Nurses caring for children nationwide witnessed major changes in pediatric care delivery because of the pandemic.
These changes include adapting to new hospital policies and communication and staffing models according to a study published October 11 in BMC Health Services Research.
The findings of the study can help guide hospital leaders in navigating the pandemic recovery and addressing future crises, the authors wrote.
2020: Catching Flaws in the System
Researchers interviewed a mix of administrators, front-line physicians, nurses, and parents from unidentified pediatric care and community hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates during the pandemic’s onset in 2020.
Analyzing the data from interviews with 30 participants at 12 hospitals, researchers found how leaders quickly changed hospital policies. Some set up command centers staffed with hospital leadership. Researchers also found that changes were facilitated by reviewing the data often and engaging stakeholders.
“We stood up a COVID command center in 2020 with the initial outbreak and in 2021 when we saw the increase in the Delta wave. We met every day at 9 [a.m.] and huddled …,” said Laurie Schulenberg, MPA/HCA, BSN, RN, NEA-BC, Interim Chief Nursing Officer at Children’s Hospital New Orleans. This facility had the highest rate of pediatric COVID-19 patients in the country during the summer of 2021, according to Schulenberg.
Nurses, including the planning chief and nursing supervisor, talked daily with other hospital leaders for updates on the hospital’s COVID-19 census, how many COVID-positive kids were in the emergency room, and how to address challenges, Schulenberg said.
“We had already come up with ideas in 2020 for the rare kids that we had with COVID — things like putting the IV pumps outside of the rooms [and] making sure we had enough negative pressure rooms,” she said.
While these command centers helped hospitals to make changes, they also served to expose process flaws. For example, the increased use of telehealth and videoconferencing in 2020 benefited physical distancing but created unique communication challenges with non-English speakers, according to the study.
“The COVID-19 pandemic resulted in widespread adoption of telemedicine, and in the inpatient setting, phone and video interpretation with reduced use of in-person interpreters to promote physical distancing,” study author Nicole Penwill, MD, MPH, FAAP, a University of California San Francisco (UCSF) Pediatric Hospital Medicine Fellow.
Several clinician participants in her study described added challenges and reduced communication quality using remote interpretation services.
“One participant described the notable challenge of trying to obtain a detailed medical history while wearing an N95, the air filtration machine running in the background, and over an interpreter,” Penwill said. “Some participants described growing comfort [and] familiarity with using remote translator services over the course of the pandemic and expansion of communication technology services at their hospital.”
Restricting visitors can be more challenging in pediatric care than in adult acute care.
There were federally mandated no-visitation policies implemented at all U.S. hospitals when the pandemic started, said Laura J. Wood, DNP, RN, NEA-BC, FAAN, EVP Patient Care Operations and System Chief Nursing Officer at Boston Children’s Hospital.
“Boston Children’s Hospital and many other pediatric care specialty hospitals recognized the essential need to maintain family presence given the distinct needs of children and parents in navigating serious illness while avoiding traumatic separations between children and parents,” Wood said. “To safely accomplish this, the hospital maintained strict visitor screening protocols, and over time, introduced a wide range of patient flow and nurse-led care delivery innovations.”
Restrictive visitor policies were particularly problematic for families with fewer resources, according to the study. Some described restrictions on sibling visitation as being challenging for single parents. Visitor policies that did not allow caregivers to switch out resulted in missed employment — and added burden on families living paycheck to paycheck, according to Penwill.
“At [UCSF], we have worked to make exceptions to sibling visitation in select cases,” she said.
In 2020, declining volumes of hospitalized children and surges of adult patients resulted in many nurses being reassigned to care for adults. Hospitals interviewed for a quality and safety analysis in hospital pediatrics during COVID-19 reported that they facilitated the change by developing care teams supported by adult hospitalists, multidisciplinary support with video-conferencing, and educational resources.
2021: The Pandemic Rages On
The CDC reported weekly COVID-19-associated hospitalization rates among children and adolescents rose nearly five-fold during late June to mid-August 2021, coinciding with increased circulation of the SARS-CoV-2 Delta variant.
“The proportions of hospitalized children and adolescents with severe disease were similar before and during the period of Delta predominance. However, hospitalization rates were reported to be 10 times higher among unvaccinated adolescents than among fully vaccinated teens,” according to CDC.
Boston Children’s Hospital did not experience an overall increase in pediatric COVID-19-associated admissions in 2021 in contrast to 2020, according to Wood, who said a high rate of adult vaccinations in Massachusetts likely helped to reduce the spread of COVID-19 to infants, children, and adolescents.
Children’s Hospital New Orleans experienced extreme census fluctuations in 2020 and 2021, according to Schulenberg. With the start of the pandemic in 2020, Children’s Hospital New Orleans saw a significant decrease in its patient census. The hospital did have an increase in hospitalized pediatric COVID-19 patients in 2021, compared to 2020.
Helping Nurses Through
Penwill said study participants described the negative mental health impacts of the pandemic on nurses, other clinicians, and staff. “A key area of focus in pandemic recovery will be to continue to focus on staff mental health and provision of mental health and wellness resources,” Penwill said.
Based on findings from three nurse-led research studies conducted at Boston Children’s Hospital more than four years ago, the pediatric hospital had already been providing additional support to nurses experiencing moral and ethical challenges prior to the pandemic.
“A team of nurse scientists evaluated the feasibility of and satisfaction with the implementation of a Nurse Education and Support Team (NEST) coach role to build moral resiliency,” Wood said.
NEST coaches provide coverage five days a week in four intensive care units and one progressive care unit, according to Wood.
“By November 2019, less than two years from the program’s launch, a total of 6262 NEST coach consultations occurred. More than 85% of respondents indicated that they were satisfied with their interactions with the NEST coach and nearly 80% indicated that they would seek consultation again,” Wood said. “The use of this program established and evaluated immediately prior to the onset of COVID-19 provided much needed, just-in-time support through new morally and ethically challenging situations that arose as a result of the pandemic.”
Approval, availability, and uptake of the vaccine among children will affect how the pandemic impacts pediatric care at hospitals in the coming months.
“Hospital nurse leaders and managers can play an integral role in education and vaccination efforts, including educating and empowering bedside and clinic-based nurses to educate patients and families on COVID-19 vaccination,” Penwill said. “ … it’s also unclear what will happen this ‘respiratory season,’ and whether we will see an influx of pediatric admissions with respiratory conditions, greater than typically expected with COVID-19 circulating, particularly if a new variant develops. Given that unknown, it may be wise for nursing leadership to prepare for that possibility in regard to nurse training and staffing.”