Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs

Global predictors of tracheostomy-related pressure injury in the COVID-19 era: A study of secondary data

OBJECTIVES

To determine the incidence and risk factors of tracheostomy-related pressure injuries (TRPI) and examine the COVID-19 pandemic's impact on TRPI incidence.

DESIGN

Secondary analysis of Global Tracheostomy Collaborative database and a multi-center hospital system's electronic medical records.

SETTING

27 hospitals, primarily in the United States, United Kingdom, and Australasia.

PATIENTS

6,400 adults and 2,405 pediatric patients hospitalized with tracheostomy between 1 January 2019 and 31 December 2021.

MEASUREMENT

TRPI as a binary outcome, reported as odds ratios.

RESULTS

TRPI incidence was 4.69 % in adults and 5.65 % in children. For adults, associated risks were female sex (OR: 0.64), severe obesity (OR: 2.62), ICU admission (OR: 2.05), cuffed tracheostomy (OR: 1.49), fenestrated tracheostomy (OR: 15.37), percutaneous insertion (OR: 2.03) and COVID-19 infection (OR: 1.66). For children, associated risks were diabetes mellitus (OR: 4.31) and ICU admission (OR: 2.68). TRPI odds increased rapidly in the first 60 days of stay. Age was positively associated with TRPI in adults (OR: 1.014) and children (OR: 1.060). Black patients had higher TRPI incidence than white patients; no moderating effects of race were found. Hospital cluster effects (adults ICC: 0.227; children ICC: 0.138) indicated unmeasured hospital-level factors played a significant role.

CONCLUSIONS

Increasing age and length of stay up to 60 days are TRPI risk factors. Other risks for adults were female sex, severe obesity, cuffed/fenestrated tracheostomy, percutaneous insertion, and COVID-19; for children, diabetes mellitus and FlexTend devices were risks. Admission during the COVID-19 pandemic had contrasting effects for adults and children. Additional research is needed on unmeasured hospital-level factors.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings can guide targeted interventions to reduce TRPI incidence and inform tracheostomy care during public health crises. Hospital benchmarking of tracheostomy-related pressure injuries is needed.

A Nonhybrid Model of Transitioning Pediatric to Adult Critical Care during the Coronavirus Disease 2019 Surge: A Single Unit Experience

To accommodate the unprecedented demand for critical care beds during the first surge of the coronavirus disease 2019 (COVID-19) pandemic in the United Kingdom, hospitals had to adapt, restructure, and collaborate to provide the best possible care for the pediatric and adult populations. This single-center experience outlines the considerations our hospital took into account when planning for this restructure and the steps taken to ensure a successful execution of the task. Cross-specialty collaboration between the pediatric and adult critical care teams adopted a unique approach to care for only critically ill COVID-19 positive adult patients in the pediatric intensive care unit (PICU), transferring out critically unwell children at an early stage before the adult intensive care unit (AICU) became overwhelmed (nonhybrid model). This was designed to be in a staggered fashion, before allowing the AICU to overflow. This approach enabled the adult critical care team to support pediatric colleagues in learning the nuances of looking after critically ill adults prior to the service being saturated by the predicted supersurge. The success of the operation hinged on two things. First, PICU staff continuing to work in a familiar environment with their usual clinical team and second, the gradual and controlled admission of adult patients into PICU before the peak in demand for critical care beds. This design helped protect staff morale and build confidence in their new clinical role. The overall case fatality of invasively ventilated patients with COVID-19 in our hospital during the first surge was 32%, which is lower than the global average of 45%. This serves as evidence that this nonhybrid model is safe and sustainable.

A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19

BACKGROUND

Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVES

To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19.

METHODS

A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values.

RESULTS

At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked.

CONCLUSIONS

Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.

Impact of adapting paediatric intensive care units for adult care during the COVID-19 pandemic: a scoping review

OBJECTIVES

The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research.

DESIGN

Scoping review.

METHODS

This study used Arksey and O'Malley's six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate.

RESULTS

47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges.

CONCLUSION

COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients.

Experience of Pediatric Nurses in Parent-Child Isolation Units of COVID-19 Designated Hospitals: A Qualitative Study

Background

The omicron pandemic in Shanghai has created unprecedented challenges for pediatric medical institutions, and the work of pediatric nurses has changed rapidly due to the introduction of parent-child treatment. This study aimed to explore the experiences of pediatric nurses in the parent-child isolation unit of COVID-19-designated hospitals and provide a basis for developing feasible interventions as the next step.

Methods

Using phenomenological research methods, 12 nurses working in the parent-child isolation unit of Shanghai Children's Medical Center affiliated with Shanghai Jiao Tong University School of Medicine from April 1, 2022, to June 15, 2022, were selected by purposive sampling. Semi-structured interviews and data analysis were conducted using Colaizzi's 7-step analysis.

