Pediatric Hospital Medicine Management, Staffing, and Well-being in the Face of COVID-19

Catheterization for Congenital Heart Disease Adjustment for Risk Method II

BACKGROUND

Current metrics used to adjust for case mix complexity in congenital cardiac catheterization are becoming outdated due to the introduction of novel procedures, innovative technologies, and expanding patient subgroups. This study aims to develop a risk adjustment methodology introducing a novel, clinically meaningful adverse event outcome and incorporating a modern understanding of risk.

METHODS

Data from diagnostic only and interventional cases with defined case types were collected for patients ≤18 years of age and ≥2.5 kg at all Congenital Cardiac Catheterization Project on Outcomes participating centers. The derivation data set consisted of cases performed from 2014 to 2017, and the validation data set consisted of cases performed from 2019 to 2020. Severity level 3 adverse events were stratified into 3 tiers by clinical impact (3a/b/c); the study outcome was clinically meaningful adverse events, severity level ≥3b (3bc/4/5).

RESULTS

The derivation data set contained 15 224 cases, and the validation data set included 9462 cases. Clinically meaningful adverse event rates were 4.5% and 4.2% in the derivation and validation cohorts, respectively. The final risk adjustment model included age <30 days, Procedural Risk in Congenital Cardiac Catheterization risk category, and hemodynamic vulnerability score (C statistic, 0.70; Hosmer-Lemeshow P value, 0.83; Brier score, 0.042).

CONCLUSIONS

CHARM II (Congenital Heart Disease Adjustment for Risk Method II) risk adjustment methodology allows for equitable comparison of clinically meaningful adverse events among institutions and operators with varying patient populations and case mix complexity performing pediatric cardiac catheterization.

Hospitalist perspective on pandemic related clinical and administrative changes: a cross sectional survey study

OBJECTIVE

Hospitalists have played a leading role in caring for hospitalized COVID-19 patients. Many clinical and administrative changes occurred in hospitals to meet the varied pandemic needs. We surveyed hospitalists to understand their perspective on pandemic-related changes in technology, models of care, administration and leadership, impact on personal lives, and which of these changes should be continued versus reverting to pre-pandemic practices.

METHODS

A 30-question survey was distributed to hospitalists working across the United States between April 6, 2022 to May 16, 2022. Baseline demographics were measured, and post-pandemic perspectives related to changes were analyzed. Perspectives were measured using a 5-point Likert scale and responses were categorized into "agree" and "did not agree" for analysis. Variation was assessed using Chi-square or Fisher exact tests. Open-ended questions were reported following qualitative content analysis organized into themes and reported as frequency.

RESULTS

177 respondents (39%) completed the survey. Nearly three-fourths favored hybrid meetings, and two-thirds preferred to continue new models of care. Nearly 90% desired more family and leisure time, continued wellness, and support services, and resumption of social gatherings. No major differences in perspectives were noted between hospitalists at teaching facilities and non-teaching facilities except for resuming protected time for non-clinical activities in those from teaching facilities (83.0% vs 62.5%). Respondents less than age 50 were more likely to prefer virtual meetings (59.0% vs 31.3%). Content analysis of open-ended questions resulted in different themes for each question. Respondents favored more work-life balance and less administrative and logistical work burden.

CONCLUSIONS

Hospitalists preferred to continue the use of technology and new models of care even in the post-pandemic period and express a desire for more work-life balance and less administrative and logistical work burden.

ICU Admission Tool for Congenital Heart Catheterization (iCATCH): A Predictive Model for High Level Post-Catheterization Care and Patient Management

OBJECTIVES

Currently, there are no prediction tools available to identify patients at risk of needing high-complexity care following cardiac catheterization for congenital heart disease. We sought to develop a method to predict the likelihood a patient will require intensive care level resources following elective cardiac catheterization.

DESIGN

Prospective single-center study capturing important patient and procedural characteristics for predicting discharge to the ICU. Characteristics significant at the 0.10 level in the derivation dataset (July 1, 2017 to December 31, 2019) were considered for inclusion in the final multivariable logistic regression model. The model was validated in the testing dataset (January 1, 2020 to December 31, 2020). The novel pre-procedure cardiac status (PCS) feature, collection started in January 2019, was assessed separately in the final model using the 2019 through 2020 dataset.

SETTING

Tertiary pediatric heart center.

