Retrospective Study Open Access
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Crit Care Med. Dec 18, 2020; 9(5): 74-87
Published online Dec 18, 2020. doi: 10.5492/wjccm.v9.i5.74
National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic
Kamal Abulebda, Rami A Ahmed, Marc A Auerbach, Anna M Bona, Lauren E Falvo, Patrick G Hughes, Isabel T Gross, Elisa J Sarmiento, Paul R Barach
Kamal Abulebda, Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN 46202, United States
Rami A Ahmed, Anna M Bona, Lauren E Falvo, Elisa J Sarmiento, Department of Emergency Medicine, School of Medicine, Indiana University, Indianapolis, IN 46202, United States
Marc A Auerbach, Department of Pediatrics, Division of Pediatrics Emergency Medicine, Yale University School of Medicine, New Haven, CT 06504, United States
Patrick G Hughes, Department of Integrated Medical Science, Florida Atlantic University, Boca Raton, FL 33431, United States
Isabel T Gross, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT 06504, United States
Paul R Barach, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48202, Jefferson College of Population Health, Philadelphia, PA, 19107, United States
ORCID number: Kamal Abulebda (0000-0002-7372-2632); Rami A Ahmed (0000-0001-8518-6083); Marc A Auerbach (0000-0002-3796-4300); Anna M Bona (0000-0001-9603-4288); Lauren E Falvo (0000-0001-5133-5247); Patrick G Hughes (0000-0002-0073-6961); Isabel T Gross (0000-0003-4410-6758); Elisa J Sarmiento (0000-0001-7283-9938); Paul R Barach (0000-0002-7906-698X).
Author contributions: Abulebda K, Ahmed RA, Auerbach MA, and Barach PR were the leaders of this project and were involved in the conception and design of the project, reviewing the available pertinent literature, data manuscript collection, drafting the initial draft of the manuscript, and final approval of the manuscript; Bona AM, Falvo LE, Hughes PG, Gross IT, and Sarmiento EJ were involved in the conception and design of the project, met regularly with the project leader to review preliminary data, analyzed the data, performed critical revisions of the manuscript, and granted final approval of the manuscript.
Institutional review board statement: In accordance with 45 CFR 46.101(b) and/or IU HRPP Policy, the above-referenced protocol is granted an exemption. Exemption of this submission is based on your agreement to abide by the policies and procedures of The Indiana University Human Research Protection Program (HRPP).
Informed consent statement: Patients were not required to give informed consent to the study because this study was a survey-based study and did not include any human subjects or patients.
Conflict-of-interest statement: None of the authors have any conflict of interest to disclose.
Data sharing statement: All authors agree on regulations and policies of the data sharing agreements.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kamal Abulebda, MD, Associate Professor, Doctor, Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Dr, Phase 2, Room 4900, Indianapolis, IN 46202, United States. kabulebd@iupui.edu
Received: August 14, 2020
Peer-review started: August 14, 2020
First decision: September 21, 2020
Revised: October 4, 2020
Accepted: October 23, 2020
Article in press: October 23, 2020
Published online: December 18, 2020

Abstract
BACKGROUND

The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections.

AIM

To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide.

METHODS

A cross-sectional multi-center national survey of PICU medical director(s) from children’s hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation.

RESULTS

We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children’s hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives.

CONCLUSIONS

A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves.

Key Words: COVID-19, Pediatric intensive care unit, Simulation, Practice innovations, Training, Preparedness

Core Tip: The coronavirus disease 2019 pandemic has forced the United States healthcare system to examine the allocation of medical resources to the highest priority patients, including the pediatric population. In this cross-sectional multicenter national survey, we provide a description of the current preparedness efforts among a set of leading United States children’s hospitals’ pediatric intensive care units during the early months of the pandemic. This survey demonstrated that several key strategies have been implemented, including modifications to staffing, personal protective equipment usage, and workflows and changes in acute resuscitation and airway management, treatment protocols and procedures to limit personnel’s exposure to the contagion, while using simulation as the preferred training modality.



INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has forced healthcare systems to examine the judicious allocation of scarce medical resources to the highest priority patients, including the pediatric population[1]. Recent studies report pediatric populations have a lower incidence and typically, a less severe presentation, as compared to adults[2]. Some children, particularly with co-morbidities, are more likely to develop critical illnesses such as respiratory and cardiac failure or shock that may require invasive respiratory support or extracorporeal hemodynamic support[3]. Recently, emerging data are suggesting, however, a more serious illness in kids, with hundreds of children sickened with severe illness due to COVID-19, now named multisystem inflammatory syndrome in children[4].

