Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists

Opportunities in Pulmonary and Critical Care Medicine for Dual-trained Medicine and Pediatric Physicians

Combined internal medicine-pediatrics (med-peds) training has been recognized as a unique, Accreditation Council for Graduate Medical Education-accredited residency pathway since 1967, resulting in more than 10,000 graduates. Med-peds graduates have the option of pursuing combined med-peds fellowships with a 1-year reduction in training time compared with pursuing such fellowships separately. The typical med-peds resident spends 8-9 months in the intensive care unit during residency, with additional rotations in pulmonary medicine; not surprisingly, residents are increasingly inquiring about combined med-peds fellowship training within the fields of pulmonary and critical care medicine. In this review, we outline both the advantages and challenges of such training and present various pathways and considerations to achieve board certification.

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.

Understanding Pediatric Surge in the United States

The concepts of pediatric surge in the United States continue to evolve from a theoretic framework to practical implementation. As disasters become more frequent, ranging from natural to human-caused, children remain a vulnerable population. The coronavirus disease 2019 pandemic and the 2022 to 2023 tripledemic respiratory surge revealed advances and continued challenges in our ability to care for a large influx of pediatric patients. Understanding pediatric surge through the framework of the 4 S's (space, staff, stuff, and systems/structures) can identify gaps at multiple levels.

COVID-19 and Children: Reflections after Three Years

Three years after the beginning of the COVID-19 pandemic, enough experience has been gained to derive reflections on the impact of SARS-CoV-2 in children [...].

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.

Triage Policies at U.S. Hospitals with Pediatric Intensive Care Units

OBJECTIVES

To characterize the prevalence and content of pediatric triage policies.

METHODS

We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators.

RESULTS

Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children's hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions shared their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions.

CONCLUSIONS

While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities.

The impact of the COVID-19 pandemic on a surgical PICU in China that did not admit COVID-19 patients

Background

The unprecedented COVID-19 pandemic has been spreading for a long time. However, it is unclear whether the pandemic influenced admission in a surgical pediatric intensive care unit (PICU) that never received COVID-19 patients during the early outbreak in China.

Methods

A retrospective study was conducted in a surgical PICU in a tertiary hospital in Chengdu, China. We sought to describe the trend in admission numbers from January 2018 to April 2021. We explored the impact of the COVID-19 outbreak on PICU admission characteristics by including all patients younger than 18 years admitted to the PICU between January 23 and April 8 in 2020 and those admitted in the same time periods in prepandemic years (2018 and 2019) and in 2021.

Results

The percentage of patients admitted to the PICU from the Chengdu region increased from 34.2 percent in 2019 to 40.4 percent in 2020, whereas that from other provinces decreased from 11.7 percent in 2019 to 5.8 percent in 2020 (P = 0.012). The median length of stay (LOS) in the PICU was significantly longer in the 2020 cohort (4.0 days) than in the 2019 cohort (2.0 days) (P < 0.001); the median hospital LOS was also significantly longer in the former (12.0 days) than in the latter (8.0 days) (P < 0.001). Hospital outcomes (P = 0.005) and primary diagnosis distributions (P = 0.025) between the 2020 and 2019 cohorts were both statistically significant.

Conclusions

In a surgical PICU that never received COVID-19 patients, the onset of the 2020 major outbreak was accompanied by changes in the composition of the regional sources of patients, longer PICU and hospital stays, increased proportions of unauthorized discharges, and changes in the distribution of primary diseases for admission. These findings have yet to be strengthened by additional studies involving similar healthcare backgrounds.

Quality of Life of Pediatric Nurses During the COVID-19 Pandemic: A Cross-sectional Study

BACKGROUND

In a public health emergency, the psychological stress of nursing staff should be assessed, and nurses who cared for coronavirus disease 2019 (COVID-19) patients were constantly under pressure. Currently, frontline health care workers are experiencing mental health issues. The personal quality of life is directly related to the working environment, especially at this moment, when nursing could be a highly stressful and emotionally draining job.

