High demand for pediatric beds stresses system
As the nation grapples with a surge in respiratory illnesses making very young children and babies ill, the high demand for inpatient and pediatric intensive-care-unit beds means children are spending days and weeks in emergency rooms designed for short-term evaluation and treatment.
The surge has hit states in the East and Southeast particularly hard, with D.C., Maryland and Virginia reporting the highest incidence of influenza-like illness, which includes RSV, according to Centers for Disease Control and Prevention data.
Pediatricians last week asked President Biden and Xavier Becerra, the secretary of the Department of Health and Human Services, to declare an emergency to give providers and hospitals more flexibility to care for sick children.
The letter from the heads of Children’s Hospital Association and the American Academy of Pediatrics said that in some states, more than 90 percent of pediatric beds are full, meaning more children like Jordan will languish in emergency departments and makeshift spaces.
A CHA spokeswoman said conversations with the administration and Congress continue but that further action has not yet been taken.
Experts say the high demand for pediatric ICU beds is due to the early onset of RSV, which is making children sicker than usual, along with the start of flu season and the continued circulation of the novel coronavirus on top of an overall decrease in pediatric beds and chronic staff shortages.
“It’s not fair for an ER doctor to have to decide which kid am I going to send to the bed,” Maeng, 42, said. “The system is not working.”
Theodore R. Delbridge, the governor-appointed head of a Maryland state agency responsible for coordinating statewide emergency management systems, saw this coming. One year ago, clinicians reported an out-of-season increase in RSV, or respiratory syncytial virus, and worried that flu and covid surges could overwhelm the system.
He expanded C4, the federally funded Critical Care Coordination Center, created in December 2020 to find intensive care beds for adults with covid, to a pediatrics call center called C4 Pediatrics. At all times, two doctors with pediatric expertise and two clinical coordinators with a bird’s-eye view of pediatric inpatient and intensive-care-bed capacity across the region field calls from doctors seeking transfers for their critically ill patients.
The pediatric division staffed up in October 2021, but, to his surprise, Delbridge said, it was not very busy, taking only about 20 calls a month, with a peak of 64 calls in June.
“That all changed in September,” he said.
The center fielded 194 pediatric requests that month and more than three times as many — 639 — in October, including nearly 600 for respiratory illnesses, Delbridge said. The center is on pace for a busy November as well, with 359 calls as of midday Tuesday.
“For the last several weeks it’s been constant phone calls,” said Jennifer Anders, medical director for C4 Pediatrics and a pediatric emergency physician at the Johns Hopkins Children’s Center. “As soon as one ends, another one begins for a 12-hour shift. It’s pretty unrelenting.”
Calls typically come from emergency department doctors at community hospitals who may be treating RSV patients with intravenous fluids and oxygen at a high-flow rate to prop open lungs, interventions that in the best of times call for the constant monitoring available in an intensive care unit.
Patients tend to be very young, with most under 5 years old, Anders said. They struggle to breathe and can’t pause the struggle for breath long enough to drink, ending up dehydrated. Most recover with treatment but they may become worse before they improve, or their condition may deteriorate rapidly.
Doctors argue their case to call center staffers who categorize patients by low, medium and high severity and repeatedly call hospitals in Maryland, D.C. and Virginia, but also in Delaware, West Virginia and Pennsylvania, in search of beds. In the meantime, doctors offer treatment guidance, knowing patients may never get ICU beds.
“The system is overwhelmed,” Anders said. Sometimes, a doctor with a patient in severe distress will activate a pediatric transport team or call a colleague’s cellphone — whatever it takes, she said.
“They all look sick; they all need ICUs,” she said. “My goal with C4 Pediatrics is that no kid dies in a community hospital waiting for a critical care bed.”
In September, when a seemingly simple cold sank Jordan’s oxygen saturation levels, paramedics took him by ambulance to Adventist HealthCare Shady Grove Medical Center in Rockville. It took all night for doctors to find the boy a pediatric intensive care bed. At 3 a.m. he was transported to Sinai Hospital in Baltimore, where he stayed for the next four days.
Then, on Oct. 11, his oxygen levels dropped again and his mother rushed him to the nearest emergency room, Holy Cross Hospital in Silver Spring. He was diagnosed with RSV and assigned an emergency department room with a small bed for him and, later, a small reclining chair where Maeng slept, leaving only when her husband could relieve her after his workday.
“It was miserable,” she said. “I have never seen my son look so down and sad and depressed. You’re in this teeny tiny room, constantly different doctors coming in.” Only visits from his siblings Katelin, 7, and Michael, 4, seemed to cheer the boy, who goes by “JoJo.”
Holley Meers, the chief of emergency medicine at Holy Cross Hospital, declined to speak about any specific case, including that of the Maeng family, but said her staff makes accommodations, such as setting aside medicine measured according to a child’s weight, pediatric gowns and oxygen-supply tubing, to care for children awaiting transfer.
“We are going to care for patients as long as they need care — if that means at our hospital, [then] that is what we are going to do,” she said. “When beds are not available, care still goes on.”
The ER was not an ideal place for Jordan, who turned 6 after this stay. Besides the discomfort and close quarters, the constant coming and going of different doctors and nurses meant his mom constantly had to explain his situation and unique needs.
Friends, family members and their church community came through with gift cards for hot meals, allowing the family to skip the boxed meals available in the ER.
Maeng watched doctors transfer a child even sicker than her son to a PICU bed first, a decision she said she understood, given the other child’s condition. She said one doctor explained to her that “there is literally not a pediatric intensive care bed to be had in the whole DMV area.”
Doctors eventually found a bed for Jordan back at Sinai in Baltimore, where he stayed a second time for another four days. Once home, his face was rubbed raw from the high-flow oxygen cannula used to support his breathing, and being stuck in a hospital bed affected his gait; he walked like a penguin for a few days, Maeng said. Now, he takes a daily steroid to keep his lungs open and avoid another ER visit.
Maeng said their Christian faith helped her family see a higher purpose in the suffering her middle child endured.
“While it was a crazy stay, seven days, I’m thankful,” she said. “I can share our story and bring light to the situation right now.”