COVID Community Peds

[Perrotfish]

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Just curious, for those of you in rural/community hospitals how are you handling kids who need admission for COVID? Are you keeping the or sending them all out?

Arguments for sending them out:
1) COVID has a history of causing sudden heart failure in previously recovering patients at around 8-14 days of symptoms. If you admit that you are dealing with that without an ICU
2) No one really has experience managing peds vents if that's what they need
3) Transport times are going to be REALLY extended and if you wait until they crump it might be days before you get them out.
4) Children's hospitals will be relatively unimpacted by this crisis and will have more capacity to spare than the community hospitals we work at
5) If we infect our already bare bones physician and nursing staff we could rapidly lose the ability to provide obstetric/neonatal care

Arguments against sending them out
1) The Children's hospitals were already at capacity before this whole thing started
2) Children's hospitals have a dismal reputation when it comes to getting their physicians to push themselves or do more work
3) It strains the local EMS network even more than its already strained
4) It increases the risk of infection spreading within a children's hospital.
5) It just looks bad for one service to be sending all of their COVID patients out.

Thoughts? What would you guys do?

 

[SurfingDoctor]

Just curious, for those of you in rural/community hospitals how are you handling kids who need admission for COVID? Are you keeping the or sending them all out?

Arguments for sending them out:
1) COVID has a history of causing sudden heart failure in previously recovering patients at around 8-14 days of symptoms. If you admit that you are dealing with that without an ICU
2) No one really has experience managing peds vents if that's what they need
3) Transport times are going to be REALLY extended and if you wait until they crump it might be days before you get them out.
4) Children's hospitals will be relatively unimpacted by this crisis and will have more capacity to spare than the community hospitals we work at
5) If we infect our already bare bones physician and nursing staff we could rapidly lose the ability to provide obstetric/neonatal care

Arguments against sending them out
1) The Children's hospitals were already at capacity before this whole thing started
2) Children's hospitals have a dismal reputation when it comes to getting their physicians to push themselves or do more work
3) It strains the local EMS network even more than its already strained
4) It increases the risk of infection spreading within a children's hospital.
5) It just looks bad for one service to be sending all of their COVID patients out.

Thoughts? What would you guys do?

Based on the Italian and Chinese experience, essentially no pediatric patients have required ICU. I mean, maybe there are outliers, but the only ones I’ve heard from Italy are chronic respiratory failure children who would have required specialized ICU anyway. In fact, there’s been difficulty in detecting in pediatric populations in general. Like children with a known exposures testing negative. That’s anecdotal and one could only surmise why, but the effect of this disease specifically on pediatrics seems negligible to non-existent.

Thus far, the only real reason I’ve seen for testing children is source control and cohorting.

Based on the Italian experience, I bet the initial in flux will be from community hospitals who don’t/want to deal with SARS-CoV2 positive patients, until the Children’s hospitals turn into adult isolation/treatment wards at which point their will be refusals and reverse transfers.

 

[BigRedBeta]

Have been on nights this week in the PICU so missed some of the webinars/conference calls about the pediatric data

I'm not aware of any pediatric deaths thus far though.
The real question will be our kids with special needs, though those are also the parents that I expect to take the social distancing to heart the best.

If you are in the community setting, I think it's reasonable to be selfish and focus on what you can control. In terms of your arguments against sending them out...I don't really think any of them are really reasonable:
1) - yes we may be busy, if it's so busy we can't accept, then we'll let you know
2) how is that your issue? If the children's hospitals deem more staff is necessary, they'll figure it out
3) maybe this is true, maybe it isn't
4) Again, how is that really your issue? If I send a patient elsewhere, I expect them to handle their own infection control measures as they see fit.
5) You're worried what medicine or ortho is thinking? If you're worried about administration then you need to sit down with them and work together on what an appropriate plan is.

 

[PTPoeny]

I think it makes sense to transfer pediatric patients. The data so far suggests that there won't be many pediatric admissions for COVID-19. Children's hospitals are likely to be least overwhelmed hospitals in any region if the cases continue expanding exponentially. Transferring the pediatric patients will be a way to free up beds and maintain capacity in the community hospitals for adult patients that might not otherwise have anywhere to go. Also, as alluded to above, at least one hospital in Italy only had pediatric admissions among the chronic trach/vent population which you wouldn't be keeping anyways.

