A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19

The research settings were 9 PICUs located in 8 cities in the states of Michigan, New York, Massachusetts, Maryland, South Carolina, Arizona, Missouri, and Utah, representing all US census regions. Over-sampling was done of New York, the US epicenter of wave 1 of the pandemic, with 2 PICUs participating. Study hospitals were recruited based on reported PICU repurpose^1–4  and via phone and e-mail correspondence to PICU hospitals across the United States.

A mixed methods (quantitative and qualitative) study was conducted between February 16, and November 10, 2021, with inclusion of all census regions as the epicenter of wave 1 of the pandemic migrated across the United States.

Each of the 9 study site investigators reviewed local hospital data to complete a questionnaire (Appendix 1) designed to inventory key hospital resources and the magnitude of their redeployment.

Descriptive analysis was performed using Stata version 15 (StataCorp), with data summarized as median values with corresponding interquartile (25th–75th percentiles) range (IQR). Resource redeployment (percentage) was calculated as: number redeployed during peak of first wave of pandemic ÷ overall number at baseline × 100.

Eligible study subjects were pediatric intensivists who redeployed to provide care to adults with COVID-19 at the study hospitals. After purposive sampling among eligible faculty who redeployed to provide adult COVID care by the site investigators, semistructured interviews were conducted by the principal investigator (F.O.O.) via a private video interface using a script (Appendix 2) constructed with information from 2 sources: priorities for rapid-cycle research and evaluation projects on COVID-19 from AcademyHealth - the leading US health services research and policymaking organization,⁵  and the authors’ experience during redeployment. The instrument was pilot tested with pediatric intensivists who were neither study participants nor redeployed. Interviews were audio-recorded and transcribed verbatim to enable comprehensive analysis of their content using RevAI, a transcription software program (San Francisco, CA). Thereafter, transcripts were manually reviewed for accuracy by 2 investigators (F.O.O. and A.D.). Each participant received a $100 gift card as a token of appreciation.

Transcripts were imported into ATLAS/ti version 9 (Berlin, Germany) and analyzed by the principal investigator (F.O.O.), with open coding of data and subsequent sorting of codes into meaningful categories. Two coinvestigators (E.C., A.D.), applied codes to the data in 5 of the transcripts and intercoder agreement was determined to be 90%.⁶  On a paragraph-by-paragraph basis, labeled categories from the data were developed following a process of category saturation and relationships between categories were established in an iterative process. The data were arranged into sections for each category with distilled summaries of views and experiences. Thematic content analysis was used to derive themes from the data using an inductive approach. Results of the analysis are presented by domain from the interview guide with report of the number (%) of intensivists who endorsed a concept within each theme. Also, data were summarized as frequency (n) and proportions (%) for interview questions that required numerical responses, such as types of COVID ICU settings, comfort with redeployment, daily unit activities, and decision-making. Finally, all data were interpreted by all investigators. Results are reported using the Standards for Reporting Qualitative Research checklist.⁷  The University Institutional Review Board approved the study.

Nine PICUs within university children’s hospitals that were not free-standing children’s hospitals participated. They had a median of 26 (IQR: 23–28) beds with 1110 (598–1683) children admitted therein in 2019. The PICUs were separate from pediatric cardiac ICUs in one-third of the hospitals, and the average nurse: patient ratio was 1:2 in 8 of 9 (89%) PICUs and 1:1 in 1.

Study hospitals, staffed with a median of 75 (49–83) adult intensivists, had a significant growth in the number of ICU beds to provide care to adults with COVID-19, from a baseline count of 100 (86–107) to 205 (108–250) at the peak of wave 1 of the pandemic. The number of beds did not completely return to baseline after wave 1, with 106 (100–110) beds on average. At the peak of wave 1, there were 241 (155–337) hospitalized adult patients with COVID-19, more than the number of children (18; 0–53) who were concurrently hospitalized regardless of COVID-19 status. At the time of the survey, hospitals were still providing care to 83 (27–87) adults and 1 (1–5) child, on average, with COVID-19.

Resource redeployment across study hospitals included a median of 88% (66–100) of pediatric intensivists, 46% (10–100) of nurses, 90% (0–100) of continuous renal replacement therapy (CRRT) machines, and 72% (0–100) of invasive mechanical ventilators (Table 1). Three of the 9 PICUs were completely repurposed to adult care.