PATIENTS

All elective cases coming from home or non-ICU who underwent a cardiac catheterization from July 2017 to December 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,192 cases were recorded in the derivation dataset, of which 11% of patients ( n = 245) were admitted to the ICU, while 64% ( n = 1,413) were admitted to a medical unit and 24% ( n = 534) were discharged home. In multivariable analysis, the following predictors were identified: 1) weight less than 5 kg and 5-9.9 kg, 2) presence of systemic illness, 3) recent cardiac intervention less than 90 days, and 4) ICU Admission Tool for Congenital Heart Catheterization case type risk categories (1-5), with C -statistics of 0.79 and 0.76 in the derivation and testing cohorts, respectively. The addition of the PCS feature fit into the final model resulted in a C -statistic of 0.79.

CONCLUSIONS

The creation of a validated pre-procedural risk prediction model for ICU admission following congenital cardiac catheterization using a large volume, single-center, academic institution will improve resource allocation and prediction of capacity needs for this complex patient population.

Challenges Created by the COVID-19 Pandemic: Pediatric Emergency Medicine and Disaster Management Perspectives

OBJECTIVE

The coronavirus disease (COVID-19) pandemic has presented unique challenges to pediatric emergency medicine (PEM) departments. The purpose of this study was to identify these challenges and ascertain how centers overcame barriers in creating solutions to continue to provide high-quality care and keep their workforce safe during the early pandemic.

METHODS

This is a qualitative study based on semi-structured interviews with physicians in leadership positions who have disaster or emergency management experience. Participants were identified through purposive sampling. Interviews were recorded and transcribed electronically. Themes and codes were extracted from the transcripts by 2 independent coders. Constant comparison analysis was performed until thematic saturation was achieved. Member-checking was completed to ensure trustworthiness.

RESULTS

Fourteen PEM-trained physicians participated in this study. Communication, leadership and planning, clinical practice, and personal adaptations were the principal themes identified. Recommendations elicited include improving communication strategies; increasing emergency department (ED) representation within hospital-wide incident command; preparing for a surge and accepting adult patients; personal protective equipment supply and usage; developing testing strategies; and adaptations individuals made to their practice to keep themselves and their families safe.

CONCLUSIONS

By sharing COVID-19 experiences and offering solutions to commonly encountered problems, pediatric EDs may be better prepared for future pandemics.

Impact of Coronavirus Disease-2019 on Hospital Care for Neonatal Opioid Withdrawal Syndrome

OBJECTIVE

To compare prenatal exposures, hospital care processes, and hospitalization outcomes for opioid-exposed newborns before and during the coronavirus disease 2019 (COVID-19) pandemic.

STUDY DESIGN

In this multicenter retrospective analysis, data were collected from 19 Massachusetts hospitals, including 5 academic and 14 community hospitals. The pre-COVID-19 cohort was defined as births occurring during March 1, 2019-February 28, 2020, and the COVID-19 cohort was defined as births occurring during March 1, 2020-December 31, 2020. Opioid-exposed newborns born at ≥35 weeks of gestation were included. Differences in prenatal substance exposures, hospital care processes, and neonatal opioid withdrawal syndrome (NOWS) outcomes, including pharmacologic treatment for NOWS (PharmTx), length of stay (LOS), and as-needed (prn) treatment failure rates, were evaluated.

RESULTS

There were 663 opioid-exposed newborns in the pre-COVID-19 group and 476 in the COVID-19 group. No between-group differences were seen in prenatal substance exposures or the need for PharmTx. Compared with the pre-COVID-19 group, in the COVID-19 group there was less rooming-in after maternal discharge (53.8% vs 63.0%; P = .001) and less care in the pediatric unit setting (23.5% vs 25.3%; P = .001), longer LOS (adjusted risk ratio, 1.04; 95% CI, 1.01-1.08), and a higher rate of breast milk receipt at discharge (aOR, 2.03; 95% CI, 1.22-3.39). Within the subset of academic centers, more infants failed prn treatment in the COVID-19 group (53.8% vs 26.5%, P = .02; aOR, 3.77; 95% CI, 0.98-14.5).

CONCLUSIONS

Among the hospitals in our collaborative, hospital processes for NOWS, including care setting, rooming-in, and LOS were negatively impacted in the COVID-19 group, particularly in academic medical centers.