OBJECTIVES

During the COVID-19 pandemic, the primary objectives of the study were to describe the quality of life, posttraumatic stress disorder, and self-efficacy and to identify any associated factors of pediatric critical care nurses. This study is a multicenter cross-sectional study.

METHODS

Data were collected between February and May 2021 from pediatric critical care nurses. The following instruments were used: the Nursing Quality of Life Scale, the Nursing Profession Self-Efficacy Scale, and the Impact of Event Scale.

RESULTS

One hundred twelve nurses participated in this study with a 40% of response rate. Data suggest a better global perception of quality of life by male subjects (F = 6.65, P = .011). The nurses who cared for COVID-19 patients reported a lower quality of social life (F = 4.09, P = .045); furthermore, the nurses who had clinically vulnerable people in their families reported a worse quality of physical life (F = 4.37, P = .045). Approximately 50% of nurses reported sleep disturbances, and 37% reported symptoms of posttraumatic stress disorder, especially female nurses (F = 8.55, P = .04).

CONCLUSION

According to this study, female nurses were more likely to experience posttraumatic stress disorder symptoms during the COVID-19 pandemic. Furthermore, findings also highlighted a lower quality of social life for those with clinically vulnerable relatives may be due to a self-limitation of interactions with other people. Finally, sleep disturbances were prevalent, potentially affecting nurses' mental health and performance.

Adult Admissions to a Canadian PICU during the COVID-19 Pandemic

In response to the burden of coronavirus disease 2019 (COVID-19) and overwhelmed intensive care unit (ICU) resources, some pediatric intensive care units (PICUs) have had to adapt. The purpose of this study was to assess the criticality, scope of diagnosis, and outcomes of an adult cohort admitted to a Canadian PICU. A retrospective chart review was completed on all patients between 17 and 50 years of age admitted to the PICU between June 2020 and December 2021. Admission data included body mass index (BMI), admission sequential organ failure assessment score (SOFA), COVID-19 status, diagnosis, and comorbidities. The duration of ventilatory support, PICU and hospital admission, and mortality and discharge disposition were assessed. Discrete variables were reported as percentages and continuous data as means with standard deviations or medians with interquartile range. Sixty-five adult patients were admitted to the PICU for a total of 437 days, with a mean SOFA score of 6.6 and the overall mortality rate of 4.6%. Six patients were diagnosed with COVID-19 pneumonia, were admitted with a mean SOFA score of 11.8 and a BMI of 38.3 kg/m2, and all were discharged to the ward. During the COVID-19 pandemic, pediatric intensivists in a Canadian PICU managed adult patients up to 50 years of age with high criticality and broad-ranging diagnoses with a low mortality rate. PICUs may be a safe critical care decompression option for adult ICUs during future endemics or pandemics.

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.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Clinical and organizational framework of repurposing pediatric intensive care unit to adult critical care in a resource-limited setting: Lessons from the response of an urban general hospital to the COVID-19 pandemic

PURPOSE

We aim to describe the action plan and clinical results of a COVID-19 unit for adult patient care in units intended for critically ill children, proposing a clinical/administrative framework.

METHODS

We reviewed the preparedness of the PICU team before the surge of cases of COVID-19 and the organizational/administrative issues to increase critical beds in a six-bed PICU allocated to adult critical care in a government-funded general hospital in Latin America. We analyzed the prospectively collected administrative/clinical data of severe COVID-19 cases admitted to PICU during the peak of the first wave of the pandemic.

RESULTS

We describe a 6-step preparedness plan: recruitment and education, admission criteria, children diversion, team hierarchy, and general and respiratory equipment. The 6-bed PICU was allocated to adult care for 20 weeks, progressively increasing capacity to a 23-bed dedicated COVID-19 unit managed by the PICU team. A six-block bed organizational units were implemented, and personnel increased from 40 to 125 healthcare workers in 24 h shifts. COVID-19 incidence in personnel was 0.5/1000 workdays. One hundred thirty-six patients were admitted, median age 59 (51,65) years old, 68% were male, and 63% had P/F ≤ 100. In addition, 48% received mechanical ventilation, the median length of stay was 7 (3,17), and in-hospital mortality was 15%.