Forty pediatric intensivists from the 9 study hospitals were interviewed. Of these, 36 (90%) trained in pediatrics and 4 (10%) in medicine-pediatrics as their primary specialty. Before the pandemic, they provided care to children and adolescents across a wide age spectrum, with 33 (83%) treating patients up to 21 years, 6 (15%) up to their 20th birthday, and 1 (2%) treating some into their 30s.

Across the 9 hospitals, faculty were redeployed to 1 of 4 models of care coverage: a repurposed PICU (42.5%), a physically separate adult COVID ICU (32.5%), a repurposed PICU and a physically separate COVID ICU (12.5%), or a repurposed pediatric ward (12.5%). Redeployment was abrupt in many instances with 16 (40%) respondents having less than 1 week to prepare, including 6 hours for 1 respondent. Thirteen (33%) faculty had a 2-week lead time before redeployment, whereas 6 (15%) had 3 to 4 weeks to prepare. Most (70%) respondents were not involved in the preparations for redeployment.

Only 10 (25%) faculty felt prepared to staff the adult COVID-ICU, and only 4 (10%) faculty reported having received formal training in adult COVID care. Faculty expressed varying levels of comfort with redeployment: 22 (55%) were uncomfortable, 11 (28%) were comfortable, and 7 (17%) were comfortable with the similarity of physiologic perturbations to that observed in pediatric patients but uncomfortable with the disease, unit culture and unfamiliarity, and patient comorbidities. Despite varying levels of comfort with redeployment, respondents were driven by either a desire to help:

“It was very clear that our adult colleagues needed help and we had to step up and help. And that was it.”

“What I think is the biggest thing is the adults were, I mean, my adult colleagues were, and probably still are, completely overworked and exhausted and burnt out.”

Or respondents were driven by a sense of duty:

“It was not the most fun experience, but I think it was meaningful. And for me, I felt like I needed to do it to sort of fulfill that duty as a physician during a pandemic.”

“I think that’s why we’re here and that it’s part of our duty to serve, and the responsibility we have for the skills and training that we’ve been given.”

Faculty were provided legal coverage for the redeployment according to 26 (65%) respondents, whereas 12 (30%) responded to the contrary, and 2 (5%) were uncertain regarding legal coverage. The duration of redeployment, in descending order of frequency was: 1 to 2 months (42%), 3 months (32%), 4 to 6 months (10%), 1 to 3 weeks (8%), and 9 months (3%). Two (5%) respondents were still redeployed at the time of interview.

Qualitative analysis revealed 5 themes regarding the redeployment experience, including:

how challenging it was:

“I’ve only been out of fellowship for about almost 3 years and it was probably the most difficult 6 weeks I think of my career because I just felt like I didn’t know what I was doing and that’s just not an easy settling feeling for me. It was sad and it was frustrating that I didn’t feel like I was providing the best care.”

the significant difference from routine clinical practice:

“I got plenty of help and we gave our nurses a ton of leeway in terms of adjusting phenylephrine drips or adjusting norepinephrine drips or propofol or hydromorphone or whatever. We gave parameters and they did it. And that’s not the way we generally would practice in pediatrics. We are such micromanagers in the pediatric ICU. We couldn’t function that way because you had to give them parameters for the once an hour when they were going into the room.”

the positive feelings engendered:

“I think that it felt like we were able to help. I think that the whole world around us was exploding and as an intensivist, you suddenly realize like you’re in small company, suddenly like respiratory therapy, ICU nursing and ICU medicine was on the daily news. And I felt like we had a great deal to offer, and we were able to offload our adult colleagues enough to be able to get through. Like we just were able to shore up the system that meant that our patients never reached this level of crisis standards of care and that felt really good.”

the extent of overlap between adult and pediatric medicine:

“I think there were a lot of things that are similar to pediatric patients, and they have a lot of strengths in that ICU that I think that the pediatric ICUs may or may not, depending on where you work. It was just an interesting experience, and I learned a lot.”

the seamless facilitation of patient flow processes by the unit or divisional leadership:

“…There was a kind of staffing call every day between the adults and us. Most of the time, as long as our medical director or our division chair was available, they would help take that call and help screen which patients the adults kind of wanted to offload and do that.”

The majority (87%) of faculty led clinical and teaching rounds and all had ample access to medical subspecialists either pediatric- or adult-focused. Access to ancillary care, including social work, pastoral care, and therapists, was limited per 10 (25%) respondents, but readily available according to others.