Pandemic-Related Experiences and Stress Among Children's Hospital Staff Predict Psychosocial Risk

GOAL

COVID-19 has imposed unique challenges for healthcare workers who have faced increased risk of exposure to the virus, heightened work demands, and disruptions in work-life balance. For some healthcare workers, these challenges may have contributed to increased stress, burnout, and psychosocial impairment, including symptoms of depression and anxiety. The current study addresses a knowledge gap of associations between pandemic-related experiences and psychosocial risk among medical and nonmedical pediatric healthcare staff.

METHODS

A sample of 369 staff (90% female) employed at an acute care, freestanding pediatric hospital in Connecticut completed an online survey. The survey assessed specific pandemic-related experiences and perceived impact with the Epidemic-Pandemic Impacts Inventory, and depression and anxiety risk with the 2-item Patient Health Questionnaire depression screen and 2-item Generalized Anxiety Disorder screen, respectively. Enrollment and survey completion occurred over a 6-week period during the pandemic (summer 2020).

PRINCIPAL FINDINGS

High rates of adverse pandemic-related experiences included workplace experiences (e.g., inadequate support, interpersonal difficulties), home life (e.g., childcare difficulties, partner conflict), and experiences reflecting social isolation and quarantine, child and adult mental health difficulties, increased alcohol or substance use, and unhealthy lifestyle behaviors. Medical relative to nonmedical staff reported significantly more adverse and fewer positive experiences, and a significantly higher perceived negative impact of workplace experiences. A positive screen for depression or anxiety was significantly predicted by cumulative adverse workplace experiences (OR = 1.15), changes in emotional/physical health (OR = 1.35), and perceived negative impact of workplace experiences (OR = 1.32).

APPLICATIONS TO PRACTICE

The present study joins recent reports of increased adverse experiences and psychosocial outcomes among healthcare workers during the COVID-19 pandemic. Findings underscore the need for pediatric hospitals to innovate ways to reduce burden and connect staff to mental health services during similar public health crises. Such services might include (1) assisting healthcare staff to navigate disruptions in their home and social lives as a result of new challenges faced at work, (2) adapting the hospital environment and culture to mitigate stress experienced by staff because of these challenges, and (3) bolstering mental health screening and services to address exacerbated or emerging mental health symptoms, such as depression and anxiety.

Bracing for the Wave: a Multi-Institutional Survey Analysis of Inpatient Workforce Adaptations in the First Phase of COVID-19

BACKGROUND

Medical centers across the country have had to rapidly adapt clinician staffing strategies to accommodate large influxes of patients with the coronavirus disease 2019 (COVID-19).

OBJECTIVE

We sought to understand the adaptations and staffing strategies that US academic medical centers employed in the inpatient setting early in the spread of COVID-19, and to assess whether those changes were sustained during the first phase of the pandemic.

DESIGN

Cross-sectional survey assessing organization-level, team-level, and clinician-level inpatient workforce adaptations.

PARTICIPANTS

Hospital medicine leadership at 27 academic medical centers in the USA.

KEY RESULTS

Twenty-seven of 36 centers responded to the survey (75%). Widespread practices included frequent staffing reassessment, organization-level changes such as geographic cohorting and redeployment of non-hospitalists, and exempting high-risk healthcare workers from direct care of patients with COVID-19. Several practices were implemented but discontinued, such as reduction of non-essential services, indicating that they were less sustainable for large centers.

CONCLUSION

These findings provide guidance for inpatient leaders seeking to identify sustainable practices for COVID-19 inpatient workforce planning.

Considerations for acute care staffing during a pandemic

The increase in interconnectedness of the global population has enabled a highly transmissible virus to spread rapidly around the globe in 2020. The COVID-19 (Coronavirus Disease 2019) pandemic has led to physical, social, and economic repercussions of previously unseen proportions. Although recommendations for pandemic preparedness have been published in response to previous viral disease outbreaks, these guidelines are primarily based on expert opinion and few of them focus on acute care staffing issues. In this review, we discuss how working in acute care medicine during a pandemic can affect the physical and mental health of medical and nursing staff. We provide ideas for limiting staff shortages and creating surge capacity in acute care settings, and strategies for sustainability that can help hospitals maintain adequate staffing throughout their pandemic response.

Changes in pediatric hospital care during the COVID-19 pandemic: a national qualitative study

Background

The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. The objectives of this study were to identify major changes in healthcare delivery for hospitalized children during the COVID-19 pandemic, identify lessons learned from these changes, and compare and contrast the experiences of children’s and community hospitals.

