Processes for Converting Pediatric ICU to COVID-19 Care Ward

Converting a pediatric intensive care unit (ICU) to care for adult coronavirus 2019 (COVID-19) patients was successful but not without hurdles, according to an editorial published in The New England Journal of Medicine.

Investigators from the Mass General Hospital for Children in Boston outlined their process for turning the pediatric hospital-within-a-hospital into an adult care ward within 72 hours. They explained that on April 2, 2020, the incident command team determined no pediatric patients would use a ventilator as other facilities had critically ill patients that required ventilators.

The hospital housed 14 pediatric ICU beds, of which 2 children had been admitted but were transferred out. Within 3 days, adult patients were admitted.

“This rapid pivot to providing adult care required cooperation between institutions to regionalize pediatric critical care, difficult discussions with families, and intensive coordination of hospital services,” investigators wrote.

To make this happen, coordination among the state’s 6 children’s hospitals occurred in the form of biweekly phone calls with pediatric intensivists. The volume in pediatric hospitals was low across the board beginning in early March, investigators explained, and they noted their regional competitors, Floating Hospital for Children and Boston Children’s Hospital, had availability and willingness to accept the pediatric ICU patients from the investigators’ facility.

However, they ran into the first hurdle when case managers required preapprovals from each patient’s insurance carrier prior to the transfer. The hospital’s chief executive officer (CEO) called the receiving hospitals’ CEOs to eliminate this barrier and provide assurance of financial coverage should the insurers decide to bill patients. The referral centers were also notified that they would not have a pediatric ICU and were instructed to transport to the other facilities.

Hospital clinicians spoke with their patients with complex, chronic conditions so their care would be continuous and also review any contingency plans. The clinicians contacted subspecialists at other hospitals when assistance was necessary, but their main goal was to ensure that patients did not feel abandoned.

Additionally, children receiving inpatient care for cancers and inflammatory bowel disease were permitted to stay with the caveat that they would be immediately transferred if care escalation was necessary.

Parents with children in the pediatric ICU were eager to leave when notified that the ward would be converted, investigators wrote, and they were not provided with the option to stay.

One of the main questions raised by this conversion was staffing—would the unit employ pediatric or adult medicine clinicians? The pediatric ICU staff advocated to remain in their familiar environment with the hopes of optimizing performance despite caring for a new set of patients.

“We recognized immediate gaps in knowledge and skills related to providing adult critical care and leveraged adult medicine expertise at our institution by establishing a consultative process,” investigators explained, though they noted that the hospital leadership team expanded their emergency credentialing for the pediatric providers.

“Pediatric intensivists and trainees remained the primary providers in the unit, with a medicine resident and adult intensive care unit consultant reviewing patient plans twice daily,” they added.

By keeping the pediatric ICU team in place, the investigators noted a boost in morale and a rapid transition to the adult care ward. By the end of the first week, the ward was full and doubt began to creep in among the staff. By the end of the month, the staff cared for 25 patients of which the majority had COVID-19. Twenty patients had been discharged from the pediatric ICU and 1 died.

As of April 28, the hospital team permitted pediatric patients to return to their designated ICU, though investigators are not sure when they will stop admitting adults.

“Faced with the dual challenges of transitioning from treating children to treating adults and implementing dynamic COVID-19 care recommendations, preserving team composition minimized unnecessary changes to personnel and the environment and was the most important factor in our success,” they concluded. “This experience will undoubtedly have lasting effects and will allow us to practice with increased empathy for all members of our patients’ families.”