Diagnostic and therapeutic guidelines used for children are commonly extrapolated from studies conducted in adults. The Society of Critical Care Medicine published a national survey of more than 4500 intensive care specialists to assess adult intensive care unit (ICU) preparedness. This survey demonstrated that adult ICU settings are preparing for COVID-19 patient care by enacting a myriad of measures including: Preparing in-hospital non-ICU space, canceling elective surgeries, and preparing temporary spaces and external facilities[5]. Reviews of adult ICU preparedness for pandemics have focused on concepts of infection control and optimal ways to increase staffing and surge capacity[6]. Pediatric preparedness for COVID-19 is distinct from adult preparedness due to important physiological and equipment differences, distinct differences in pediatric COVID-19 presentations, the child’s stage of development, and the intimate need for parent involvement as part of the care delivery model.

It is important to assess pediatric ICU preparedness to identify gaps and inform improvements as we prepare for present and future waves of the COVID-19 pandemic. Most children’s hospitals in response to the pandemic have rapidly escalated their health systems preparedness and implemented innovative processes to prevent disease transmission and prepare their staff to care for COVID-19 patients[7,8]. Despite a widely accepted standard of care and national accreditation for pandemics and mass disasters for neonatal and pediatric critical care in the United States, recent data suggest that the United States system lacks adequate surge capacity and would benefit from a well-organized, nationally directed and cohesive approach[9,10].

There are limited data describing the extent of the actual changes implemented by pediatric ICUs (PICUs) and their approaches to improve pandemic their preparedness[11]. This survey aims to describe the current: (1) Preparedness efforts by a group of leading United States children’s hospitals’ PICUs; (2) Changes in policies/procedures /guidelines; and (3) Training modalities and innovations including use of simulation for COVID-19 care.

MATERIALS AND METHODS
Survey design

We conducted a cross-sectional multi-center national survey of PICU medical director(s) across children’s hospitals in the United States. An established team of researchers designed and analyzed the survey. This survey was reviewed and approved by the local institutional review board at Indiana University Health.

PICUs

Thirty-five children’s hospitals were identified for recruitment through an established national research network “Improving Pediatric Acute Care Through Simulation” (ImPACTS). The ImPACTS was founded in 2013 to improve the quality of care delivered to acutely ill and injured children and has conducted multiple research projects assessing the readiness of emergency departments through mixed methods research and simulation use[12]. The survey was conducted between May 2020 and June 2020. An anonymous Qualtrics survey (www.qualtrics.com) was distributed via e-mail to all lead investigators of 35 leading children’s hospitals across the ImPACTS network. Each network site lead was instructed to e-mail the link to their PICU medical directors and copy the study coordinator. Three e-mail reminders were sent by the study coordinator to the medical directors 1 week apart over a 3 weeks period.

Survey development

The questionnaire was developed and reviewed by physicians and researchers with expertise in pediatric critical care, disaster readiness, and survey development. The survey was pretested for length and comprehensibility at five different PICUs not included in the survey to improve the face validity (defined as whether or not the survey measures what it is supposed to measure) and the content validity (defined as the degree to which the survey is representative of the topic). The survey was iteratively revised in three cycles based on the feedback and pilot data.

The physician survey included 49 questions in multiple parts addressing six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation. An open comment section was available at the end of the survey.

Statistical analysis

We compared the frequencies and percentages responses by testing differences using the Fisher's exact test. A statistical review of the study was performed by a biomedical statistician. All reported P values are based on two-sided tests.

RESULTS

A total of 35 PICUs within the network were identified. Responses from 22 PICUs (63%) were received (Table 1).

