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The WHO declared COVID-19 a pandemic in March 2020. By the end of 2020, the US Centers for Disease Control and Prevention demonstrated that the cumulative rate of COVID-19-associated hospitalisations for patients <18 years of age was 23.9 per 100 000 population compared with adults 18 or older at 449.9 per 100 000 population.1 A recent assessment done by the Society of Critical Care Medicine estimated that the USA had 34.7 critical care beds per 100 000 population; 5% of which are paediatric critical care beds and 24% being neonatal intensive care beds.2 The resultant shortage of adult intensive care unit (AICU) resources due to the surge of COVID-19 infections sparked ingenuity in a time when the world was thrust into chaos.
Amid this, Sinha et al in this issue found creative ways for children’s doctors to care for sick adults with COVID-19 disease.3 In a carefully crafted rubric, the authors show how thoughtful planning and methodical implementation in England can mobilise emergency resources in a time of crisis. As such, their success met the demand to increase AICU resources during the early surge of the COVID-19 pandemic while still meeting the paediatric critical care needs of the country.
At the beginning of the pandemic a number of adult and paediatric-trained critical care physician experts developed recommendations on how to care clinically for adults in paediatric settings.4 5 As the world disaster continued to unfold, several models to implement these recommendations began to take shape in three differing models: exclusive management of adults in paediatric ICUs (PICU) with a centrally located PICU regionally to care for children, a hybrid adult and PICU, or the establishment of new AICUs staffed by paediatric critical care physicians (summarised in table 1). These models were aptly developed by multiple institutions across the world. Sinha et al’s experience in England is unique due to the magnitude and coordination of their efforts across an entire country.
Early in the pandemic our institution initially adopted a model of PICU physicians caring for critically ill adults in our paediatric hospital alongside children. However, in the second wave (Fall 2020), we mobilised PICU physicians and nurses to adult COVID-19 ICUs across our health system, as additional adult COVID-19 ICUs were developed when additional physical spaces were identified. From these experiences we were able to consider which aspects of these models worked well and further identify additional opportunities for growth. While caring for adults in our PICU, we relied on our strong well-established communication systems among familiar team members to adapt to this new patient population. However, we were persistently aware that should adult-specific procedural care be required (ie, interventional catheterisation) adult patients would need to be transported back to the adult hospital, possibly resulting in delayed care. In the second wave, as PICU providers were covering the adult COVID-19 ICUs in the adult hospital, some patients did require emergent evaluation for acute coronary syndrome and cerebrovascular accident, which was facilitated with adult-specific providers—accustomed to providing these evaluations and interventions in their familiar surroundings. However, this ‘luxury’ of providing care in the adult hospital by paediatric providers was in part possible because of available physical space. If capacity were reached in these locations, system-wide planning already deemed that overflow would return adults to be cared for in the PICU.
Regardless of the model for using paediatric critical care physicians for adult critical care needs there are key differences in adult and paediatric critical care as children are not ‘little adults’, nor adults ‘big kids’. Recognising that adults can be cared for in paediatric settings or by paediatric practitioners in a different fashion than adult counterparts and acknowledge gaps in this care is paramount for success. To successfully deploy resources to a PICU repurposed for adults, a structure framework must be first undertaken to ensure success. This framework must include a fundamental understanding (or recognition where knowledge gaps exist) of potential adult diseases with complications, the availability of adult consultation services, the retraining of relevant staff, the ability to repurpose the PICU space, the ability to stock appropriate equipment and supplies and the development of a command centre that can oversee operations. These needs occur only after a strong organisational leadership is developed that can focus on these aspects while managing in times of crisis and surge. Likewise, providing transparency in the system and to patients via effective communication that standards of care may be different during a pandemic than outside of a crisis surge is prudent for any repurposed model to engage success.4
There are some key concerns and questions that still remain with all of these approaches that beckon the old adage ‘just because you can do something, should you?’ First, were clinical outcomes worse or better when paediatric practitioners were caring for adult patients? Second, was standard of care for adults compromised with delays in management due to a lack of experience with diseases that require timely intervention, that is, delays to percutaneous coronary intervention in myocardial infarction or to alteplase administration in cerebrovascular accident? This may be difficult to ascertain as delays in care across all health systems were occurring with the flood of patients with COVID-19 disease. Nonetheless, these are important concerns that should be evaluated across all models to see if one method had improved outcomes. Third, did ICU workflow and ICU personnel need change in PICUs whether adult patients who were triaged were COVID-19 or non-COVID-19, that is, in a pandemic is it prudent to triage the patient with the ‘pandemic disease’ to these settings or instead triage patients with known adult diseases (ie, chronic obstructive pulmonary disease exacerbation, pancreatitis, diabetic ketoacidosis, hyperglycaemic hyperosmolar state) to the PICU setting or for paediatric practitioners? Finally, with dual-trained internal medicine-paediatrics physicians and nurses, should there be a move in physician and nurse training for more adult (or paediatric) training to develop familiarity in clinical management? This training may be crucial as we work towards future pandemics, especially as the frequency of such has seemingly increased over the past 20 years (SARS, Zika, Ebola, COVID-19). The answers to these questions with rigorous evaluation of not just ‘that we were able to do something’ but rather ‘that we were able to do so in a fashion that provided equal or even better patient outcomes’ are paramount for future considerations.
Nonetheless, the COVID-19 pandemic has undeniably shown under times of great duress to the medical profession, the best of collegiality and truthfully humanity. The ability to manage patients outside the scope of standard practice to meet the needs of a country surging after careful and thoughtful strategic planning provides hope to many other regions that need guidance for this or any future pandemics. Crisis surge and implementation planning tenants have not changed per se in this pandemic but rather the manner and scope by which these have been applied by necessity has altered the manner in which systems may need to approach the delivery of healthcare to institutions, regions and countries. Novel methods of system and ICU simulation may further refine methodology, system dynamics, group modelling, and improve rapid deployment to meet surge needs more expeditiously in future pandemics. Fortunately, these successful experiences with ICU repurposing are possible in a time where paediatric patients are largely unaffected en masse. However, the lessons learnt from these preparations are grossly important as the potential for a future pandemic that affects both adults and children may present unfathomable challenges.
Correction notice This article has been amended since it was published online. The affiliation for the first author has been corrected.
Funding This study was funded by the National Institutes of Health National Institute of General Medical Sciences (GM129763) and the National Center for Advancing Translational Sciences (UL1 TR002345).
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.