Caring for Patients in Inpatient and Outpatient Settings During Episodes of Surge

Overview

The American Academy of Pediatrics (AAP) strongly supports the uninterrupted care of children during surges in patient volume and acuity created by infectious disease outbreaks, including COVID-19, influenza, and respiratory syncytial virus (RSV) as well as the continued crisis in mental health to ensure timely access to care and optimal care outcomes. Enhancing both capabilities and capacity for emergency readiness on a day-to-day basis in all settings is the first step toward operational preparedness and resiliency to accommodate for daily, weekly and seasonal variations in patient volumes. Readiness preparations must consider the physical and mental health care needs of children of all ages, including children with special health care needs. The AAP recognizes that many areas of the United States have experienced and continue to experience surge episodes attributable to infectious disease outbreaks and local large-scale crises. It is also well understood that existing health disparities are often further magnified during surge events. This document provides a framework of prevention strategies as well as proactive planning to guide efforts for continued surge response and additional preparedness, focusing primarily on responses that can be readily implemented.

Patient volume or disease prevalence surges are common occurrences in pediatric care. Seasonal viral outbreaks, such as those attributable to influenza or RSV, typically occur annually, and pediatricians and children’s hospitals are generally able to anticipate and respond to these events when they occur. The COVID-19 pandemic, the increase in other pediatric respiratory disease, and the continued pediatric mental health crisis have resulted in an extraordinary surge in health care demand of unpredictable severity and duration. There have been substantial increases in morbidity and mortality seen across multiple “waves” of illness, as well as unprecedented stresses on health care workers and support structures. This stress on health care systems and providers, patients and families can be overwhelming when simultaneous outbreaks of multiple diseases occur, with the potential for impact on access to both routine and acute care.

Surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal variations in operating capacity. Surge capability refers to the ability to add specialized medical services for unique patient populations, such as children, that may not be routinely available in all facilities under normal operating conditions. Surges may require alternate care processes and additional resources to meet the demand for services. Critical surges may require consideration of contingency plans, which typically require activation of incident command systems and alternate care standards. Surges that exceed the additional capacity of contingency planning may require implementation of crisis standards of care. During a public health emergency, surge requirements may extend beyond direct patient care to include access to medications and vaccines, availability of pediatric equipment, as well as laboratory screening or epidemiologic investigations.

Planning should include readiness for increased numbers of patients seeking care, whether caused by COVID-19, other communicable diseases, mental and behavioral health challenges, local large-scale crises or the many other concerns prompting patients to seek care. As seen during the COVID-19 pandemic, active response must address ongoing shortages of health care staff, financial stresses on health care systems and pediatricians and supply chain issues affecting needed medications, equipment and supplies. Ongoing collaboration among community and regional partners is necessary to address the current surge of patients requiring care, as well as consideration of situations that could lead to further increases in patient volume or acuity.

All Settings

The following are concerns common to pediatricians in all settings:

• Uneven distribution of pediatric services is common, in part because of the concentration of advanced care in centralized children’s hospitals, with varying degrees of pediatric services available within community practices and at community hospitals. For some communities, access to certain services has been further challenged as many community hospitals have closed pediatric inpatient units, reducing availability of care. This is especially problematic in under-resourced communities, further worsening existing inequities in care and outcomes. Equitable access to care requires regional coordination of services, beginning with an inventory of available facilities followed by the development and testing of protocols for utilizing all available services to the greatest level of equity and efficiency in the event of a surge in need. This regional planning should not occur from the top (children’s hospitals) down; rather, it should be the product of discussions and information sharing facilitated by regional leadership (eg, departments of health, health care coalitions, disaster coalitions or Emergency Medical Services for Children state partners) and include all participants in the area. Surge planning at the local or regional level that includes consideration of the unique needs of children will benefit from the participation of pediatric clinicians. This planning would also include protocols for transitioning children to either lower levels of care or long-term care facilities, as appropriate, during their recovery phase.
• State and regional variation. The recommendations and mechanisms for patient testing and treatment may vary by state or region. Be aware of current local/state public health guidance on tiering of testing and treatment, particularly for high-risk patients.
• Even during times of surge, other routine pediatric care cannot be neglected. Neglecting routine care and chronic disease management, as well as delaying immunizations, which serve to prevent outbreaks of other communicable diseases, can lead to further volume surges, continuing to stress an overloaded pediatric health care system. If availability of services such as well care and immunization, mental health care, subspecialty referrals and elective surgeries and procedures must be limited, these services should be prioritized and made available to the most vulnerable populations. Families should be included in discussions about the need for delays in care when these choices need to be made.
• Staffing is critical. Ongoing shortages of pediatric health care staff have intensified during the pandemic, and recruitment of new staff and cross training of existing staff may be needed to ensure adequate staffing levels. The exclusion of infected staff members from health care settings may produce additional strain on the remaining staff. The CDC updated guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 and Strategies to Mitigate Healthcare Personnel Staffing Shortages balances managing the burden on the health care system, particularly during surges of SARS-CoV-2 and other infections, while protecting those who work with high risk and/or immunocompromised patients. Pediatricians, pediatric medical subspecialists and pediatric surgical specialists may also face the additional demands of providing expertise to public health agencies, health care coalitions, schools, community hospitals and others. In addition, increased levels of patient acuity may cause mental and emotional stress for health care workers. Availability of mental health care and support should be ensured for all staff, especially those on the front lines.
• Maintain vigilance on infection prevention protocols. All clinical and office staff should be up to date with current COVID-19 and influenza vaccines, and all should adopt and demonstrate compliance with infection prevention and control (IPC) procedures. AAP interim guidance on the use of PPE and Occupational and Safety Health Administration (OSHA) requirements for the protection of office workers should be followed. Specific to PPE shortages, allocation of limited resources should be managed in compliance with state and local public health guidance. Requests for testing related to surge may increase the need for diagnostic testing for a variety of reasons. The need for testing supplies should be anticipated, and these supplies should be made available for point-of-care use and/or for sending specimens to a reference laboratory. See AAP Guidance on Face Masks and CDC information on infection control for recommendations on use of masks and other source control methods.
• Mental health needs are increasing. The mental health and wellness of pediatric health care workers should be supported. Health care settings are encouraged to incorporate wellness into staff initiatives/meetings/work flow and to increase mental health screening and support for patients, families, clinicians, and other staff. Health care settings are also encouraged to maximize mental health supports for patients and families during or after disaster events and maintain updated awareness of available community resources given the increase in visits for emotional and mental health concerns.

Ambulatory Care Settings

As with any infectious disease, the ambulatory care setting (office, clinic, urgent care) is often the first place affected by a patient surge. Ideally, many children with suspected COVID-19 or other respiratory viral infection or mild, confirmed disease can receive triage and initial care in the medical home (see AAP interim guidance on Providing Acute Care in the Ambulatory Setting during the COVID-19 Pandemic). Referral to hospitals, especially hospital emergency departments (EDs), should be reserved for those children whose illness severity or associated medical disorders require a higher level of care to avoid ED overcrowding, extended patient waiting times and delay of care in those facilities. Ambulatory care pediatricians and other clinicians caring for children should remain current with disease prevalence, incidence and severity in their communities. Maintaining situational awareness of the operating conditions (eg, overcrowding, patient boarding, waiting times) within local EDs is essential for effective referral practices and optimizing care.

Unique Challenges

• Ambulatory settings and EDs may experience challenges related to limitations of staffing, space (ie, limited room availability, location other than ground floors making outdoor visits difficult), medications and supplies (ie, oxygen, syringes and needles).
• Routine referral practices during normal operations (ie, transfer of children to an inpatient setting) may be disrupted because of limited ambulance availability or limited access to staffed inpatient beds.
• Increased acuity of patients and increased volumes of non-infectious concerns may also occur.
• Staff shortages and hiring challenges have contributed meaningfully to reduced capacity and capability.
• Increased office volume attributable to other pandemic-related responses in the ambulatory setting may further impact practice workflows and stresses.

Materials and Equipment

Having appropriate supplies for pediatric patients is critical.

• Ensure adequate personal protective equipment (PPE) for staff and patients. Maintain appropriate supplies and anticipate the need to order supplies in advance or extend the use of existing supplies.

Space

The AAP supports the continuation of routine well-child care and vaccination during the pandemic and times of anticipated and unanticipated patient surge.

• To safely care for patients and reduce the risk of disease transmission in the office, all patients should be screened for symptoms. Sick patients should be separated from children seeking well-child care. This cohorting can be accomplished through scheduling modifications or separating patients spatially, such as placing patients seeking care for illness in different areas of the primary care clinic, outdoors or in another location away from patients in the facility for well visits.
• Communication/messaging and plans for management of pediatric illnesses as well as vaccination recommendations for COVID and influenza should be developed in advance of the need.
• Clear communication regarding infection prevention control expectations for staff and patients/families.

Staff

A surge in patient volume impacts all ambulatory care staff.

• Options for enhancing staffing should be assessed and planned for prior to need.
• The ability to expand patient care capacity can assist with surges in patient volume, yet this approach may be limited by the availability of space, staff and clinician resources. Expansion of care hours should only be undertaken with consideration of staff availability and clinician workload limits.
• Pediatricians may be asked to provide expertise in a variety of settings, including but not limited to public health agencies, health care coalitions, schools and community hospitals. Pediatricians should be aware of the requirements for emergency credentialing privileges.
• The use of telehealth care may allow shifting of less acute care to a time when pediatricians and pediatric clinicians are removed from in-office stresses. This may serve to increase capacity for both routine and acute illness visits. Telephone advice lines, using appropriate protocols, can also reduce the time burden on pediatricians. Providers should keep abreast of state and local telemedicine regulations and be cognizant that guidelines may change during critical surge events that could impact ED referrals.

Structure

• Optimize the use of telehealth visits for conditions as appropriate.
• Develop and utilize mechanisms for patient referrals, testing and treatment that cannot be performed in the ambulatory clinic. When testing or treatment resources are overwhelmed, understand local/state public health guidance on tiering of testing and treatment for high-risk patients.
• Increase communication with families: utilize nursing staff to provide clinical advice and encourage the use of asynchronous communication methods such as web-based patient portals for nonurgent communications. Ensure that staff engaging with patients/families are aware of local surge conditions and alternate treatment options, such as being seen in the medical home or by remote visits, to avoid further overloading the ED.
• Use social media to communicate on practice updates such as wait times and appropriate use of other health care settings (urgent care, retail clinics, hospital EDs) and to convey public health information including IPC measures, vaccination and medical countermeasure guidance.

Community Hospitals

Unique Challenges

• Many community hospitals may not care for large numbers of children, including inpatients, during normal operating conditions. Community hospitals may need to prepare to care for more pediatric patients during a surge and should have plans in place to provide staff and space to care for children when needed.
• The recent pattern of community and even some academic hospitals reducing or eliminating pediatric services may further exacerbate shortages of care options and place added burdens on tertiary-level children’s hospitals. It should be noted that these closures are disproportionately occurring in already under-resourced areas, producing further health inequity.
• Routine referral practices during normal operations (ie, transfer of children to a pediatric facility) may be disrupted.
• The pandemic-related adult patient surge reduced pediatric care capacity and capabilities for many community hospitals. Some hospitals have not restored their pediatric care capacity and may not return to providing pediatric care.
• High census at tertiary centers and limited access to interfacility transport has resulted in increased length of stay at referring hospital EDs.
• As more community hospitals are providing prolonged care for children with respiratory illness, these hospitals may require additional equipment, clinical care guidelines or staff education on managing advanced respiratory support, if these children are unable to be transferred to higher-level care facilities.
• Increased load of acutely ill patients may require limitation of non-urgent surgery and procedures because of space and staff limitations.

Materials and Equipment

• Ensure that pediatric equipment, supplies, and medications for all ages of children and adolescents are available in the ED and other settings providing care to pediatric patients. See National Pediatric Readiness Project Toolkit, developed through the EMSC Innovation and Improvement Center, of which the AAP is a partner.
• Consult with hospital incident command leaders and regional health care coalitions to develop strategies for obtaining pediatric supplies and conserving PPE and critical medications.
• Consider supplies/assistance needed to support telehealth, such as reliable Wi-Fi, tablets or mobile computers and technical support.

Space

• Consider the family-centered care model that would work best in a facility during a surge. Optimal care of children, even during a pandemic, requires the presence of at least 1 parent or family member at the bedside. This might mean keeping families together (especially if several members of the family present with potentially the same type of illness) or separating the treatment of children from adults. Partnering with families may help to reduce the care burden on limited numbers of hospital staff.
• Coordination with the child’s medical home, as well as utilizing home health care programs and other community supports, will help with transitioning children out of acute care settings.
• Coordinate with adult services that can potentially provide care to older adolescents.
• Be prepared to provide pediatric patients access to adult inpatient beds when there are no pediatric beds. This will include being prepared to provide either pediatric-trained staff or oversight by pediatric-trained staff to care for children

Staff

• Review staffing guidelines in advance to ensure the capacity and capability to ramp up and address surges as they occur. Plan for circumstances when staffing becomes limited.
• During times of high SARS-CoV-2 and other pathogen transmission, ensure staff have access to necessary PPE and understand expectations related to use of PPE (ie, which settings require use of masks and other PPE) and other infection prevention and control risk mitigation measures.
• Encourage staff to seek and maintain pediatric training (ie, Pediatric Advanced Life Support [PALS], Certified Pediatric Emergency Nurse Specialization) and ensure they are comfortable caring for children. Consider conducting pediatric disaster simulations/exercises involving scenarios with staff that include ill or injured children.
• The presence of a nurse and/or physician serving as a hospital’s pediatric emergency care coordinator can serve to improve both readiness for day-to-day pediatric emergencies and disasters.
• Utilize pediatricians in advisory roles for the hospital’s incident command structure and for hospital-wide planning and response for pediatric surge and in the development of alternate and crisis care standards.
• Ensure staff have access to up-to-date evidence-based pediatric management guidelines on critical topics (such as COVID-19 immunization, multisystem inflammatory syndrome in children (MIS-C), RSV/palivizumab, and use of COVID-19 therapeutics) or pediatric subject matter expert consultation, as well as guidelines for more common pediatric illnesses, such as influenza and bronchiolitis.
• Engage with the local pediatric community as a potential resource for acute staffing needs.
• Ensure that those providing telemedicine are properly credentialed and aware of local regulations.

Structure

• Develop a telehealth/pediatric consultation process or policy for higher acuity ill or injured children presenting to the hospital ED or for those requiring admission to an inpatient care unit. This consultation resource will be especially important when caring for children who require higher levels of care but cannot be transferred. See the AAP policy on Telehealth: Access to and Quality of Pediatric Health Care.
• Review or develop interfacility transfer agreements and guidelines that detail the policies and procedures for patient transfer to other hospitals. The creation of robust transfer agreements including patient communications and bi-directional transport options with local or regional tertiary or children’s hospitals is particularly beneficial before a surge.
• Confirm potential transfer sites outside typical referral patterns and best means of communication. Include payers in these arrangements to ensure that payment will be received for transfers to higher-acuity facilities as well as back transfer to lower-acuity facilities after illness severity abates.
• Explore potential mutual support relationships with similar hospitals within the same region and develop pathways for lateral transfers to optimize capacity and to relieve overcrowding. 
• Consider credentialing requirements to support telehealth options within and across state lines and related payment.

Children’s Hospitals and Pediatric Tertiary Care/Critical Care Facilities

Unique Challenges

• Pediatric tertiary care/critical care facilities typically operate at high baseline inpatient bed and intensive care unit (ICU) census and, therefore, have limited surge capacities. This capacity has been further affected by staffing (nurses, therapists, etc) and pediatrician shortages and by reduced availability of pediatric services at community-level facilities.
• There is a potential need for triaging resources and ethical considerations for prioritizing care under crisis care conditions. Crisis care standards are necessary and are best considered and vetted with key stakeholders in advance of their need. Consider the HHS guidance from the Office of Civil Rights when developing or accepting crisis care standards.
• There are individual needs of children with medical complexity that may exceed intensive care unit surge capabilities.
• Collaboration in planning with community ambulatory care settings is not always easy to achieve, yet these efforts are critical.
• There is an economic impact of the ongoing pandemic and staffing shortages on pediatric tertiary institutions and health care professionals/staff.

Materials and Equipment

• Consider clinical guidelines and conservation strategies for highly utilized medications (ie, oxygen, sedation medications, antimicrobials), testing materials, and PPE.

Space

• Utilize clinical spaces first as alternate care sites; consider creating alternate care sites (ie, parking lots, conference space) for routine care, vaccinations, testing or care of children with low-acuity illnesses.
• To improve efficiency, consider availability of negative airflow rooms in alternative care sites.
• Consider transferring children back to their local community hospital or other lower-acuity facilities once acute issues are resolved to allow for beds at higher-acuity facilities to be optimally utilized.
• Coordination with the child’s medical home, as well as utilizing home health care programs and other community supports will help with transitioning children out of acute care settings.

Staff

• Ensure pediatric staffing. Plan and train for alternate and crisis care standards.
• Identify providers who may have overlapping roles and may be able to help during a surge (such as med-peds nurses, respiratory therapists, hospitalists, advanced practice nurses or other staff who can assist with care in the ICU, ED, inpatient settings and other areas of need).
• Seek out and cross-train staff who normally care for adults to prepare them to provide care to pediatric patients. Staff with experience providing care to children during previous COVID-19 pandemic or other surges can be particularly helpful.
• Recommend that pediatricians are involved with the hospital/health care system ethics committee and in policies/decisions for resource allocation, and inclusion of children in crisis standards of care at the community/regional level.

Structure

• Have a process or policy on how to triage and transfer children to other facilities, addressing under what conditions children will need equivalent care versus a transfer to a community hospital to increase pediatric intensive care unit (PICU) capacity. Leverage community pediatric hospital beds to allow for the care of near-critically ill or critically ill pediatric patients at tertiary pediatric centers.
• Have a policy in place for allocation of scarce resources including prioritization of children with high-risk conditions for access to testing and treatment.
• Implement processes supporting more timely inpatient bed placement for ED patients and interhospital transfers as well as processes that reduce inpatient length of stay.
• Work with other regional pediatric tertiary centers to maximize shared inpatient care and critical care capacity and interhospital transport resources by developing a regional system for triage and referral. Establish and maintain open lines of communication with nearby pediatric centers to allow for timely load-balancing and mutual aid.
• Consider alternate care standards and staffing models that allow for the expansion of inpatient unit capabilities toward maximizing ICU access for the sickest children.
• Collaborate with regional community hospitals, and community pediatricians to enhance their pediatric care capabilities and capacity. This is an opportunity to leverage training and telemedicine as an asset. This planning should include mental and behavioral health.
• Connect with local or regional health care coalitions and local or county public health departments and community-based pediatric providers for situational awareness and feedback on pediatric surge planning-related policies and procedures.
• Collaborate with the department of health, local health care coalitions and the medical home in messaging to the public.