CONCLUSIONS

We propose an organizational framework for the role of PICU in the hospital action plan to increase adult critical beds. The cohort of patients admitted to a PICU repurposed as a COVID-19 ICU had good outcomes. These data are valuable to plan coordinated actions of the healthcare system for future scenarios.

Posttraumatic Stress Namong Pediatric Critical Care Physicians in the United States in Association with Coronavirus Disease 2019 Patient Care Experiences

Posttraumatic stress among pediatric critical care physicians in the United States in association with coronavirus disease 2019 patient care experiences. Our objective was to assess the prevalence of posttraumatic stress (PTS) and its association with COVID-19 patient care experiences among pediatric critical care physicians. Our study was a cross-sectional study of pediatric critical care physicians in the United States. We measured PTS which included posttraumatic stress disorder (PTSD) and subthreshold posttraumatic stress disorder (SubPTSD) using validated PTSD Checklist- 5 survey tool. Association of PTS with COVID-19 patient care experiences was analyzed using regression analysis. Prevalence of PTS was noted in 120 among 294 pediatric critical care physicians (41%; 95% CI, 35-47%). The predominant symptoms were that of hyperarousal and feelings of negative cognition and mood. Among our physicians with PTS, 19% had PTSD and 81% had SubPTSD. Demographic and practice characteristics were not significant for increased PTS on regression analysis. Posttraumatic stress was significantly associated with physicians testing positive or taking time off for COVID-19 illness, self-isolation, fear of infecting their loved ones, families scared of being infected, feeling helpless, patients expressing fears of dying, having pre-existing depression, anxiety, or insomnia, working beyond comfort level of training and having thoughts of quitting (p < 0.05). Thoughts of quitting was associated with the highest significant increase in PTS scores (coefficient:11.643; 95% CI:8.551,14.735; P < 0.01) followed by feeling of helplessness (coefficient:11.055; 95% CI: 8.484,13.624; P < 0.01) and need for additional medications for depression, anxiety and insomnia (coefficient: 10.980; 95% CI: 4.970, 16.990; P < 0.01). Posttraumatic stress is high in pediatric critical care physicians and is associated with various COVID-19 patient care experiences. Thoughts of quitting was associated with highest increase in posttraumatic stress score which could have major implications for the workforce in the future. Subthreshold posttraumatic stress disorder should be recognized, and mental health issues of pediatric critical care physicians addressed.

Preparedness for Pediatric COVID-19 Using Systems Approach: Experience of a Health Care Facility from India

A pandemic leads to disruption and stretching of an existing health care system and its resources. Coronavirus disease 2019 (COVID-19) data show distinct and severe manifestations in children necessitating critical care. Children need prioritization as they are susceptible to COVID-19 as part of the family cluster, varied presentations, and mortality. The purpose of this report is to discuss the optimization of the health care system for pediatric care. The key initiatives were to identify our objectives, bring out changes to the organizational processes, and integrate the same into the existing system. A systems approach to health care delivery by optimizing infrastructure, human resources, materials, funding, leadership, and governance was undertaken. This resulted in creation of distinct COVID-19 and non-COVID-19 service areas, management protocols, and trained health care workers. Partnership was forged with the public health system. This preparedness and continued responses to the demands of the health care system helped us manage children ranging from neonates to adolescents efficiently. Though the health care system is mostly open, acting upon the modifiable factors gave better preparedness in a short time.

Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study

Background

Several factors influence patients’ length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs).

Methods

This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units’ leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days.

Results

Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million).

Conclusion

If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.

Caring for critically ill adults in paediatric intensive care units in England during the COVID-19 pandemic: planning, implementation and lessons for the future

OBJECTIVE

To describe the experience of paediatric intensive care units (PICUs) in England that repurposed their units, equipment and staff to care for critically ill adults during the first wave of the COVID-19 pandemic.