Table 1 Hospital pediatric intensive care unit characteristics.
Characteristics of the pediatric intensive care unitsn = 22 (%)
Primary hospital setting description
Academic children’s hospital14 (63.64)a
Community children’s hospital5 (22.73)
Children’s hospital with a combined pediatric/adult hospital2 (9.09)
Other1 (4.55)
Number of children’s hospitals by bed capacity
Less than 1004 (18.18)
100-1994 (18.18)
200-2995 (22.73)
300-3995 (22.73)
400+4 (18.18)
PICU description
Combined PICU/Cardiac ICU6 (27.27)
PICU with a separate CICU at our institution11 (50.00)
PICU only/ No CICU at our institution5 (22.73)
Number of PICU beds per institution
< 166 (27.27)
16-3010 (45.45)
31-454 (18.18)
> 452 (9.09)
Number of patients with confirmed COVID admitted to PICUs
1-313 (61.90)
4-61 (4.76)
7-94 (19.05)
> 103 (14.29)
PICUs and medical director characteristics

The majority of PICUs were located within children’s hospitals, either in academic (64%) or community children’s hospitals (23%). The geographic distribution of these hospitals within the United States was five (23%) in the West region, eight (36%) in the Northeast region, five (23%) in the Midwest region, and four (18%) in the southeast region. All PICUs (100%) cared for pediatric patients with COVID-19 at the time of the survey. Other key PICU characteristics are summarized in Table 1.

Changes in patients flow across PICUs

The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patient care. Forty-three percent had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients (Table 2).

Table 2 Preparedness efforts of pediatric intensive care units.
Changes in patient flow across PICUs
n (%)
Changes in the average non-COVID patients seen during the COVID season
Increase in non-COVID patients
Decrease in non-COVID patients19 (83.4)a
No change2 (9.52)
Presence of COVID dedicated unit(s)?
Yes9 (42.86)
No12 (57.14)
Change in patients age range to include adult patients?
Yes10 (74.62)
No11 (52.38)
Changes in the staffing model
Implementation of changes to the healthcare provider staffing model
Change in length of shift4 (18.8)
Change in providers assignment for COVID-19 patients, dedicated teams5 (22.73)
Change in patient triaging model7 (31.82)
Change in room assignment11 (50.00)
Introducing remote patient monitoring in PICU8 (36.63)
Other5 (22.73)
Limiting the exposure of medical trainees for patients with known or suspected COVID-19
Fellows prohibited from direct patient contact
Fellows limited but not prohibited from direct patient care7 (31.82)
APPs students prohibited from direct patient10 (45.45)
APPs students limited but not prohibited from direct patient care1 (4.55)
Residents prohibited from direct patient care5 (22.73)
Residents limited but not prohibited from direct patient care11 (50.00)
Medical students prohibited from direct patient care20 (90.91)a
Medical students limited but not prohibited from direct patient care1 (4.55)
No changes
Changes in the staffing model

All PICUs in the survey (100%) implemented extensive changes to their staffing model. The most common changes were patient room assignment (50%), introducing remote patient monitoring (37%), and changes in their patient triage model (32%). The majority (90%) prohibited medical students from any direct patient care, while 50% and 32%, respectively, limited but did not prohibit residents and fellows from direct patient care (Table 2).

Use of PPE

The majority of PICUs (95%) conducted training for appropriate donning and doffing of enhanced PPE. The two most common educational formats were hands-on and video-based training (73% and 82%, respectively). Dedicated staff (spotter) were reported to be used only by 50% of the respondents. The majority (63.4%) of respondents reported they had dedicated zoning to distinguish clean areas from contaminated areas to reduce the likelihood that team members would cross over between areas leading to further contamination.

All PICUs developed and implemented procedures to enhance PPE practice safely and audit the competencies of their providers. The majority of PICUs (90%) conducted procedures to enhance the safety of enhanced PPE use. One-third of PICUs reported regular shortages of PPE (Table 3).

Table 3 Personal preparedness efforts by pediatric intensive care units.
The use of PPEsn (%)
Current issues/limitations in regards to the utilization of PPE
Lack of access to PPE
Shortage in PPE7 (31.82)
Inability to reuse PPE1 (4.55)
No issues14 (63.64)
Conducting training to appropriately don and doff PPE for PICU staff
Yes21 (95.45)a
No
Unsure
Format of PPE training
Hands-on training16 (72.73)a
Video-based content18 (81.82)a
Didactic/small group training7 (31.82)
Email material13 (59.09)
Other2 (9.09)
Procedures to enhance safety of PPE
Buddy system8 (36.36)
Increased staff6 (27.27)
Dedicated staff, spotter11 (50.00)
Distribution of printed safety13 (59.09)
Other1 (4.55)
None2 (9.09)
Auditing PPE competencies
Assess the performance of doffing team14 (63.64)
Written examination
Simulation assessment7 (31.82)
Provide structured feedback around key competency areas4 (18.18)
Regularly assess competencies with spot checks and/or video6 (27.27)
None1 (4.55)
Optimization of PPE doffing areas
Dedicated doffing area to avoid team members from bumping into one another or equipment4 (18.18)
Zoning to distinguish clean area from potentially contaminated areas to reduce the likelihood that team members cross over between areas spreading contamination8 (63.64)
Use the same space for donning and doffing of PPE14 (63.64)
Dedicated staff to observe the doffing process, Doffing spotters7 (31.82)
Other5 (22.73)
Practice changes and innovations

