Hospital pediatric beds in short supply

After a long hiatus, Dr. Jarone Lee, an emergency and ICU physician at Massachusetts General Hospital and associate professor at Harvard Medical School, resumes his conversation about frontline critical care with Dr. Paul Hattis, a fellow at the Lown Institute who participates in CommonWealth’s Health or Consequences Codcast. 

PAUL HATTIS: It has been awhile since we have talked about COVID-19 and its impact on frontline clinicians like yourself. Since there has been a lot of talk about pediatric care challenges from Respiratory Syncytial Virus (RSV) over the past six weeks or so, it’s a good time to check-in about the current or anticipated burden of caring for hospitalized patients across Mass General Brigham from patients with RSV, plus whatever is happening now with COVID, influenza, and/or other illnesses that could be contributing to bed capacity challenges at your system.

JARONE LEE: Thanks for having me back. I’m happy that we have not reconnected about COVID-19 for a while. Overall, hospitals and emergency departments are full and busy. As reported nationally, the RSV season hit our children hard this year, with many requiring hospitalization. These sick kids filled up pediatric hospital beds and our pediatric ICUs (PICUs) across the nation. Locally, the closure of Tuft’s Children’s Hospital came at the worst time as the uptick in sick kids with RSV came soon afterward. The good news is that RSV season seems to be subsiding and we are seeing a decreasing number of RSV cases daily at our hospitals.

Unfortunately, as RSV cases recede, we are concomitantly seeing increased numbers of adult and pediatric patients diagnosed with influenza. Nationally, the FluSurv-Net, an influenza hospitalization surveillance network, reported that the hospitalization rate for patients with influenza this year is 9.6 times higher than in previous years. The good news is that the overall hospitalization numbers are still low despite the rapid uptrend in cases. As of the end of last week, we had 74 patients admitted with influenza across all nine Mass General Brigham hospitals, with 14 at Mass General. While this is an uptick from prior numbers, the overall numbers remain reassuring from a bed demand perspective. According to the CDC, the flu vaccine this season protects better than most years – with  40-60 percent reduction of flu illness in those vaccinated compared to the unvaccinated—a number as low as 10 percent in past years.  Regardless of these percentages, people vaccinated who get flu develop severe disease and need hospitalization about 35 percent less than those who get flu and have not had the vaccine.

Similarly, new COVID cases are up, but the number that need hospitalization and ICU care is minimal. The flu and COVID data show that vaccines protect well, so I highly recommend that folks get their Bivalent COVID booster and their flu vaccine as soon as possible.

HATTIS: You noted the current and continuing pediatric bed capacity challenge. What is happening right now at other hospitals in the region that do not have inpatient pediatrics or pediatric ICU capacity?

LEE: Pediatric and PICU beds continue to be challenging to find in our region.  Most recently, hospitals with pediatric beds have had to delay elective surgeries. As most acute care hospitals do not have inpatient beds for kids, they traditionally must transfer to other hospitals with pediatric beds—often these days needing to make many calls—including to hospitals far from their location. With pediatric beds full everywhere now, the Massachusetts Department of Public Health has recommended that patients age 15 and older go to adult inpatient units, including adult ICUs, to free up pediatric beds.

HATTIS: What sort of operational impacts is this resulting in at hospitals such as yours?

LEE: At Mass General, we created a system to take 15-and-older patients to our adult ICUs to help our PICU colleagues as we have many more adult ICU beds than PICU beds. Similarly, we also started doing this at Newton Wellesley Hospital. In addition, our Mass General PICU service now runs a telemedicine consult system for any hospital in our system that wants to reach a PICU specialist for these sick kids. The PICU team staffs this service all day, seven days a week, which is above and beyond their normal workload in the MGH PICU.

What has not been fully appreciated by the public is that already the adult side of the hospitals in our region are already at or close to capacity. So even small incremental increases in flu, COVID, or RSV pediatric volume will add to the current capacity constraints.   Furthermore, flu, COVID, and RSV will also lead to additional hospitalizations by adults, especially older adults with co-morbidities. These adults are much more susceptible to getting sick, requiring hospitalization and ICU-level care. For example, I’ve seen many adult patients with emphysema who get the flu and require supplemental oxygen support and hospitalization. The good news is that they recovered because the flu vaccine protected them from severe disease. Regardless, this still means that they will need to take up a hospital bed for a few days, sometimes longer – adding to our full hospitals.

Though we are handling the capacity challenges now, there is worry that if flu and COVID cases build with winter, along with holiday and New Years’ indoor gatherings, a surge of cases could follow and worsening our capacity constraints.

HATTIS: Any thoughts on what you and others have learned during the COVID era that helps with how current illness challenges are being handled either tied to inpatient or outpatient services?

LEE: A silver lining to COVID is that it helped us create systems, plans, and relationships for new surges of patients, regardless of cause. For example, the state still has active regional surge and capacity systems. Hospital leaders regularly communicate across organizational lines to see how they can support each other.

Another example is that we created a Mass General Brigham-wide group to share ventilators and dialysis machines across our region so that no single hospital ran out of equipment. This group continues to meet weekly to work on a number of biomedical/equipment-related issues. This made supporting our hospitals with additional oxygen equipment for the RSV surge streamlined and efficient.

HATTIS: As we approach the holiday season and New Year, anything else going on in your life that ties into COVID issues with your family or with the dedicated work that I know that you and colleagues have been doing to support the life and health of Ukrainian citizens?

LEE: Seeing sick kids is especially difficult. The issue is that we do not know which kids will get very ill from RSV, flu, or COVID, so we were aggressive about ensuring that our son received the COVID booster and flu vaccines as soon as possible.  Unfortunately, after 2 1/2  years of dodging COVID in the hospital, I brought it home to my family. My wife and I were sick for a few days; luckily, our son was only sick for half a day.  The challenging part was that we were still feeling sick when he was back to normal and ready to resume play – with no easy solutions for childcare because of his COVID status.

Another silver lining to COVID is that it showed that telemedicine/digital health works and can increase access to care, especially for specific at-risk populations in remote, rural environments. When the Ukraine conflict started, using lessons learned from COVID, I and two of my colleagues started Health Tech Without Borders, a global non-profit that supports communities affected by sudden humanitarian emergencies using digital health technologies. I’m happy to report that since the start of the Ukrainian humanitarian disaster, Health Tech Without Borders, in collaboration with the MGH Center for Global Health, completed over 61,000 telemedicine consults with Ukrainian families, children, and patients. We never expected such a demand and are at a tipping point now after 10 months of pro bono work, so we are discussing how to become financially sustainable to continue this essential work to help Ukrainian people.