Methods

We purposefully sampled participants from both community and children’s hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates at the onset of the pandemic. We recruited 2–3 participants from each hospital (mix of administrators, front-line physicians, nurses, and parents/caregivers) for semi-structured interviews. We analyzed interview data using constant comparative methods to identify major themes.

Results

We interviewed 30 participants from 12 hospitals. Participants described how leaders rapidly developed new hospital policies (e.g., directing use of personal protective equipment) and how this was facilitated by reviewing internal and external data frequently and engaging all relevant stakeholders. Hospital leaders optimized communication through regular, transparent, multi-modal, and bi-directional communication. Clinicians increased use of videoconference and telehealth to facilitate physical distancing, but these technologies may have disadvantaged non-English speakers. Due to declining volumes of hospitalized children and surges of adult patients, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, multidisciplinary support via videoconference, and educational resources. Participants described how the pandemic negatively impacted clinicians’ mental health, and they stressed the importance of mental health resources and wellness activities/spaces.

Conclusions

We identified several major changes in inpatient pediatric care delivery during the COVID-19 pandemic, including the adoption of new hospital policies, video communication, staffing models, education strategies, and staff mental health supports. We outline important lessons learned, including strategies for successfully developing new policies, effectively communicating with staff, and supporting clinicians’ expanding scope of practice. Potentially important focus areas in pandemic recovery include assessing and supporting clinicians’ mental health and well-being, re-evaluating trainees’ skills/competencies, and adapting educational strategies as needed. These findings can help guide hospital leaders in supporting pandemic recovery and addressing future crises.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06947-7.

Advancing Opportunities for Clinical Inquiry and Professional Development During a Pandemic

A notable challenge faced by pediatric hospitals during the COVID-19 pandemic included the need to decrease inpatient census and socially distant non-clinical hospital employees to alternative work arrangements. In doing so, nurses and other clinical care services employees were reassigned to new roles, while others continue to work from home. This paper aims to describe how during the COVID-19 pandemic, a pediatric hospital-based center for nursing research and evidence-based practice used this opportunity to virtually engage staff across the department in topics of clinical inquiry through education sessions, office hours, and individualized/team consultation. Therefore, elevating and increasing the presence of nursing research and evidence-based practice while providing opportunities for the continued professional development of nurses, respiratory therapists, clinical dietitians, child life specialists and employees in neurodiagnostics.

The COVID-19 Army: Experiences From the Deployment of Non-Hospitalist Physician Volunteers During the COVID-19 Pandemic

OBJECTIVE

New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a "COVID Army," consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics.

METHODS

To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results.

RESULTS

Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available.

CONCLUSIONS

Lessons from our deployment and assessment are scalable at other institutions.

Maintenance of Elective Patient Care at Berlin University Children's Hospital During the COVID-19 Pandemic

Background: In Germany, so far the COVID-19 pandemic evolved in two distinct waves, the first beginning in February and the second in July, 2020. The Berlin University Children's Hospital at Charité (BCH) had to ensure treatment for children not infected and infected with SARS-CoV-2. Prevention of nosocomial SARS-CoV-2 infection of patients and staff was a paramount goal. Pediatric hospitals worldwide discontinued elective treatments and established a centralized admission process. Methods: The response of BCH to the pandemic adapted to emerging evidence. This resulted in centralized admission via one ward exclusively dedicated to children with unclear SARS-CoV-2 status and discontinuation of elective treatment during the first wave, but maintenance of elective care and decentralized admissions during the second wave. We report numbers of patients treated and of nosocomial SARS-CoV-2 infections during the two waves of the pandemic. Results: During the first wave, weekly numbers of inpatient and outpatient cases declined by 37% (p < 0.001) and 29% (p = 0.003), respectively. During the second wave, however, inpatient case numbers were 7% higher (p = 0.06) and outpatient case numbers only 6% lower (p = 0.25), compared to the previous year. Only a minority of inpatients were tested positive for SARS-CoV-2 by RT-PCR (0.47% during the first, 0.63% during the second wave). No nosocomial infection of pediatric patients by SARS-CoV-2 occurred. Conclusion: In contrast to centralized admission via a ward exclusively dedicated to children with unclear SARS-CoV-2 status and discontinuation of elective treatments, maintenance of elective care and decentralized admission allowed the almost normal use of hospital resources, yet without increased risk of nosocomial infections with SARS-CoV-2. By this approach unwanted sequelae of withheld specialized pediatric non-emergency treatment to child and adolescent health may be avoided.