The most common concerns for PICU directors related to the changing COVID-19 treatment protocols and instituting new guidelines (50%) and shortage of PPE equipment and supplies (36%). The majority implemented changes in their airway management protocols (82%). The most common innovations were decreasing the number of team members in the patient room during resuscitation and incorporating new methods of communication (73% and 86%, respectively). Other innovations included using video laryngoscopy for intubation (68%) and implementing a COVID-19 specific airway management checklist. Sixty-eight percent of PICUs implemented changes in their cardiac arrest management of COVID-19 patients. Only 36% of PICUs implemented training for managing surge capacity. The most common methods for keeping PICU providers updated and best-prepared regarding COVID-19 preparedness activities were mass e-mail messaging or virtual meetings (91% and 77%, respectively) (Table 4).

Table 4 Preparedness efforts by pediatric intensive care units.
Practice change/Innovationsn (%)
Concerns related to the current COVID-19 clinical practice
Lack of clinical guidelines/protocols5 (22.73)
Changes in guidelines/protocols11 (50.00)
Lack of PPE training3 (13.64)
Physician staff shortage
RN staff shortage2 (9.09)
Other staff shortage1 (4.55)
Shortage in equipment/supplies8 (36.36)
Patient surge and crowding5 (22.73)
Other5 (22.73)
Implementation of COVID focused airway management training
Yes18 (81.82)
No3 (13.64)
Unsure
Practice innovations for airway management
Caring for patients with suspected or confirmed COVID in negative pressure room14 (63.64)
Using video laryngoscopy only for intubation15 (68.18)
Decreased clinical care team numbers at bedside19 (86.36)a
Incorporating new methods of communication between team members16 (72.73)a
Implementing airway management checklists15 (68.18)
Using telemedicine/video technology9 (40.91)
Other2 (9.09)
Intubation of suspected or confirmed COVID patients
By anesthesiologist who responds as part of the Airway Team5 (22.73)
Anesthesiologist or other dedicated airway provider who is called if intubation is required7 (31.82)
Attending physician unless the patient is suspected of having a difficult airway12 (54.55)
Attending physician or fellow7 (31.82)
Any appropriately trained member of the team
Other8 (36.36)
Implementation of COVID focused cardiac arrest management training
Yes15 (68.18)
No6 (27.27)
Unsure
Practice innovations for cardiac arrest management
Caring for patients with suspected or confirmed COVID in negative pressure rooms only13 (59.09)
Changing CPR practices10 (45.45)
Decreased clinical care team numbers at bedside16 (72.73)a
Incorporating new methods of communication between team members15 (68.18)a
Using telemedicine/video technology7 (31.82)
Other4 (18.18)
Implementation of surge capacity management training
Yes8 (36.36)
No13 (59.09)
Unsure
How does your PICU keep all providers updated regarding COVID preparedness activities?
Mass e-mails20 (90.91)a
Regular in-person huddle/meetings11 (50.00)
Virtual conferences/meetings17 (77.27)a
Simulation-based9 (40.91)
Other
Training modalities for COVID-19

Simulation-based training was the most commonly utilized training method (82%). The most common learning objectives were enhanced team training (73%) and improved team dynamics (77%). The majority of simulation occurred in the settings of patient care areas (77%). The majority of PICU directors felt that simulation was important to prepare better their PICU staff for COVID-19 patient management while protecting their staff from contamination. Simulation experts were the most common facilitators working within the department/hospital (68%). The most common challenges to increased simulation training were related to limited financial resources (32%) and securing adequate PPE (32%) (Table 5).

