of such restrictions.

Data were analysed using the Statistical Package for the Social Sciences (SPSS, Version 28.0). Prior to analysis, the data were thoroughly cleaned and checked for accuracy and completeness. The analysis included chi-squared (χ²) goodness-of-fit tests to examine differences between emergency injury presentations and key variables. Significance was determined at a two-tailed p < 0.05, as described in Pallant [27].

3. Results

3.1. Demographics

Across the six-year study period there were a total of 21,072 children aged 0–14 years having a principal injury-related emergency presentation to a participating hospital within Southwest Victoria. Of the entire sample, males (12,146, 57.6%) had higher numbers of injury presentations than females (8926, 42.3%), 10–14-year-olds (8396, 39.8%) represented the largest cohort of injury presentations, and more than half (12,465, 59.1%) presented to EDs (VEMD-reporting facilities).

The chi-squared goodness-of-fit test indicated there was significant differences between time periods for females and males, each age group, and between VEMD and non-VEMD health services. Overall, when categorising by gender there were a higher proportion of cases in the pre-COVID period and a decrease in presentations in the time period after. Similarly, when classifying by age, this was the case for those in the 0–4 and 5–9 aged groups, however, for those within the 10–14 age group, there was a higher proportion of injury presentation prior to COVID only. Lastly, VEMD services had a much lower proportion of cases presenting after the COVID period, while non-VEMD services experienced a lower proportion of presentations during the COVID period (

Table 1. Demographic data of emergency injury presentations.

Factor	Pre-COVID		COVID		Post-COVID		Total		p-Value
	(2018–2019)		(2020–2021)		(2022–2023)
n = 21,076	n	%	n	%	n	%	n	%
Gender
Female	3189	35.7%	2992	33.5%	2745	30.8%	8926	100.0%	<0.001
Male	4310	35.5%	4066	33.5%	3770	31.0%	12,146	100.0%	<0.001
Age group
0–4 years	2186	35.0%	2149	34.5%	1900	30.5%	6235	100.0%	<0.001
5–9 years	2341	36.3%	2200	34.2%	1903	29.5%	6444	100.0%	<0.001
10–14 years	2972	35.4%	2709	32.3%	2712	32.3%	8393	100.0%	<0.001
Where presented
non-VEMD	2952	34.3%	2710	31.5%	2947	34.2%	8611	100.0%	0.001
VEMD	4547	36.5%	4348	34.9%	3568	28.6%	12,461	100.0%	<0.001

).

When examining age groups within gender across the time periods, there were significant differences noted for all gender/age group combinations except for 10–14-year-old males (

Table 2. Demographic data of emergency injury presentations by age group.

Year		Pre-COVID (2018–2019)		COVID (2020–2021)		Post-COVID (2022–2023)		p-Value
		n	%	n	%	n	%
0–4 years	Female	963	30.2%	958	32.0%	852	31.0%	0.014
5–9 years		1009	31.6%	965	32.3%	857	31.2%	0.002
10–14 years		1217	38.2%	1069	35.7%	1036	37.8%	<0.001
0–4 years	Male	1223	28.4%	1191	29.3%	1048	27.8%	<0.001
5–9 years		1332	30.9%	1235	30.4%	1046	27.7%	<0.001
10–14 years		1755	40.7%	1640	40.3%	1676	44.5%	0.129
Total		7499		7058		6515

). An increase in the overall proportion of presentations was observed during the COVID period for females in the 0–4 and 5–9 age groups, followed by post-COVID decreases. Conversely, females aged 10–14 had a lower proportion of injury presentations during the COVID timeframe. There has been a general decline in the number of presentations across all ages and timeframes for female children.

A similar trend was observed for 0–4-year-old male children, with proportional increases in presentations during the COVID period and a general decline in presentation numbers across the study period. In contrast, there was a slight decrease in the proportion of presentations during COVID for the 5–9 and 10–14 age groups. The change observed post-COVID for the 5–9 age group (decrease) was consistent with those seen in females, however, within the 10–14 age group, the slight fall was followed by a rise, resulting in no significant differences in injury presentation across the three time periods.