Results

Data analysis revealed three major themes and 11 subthemes. The main themes were "risk factors", "protection factors", and "resilience strategies". The sub-themes were "challenge of caring for both adults and children simultaneously", "lack of adult expertise leads to inadequate coping skills", "change in the care population increased communication difficulties", "physical and psychological distress", "social support", "social recognition", "awareness of responsibilities and roles", "team coming together", "hunger for knowledge", "health promotion", and "psychological adjustment strategies".

Conclusion

Hospital managers should optimize hospital management strategies, pay attention to multi-departmental and multidisciplinary team cooperation, reduce the burden on pediatric nurses, improve the work and rest environment, mobilize the hospital support system, and maintain nurse's physical and mental health, establish a warm parent-child isolation unit encourages nurses to listen to the patients' voices and adopt diversified communication methods, and strengthen the publicity of the nursing profession, improve social support and recognition, and enhance the sense of self-worth and mission.

Voices of Pandemic Care: Perspectives from Pediatric Providers During the First SARS-CoV-2 Surge

Pediatric providers were called on to care for adult patients well beyond their typical scope of practice during the first surge of the SARS-CoV-2 pandemic. Here, the authors share novel viewpoints and innovations from the perspective of providers, consultants, and families. The authors enumerate several of the challenges encountered, including those faced by leadership in supporting teams, balancing competing responsibilities to children while caring for critically ill adult patients, preserving the model of interdisciplinary care, maintaining communication with families, and finding meaning in work during this unprecedented crisis.

Organisation of care in paediatric intensive care units during the first 18 months of the COVID-19 pandemic: a scoping review protocol

INTRODUCTION

The emergence of COVID-19 has had a significant impact on hospital services, particularly care delivered to those in intensive care units (ICUs) and paediatric ICUs (PICUs) across the world. Although much has been written about healthcare delivery and the healthcare setting since COVID-19 began, to the authors' knowledge, this is the first scoping review to investigate the organisation of care and changes implemented in PICUs during the COVID-19 pandemic. The aim is to conduct a scoping review of the literature to map out the existing studies about care delivery in PICUs during the COVID-19 pandemic and the changes made to the organisation of care in these units during the first 18 months of the pandemic. This review will also identify gaps in current knowledge in this area.

METHODS AND ANALYSIS

This study will be guided by the Joanna Briggs Institute's methodology for scoping reviews, using Arksey and O'Malley's six-stage scoping review framework: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) data charting; (5) collating, summarising and reporting results; and (6) consulting with experts. A comprehensive search will be conducted using the following databases: CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE. A search strategy with predefined inclusion and exclusion criteria will be used to uncover relevant research in this area. This study will include quantitative, qualitative and mixed research methods studies published in English from 2019 to May 2021.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The results from this study will be disseminated through conferences and in peer-reviewed academic journals for those working in the healthcare arena.

Modeling robust COVID-19 intensive care unit occupancy thresholds for imposing mitigation to prevent exceeding capacities

In non-pharmaceutical management of COVID-19, occupancy of intensive care units (ICU) is often used as an indicator to inform when to intensify mitigation and thus reduce SARS-CoV-2 transmission, strain on ICUs, and deaths. However, ICU occupancy thresholds at which action should be taken are often selected arbitrarily. We propose a quantitative approach using mathematical modeling to identify ICU occupancy thresholds at which mitigation should be triggered to avoid exceeding the ICU capacity available for COVID-19 patients and demonstrate this approach for the United States city of Chicago. We used a stochastic compartmental model to simulate SARS-CoV-2 transmission and disease progression, including critical cases that would require intensive care. We calibrated the model using daily COVID-19 ICU and hospital census data between March and August 2020. We projected various possible ICU occupancy trajectories from September 2020 to May 2021 with two possible levels of transmission increase and uncertainty in core model parameters. The effect of combined mitigation measures was modeled as a decrease in the transmission rate that took effect when projected ICU occupancy reached a specified threshold. We found that mitigation did not immediately eliminate the risk of exceeding ICU capacity. Delaying action by 7 days increased the probability of exceeding ICU capacity by 10-60% and this increase could not be counteracted by stronger mitigation. Even under modest transmission increase, a threshold occupancy no higher than 60% was required when mitigation reduced the reproductive number Rt to just below 1. At higher transmission increase, a threshold of at most 40% was required with mitigation that reduced Rt below 0.75 within the first two weeks after mitigation. Our analysis demonstrates a quantitative approach for the selection of ICU occupancy thresholds that considers parameter uncertainty and compares relevant mitigation and transmission scenarios. An appropriate threshold will depend on the location, number of ICU beds available for COVID-19, available mitigation options, feasible mitigation strengths, and tolerated durations of intensified mitigation.

Organizational aspects of pediatric anesthesia and surgery between two waves of Covid-19

Background

The initial wave of the Covid‐19 pandemic has hit Italy, and Lombardy in particular, with violence, forcing to reshape all hospitals' activities; this happened even in pediatric hospitals, although the young population seemed initially spared from the disease. “Vittore Buzzi” Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), had to stop elective procedures—with the exception of urgent/emergent ones—between February and May 2020 to leave space and resources to adults' care. We describe the challenges of reshaping the hospital's identity and structure, and restarting pediatric surgery and anesthesia, from May on, in the most hit area of the world, with the purpose to avoid and contain infections. Both patients and caregivers admitted to hospital have been tested for Sars‐CoV‐2 in every case.

