This study outlines the impact of COVID-19 on paediatric emergency department (ED) utilisation and assesses the extent of healthcare avoidance during each stage of the public health response strategy. Records from five EDs and one urgent care centre in Ireland, representing approximately 48% of national annual public paediatric ED attendances, are analysed to determine changes in characteristics of attendance during the three month period following the first reported COVID-19 case in Ireland, with reference to specific national public health stages. ED attendance reduced by 27–62% across all categories of diagnosis in the Delay phase and remained significantly below prior year levels as the country began Phase One of Reopening, with an incident rate ratio (IRR) of 0.58. The decrease was predominantly attributable to reduced attendance for injury and viral/viral induced conditions resulting from changed living conditions imposed by the public health response. However, attendance for complex chronic conditions also reduced and had yet to return to pre-COVID levels as reopening began. Attendances referred by general practitioners (GPs) dropped by 13 percentage points in the Delay phase and remained at that level. While changes in living conditions explain much of the decrease in overall attendance and in GP referrals, reduced attendance for complex chronic conditions may indicate avoidance behaviour and continued surveillance is necessary.

A decrease in attendance at emergency departments among paediatric populations has been reported during the Coronavirus Disease 2019 (COVID-19) pandemic. The present study sought to understand parents’ hesitancy and concerns around accessing healthcare during the pandemic using a cross-sectional survey of parents of children under the age of 16 (N = 1044) in Ireland. Multinomial and logistic regression analyses were used to determine the factors that influenced avoidance and hesitancy. In total, 34% of participants stated that their child required healthcare during the pandemic, of whom 22% decided against seeking healthcare. Parents who reported being much more hesitant about accessing healthcare were more likely to report mild–moderate (Relative Risk Ratio (RRR) = 2.31, CI: 1.54–3.47) and severe–extremely severe stress (RRR: 3.37, CI: 1.81–6.27). Parents who understood government advice to mean avoiding health services were more likely to be hesitant to attend (RRR: 1.71, CI; 1.10–2.67). These effects held when restrictions were beginning to be lifted. Higher levels of stress were associated with a parent believing that the government advice meant that they should not attend health services (OR: 1.66, CI: 1.14–2.41). Public health messaging must ensure parents are reassured on the accessibility and safety of paediatric healthcare services as this public health emergency continues.

Background: Clinical guidelines are integral to a general practitioner’s decision to refer a paediatric patient to emergency care. The influence of non-clinical factors must also be considered. This review explores the non-clinical factors that may influence general practitioners (GPs) when deciding whether or not to refer a paediatric patient to the Emergency Department (ED). Methods: A systematic review of peer-reviewed literature published from August 1980 to July 2019 was conducted to explore the non-clinical factors that influence GPs’ decision-making in referring paediatric patients to the emergency department. The results were synthesised using a narrative approach. Results: Seven studies met the inclusion criteria. Non-clinical factors relating to patients, GPs and health systems influence GPs decision to refer children to the ED. GPs reported parents/ caregivers influence, including their perception of severity of child’s illness, parent’s request for onward referral and GPs’ appraisal of parents’ ability to cope. Socio-economic status, GPs’ aversion to risk and system level factors such as access to diagnostics and specialist services also influenced referral decisions. Conclusions: A myriad of non-clinical factors influence GP referrals of children to the ED. Further research on the impact of non-clinical factors on clinical decision-making can help to elucidate patterns and trends of paediatric healthcare and identify areas for intervention to utilise resources efficiently and improve healthcare delivery.