 

[SurfingDoctor]

Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding - Nature Medicine

Children infected with the COVID-19 outbreak coronavirus, SARS-CoV-2, show mild symptoms but prolonged shedding of viral RNA in feces, suggesting that the fecal–oral route might play a role in virus transmission.

www.nature.com

 

[professorjames]

I think transferring them is the smartest. If you don't usually take care of peds or very few, this isn't a good time to practice. And, if they need a higher level of care, they are already where they need to be.

 

[Naruhodo]

Question to the group: I've heard that our 2 semi-local children's hospitals are both discharging as many patients as possible to get down to 70-80% capacity. Do you truly think this is in anticipation that they will need those beds for adults? Or because they are expecting pediatric transfers from community hospitals? I'm just trying to think through whether realistically these hospitals are going to start treating adults without any changes to staffing and given most of the equipment they currently have is geared towards children...

 

[SurfingDoctor]

Question to the group: I've heard that our 2 semi-local children's hospitals are both discharging as many patients as possible to get down to 70-80% capacity. Do you truly think this is in anticipation that they will need those beds for adults? Or because they are expecting pediatric transfers from community hospitals? I'm just trying to think through whether realistically these hospitals are going to start treating adults without any changes to staffing and given most of the equipment they currently have is geared towards children...

It’s based on the Italian experience where Children’s beds became Adult CoVID units. Whether it will actually be needed... it’s probably very geographically dependent. In NYC, sure. In Nebraska, probably not. But I think many people are approaching this as worse case scenario.

 

[mvenus929]

Question to the group: I've heard that our 2 semi-local children's hospitals are both discharging as many patients as possible to get down to 70-80% capacity. Do you truly think this is in anticipation that they will need those beds for adults? Or because they are expecting pediatric transfers from community hospitals? I'm just trying to think through whether realistically these hospitals are going to start treating adults without any changes to staffing and given most of the equipment they currently have is geared towards children...

I live in the midwest. Our children's hospital has two locations in one city; we shut down the inpatient wards in the smaller hospital in anticipation of using that space as a relief for the local adult hospitals. The main location is not anticipating taking adults, but rather accepting more transfers from community hospitals to allow them to focus on adults. Our census is actually way down, but COVID hasn't really hit here yet (I think we've had ~20 cases in the city).

 

[BigRedBeta]

We're at summer census in our ICU at the moment, the rest of the hospital is slower than that with all the surgeries cancelled
There are only a few places with peds floors around town, but yes, leadership has communicated our desire to take their peds patients off their hands to open up space for more adults. Long term plan if needed would be taking non-COVID adults especially those who are younger. Hoping that there would be some readily available IM consultants if it came to that. As an ICU doc, I'd rather be running vents on COVID patients, rather than having to recognize STEMI's

 

[NurWollen]

We're at summer census in our ICU at the moment, the rest of the hospital is slower than that with all the surgeries cancelled
There are only a few places with peds floors around town, but yes, leadership has communicated our desire to take their peds patients off their hands to open up space for more adults. Long term plan if needed would be taking non-COVID adults especially those who are younger. Hoping that there would be some readily available IM consultants if it came to that. As an ICU doc, I'd rather be running vents on COVID patients, rather than having to recognize STEMI's

This would certainly be a chance for any med-peds trained faculty to shine.



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[WheezyBaby]

I live in the midwest. Our children's hospital has two locations in one city; we shut down the inpatient wards in the smaller hospital in anticipation of using that space as a relief for the local adult hospitals. The main location is not anticipating taking adults, but rather accepting more transfers from community hospitals to allow them to focus on adults. Our census is actually way down, but COVID hasn't really hit here yet (I think we've had ~20 cases in the city).

Exact same, except we have a fair amount of covid in the city

This would certainly be a chance for any med-peds trained faculty to shine.



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I'm certainly interested to see what the environment looks like, would be happy to work in that role as needed