Eight (20%) respondents did not institute extracorporeal membrane oxygenation (ECMO) or CRRT in their patients, 16 (40%) used both technologies, and 16 (40%) deployed CRRT but not ECMO. Regarding the existence and use of dedicated procedure teams at their hospitals, 19 (47.5%) respondents acknowledged their existence and used them, 9 (22.5%) were aware of them but did not use them, 11 (27.5%) did not have procedure teams available, and 1 respondent was unaware if they existed.

Thirty (75%) respondents experienced difficulties with decision making often driven by paucity of knowledge about COVID-19. Themes regarding these difficulties, illustrated in Table 2, included: when to escalate care, the jarring difference in clinical practice settings and patient population, self-doubt, end-of-life decision making, and prognostic uncertainty.

Adult intensivists served as consultants (53%), a resource (18%), or coattending physicians (13%), whereas 15% of respondents reported no involvement of adult intensivists. Over half (53%) of the respondents reported inclusion of families in decision making more than half the time, 42% less than half the time, and 5% seldom. Bedside visits were only permitted at end-of-life according to all respondents.

Respondents faced several challenges including unfamiliarity with unit operations and culture (30%), lack of knowledge of COVID-19 (23%), fear of contracting COVID-19 (20%), limited human and material resources (10%), mental and physical exhaustion (10%), and not having family members at the bedside (7%).

Lessons learnt were captured by these themes: interprofessional collaboration, overlap in care, flexibility, altruism, enhanced clinical skills, happiness in being a pediatrician, and attention to detail (Table 3).

Of 35 respondents, only 3 (9%) felt no significant personal toll was incurred from the pandemic, whereas 32 (91%) reported the personal toll in 4 themes: high stress, social isolation, physical and mental distress, and fractured society (Table 4). Despite this toll, respondents described significant increase in not only their clinical but also administrative workload during the pandemic. Four respondents were new faculty who relocated and felt very isolated at work and in the community. Two-thirds of respondents felt supported by their division, department, and institution. All but 4 respondents reported significant negative impact of the pandemic on child health care delivery at their hospital.

Respondents felt that preparation for future public health emergencies (PHEs) should entail strategic foreplanning, development of a robust supply chain, rapidly adaptable health systems and ensuring autonomy and protection of children’s hospitals to ensure child health care delivery is not compromised (Table 5).

All respondents were willing to redeploy again to take care of adults with COVID-19 if asked.

The redeployment of pediatric-focused resources to the care of critically ill adults during wave 1 of the COVID-19 pandemic was abrupt and significant in magnitude. Driven by a massive surge in hospitalizations for adult COVID care, there was substantial redeployment of PICU beds, technology, including ventilators and CRRT machines, and human resources including faculty, respiratory therapists, nurses, advanced practice providers, and trainees.

Redeployment of pediatric resources was made possible by low in-hospital census at the children’s hospitals and cancelation of elective surgery. On average, nearly 22% of general care ward beds were repurposed for adult COVID care. Certain technologies, such as high flow nasal cannula devices and noninvasive ventilators were seldom redeployed, likely reflecting their limited use early in wave 1 of the pandemic. This practice was likely buoyed by recommendations against the use of noninvasive ventilators, given concern for aerosol generation.⁸ 

The rapidity of redeployment of resources from the study hospitals was likely bolstered by their proximity in space and relationship to adult-focused hospitals to which the resources were relocated. This proximity could be capitalized upon in the future by coordinated efforts at cross-training of clinical staff to provide care across the age spectrum as recommended by respondents; this would be a novel and important ingredient for future planning for PHEs.

Of note, proximity to adult hospitals might not be always salubrious to children’s hospitals if child health care delivery services are compromised or lost, as occurred at some of the study hospitals. This cautionary note is important given the potential for sustained downturn in patient census and loss of child health care services beyond the duration of the event that triggered the resource-diversion.

In preparing for future PHEs, it is important that processes of care, designed in collaboration with frontline workers, are put in place at hospital and regional levels. This inclusive approach will likely enhance the creation of methodologically robust and easily operated clinical processes, unlike what occurred early in the ongoing pandemic.⁹  The families of the critically ill should be included in such planning as they carry the burden after hospital discharge and their presence can be salutary to patient outcomes.¹⁰  Study respondents recommended strategic foreplanning with a clear process to ensure enduring cross-trained staffing models and event simulation, development of a robust supply chain with efficient and equitable distribution of human and material resources, and creation of rapidly adaptable hospital operations. These recommendations, in retrospect, might have addressed concerns expressed by over 4800 US critical care professionals who responded to a survey at the outset of the ongoing pandemic.¹¹  Approximately two-thirds of respondents believed their ICUs were inadequately prepared to treat COVID-19 patients and 94% anticipated ICU personal protective equipment (PPE) shortages with ongoing use at the time.¹¹ 

