What the wave of RSV and other viruses has revealed about pediatric care in the United States: The gunshots
Research shows that many hospitals in the United States are not fully prepared to deal with the increase in 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 the increase in sick children.
John Moore/Getty Images
“Daddy, I can’t breathe.”
That’s how Dr. Mark Auerbach’s 8-year-old son woke him up one night last year.
The family was vacationing in the Adirondacks of upstate New York, a few hours from Yale-New Haven Children’s Hospital, where Auerbach works in pediatric emergency medicine.
Like many parents whose children have become seriously ill with respiratory syncytial virus (RSV), Auerbach recognized that her son made a loud, wheezing sound. This was a sign that his airways were blocked. He knew he needed to go to the nearest emergency room immediately.
But as Auerbach loaded her son into the car and drove down dark mountain roads, she questioned whether local emergency services were fully equipped to treat her son.
“I was very nervous as a pediatric emergency physician,” she recalls. “Honestly, do I have to fix it myself? Will they even own the equipment?
Many children’s hospital staff are breathing a sigh of relief these days. A wave of common bugs like RSV and the flu has slowed the rise in childhood illnesses in the fall and early winter. But for parents who waited hours, even days, for their child to get into a hospital bed, one thing was clear: It wasn’t enough.
Even in the best of times, children’s hospitals can be stretched thin by years of cutbacks and a health care workforce crisis. Experts say the latest season showed what happens in America’s health care system during a major crisis of critically ill patients.
“When the (patient) volume doubles or more in some communities, it leaves a gap — a big gap,” said Dr. Larry Kociolek, medical director of infection prevention and control at Lurie Children’s. Chicago Hospital. “So the kids are going to suffer.”
Many emergency departments are not prepared to work with children
Auerbach had reason to be wary of taking her child to an unfamiliar emergency room.
He found that a child’s survival rate was four times higher in an emergency department well-equipped to care for critically ill children. And he learned that too many emergency services are not enough.
In fact, emergency departments have a so-called “weighted pediatric readiness score.” It is a way of assessing whether a service has adequate equipment, staff, training policies and patient safety protocols to care for critically ill and injured children.
According to the 2015 analysis, the median score is D.
A study of nearly 1,000 emergency departments published earlier this year found that more than 1,400 child deaths could be prevented over six years if each department were better prepared for pediatric cases.
Auerbach says most children are well cared for and parents shouldn’t hesitate to bring their children in for an emergency, but the reality is that children “were not in the middle” of the emergency system. of a developing country. In general, emergency departments treat more adults than children.
Although children account for 30% of all ER visits in the United States, most are seen in emergency departments that care for fewer than 15 children per day. That’s why many transfer children to children’s hospitals that have the capacity to treat children in critical condition, Auerbach said.
But during the latest wave of disease, these specialized hospitals were quickly overwhelmed. “We’ve seen a patient who needs emergency intervention sometimes wait six, eight, 12 hours in this community (emergency room),” Auerbach said.
After years of cutting pediatric beds, the tide has turned
During the fall and winter, some children’s hospitals doubled the number of patient rooms and expanded their limited staff and equipment, all in an effort to keep children from returning. But they have failed to recoup years of underinvestment that have cut the country’s supply of children’s beds and trained staff.
Between 2008 and 2018, US hospitals reduced pediatric inpatient units (ie, units with more than one pediatric bed, such as pediatric intensive care units) by nearly 20%. The number of children’s beds has fallen by almost 12% – and most of the remaining beds are now concentrated in urban areas, making it harder for rural families to access care.
Finances—more than anything else—have pushed hospitals to cut back on pediatric care; Hospital beds with children do not bring as much money as adult beds. For example, more than one in three children are covered by Medicaid. While the Medicaid reimbursement rate for hospitals varies by location, it may be lower than what hospitals charge when caring for an adult with Medicare or commercial insurance.
“Adult care is often more complex, more chronic, may involve more medication … (and) may be less effective,” Auerbach says.
That doesn’t go unnoticed by hospital administrators, Kociolek says.
“If you invest in adult health, it’s a higher (financial) margin (for hospitals),” he says. “Thus, the adult health community may benefit, while the pediatric health community is left behind.”
How about next time?
Hospitals aren’t sure if there will be a repeat of last season, said Dr. Chris Bryant, a pediatric infectious disease specialist at Norton Children’s Hospital in Louisville, Kentucky.
“But I suspect that all these viruses will circulate and cause their own outbreaks. If they all happen at once, we rush back to bed,” he says.
Infants are at higher risk of severe RSV, but Kociolek says that older children also getting seriously ill has put additional pressure on the health care system.
“The two- and three-year-olds who got RSV did much worse with this virus than they did in 2018 or 2019,” he says.
Bryant said these babies may not have been exposed to RSV and other common viruses after a year or more of social distancing and pandemic precautions. “We’ve had several years where we haven’t seen much circulation of a respiratory virus.”
So next fall and winter may look different, but Bryant says the health care system needs to act now to prepare.
Getting more vaccinations for children is one way to keep children from being hospitalized, he said. “If we don’t increase the number of kids immunized, we’re going to see an outbreak of vaccine-preventable diseases,” he says, referring to a recent measles outbreak that sickened nearly 100 children and hospitalized more than 30 in Columbus, Ohio.
Meanwhile, better treatments are on the horizon: The Food and Drug Administration may approve Pfizer’s RSV vaccine later this year, and other antibody therapies are expected to become more widely available.
But ensuring children get the best care also requires major systemic changes. “I don’t see how our children’s health care system can be sustainable without major financial reforms,” says Kociolek. These include changing the way pediatric care is reimbursed, making the choice of pediatric specialty more affordable for medical students, and investing more hospital resources in child care.
In the meantime, community hospitals and small emergency rooms can serve as “lifeboats” to help during storms, Kociolek said. For example, in this latest wave, some children’s hospitals have used telemedicine to provide 24/7 virtual care to rural or smaller hospitals and emergency departments.
And emergency departments don’t need to invest in expensive specialists or add pediatric beds to be better prepared to treat critically ill and injured children. According to Auerbach, most emergency physicians have extensive training in pediatric care. Often the biggest improvement is to designate a staff member as a pediatric care coordinator—her job is to ensure that all aspects of emergency care, including emergency equipment inspections, are done with children in mind.
To Auerbach’s relief, New York Field Hospital, where her son was being treated, took similar action. It partnered with a large teaching hospital and had the right equipment, the right policies, the right staff training to care for critically ill children.
If every ED was like this, he says, thousands of children’s lives could be saved.
“They evaluated him quickly (and) started very favorable respiratory and medical treatment,” Auerbach said. “After about six hours of looking, we stopped at Dunkin’ Donuts on the way back to see his mom and brother.”
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