Walking out of a shift in the pediatric emergency department (ED) lately is a heavy mix of relief, guilt, and pure exhaustion. Wading through wall-to-wall families, huddled in blankets and sweatshirts through long hours waiting to be seen, you wish you could do more, find more beds, create more staff. You've spent hours running from room to room, caring for sick kids who should be in hospital beds -- but none currently exist. For weeks you've been evaluating and treating the deluge of incoming sick children and dropping everything when a child arrives in extremis and needs resuscitation; you've dedicated time talking to parents whose children are well enough to be cared for at home but need the courage and anticipatory guidance to do so; and you've been intermittently talking to physicians at smaller hospitals, supporting them as they try to care for sick children who would normally be transferred to you immediately, but there's simply no room to take them now.
The mix of normal pediatric illness and a raging viral respiratory season has brought pediatric healthcare to its knees. But in many ways, it's because we were so close to the knockout already.
Pediatric hospital beds have been evaporating for years, and this only escalated during the pandemic. Reimbursement for pediatric care has long lagged tragically behind that for similar adult care, pushing pediatric facilities to maximize occupancy to remain solvent and pushing general hospitals to convert pediatric wards to care for adults. Low pediatric volumes in 2020, due to COVID-19 mitigation strategies, escalated these trends. In addition, staffing issues across healthcare didn't spare pediatric facilities, and now some hospitals with physical beds for children can't utilize them due to lack of staff. Finally, the ongoing pediatric mental health crisis leaves many children boarding in EDs and sitting in medical hospital beds, just waiting for a psychiatric bed to open, limiting the bed capacity for incoming children.
In the face of the current surge of respiratory illnesses, this leaves us with few pediatric intensive care unit beds, few pediatric inpatient beds, and little ED capacity at regional children's hospitals. Sick children are left sitting in adult EDs, waiting for transfers to pediatric beds that seem like they will never come. Emergency clinicians are spending valuable time they could use to care for patients instead calling dozens of hospitals trying to find a bed, and reaching out to distant states in hopes of the precious acceptance of a transfer.
So, what can we do?
General community hospitals more used to caring for adults need to stretch to develop ways to provide care to pediatric patients who fall within their comfort zone, especially those who are physiologically mature and do not require pediatric-specific subspecialty care. Children's hospitals created a roadmap for this during the COVID-19 pandemic, when they stepped up to assist adult hospitals by taking on those patients who could be safely cared for within pediatric floors and intensive care units. For community hospitals, this may involve extending age ranges for neonatal intensive care units to take older infants and toddlers, or taking older teens with straightforward medical problems onto medical floors. Some hospitals can lean on their own family medicine and med/peds trained physicians, while others may require support from outside pediatric consultants. Issues around state board and privilege must be considered, especially regarding telehealth options to support this consultative care. Governments should review precedents for rapid expansion created during the pandemic and reinvigorate this work, and adult hospitals should lean on existing structures allowing obstetric and trauma care for teens within these facilities.
In addition, we need to support hospitals treating children with conditions outside their comfort zone that are forced to provide care for prolonged periods of time. Pediatric carts with appropriate supplies should be stocked in all hospitals, perhaps with the assistance of state and regional health departments and coalitions. Centralized transfer centers can expedite identification of appropriate open beds and minimize the time community hospitals need to dedicate to calling multiple acceptance facilities. These centers can also provide centralized medical command, staffed by pediatric emergency medicine physicians, who can virtually support care onsite until the child can be picked up by transport. While these centers offer a promising option, they would require money to start up and maintain, and may require state and federal involvement to minimize barriers to cross-facility and interstate medical support. Furthermore, once beds are found in the community, facilities often face delays due to lack of appropriate medical transport vehicles. City, state, and federal resources may need to be redirected to increase the pool of staff and the number of vehicles available to move children between facilities. State and territory disaster declarations would be beneficial to provide the rapid flexibility and resource acquisition to support these creative initiatives.
What else can individual doctors and smaller practices do? First of all, we must continue to encourage COVID-19 and influenza vaccination among all patients, both adult and pediatric. In addition, we need to be voices for children in our community, encouraging smart school attendance policies and viral mitigation strategies. Indications from the southern hemisphere, and more recently from the southern U.S., show that flu season will be early and severe. By minimizing the spread and severity of influenza, COVID-19, and other viral pathogens, we can reduce the strain on the pediatric healthcare infrastructure. In addition, healthcare practices or professionals who have a touchpoint with parents should reach out proactively and clarify (perhaps through email newsletters, texts, or phone calls) when and where to seek care for illness in children. While we are seeing many very sick children in the hospital, most children who come down with RSV, enterovirus, the common cold, or even flu, can be appropriately cared for at home. Helping families feel confident and prepared to provide care at home can decrease the number of sick visits across the healthcare spectrum. Practices can distribute online, patient-facing materials developed by children's hospitals and national pediatric organizations to equip parents ahead of illness, building on the important guidance provided to families during appointments and calls.
We, in pediatric emergency care, are doing everything we can to care for the river of children flooding our doors. I know we are all sick of the word "unprecedented" at this point, but in more than 15 years of providing pediatric emergency care, I've never seen anything like this. The more we raise awareness, the more creative support we can find across the community, healthcare, and government agencies, and the more we can minimize barriers to working together, the better care we can provide to each of those sick children.
Sage Myers, MD, MSCE, is a pediatric emergency medicine physician at Children's Hospital of Philadelphia (CHOP) and Medical Director of Emergency Preparedness.