REFLECTING ON THE IMPACT OF THE “TRIPLEDEMIC” ON CHILDREN’S HOSPITALS

Jia Xin Huang, MD; Lindsay Braun, MD; Duncan Henry, MD and Sandrijn van Schaik MD, PhD

“Do we have a bed?” This single phrase was repeated countless times during the “tripledemic” in December 2022 and January 2023, a term that refers to the surge of COVID-19, respiratory syncytial virus (RSV), and influenza viruses. Even when the answer was yes, the question remained: How does one decide which child receives the last bed in the Pediatric Intensive Care Unit (PICU)? Once again, the U.S. healthcare system was significantly overwhelmed. Emergency rooms across the country were inundated by children with respiratory symptoms waiting to be seen by a healthcare provider. Many of these children were on the verge of respiratory failure, requiring support and monitoring that would normally take place in a PICU. However, many pediatric ICUs were already at maximal capacity, forcing emergency rooms to run mini-ICUs until they could find an accepting facility. Similarly, pediatric acute care units faced bed shortages and were also pushed beyond their comfort level as they cared for children requiring higher respiratory support. Beyond the immediate need, the paucity of PICU beds meant delaying or even cancelling necessary and urgent surgeries, creating additional stressors on the system. ICU capacity across the country has always been limited to begin with and overwhelmed under the extreme circumstances of the recent pandemics that created high demands.

The reduced capacity to care for children during this respiratory viral surge was further compounded by the national shortage of nurses. Data from the U.S. Department of Health and Human Services already showed a growing gap between the supply of and demand for available nurses prior to the COVID-19 pandemic. This gap has widened over time. One of the tolls of the pandemic has been worsening levels of employee burnout, leading nurses to leave their jobs in large numbers. Children’s hospitals across the country are impacted by this nursing shortage. In the short term, the answer is to increase patient to nurse ratios to acceptable maximums, though these ratios inevitably lead to worsening burnout, thus creating a vicious cycle. While there are ongoing efforts among hospitals to reduce nursing shortage and burnout, they were too late to meet the needs of the tripledemic and leave us currently ill prepared for future ones.

The impact of the tripledemic on children’s hospitals is substantial, but the response to this crisis has been minimal compared to the response to the COVID-19 pandemic. While COVID was front page news for almost two years, media coverage of the tripledemic has been limited. The White House declined a request by the American Academy of Pediatrics to declare a state of emergency, which would have secured additional resources for children’s hospitals to take care of children during the surge. During the peak of the COVID-19 pandemic, many PICU and pediatric acute care beds were converted to adult ICU beds, yet the reverse has been more difficult to accomplish. In part, this is because in some areas adult hospitals were also impacted by the surge of non-COVID respiratory diseases, but additionally this appeared to be driven by finances. In fact, low federal reimbursement for pediatric patients compared to adult patients and overall limited revenue from pediatric healthcare has led to closures of multiple pediatric units and even whole children’s hospitals across the nation. Simply put, children’s healthcare has little financial leverage in our current economy.

The Bay Area is fortunate to have significant capacity to care for critically ill children given its multiple PICUs, but we are not shielded from the moral distress that comes with turning away sick children due to limited nursing and bed availability. For us, this occurred on a daily basis, multiple times per day. Nonetheless, the distress we felt is insignificant compared to that experienced by families with critically ill children awaiting an available bed. For some families, the closest PICU bed their child received was hundreds of miles away or even in a neighboring state, creating additional financial burden and logistical challenges. The need to transfer sick children over long distances highlights the inequities in access to care, especially in rural parts of the country where hospitals are often not equipped to care for critically ill children. Beyond the geographical impact of the tripledemic, we know that families from marginalized groups, families with limited resources, and families for whom English is not their primary language already have worse health outcomes compared with others. The additional challenges created during the tripledemic further exacerbated healthcare inequity.

We must do more to ensure children have equitable access to healthcare before, during and after any epidemics and pandemics that come our way. It is appalling to see the paucity of legislative support and funding for pediatric hospitals. The Pediatric Access to Critical Health Care Act was introduced in 2022 to increase capacity for the care of children, but the bill never advanced past the assigned committee. Policy makers must continue efforts to increase support for pediatric healthcare services, as they were already inadequate prior to the start of the pandemics. There needs to be more legislative support to increase infrastructure for pediatric health services, increase Medicaid reimbursement rates, and funding for pediatric procedures that can help keep children’s hospitals financially viable and remain afloat. Investing in pediatric healthcare is investing in the future. If we want future generations to thrive, we have to ensure that our nation’s children receive the care they need when they get sick.

One thing is for sure: We, pediatric intensive care physicians, don’t want to have to decide who gets the last bed in our PICU. We want there to be sufficient beds, personnel and resources so we can do what we are called to do: take care of critically ill children, all of them, at any time.

Jia Xin (Jess) Huang, MD is a pediatric critical care fellow at the University of California San Francisco.

Lindsay Braun, MD is an Assistant Professor of Pediatrics at the University of California San Francisco with a clinical appointment in Pediatric Critical Care Medicine at UCSF Benioff Children’s Hospital. She is the Assistant Medical Director of the Pediatric Intensive Care Unit and the Transitional Care Unit.

Duncan Henry, MD is associate clinical professor at the University of California San Francisco with a clinical appointment in Pediatric Critical Care Medicine at UCSF Benioff Children’s Hospital San Francisco. He is the Medical Director of the Mission Bay Pediatric Intensive Care Unit and the UCSF Pediatric Complex Care Program (FLIGHT). He is also an Associate Program Director for Assessment in the UCSF Pediatric Residency Program.

Sandrijn van Schaik, MD, PhD is Professor of Pediatrics at the University of California San Francisco with a clinical appointment in Pediatric Critical Care Medicine at UCSF Benioff Children’s Hospital. She is the Baum Family Presidential Chair for Experiential Learning and Vice Chair for Education in Pediatrics.