Table 5 Preparedness efforts by pediatric intensive care units.
COVID-19 training modalitiesn (%)
Modalities currently utilized for training staff?
Video/teleconference17 (7.27)
Didactic12 (54.55)
Online modules10 (45.45)
Simulation-based training18 (81.82)
Virtual reality1 (4.55)
Other
Importance of simulation-based training for the preparation of PICU staff for COVID-19 patient management
Extremely important9 (40.91)
Important7 (31.82)
Neutral1 (4.55)
Unimportant
Not at all important
Objectives of the simulation-based training
PPE, donning and doffing12 (54.55)
Individual procedural skills, i.e. intubation13 (59.09)
Team training, i.e. CPR16 (72.73)
Team dynamics, i.e. communication17 (77.27)
Mass casualty and surge capacity management1 (4.55)
Diagnostic testing1 (4.55)
Facility utilization and contingency planning, use of negative pressure rooms2 (9.09)
Tent deployment1 (4.55)
Other
Location of the training
Simulation center3 (13.64)
In situ, in its original place or location17 (77.27)
Classroom setting
Other format, boot camp1 (4.55)
Simulation equipment
High-fidelity, full body mannequin, simulator13 (59.09)
Low-fidelity, full body mannequin, simulator 7 (31.82)
Task trainers, intubation heads, central line trainers, etc.7 (31.81)
Standardized patients, actors1 (4.55)
Virtual Reality3 (13.64)
Other
Participating members
Physicians17 (77.27)
Nurses17 (77.27)
Respiratory therapists15 (68.18)
Technicians5 (22.73)
Residents/fellows15 (68.18)
Students
Other staff
What simulation training was the MOST helpful
PPE, donning and doffing6 (27.27)
Individual procedural skills, i.e. intubation8 (36.36)
Team training, i.e. CPR12 (54.55)
Team dynamics, i.e. communication10 (45.45)
Other1 (4.55)
What simulation training was the LEAST helpful
PPE, donning and doffing3 (13.64)
Individual procedural skills, i.e. intubation2 (9.09)
Team training, i.e. CPR2 (9.09)
Team dynamics, i.e. communication2 (9.09)
Other8 (36.36)
Facilitators of the simulation-based training
Presence of a simulation center7 (31.82)
Presence of a simulation team in your department/hospital15 (68.18)
Buy-in/support from hospital administration team8 (36.36)
Involvement in other simulation collaborative and simulation leadership7 (31.82)
Other8 (36.36)
Challenges to execute simulation-based training
Buy-in/support from hospital administration team1 (4.55)
Financial resources7 (31.82)
Securing adequate supplies, PPE7 (31.82)
Staff buy-in and participation4 (18.18)
Lack of a trained simulation team
Lack of simulation logistics/supplies4 (18.18)
Lack of time for preparation5 (22.73)
Lack of desire for this form of training1 (4.55)
Other7 (31.82)
Development of novel or unique training equipment or training aides
Yes, i.e. intubating fume hood, please share7 (31.82)
No10 (45.45)
DISCUSSION

COVID-19 has placed extraordinary and sustained resource demands on critical care services. This survey provides a first snapshot of the current preparedness efforts among a set of leading PICUs in the United States during the first months of the pandemic. The majority of surveyed PICUs implemented dramatic changes to their workflow and adapted their staffing models, with 43% creating dedicated COVID-19 care units. Additionally, medical trainees with different professional backgrounds were either limited or prohibited from participating in direct patient care, posing significant workload burdens on PICU staff.

In March 2020, during the peak of the pandemic in New York City, The Association of American Medical Colleges and The Liaison Committee on Medical Education issued guidance that medical students should not be involved in the care of COVID-19 patients or persons under investigation, and many medical schools near the early epicenter of the pandemic discontinued clinical rotations[13]. Surveyed directors reported that they conducted extensive training on the proper use of enhanced PPE among their providers, while a third of surveyed programs reported regular shortages in PPE. Even 6 months into the pandemic, PPE shortages continue to be reported across the United States. Beyond this, more than two-thirds of PICUs implemented innovative training for their providers targeted at modified clinical practices for airway and cardiac arrest management, while only one-third implemented surge management training. Simulation conducted in situ is a well-established method for effective team training and was the most common training modality in our survey and was frequently utilized to support interprofessional team training and improve team dynamics in the ICU setting[14,15].

Our survey results are the first nationwide reports from pediatric ICUs with that have active simulation programs about their state of preparedness[7,16]. PICUs initiated rapid cycle planning and implementation of changes to established childcare models to ensure that safe and effective care was being maintained. Although many adult ICUs have reported on current approaches to improve preparedness, this is the first survey outlining the detailed preparedness steps and response efforts adopted by PICUs[17].