Methods

Observational cohort study via review of clinical charts of patients undergoing surgery between 16th May and 30th September 2020, together with SARS‐CoV ‐2 RT‐PCR testing outcomes, and comparison to same period surgeries in 2019.

Results

An increase of approximately 70% in pediatric surgeries (OR 1.68 [1.33‐2.13], P < .001) and a higher increase in the number of surgeries were reported (OR 1.75 (1.43‐2.15), P < .001). Considering only urgent procedures, a significant difference in the distribution of the type of surgery was observed (Chi‐squared P‐value < .001). Sars‐CoV‐2‐positive patients have been 0.8% of total number; 14% of these was discovered through caregiver's positivity.

Conclusion

We describe our pathway for safe pediatric surgery and anesthesia and the importance of testing both patient and caregiver.

The Effects of ICU Crisis Reorganization on Outcomes in Patients Not Infected With Coronavirus Disease 2019 During the Initial Surge of the Coronavirus Disease 2019 Pandemic

To determine if ICU reorganization due to the coronavirus disease 2019 pandemic affected outcomes in critically ill patients who were not infected with coronavirus disease 2019.

DESIGN

This was a Before-After study, with coronavirus disease 2019-induced ICU reorganization as the intervention. A retrospective chart review of adult patients admitted to a reorganized ICU during the coronavirus disease 2019 surge (from March 23, 2020, to May 06, 2020: intervention group) was compared with patients admitted to the ICU prior to coronavirus disease 2019 surge (from January 10, 2020, to February 23, 2020: before group).

SETTING

High-intensity cardiac, medical, and surgical ICUs of a community hospital in metropolitan Missouri.

PATIENTS

All patients admitted to the ICU during the before and intervention period were included. Patients younger than 18 years old and those admitted after an elective procedure or surgery were excluded. Patients with coronavirus disease 2019 were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified a total of 524 eligible patients: 342 patients in the before group and 182 in the intervention group. The 28-day mortality was 25.1% (86/342) and 28.6% (52/182), respectively (p = 0.40). The ICU length of stay, ventilator length of stay, and ventilator-free days were similar in both groups. Rates of patient adverse events including falls, inadvertent endotracheal tube removal, reintubation within 48 hours of extubation, and hospital acquired pressure ulcers occurred more frequently in the study group (20 events, 11%) versus control group (12 events, 3.5%) (p = 0.001).

CONCLUSIONS

Twenty-eight-day mortality, in patients who required ICU care and were not infected with coronavirus disease 2019, was not significantly affected by ICU reorganization during a pandemic.

Repurposing a PICU for Adult Care in a State Mandated COVID-19 Only Hospital: Outcome Comparison to the MICU Cohort to Determine Safety and Effectiveness

Objective: The ongoing coronavirus 2019 (COVID-19) pandemic is disproportionally impacting the adult population. This study describes the experiences after repurposing a PICU and its staff for adult critical care within a state mandated COVID-19 hospital and compares the outcomes to adult patients admitted to the institution's MICU during the same period. Design: A retrospective chart review was performed to analyze outcomes for the adults admitted to the PICU and MICU during the 27-day period the PICU was incorporated into the institution's adult critical care surge plan. Setting: Tertiary care state University hospital. Patients: Critically ill adult patients with proven or suspected COVID-19. Interventions: To select the most ideal adult patients for PICU admission a tiered approach that incorporated older patients with more comorbidities at each stage was implemented. Measurements and Main Results: There were 140 patients admitted to the MICU and 9 patients admitted to the PICU during this period. The mean age of the adult patients admitted to the PICU was lower (49.1 vs. 63.2 p = 0.017). There was no statistically significant difference in the number of comorbidities, intubation rates, days of ventilation, dialysis or LOS. Patients selected for PICU care did not have coronary artery disease, CHF, cerebrovascular disease or COPD. Mean admission Sequential Organ Failure Assessment (SOFA) score was lower in patients admitted to the PICU (4 vs. 6.4, p = 0.017) with similar rates of survival to discharge (66.7 vs. 44.4%, p = 0.64). Conclusion: Outcomes for the adult patients who received care in the PICU did not appear to be worse than those who were admitted to the MICU during this time. While limited by a small sample size, this single center cohort study revealed that careful assessment of critical illness considering age and type of co-morbidities may be a safe and effective approach in determining which critically ill adult patients with known or suspected COVID-19 are the most appropriate for PICU admission in general hospitals with primary management by its physicians and nurses.

Adult COVID-19 Patients Cared for in a Pediatric ICU Embedded in a Regional Biothreat Center: Disease Severity and Outcomes

The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH₂O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible.