Research shows that many hospitals in the United States are not fully prepared to deal with a surge of sick children.
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John Moore/Getty Images
Research shows that many hospitals in the United States are not fully prepared to deal with a surge of sick children.
John Moore/Getty Images
“Dad, I can’t breathe.”
That’s how Dr. Marc Auerbach’s 8-year-old son woke him up one night last year.
Their family was vacationing in the Adirondacks in upstate New York, a few hours from Yale New Haven Children’s Hospital, where Auerbach works in pediatric emergency medicine.
Like so many parents whose children are seriously ill with respiratory syncytial virus (RSV), Auerbach recognized the high-pitched, hissing whistle his son was making. It was a sign that his airways were obstructed. He knew they needed to get to the nearest emergency department immediately.
But as Auerbach loaded his son into the car and began driving down the dark mountain roads, he was unsure if the local emergency service would be fully equipped to treat his child.
“I was quite nervous as a pediatric emergency doctor,” he recalls. “Honestly, am I going to have to fix it myself? Are they even going to have the equipment?
These days, staff at many children’s hospitals breathe a sigh of relief. The surge in childhood illnesses during the fall and early winter – propelled by a tidal wave of common insects like RSV and influenza – has faded. But for parents who waited hours, if not days, for their child to get a hospital bed, one thing became clear: there simply wasn’t enough.
Even during the best of times, children’s hospitals can find themselves stretched thin, due to years of cutbacks and an ongoing healthcare workforce crisis. And experts say this latest season revealed what happens to America’s healthcare system when there’s a major crisis of critically ill children.
“During a power surge, when [patient] volumes can double or even more in some communities, leaving a gap — a major gap,” says Dr. Larry Kociolek, medical director of infection prevention and control at Lurie Children’s Hospital in Chicago. “And the children suffer the consequences.”
Many emergency departments are unprepared to deal with children
Auerbach had reason to be wary of taking her child to an unfamiliar emergency department.
He knew that the survival rate of a child is four times higher in an emergency department well prepared to care for seriously ill children. And he knew that too many emergency services were insufficient.
In fact, emergency services receive what is called a “Weighted Pediatric Readiness Score.“It is a way to assess whether a service has the appropriate equipment, staff, training policies and patient safety protocols to care for critically ill and injured children.
According a 2015 analysisthe median score is equivalent to a D.
A study published earlier this year, examining nearly 1,000 emergency departments, found that more than 1,400 child deaths could have been prevented over a six-year period, had every department been properly prepared for pediatric cases.
Auerbach points out that most children receive good care – and parents shouldn’t hesitate to bring their children in in an emergency – but the reality is that children “were not at the center” of the emergency system. of the country as it develops. In general, emergency departments treat many more adults than children.
While children make up 30% of all ER visits in the United States, most of them are seen in emergency departments that care for fewer than 15 children per day. That’s why many end up transferring children to children’s hospitals, which have the resources to treat children in critical condition, Auerbach says.
But during this latest wave of illnesses, these specialist hospitals were quickly overwhelmed. “We were seeing that a patient who might need urgent interventions was now waiting for those interventions, sometimes six, eight, 12 hours in this community [emergency department] tuning,” says Auerbach.
A wave hits after years of cutting pediatric beds
During the fall and winter, some children’s hospitals lined patient rooms and stretched their limited staff and equipment – all in a desperate attempt not to turn children away. But they couldn’t undo the years of underinvestment that had reduced the country’s supply of pediatric beds and trained staff.
Between 2008 and 2018, American hospitals reduced nearly 20% of pediatric hospitalization units (i.e. departments with more than one pediatric bed, such as pediatric intensive care units.) The number of children’s beds has fallen by almost 12% – and many of the remaining beds are now concentrated in urban areas, making it even more difficult for rural families to access care.
Finances – more than anything else – had driven hospitals to cut pediatric care; hospital beds with children don’t make as much money as adult beds. For example, more than one in three children are covered by Medicaid. And while the Medicaid reimbursement rate for hospitals varies widely by location, it can often be lower than what hospitals get by caring for an adult who has health insurance or commercial insurance.
“Adult care is often more complex, more chronic, may involve more medication…[and] could be more lucrative,” says Auerbach.
This is not lost on hospital administrators, says Kociolek.
“This [financial] the margin is higher [for hospitals] if you preferentially invest in adult health care,” he says. “While the adult healthcare community stands to benefit, the pediatric healthcare community is being left behind.
How will it go next time?
It’s unclear if hospitals will see a repeat of this final season anytime soon, says Dr Kris Bryantpediatric infectious disease specialist at Norton Children’s Hospital in Louisville, Kentucky.
“But I suspect all of these viruses will continue to circulate and cause their own flare-ups. And if they all happen at once, we’ll be in a rush for beds again,” she says.
Infants are at particularly high risk of severe RSV, but Kociolek says the fact that older children were also getting very sick has put additional pressure on the healthcare system.
“Children aged two to three with RSV were faring much worse with this virus than they would have in 2018 or 2019,” he says.
That could be because those toddlers hadn’t been exposed to RSV and other common viruses after a year or more of social distancing and pandemic precautions, Bryant says. “We’ve had a few years where we haven’t seen a lot of respiratory virus circulation.”
So while next fall and winter may look different, Bryant says the healthcare system needs to take action now to prepare.
She says getting more children vaccinated is one way to keep children out of hospital. “If we don’t increase the number of children immunized, we will see outbreaks of vaccine-preventable diseases,” she says, citing the recent measles outbreak in Columbus, Ohio which sickened nearly 100 children and hospitalized more than 30.
In the meantime, better treatments are also on the horizon: the Food and Drug Administration could approve Pfizer RSV vaccine later this year, and other antibody therapies are likely to become more widely available.
But ensuring children receive the best possible care will also require big systemic changes. “I don’t see how our pediatric healthcare system can be sustainable without major financial reforms,” Kociolek says. This includes changing the way pediatric care is reimbursed, making it more affordable for medical students to choose a career in pediatrics, and investing more hospital resources in child care.
In the meantime, community hospitals and small emergency departments can essentially serve as “lifeboats” that help out during a storm, Kociolek says. For example, in the past wave, some children’s hospitals used telemedicine to offer virtual services, 24 hour support to rural or smaller hospitals and emergency departments.
And emergency departments don’t have to invest in expensive specialists or add pediatric beds to be better prepared to treat critically ill and injured children. Most emergency physicians already have significant training in pediatric care, Auerbach says. Often the biggest improvement comes from designating a member of staff to be the pediatric care coordinator – someone whose job it is to ensure that every aspect of emergency care, disaster drills equipment checks, is done with the kids in mind.
Much to Auerbach’s relief, the New York field hospital where her son was being treated had taken such action. It had partnered with a large teaching hospital and had the right equipment, the right policies, the right staff training, to care for seriously ill children.
If every ED was like this, he says, it could save the lives of thousands of children.
“They quickly assessed him, [and] began very appropriate respiratory and medical treatments,” says Auerbach. “And after about six hours of watching, we were able to stop at Dunkin Donuts on the way back and come see his mother and brother.