3.2. Lockdown Comparison

The proportion of injury presentations for each gender/age group combination occurring during the COVID Lockdown period were compared to the same dates in the corresponding period in the Pre-COVID (Pre-COVID Lockdown) and Post-COVID (Post-COVID Lockdown) timeframes to determine if presentations differed specifically during COVID-19. The proportion of injury presentations of 0–4-year-old females increased during the COVID Lockdown period compared to the same timeframes pre- and post-COVID, p < 0.001 (Figure 1); no differences were noted in 5–9 year olds of either gender (Figure 2). Conversely, a lower proportion of injury presentations was observed among 10–14-year-old males during COVID Lockdown when compared to Pre- and Post-COVID Lockdown (p < 0.001, Figure 3). Similarly, the proportion of injury presentations among 10–14-year-old females also decreased over the defined COVID Lockdown time frame, compared to the corresponding pre-/post-COVID lockdown dates, p < 0.001.

3.3. Comparative Time Period by Most Common Injury Type

When examining the injury types of females aged 0–4, they experienced higher proportions of injuries to the head/face, the wrist/hand, and intracranial injuries than other injury locations (Figure 4). These differed between time periods, with a greater proportion of wrist/ hand injuries occurring prior to COVID, and a larger proportion of intracranial injuries noted during COVID. However, these injury types were not significantly different statistically between time periods, potentially due to smaller total numbers (head/face p = 0.066; wrist/hand p = 0.060; intracranial p = 0.689). Nevertheless, in most cases injuries to these three areas were associated with causes such as falls less than a metre (63.6%), followed by being struck by or having a collision with an object or person (15.5%), and being cut or pierced by object (13.3%).

Females aged 10–14 had most frequently experienced injuries to the wrist/hand, elbow/forearm, or the ankle/foot than other injury locations (Figure 5). These differed between time periods, with a significantly greater proportion of injuries to the elbow/forearm occurring prior to COVID (p = 0.014). In addition, injuries to wrist/hand had declined over time, with the post-COVID period recording significantly fewer injuries than the prior time periods (p = 0.043). However, injury to ankle/foot was not significantly different between time periods (p = 0.395). In most cases, injuries to these three body areas were associated with causes such as falls less than one metre (49.9%), followed by being struck by or having a collision with an object or person (23.4%), or some other external cause (17.7%).

The most common injuries sustained by males aged 10–14 were injuries to the ankle/foot, wrist/hand, or an intracranial/head injury. These differed between time periods, with a greater proportion of injuries occurring prior to COVID, particularly intracranial/head injuries (Figure 6). However, these were not significantly different between time periods for ankle or foot (p = 0.915), to the wrist or hand (p = 0.111), and intracranial injuries (p = 0.125). Nevertheless, in most cases the injuries to these three body areas were associated with falls of less than one metre (41.7%), followed by collision with an object or person (28.4%), or some other external cause (26.4%).

Although unlikely to greatly impact the number of injuries related to work arrangements and parental supervision during lockdown periods, there were no statistically significant differences found in traffic-related accidents across the study period despite the reduction in motor vehicles travelling during this time.

4. Discussion

Consistent with existing pandemic-related studies across a number of countries, we observed alterations in the profile of emergency paediatric injury presentations in South West Victoria, with rates of children presenting to the larger VEMD-reporting facilities (EDs) decreasing during the years of recurrent COVID-19 (2020–2021) period [28,29,30]. Tan et al. [31] suggests that the global reduction in ED presentations may be explained by a lower incidence of injuries considering the strict social restrictions. Other research suggests that this reduction is tied to health seeking during the complex circumstances presented by COVID-19 [32]. Parents were required to evaluate information regarding their child’s need for healthcare for a non-COVID-19 related illness, such as an injury, against the suspected level of risk of their child or themselves contracting COVID-19 [33,34]. Access to formal and informal social support structures were impacted making it harder to manage the logistics of travel to hospital or perhaps the ongoing care needs of the wider family. Government public heath advice was constantly evolving; delayed presentation to healthcare services during the pandemic has been shown to have led to severe illness and harm in children [35,36].

Our data highlighted that non-VEMD reporting facilities, such as smaller rural UCCs, experienced a less pronounced decline in childhood injury presentations compared to their VEMD (ED) counterparts. While both facility types observed reductions, the decrease in presentations was more substantial in larger EDs, particularly in the post-COVID period. This suggests families may have been increasingly avoiding larger, more populated EDs for non-urgent injuries, possibly due to lingering concerns about exposure to illness or changes in health-seeking behaviour. In contrast, UCCs may continue to serve as accessible and trusted points of care for minor injuries, especially in communities with limited healthcare alternatives. These findings highlight the importance of maintaining and supporting non-VEMD services as vital components of the paediatric injury care landscape in the post-pandemic era [37].