Background: Unscheduled health care constitutes a significant proportion of health‐care utilization. Parental decision making when accessing unscheduled care for their children is multifaceted and must be better understood to inform policy and practice.Design: Nineteen semi‐structured interviews and one focus group (n = 4) with parents of children younger than twelve in Ireland were conducted. Participants had accessed unscheduled care for their children in the past. Data were thematically analysed.Results: Parents accessed unscheduled care for their children after reaching capacity to manage the child's health themselves. This was informed by factors such as parental experience, perceived urgency and need for reassurance. Parents considered the necessity to access care and situated their health‐seeking behaviour within a framework of ‘appropriateness’. Where parents sought unscheduled care was largely determined by timely access, and inability to secure a general practitioner (GP) appointment often led parents to access other services. Parents expressed a need for more support in navigating unscheduled care options.Conclusions: Better resources to educate and support parents are required, and structural issues, such as accessibility to GPs, need to be addressed to enable parents to better navigate the unscheduled health system and manage their children's health. The discourse around ‘appropriate’ and ‘inappropriate’ access to health care has permeated parental decision making when accessing unscheduled health care for their children. What constitutes appropriate access should be examined, and a shift away from this framing of health‐seeking behaviour may be warranted.Patient or Public Contribution: There was no explicit patient or public involvement. All authors hold experience as users of the health system.

Ireland does not yet have a comprehensive system of universal access to primary care. In 2015, access to general practitioner (GP) care at no charge was introduced for the 70% of children aged under six who previously paid out-of-pocket fees. This study uses data from 16 practices and a regional out-of-hours (OOH) GP service to assess the impact of this policy on attendance. A difference-in-difference (DiD) analysis was applied to visit records of paediatric patients over a period of five years, two years of which were pre-policy, with treatment and control differentiated by age. Attendance at daytime GP by children aged under-six increased by 20%-21% in the three years following the introduction of the policy, largely explained by an increase in the number of patients attending (17.4%-18.6%). Of children aged under-six attending pre-policy, 14.9%-15.8% had >6 visits annually, increasing to 18.5%-20.3% post-policy. OOH GP attendance also increased by 20.5%-29.4% over the same period. Findings are consistent with international literature on the provision of financially accessible healthcare. Prior unmet need, the provision of additional assessments to children aged under six, parental response to a service at no charge, and rerouting of access to the ED through GP, are all possible contributors to this increased demand. A more integrated policy of boosting supply as well as demand is desirable, particularly in the context of future expansion plans, to ensure the health benefits anticipated from the introduction of this policy have every opportunity to be realised.

Background: Critical care bed capacity per capita in Ireland is among the lowest in Europe. The COVID‐19 pandemic has put additional strain on an over‐stretched healthcare system. COVID‐19 community assessment hubs (CAHs) were established to prevent unnecessary admission to acute hospitals and to reduce infection spread.Objective: The aim of this study was to assess the effectiveness and acceptability of CAHs and identify how the service might be improved or adapted for possible future use.Design: This was a mixed methods study, incorporating co‐design with clinical stakeholders. Data collection was via an online survey and semistructured telephone interviews with staff and patients conducted between January and May 2021.Setting and participants: Thirty‐one patients completed the survey and nine were interviewed. Twenty interviews were conducted with staff.Results: The findings suggest that the CAH model was successful in providing a dedicated pathway for assessing patients with COVID‐19 symptoms, whilst mitigating the risk of infection. Patients were particularly positive about the timely, comprehensive and holistic care they received, as well as the accessibility of the clinics and the friendly attitudes of the staff. Staff welcomed the training and clinical protocols which contributed to their feelings of safety and competency in delivering care to this cohort of patients. They also highlighted the benefits of working in a multidisciplinary environment. Both staff and patients felt that the hubs could be repurposed for alternative use, including the treatment of chronic diseases.Discussion: This study describes staff and patients' experiences of these hubs. An unexpected outcome of this study is its demonstration of the true value of effective multidisciplinary working, not only for the staff who were deployed to this service but also for the patients in receipt of care in these hubs.Conclusion: This multidisciplinary patient‐centred service may provide a useful model for the delivery of other services currently delivered in hospital settings.Patient or Public Contribution: An earlier phase of this study involved interviews with COVID‐19‐positive patients on a remote monitoring programme. The data informed this phase. Several of the authors had worked in the CAHs and provided valuable input into the design of the staff and patient interviews.