Many PICUs encountered a dramatic decrease in the number of non-COVID-19 patients as the pandemic evolved, which has likely helped balance the need for additional resources and training for all bedside providers to care for COVID-19 patients. In this survey, one-third of PICUs reported a consistent shortage in PPEs, which is similar to what has been reported in previous pandemics and which continues to put healthcare workers at risk[18-20]. This ongoing shortage of PPE is notable given the high risk of PICU staff exposed to aerosol-generating procedures, with recent data suggesting over 3000 healthcare workers have died caring for COVID-19 patients, including several intensive care providers, and at least 500000 healthcare providers reported infected worldwide[21,22].

The findings of the survey are a reflection of the overall preparedness efforts among the participating PICUs and the changes completed in operational policies by the surveyed PICUs. These changes translate into clinical and occupational benefits and can help in optimizing the clinical services of PICUs nationwide who are under resource constraints. These benefits include protecting healthcare providers and patients from the virus exposure to reduce the infection risks, establishing a community of practice among PICU clinical services and medical directors to avoid “reinventing the wheel” during the current pandemic, and more importantly identifying how best to prepare and implement more effective operational plans for predictable future pandemics. Furthermore, this survey serves as a guide to highlight and address present PICU system vulnerabilities. It supports PICU leadership and bedside providers in providing the highest quality of care and a laser-like focus on the safety of healthcare providers.

This survey has several limitations. While 22 of 35 major leading PICU medical directors responded, this represents only a sample of all United States PICUs, which may impact the generalizability of our findings. Additionally, this survey targeted PICUs that have active simulation programs, which may reflect more well-funded facilities. The survey, nonetheless, can provide deep insights into how PICU directors and programs are adapting their training, staffing, and workflow to address the ongoing, shifting pandemic demands. Additionally, the survey responses are inherently prone to bias and may not always accurately reflect the actual practice of clinical performance but rather the policies and intent. Lastly, we did not capture certain data such as the percent decrease in non-COVID-19 patients seen or visitors’ policy to the PICUs.

CONCLUSION

We conclude in this first national survey that the current preparedness efforts among PICUs in the United States during the first few months of the COVID-19 pandemic have been highly variable, with one-third lacking adequate PPE. PICUs have implemented several strategies including modifications to staffing and workflows, changes in their acute resuscitation and airway management, treatment protocols, limiting personnel’s exposure to contagion, while using simulation as the preferred training modality to support protocol changes in response to COVID-19. Our findings highlight the importance of sharing experiences among PICUs, particularly during these challenging times. Future research is needed to better appreciate the effectiveness of better PPE preparedness, workflow, and training changes. We also need to better understand what are the impacts of limiting trainees’ exposure to COVID-19 care on their clinical competencies in preparation for ongoing and future pandemics.

ARTICLE HIGHLIGHTS
Research background

The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients.

Research motivation

To help in optimizing the clinical services of pediatric intensive care units (PICUs) nationwide under resource constraints through a reflection of the overall preparedness efforts among a set of PICUs.

Research objectives

To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide.

Research methods

A cross-sectional multi-center national survey of PICU medical director(s) across children’s hospitals in the United States.

Research results

Responses from 22 of 35 PICUs (63%) were received. All PICUs cared for pediatric patients with COVID-19 at the time of the survey, and the majority witnessed decreases in non-COVID-19 patients. All PICUs implemented changes to their staffing models, and 95% of PICUs conducted training for donning and doffing of enhanced personal protective equipment. The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training and team dynamics were the most common training objectives.

Research conclusions

The current preparedness efforts among PICUs in the United States during the first few months of the COVID-19 pandemic have been highly variable. PICUs have implemented several strategies including modifications to staffing and workflows, changes in their acute resuscitation and airway management, treatment protocols, limiting personnel’s exposure to contagion, while using simulation as the preferred training modality to support protocol changes in response to COVID-19.

Research perspectives

This survey highlights the importance of sharing experiences among PICUs, particularly during these challenging times, and how to prepare and implement more effective operational plans for predictable future pandemics.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Critical care medicine

Country/Territory of origin: United States

Peer-review report’s scientific quality classification

Grade A (Excellent): A

Grade B (Very good): 0

Grade C (Good): C, C

Grade D (Fair): D, D

Grade E (Poor): 0

P-Reviewer: Jeong KY, Lalmuanawma S, Mohammadi M, Ooi L, Wang R S-Editor: Huang P L-Editor: Filipodia P-Editor: Li JH

References
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