School causes constipation: Decrease in emergency department visits for constipation during COVID-19 pandemic school closures

The COVID-19 pandemic has resulted in the implementation of alternative models of education, with virtual learning in lieu of in-person schooling. School schedules significantly affect children's routines, including levels of activity, meals, and access to restrooms. The Dayton Children's Health Partners clinically integrated network has been working on a program to decrease costs associated with pediatric constipation in southwest Ohio, including emergency department (ED) utilization. We hypothesized that there would be a decrease in encounters due to constipation with the interruption of traditional in-person learning due to the coronavirus disease 2019 (COVID-19) pandemic. We have collected data on emergency department, primary care, and specialist outpatient encounters and hospital admissions for patients who have been diagnosed with constipation. We analyzed Dayton Children's Hospital (DCH) ED visits of school age children (5-18 years old) for constipation-related diagnosis codes and correlated the patients' street addresses and zip codes to state assigned school districts. Data were aggregated using Microsoft Power BI. We used the online quality improvement (QI) platform LifeQI to create control charts. Individual school district in-person/remote learning schedules were overlaid using local news reporting. We found that DCH ED visits for all causes decreased significantly beginning in March 2020, with the lowest point being in April/May 2020. Since that time, ED visits for all causes have gradually increased, although they have not yet returned to their pre-COVID-19 levels. Before COVID-19, DCH ED visits related to constipation were lower in the summer and rose when school began. Once there were school closures the percentage of DCH ED visits for constipation decreased and remained low even when school resumed in September, as many children were learning remotely. Many schools began in-person/hybrid learning in October or November 2020, and the percentage of constipation-related DCH ED visits began to rise around this time. School closure and re-opening affected the rate of DCH ED visits for constipation. Analysis of children from specific school districts demonstrated varying constipation ED visit rates related to in-person and remote learning.