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness

OBJECTIVE

We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States.

METHODS

We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network.

RESULTS

We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%).

CONCLUSIONS

This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

Changes from COVID-19. A perspective from internal pediatric medicine

The SARS-CoV2 pandemic dimension has affected the Hospital Pediatrics Medicine assistance in our country. New challenges generated by COVID-19 require a series of proactive measures, based on existing scientific knowledge and standards of good practice, that allow the Pediatric Hospital services readiness and operability. Hospital Internal Pediatrics, as responsible of integral care of the hospitalized child, plays a leading role in the new hospital model emerging from this crisis. This review analyzes the impact of the current SARS-CoV2 epidemic on pediatric care, and perspective of new COVID-19 outbreaks in coexistence with other viral infections. Changes secondary to pandemic involved in Hospital pediatric units must be analyzed, and how to prepare for future epidemics, also the involvement of pediatric units in adult care and the possible opportunities for improvement. Assistance of patients with chronic complex conditions in epidemic circumstances, safety aspects, opportunities for teaching and ethical considerations are reviewed. The Spanish Society of Hospital Pediatrics Medicine offers with this article a series of resources for Internal pediatric Medicine practitioners responsible to face next challenges in pediatric hospitalization units.

[Changes from COVID-19. A perspective from internal pediatric medicine]

SARS-CoV-2 pandemic dimension has affected the Hospital Pediatrics Medicine assistance in our country. New challenges generated by COVID-19 require a series of proactive measures, based on existing scientific knowledge and standards of good practice, that allow the Pediatric Hospital services readiness and operability. Hospital Internal Pediatrics, as responsible of integral care of the hospitalized child, plays a leading role in the new hospital model emerging from this crisis. This review analyzes the impact of the current SARS-CoV-2 epidemic on pediatric care, and perspective of new COVID-19 outbreaks in coexistence with other viral infections. Changes secondary to pandemic involved in Hospital Pediatric units, how to prepare for future epidemics, also the involvement of pediatric units in adult care and the possible opportunities for improvement need to be revised. Assistance of patients with chronic complex conditions in epidemic circumstances, safety aspects, opportunities for teaching and ethical considerations are reviewed. The Spanish Society of Hospital Pediatrics Medicine offers with this article a series of resources for Internal Pediatric Medicine practitioners responsible to face next challenges in pediatric hospitalization units.

Collaborating Across Private, Public, Community, and Federal Hospital Systems: Lessons Learned from the Covid-19 Pandemic Response in NYC

In the spring of 2020, New York City became the epicenter of the Covid-19 pandemic in the United States. During the peak from March 10 to May 1, the hospitals of the Department of Medicine at New York University Grossman School of Medicine — including an academic, private hospital in a community setting, a private hospital, an affiliated public hospital, and an affiliated Veterans Affairs federal hospital — cared for more than 5,000 hospitalized patients with Covid-19. Each hospital encountered unique challenges based on its own resources, affiliations, size, and patient populations. However, with ongoing collaboration, leadership developed protocols applicable across sites. Despite these four hospitals being distinct, these collaborations resulted in many strategies that can be applied to a wide variety of medical centers that must rapidly respond to the unprecedented challenges created by the Covid-19 pandemic. In this article, the authors describe strategies for communication, surge planning, clinical care, and staff wellness.

Harnessing the Power of Hospitalists in Operational Disaster Planning: COVID-19

Hospitalists are well poised to serve in key leadership roles and in frontline care in particular when facing a pandemic such as the SARS-CoV-2 (COVID-19) infection. Much of the disaster planning in hospitals around the country addresses overcrowded emergency departments and decompressing these locations; however, in the case of COVID-19, intensive care units, emergency departments, and medical wards ran the risk of being overwhelmed by a large influx of patients needing high-level medical care. In a matter of days, our Division of Hospital Medicine, in partnership with our hospital, health system, and academic institution, was able to modify and deploy existing disaster plans to quickly care for an influx of medically complex patients. We describe a scaled approach to managing hospitalist clinical operations during the COVID-19 pandemic.