Nurses caring for children across the country observed significant changes in pediatric care delivery as a result of the pandemic.
According to a study which was published on October 11 in BMC Health Services Research, these changes include responding to new hospital regulations, communication, and staffing patterns.
According to the authors, the study’s findings can assist hospital leaders in navigating the pandemic recovery process and managing future emergencies.
2020: Identifying Systemic Flaws
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The researchers questioned administrators, front-line physicians, nurses, and parents from undisclosed pediatric care and community hospitals serving pediatric patients in the six United States with the highest COVID-19 hospitalization rates in 2020.
Researchers discovered how leaders quickly modified hospital policy after conducting interviews with 30 participants at 12 hospitals. Several hospitals established command centers manned by hospital leadership. Additionally, the researchers discovered that frequent data reviews and engagement with stakeholders supported improvement.
“We established a COVID command center in 2020 in response to the initial outbreak and again in 2021 in response to the onset of the Delta wave. We convened daily at 9 a.m.,” said Laurie Schulenberg, MPA/HCA, BSN, RN, NEA-BC, Interim Chief Nursing Officer at Children’s Hospital New Orleans. According to Schulenberg, this clinic had the highest rate of pediatric COVID-19 patients in the country during the summer of 2021.
Nurses, including the planning chief and nursing supervisor, communicated regularly with other hospital management on the hospital’s COVID-19 census, the number of COVID-positive children admitted to the emergency room, and strategies for addressing difficulties, Schulenberg said.
“By 2020, we had already come up with strategies for the few children we had with COVID — things like locating the IV pumps outside the rooms [and] ensuring we had enough negative pressure rooms,” she explained.
While these command centers aided hospitals in making changes, they also exposed process inefficiencies. For example, the study found that increased usage of telemedicine and videoconferencing in 2020 aided physical separation but caused distinct communication issues for non-English speakers.
“The COVID-19 pandemic resulted in widespread adoption of telemedicine and, in the inpatient setting, phone and video interpretation with less reliance on in-person interpreters to promote physical distancing,” study author Nicole Penwill, MD, MPH, FAAP, a Pediatric Hospital Medicine Fellow at the University of California San Francisco (UCSF).
Several physician participants in her study mentioned additional difficulties and worse communication quality associated with the use of remote interpretation services.
Restriction on Visitors
Restricting visitors in pediatric care can be more difficult than in adult acute care.
When the pandemic began, all U.S. hospitals instituted federally mandated no-visitation regulations, according to 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 a number of other pediatric care specialist hospitals recognized the critical necessity to preserve family presence in light of the unique needs of children and parents in navigating serious illness while avoiding traumatic separations,” Wood said. “To accomplish this safely, the hospital used a variety of patient flow and nurse-led care delivery improvements throughout time.”
According to the study, restrictive visitor regulations were particularly troublesome for families with fewer resources. Restrictions on sibling visits have been considered as difficult for single parents. According to Penwill, visitor restrictions that did not allow caregivers to switch out resulted in lost employment – and increased financial strain on families living paycheck to paycheck.
“At [UCSF], we’ve worked to provide certain exceptions to sibling visits,” she explained.
In 2020, when the number of hospitalized children declines and the number of adult patients increases, many nurses will be reassigned to care for adults. Hospitals interviewed for a COVID-19 quality and safety analysis in hospital pediatrics reported that they promoted change by establishing care teams backed by adult hospitalists, comprehensive support via video conferencing, and educational tools.
2021: The Pandemic Continues
The CDC stated that weekly COVID-19-associated hospitalization rates among children and adolescents approximately doubled between late June and mid-August 2021, corresponding with an increase in the spread of the SARS-CoV-2 Delta variant.
“Pre- and post-Delta predominance, the percentage of hospitalized children and adolescents with severe illness were comparable. However, hospitalization rates among unvaccinated adolescents were reported to be tenfold those of fully vaccinated adolescents,” according to the CDC.
According to Wood, Boston Children’s Hospital did not see an overall increase in pediatric COVID-19-associated admissions in 2021 compared to 2020, owing to a high rate of adult vaccination in Massachusetts, which likely aided in the reduction of COVID-19 transmission to infants, children, and adolescents.
According to Schulenberg, Children’s Hospital New Orleans saw dramatic census changes between 2020 and 2021. Children’s Hospital New Orleans’ patient census decreased significantly when the pandemic began in 2020. The hospital did see an increase of pediatric COVID-19 patients admitted to the hospital in 2021, compared to 2020.
Assisting Nurses
According to Penwill, study participants noted the pandemic’s significant mental health effects on nurses, other clinicians, and personnel. “A critical area of attention during the pandemic recovery period will be to maintain a strong emphasis on staff mental health and the availability of mental health and wellness resources,” Penwill added.
According to data from three nurse-led research studies completed more than four years ago at Boston Children’s Hospital, the pediatric hospital was already offering additional support to nurses facing moral and ethical dilemmas prior to the pandemic.
“An effective team of nurse scientists assessed the feasibility and satisfaction with the establishment of a Nurse Education and Support Team (NEST) coach role to promote moral resiliency,” Wood explained.
According to Wood, NEST coaches provide coverage five days a week in four intensive care units and one progressive care unit.
“By November 2019, less than two years after the program’s commencement, there had been 6262 NEST coach consultations. Over 85% of respondents expressed satisfaction with their encounters with the NEST coach, and over 80% stated that they would seek assistance again,” Wood explained. “The utilization of this program, which was designed and evaluated immediately prior to the commencement of COVID-19, offered critical, just-in-time support during the pandemic’s unprecedented moral and ethically problematic conditions.”
Progression
The vaccine’s approval, availability, and uptake among children will all have an effect on how the pandemic affects pediatric treatment in hospitals in the following months.
“Hospital nurse leaders and managers can make a significant contribution to education and immunization initiatives by training and empowering bedside and clinic-based nurses to educate patients and families about COVID-19 vaccination,” Penwill added. “… it is also unknown what will happen during this ‘respiratory season,’ and whether we will witness an increase in pediatric admissions for respiratory disorders, bigger than what is generally expected when COVID-19 is circulating, especially if a new variety arises. Given that unknown, nursing leadership may choose to plan for it in terms of nurse training and staffing.”