DESIGN

Descriptive study.

SETTING

Seven PICUs in England.

MAIN OUTCOME MEASURES

(1) Modelling using historical Paediatric Intensive Care Audit Network data; (2) space, staff, equipment, clinical care, communication and governance considerations during repurposing of PICUs; (3) characteristics, interventions and outcomes of adults cared for in repurposed PICUs.

RESULTS

Seven English PICUs, accounting for 137 beds, repurposed their space, staff and equipment to admit critically ill adults. Neighbouring PICUs increased their bed capacity to maintain overall bed numbers for children, which was informed by historical data modelling (median 280-307 PICU beds were required in England from March to June). A total of 145 adult patients (median age 50-62 years) were cared for in repurposed PICUs (1553 bed-days). The vast majority of patients had COVID-19 (109/145, 75%); the majority required invasive ventilation (91/109, 85%). Nearly, a third of patients (42/145, 29%) underwent a tracheostomy. Renal replacement therapy was provided in 20/145 (14%) patients. Twenty adults died in PICU (14%).

CONCLUSION

In a rapid and unprecedented effort during the first wave of the COVID-19 pandemic, seven PICUs in England were repurposed to care for adult patients. The success of this effort was underpinned by extensive local preparation, close collaboration with adult intensivists and careful national planning to safeguard paediatric critical care capacity.

Resident Education and Redeployment During a Disaster

COVID-19 challenged many facets of medicine. At the frontlines of managing the health care of the infected were anesthesiologists and critical care physicians, especially those in large cities. The Hospital of the University of Pennsylvania [HUP] was no exception. Through simulations, online education platforms, and most importantly creative scheduling that allows acquisition of skills and ACGME milestones to be met, COVID-19 allowed the Department of Anesthesiology and Critical Care at HUP to meet the challenges presented during the surge and create a template for future challenges to the US health care system.

A Hybrid Model of Pediatric and Adult Critical Care During the Coronavirus Disease 2019 Surge: The Experience of Two Tertiary Hospitals in London and New York

OBJECTIVES

The current novel severe acute respiratory syndrome coronavirus 2 outbreak has caused an unprecedented demand on global adult critical care services. As adult patients have been disproportionately affected by the coronavirus disease 2019 pandemic, pediatric practitioners world-wide have stepped forward to support their adult colleagues. In general, standalone pediatric hospitals expanded their capacity to centralize pediatric critical care, decanting patients from other institutions. There are few units that ran a hybrid model, managing both adult and pediatric patients with the same PICU staff. In this report, we describe the hybrid model implemented at our respective institutions with shared experiences, pitfalls, challenges, and adjustments required in caring for both young and older patients.

DESIGN

Retrospective cohort study.

SETTING

Two PICUs in urban tertiary hospitals in London and New York.

PATIENTS

Adult and pediatric patients admitted to the PICU in roughly a 6-week period during the coronavirus disease 2019 surge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The PICU at King's College Hospital admitted 23 non-coronavirus disease adult patients, while whereas the PICU at Morgan Stanley's Children Hospital in New York admitted 46 adults, 30 of whom were coronavirus disease positive. The median age of adult patients at King's College Hospital was higher than those admitted in New York, 53 years (19-77 yr) and 24.4 years (18-52 yr), respectively. Catering to the different physical, emotional, and social needs of both children and adults by the same PICU team was challenging. One important consideration in both locations was the continued care of patients with severe non-coronavirus disease-related illnesses such as neurosurgical emergencies, trauma, and septic shock. Furthermore, retention of critical specialists such as transplant services allowed for nine and four solid organ transplants to occur in London and New York, respectively.

CONCLUSIONS

This hybrid model successfully allowed for the expansion into adult critical care while maintaining essential services for critically ill children. Simultaneous care of adults and children in the ICU can be sustained if healthcare professionals work collaboratively, show proactive insight into anticipated issues, and exhibit clear leadership.