Redeployment of pediatric intensivists to provide care to adults with COVID-19 triggered several concerns for many respondents, including their ability to appropriately care for critically ill adults and lack of familiarity with the space and personnel in the COVID ICU, likely stressors aside from the abrupt transition to a new practice environment. Cross-training and simulation of events across pediatric and adult ICUs would ameliorate the unfamiliarity with critically ill adults and with the culture and operations within the ICU of redeployment. Respondents felt event simulation should be an ongoing experience given the laborious, distressful, and often patient-endangering experience of donning and doffing PPE and having to consciously desist from running headlong into patient rooms in an emergency without appropriate PPE. Importantly, faculty with dual adult and pediatric critical care training recently provided important clinical pearls to aid in the care of adult patients with COVID-19¹² ; this could serve as a primer for structured programs of interprofessional training and preparedness for future PHEs.

Respondents advocated efficient and equitable distribution of human and material resources to various clinical settings to optimize workflow and patient care in future PHEs. A prior report¹³  suggested that coordinated planning for PHEs at the regional level might enhance equitable distribution of resources and avoid the shouldering of the burden by individual hospitals.

Findings of similar immediate outcomes of care delivered in the traditional adult ICUs, versus expanded ICUs (including repurposed PICUs) in New York,¹⁴  are likely to assuage concerns regarding outcomes of adult COVID care delivered by pediatric instead of adult intensivists. Ethical concerns raised about the care of critically ill adults by pediatric intensivists and the redeployment of resources from children’s hospitals to adult care are also worthy of note.^13,15,16  Given the suddenness of the pandemic, however, there was little time for hospitals to adequately prepare and redeployment was deemed appropriate to provide care to adults who were disproportionately afflicted during wave 1. At the individual level, pediatric intensivists had to balance their personal burden of providing care out of their normal scope of practice with the community-level benefit that accrued from providing care to a large population of sick adults and mitigating burnout in their adult counterparts.

Although concerns regarding legal coverage for redeployment were not uppermost in the respondents’ consciousness as many felt state governments had permitted such redeployment given the dire circumstances, planning for future PHEs should incorporate documented legal coverage that is known to those who redeploy. Heartwarmingly, all respondents would accede to requests to redeploy in the future as a sense of professional duty and obligation.

In addition to the burden of caring for a new population, respondents described the personal toll incurred from the pandemic as significant, including stress, social isolation, physical and mental distress, and exhaustion, corroborating prior literature.^17–21  Concerted efforts by institutional leaders to ensure well-being of health care workers is important during a PHE. A model program created to address negative effects of the pandemic on the well-being of faculty has been described.²²  It was instructive to learn that respondents greatly appreciated the efforts by ICU leaders to ensure smooth workflow during the redeployment period. Leadership is critical during PHEs and communication about plans and workflow needs to be measured and well-paced.²³  Corroborating prior literature,^4,24  several respondents also commended their leaders for keeping them in a repurposed PICU rather than relocating to an unfamiliar environment.^4,24 

The study findings should be interpreted in light of certain limitations. The study was conducted 10 months after the onset of the pandemic subjecting the findings to recall bias. It was, however, important to delay the study till the pandemic spread to all census regions to enhance the external validity of the findings. Also, pediatric intensivists face end-of-life and other serious clinical scenarios often in their daily work so forgetting the important events surrounding the redeployment is very unlikely. The full extent of redeployment of pediatric resources at children’s hospitals in the United States is unknown, however, this limitation to the generalizability of the reported findings is likely mitigated by including hospitals across all census regions. The findings are descriptive and hypothesis-generating in nature. The interactive and open-ended nature of the interviews, however, made it possible to obtain in-depth and experiential information on an unprecedented event that may generate hypotheses for future studies regarding response to PHEs.

Though prior reports described the process of reconfiguration of space into a COVID ICU, including PICU repurpose,^24–28  and highlighted critical steps to ensure the successful launch of such units, this is the first study to explore the in-depth experience of pediatric intensivists who redeployed as frontline care providers, providing a rich overview of the experience with insight into the daily workings in units rapidly created to provide care to an unfamiliar critically ill adult population with an often lethal disease.

Pediatric hospital resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.