When examining injury presentations by age and gender, we observed nuanced trends. For instance, females aged 0–4 years experienced a statistically significant increase in injury presentations during the COVID lockdown period compared to the same periods pre- and post-COVID. This may have been due to periods of reduced supervision, creating an environment where falls and bumps were more likely for younger children. Children who would have usually been in a formal childcare setting with ongoing supervision were now in a situation where parents were having to divide their attention across multiple responsibilities, increasing the chances of minor injuries occurring such as low height falls or collisions at home [1].

Conversely, injury presentations among 10–14-year-old females and males decreased during the lockdown period, contrary to some expectations. While previous literature suggests older children may engage in more risk-taking behaviour when unsupervised [38,39], our data did not show a significant increase in injuries for this group during lockdown. This decline may be due to reduced participation in organized sports and outdoor activities, which are common sources of injury in this age group. Social restrictions likely limited peer interactions and unsupervised play, while increased parental presence at home may have contributed to safer environments. Additionally, some injuries may have gone unreported due to families avoiding healthcare settings during the pandemic. Increased screen time and sedentary behaviour may also have reduced physical activity levels, further lowering injury risk [40]. These findings suggest that while lockdowns altered behaviour, they may have temporarily reduced injury exposure for older children.

Although triage acuity was not specifically extracted for each presentation, ICD-10-AM diagnoses recorded at discharge from the ED or UCC are grouped by Major Diagnosis Blocks [25] to identify injuries as Single Site Minor, Single Site Major, and Multiple Site injuries. These assist in determining the acuity of the injury presentation following full assessment rather than the acuity judged during triage. Although some international literature has suggested an increase in injury severity during the pandemic [12,13], there were no statistically significant differences observed across injury Major Diagnostic Block classifications during the study time periods, suggesting no significant changes in acuity occurred. This may be related to the geographical location of the current study, non-metropolitan, however future studies would benefit from having triage acuity recorded for each presentation to further investigate this issue.

Seasonal and temporal patterns in injury risk may also help contextualise our findings. Ramgopal et al. [41] has suggested injury is more common during spring, summer, afternoons, evenings and weekends. Without the inherent structure that school provides, inclusive of extra-curricular activities, children may have been at greater risk of injury whilst engaging in unsupervised activities, even in the home [39]. Other studies suggest the role that risk-taking behaviours might have and identify children, particularly older children, tend to engage in more risky behaviour when they are unsupervised [38]. Unstructured activities were noted to rise during periods of working from home during the COVID-19 lockdown [42], which may have contributed to the increased injury rates in these children. In the context of our data, it is suggested altered supervision and activity patterns during the pandemic likely influenced the injury profile of children. This warrants further investigation into parental experiences and decision-making, in addition to attention in future injury prevention strategies.

One limitation is the use of retrospective emergency presentation data that lacks acuity information. In addition, the use of the triangulation method to exclude duplicate or repeat visits within the de-identified dataset may have not identified all cases where this occurred. The presentations captured by this study also represent a small percentage of children living across Victoria and the results need to be meaningfully considered in this context. However, a strength of this study is the use of previously missing emergency presentation data from non-VEMD reporting health services, typically found in regional areas of the state, which provides invaluable and nuanced insights to facilitate the targeting of programs and resources to support children and families in these settings.

5. Conclusions

This study aimed to understand the implications of the COVID-19 period on the profile of injury amongst children aged 0–14 and investigate potential impacts of working from home-related supervision. Injury rates and causes differed across gender and age groups, some of which may be explained by changing parental responsibilities during lockdown. Additionally, having access to the smaller non-VEMD reporting health services data has provided some insights that shed light on findings that are consistent with existing research, while also emphasising unique population characteristics. We found decreases in presentations during COVID-19 were not sustained for UCCs, with increased use of the service as a point of access to the health system for injury in the post-COVID-19 period. We suggest that the COVID-19-related changes to working from home and related childcare responsibilities has had an impact upon children in ways that have not yet been conceptualised and propose that ongoing tracking of this shift in working may offer new insights into child injury causes and prevention.