Transforming a paediatric ICU to an adult ICU for severe Covid-19: lessons learned

During the first Covid-19 wave, our paediatric intensive care unit (PICU), like many others across the globe, was transformed into an adult ICU for patients with severe Covid-19, due to a shortage of adult ICU beds. Here, we provide a comprehensive description of all the conditions that must be fulfilled to successfully accomplish this transformation. Strong support from all hospital departments was crucial, as their activity was modified by the change. Healthcare workers from various units, notably the paediatric anaesthesiology department, worked in the adult ICU to ensure sufficient staffing. The number of physiotherapists and psychologists was increased. A support system for both healthcare workers and patients' relatives was set up with the help of the mobile paediatric palliative care and support team. Supplies suitable for adults were ordered. Protocols for numerous procedures were written within a few days. Video tutorials, checklists, and simulation sessions were circulated to the entire staff. The head nurses guided and supported the new staff and usual PICU staff. The transformation was achieved within a week. The main difficulties were healthcare worker stress, changes in recommendations over time, absence of visits from relatives, and specific adult issues that paediatricians are unfamiliar with.Conclusion: For the staff, caring for adult patients was made easier by working in their familiar unit instead of being moved to an adult hospital with unfamiliar staff members and equipment. Strong support from the hospital and the assistance of consultants from adult hospital departments were crucial. What is Known: • The dramatic spread across the world of coronavirus disease 2019 generated critical care needs that drastically exceeded resources in many countries worldwide. • Paediatric ICU activity during this period decreased due to lockdown measures and the fact that children rarely required ICU for coronavirus disease 2019. What is New: • We describe how an 18-bed adult Covid-19 ICU was successfully set up in a paediatric hospital during the first wave of the Covid-19 pandemic. • Specific requirements regarding supply, human resources, and procedures, as well as difficulties encountered, are described.

Rapid Transition of a PICU Space and Staff to Adult Coronavirus Disease 2019 ICU Care

OBJECTIVES

We describe the process by which a PICU and a PICU care team were incorporated into a hospital-wide ICU care model during the coronavirus disease 2019 pandemic.

DESIGN

A descriptive, retrospective report from a single-center PICU.

SETTING

Twenty-three bed, quaternary PICU, within an 862-bed hospital.

PATIENTS

Critically ill adults, with coronavirus disease 2019-related disease.

INTERVENTIONS

ICU care provided by pediatric intensivists with training and support from medical intensivists.

MEASUREMENTS AND MAIN RESULTS

Within the context of the institution's comprehensive effort to centralize and systematize care for adults with severe coronavirus disease 2019 disease, the PICU was transitioned to an adult coronavirus disease 2019 critical care unit. Nurses and physicians underwent just-in-time training over 3 days and 2 weeks, respectively. Medical ICU physicians and nurses provided oversight for care and designated hospital-based teams were available for procedures and common adult emergencies. Over a 7-week period, the PICU cared for 60 adults with coronavirus disease 2019-related critical illness. Fifty-three required intubation and mechanical ventilation for a median of 18 days. Eighteen required renal replacement therapy and 17 died.

CONCLUSIONS

During the current and potentially in future pandemics, where critical care resources are limited, pediatric intensivists and staff can be readily utilized to meaningfully contribute to the care of critically ill adults.

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.

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

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We describe the process converting half of our 40-bed PICU into a negative-pressure biocontainment ICU dedicated to adult coronavirus disease 2019 patients within a 1,003-bed academic quaternary hospital. We outline the construction, logistics, supplies, provider education, staffing, and operations. We share lessons learned of working with a predominantly pediatric staff blended with adult expertise staff while maintaining elements of family-centered care typical of pediatric critical care medicine. Critically ill coronavirus disease 2019 adult patients may be cared for in a PICU and care may be augmented by implementing elements of holistic, family-centered PICU practice.

Should Pediatric Patients Be Prioritized When Rationing Life-Saving Treatments During COVID-19 Pandemic

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and health policy discuss if age should guide rationing decisions.