When Pediatric Hospitalists Took Care of Adults During the COVID-19 Pandemic.

Abstract

In April 2020, the coronavirus disease 2019 (COVID-19) pandemic raged through our hospital system in Connecticut.1 Medical teams for adult patients mobilized their staff and units for the incessant surge. Patient volume and acuity on the adult units began to rise amid the uncertainty of personal protective equipment (PPE) supplies, fear of a formidable impact, and potential depletion of the clinical workforce. In preparation, the pediatrics department chair of our children’s hospital within a larger academic medical center asked for volunteers to help the adult teams. The pediatric wards were strangely quiet as patients and families stayed away from the hospital and elective surgeries were canceled. In comparison, admissions to adult units in our hospital continued to rise exponentially (3 cases of COVID-19 on March 15 and 354 on April 9), further displaying the disproportionate impact of the pandemic on adults. Because pediatric hospitalizations to COVID-19 remained low and the demand for beds for hospitalized adults continued to rise, we initially gave two of our pediatric units to internal medicine clinician teams for adult admissions.Along with more hospitalized patients, the need for more clinicians to care for patients became more apparent. We heard that our pediatric critical care and pediatric emergency department faculty were helping to staff with adult medical ICUs. We knew that would be us soon and began work to brush up on our internal medicine skills.2 Instead of waiting to be asked, we decided proactively to offer our services to the internal medicine department as a team of pediatric nurses, pediatric housestaff, and pediatric hospitalists under the guidance of medicine-pediatrics hospitalists and medicine-pediatrics housestaff. Shortly, we were deployed to open a new adult COVID-19 unit outside of the children’s hospital where we would care for adults with COVID-19 and also care for patients with COVID-19 at the end of their lives who were “comfort measures only.” We chose to staff the 24-bed unit with 3 physician teams, specifically 1 pediatric hospitalist paired with a medicine-pediatrics intern, 1 pediatric hospitalist with a pediatric intern and senior pediatric resident, and 1 medicine-pediatrics hospitalist with a senior pediatric resident for 12-hour day shifts (7 am to 7 pm). Night coverage included a senior medicine-pediatrics resident and a senior pediatric resident with backup from a medicine-pediatrics hospitalist from home (7 pm to 7 am). Both day and night teams switched off every 7 days. In an effort to share our experience with others who find themselves in a similar situation, we share our lessons learned below (Table 1).Teamwork is defined as a process that describes interactions among members who combine collective resources to resolve task demands.3 At its foundation, teamwork that results in high-quality outcomes relies on trust, shared goals, open communication, and clear delineation of responsibilities. We realized that a high-functioning team is a dynamic social concept. We started with years of collegiality and a strong base of trust, which was essential during the challenge of this new ward. We chose to transplant an entire team, including medicine-pediatrics physicians with a strong understanding of the pediatric world, and brought a foundation of teamwork that allowed us to reach our full potential. The presence of medicine-pediatrics faculty as part of our team also served as a helpful bridge. As internists, they provided a knowledge resource when needed and as pediatricians, they understood the culture of the ward team. We traveled as a team (ie, nurses, residents, and faculty) to care for patients on our new COVID-19 unit. We also brought our pediatric infection prevention (IP) team with us. The pediatric IP team led “just-in-time” PPE trainings during multiple shifts, and the familiarity of team members to our staff and physicians added an additional layer of comfort with asking questions and maintaining a culture of accountability.When the institution initially asked for volunteers to help in the department of medicine, many of us were uncertain if our skill set would translate in unfamiliar surroundings. Successful deployment of clinicians, including pediatricians to adult clinical teams caring for patients with COVID-19 using a tiered staffing system, has been described.4 It is our opinion that if we had scattered to other units to integrate into other teams, the connection and trust of long-standing relationships would have been lost. Time and energy would have been wasted building that foundation anew with other teams and our impact would have been lessened. Anecdotally, during leadership meetings of medical directors and nurse managers leading COVID-19 units, we learned that the presence of a solo clinician deployed to work with new teams on unfamiliar units led to some communication breakdown and conflict.When we were initially asked to care for patients with COVID-19 who were comfort measures only, many of us bristled at the thought. At first pass, an elderly patient with multiple comorbidities felt like the exact opposite of our usual patient population. However, pediatricians are experienced with family engagement and communication, comfort of an ill person who lacks capacity to express fear, and the insight to recognize the whole person. The well-child visit teaches us to see all parts of a patient and recognize with joy their humanity even when there is no verbal connection. Family-centered rounds in the inpatient setting teaches us to involve families early and use them as advocates for the values and ideals of their loved one. In light of the hospital-wide no-visitor policy, we were deliberate about daily communication with the patient’s point of contact either by calling him or her during rounds in the room by phone or through virtual platforms to include multiple family members either during rounds or immediately after. We conducted numerous phone and virtual family meetings, sometimes multiple per day, guiding family members of our mostly elderly patients with COVID-19 through difficult decisions such as changes in code status to do not resuscitate or changing goals of care to comfort measures only. Many families of patients who died sought out our team later to thank us for calling them every day and for engaging them as critical team members in their dying loved one’s course. Pediatricians simply would not have known how to do it in any other way.Although everyone at our institution shared a patient-centered vision and a desire to do the best job possible, leadership across the adult hospital was not initially supportive of the model to transplant an entire pediatric team in this manner. There were times in which the nuances and details of our vision conflicted with what they had imagined. We had to be tenacious and steadfast in our belief that this was the right choice, asking leadership more than once for the chance to use our skills in the way we knew best. Pediatricians are not simply doctors not otherwise specified who can slot into the role of an internist, and nor are we care-team extenders whose only role could be that of order entry. We had particular skills and positioned ourselves to bring them to the crisis. We needed to be specific in identifying the patients for our unit, and we needed to function self-sufficiently. The presence of our medicine-pediatrics colleagues was critical in bridging the divide between our vision for what we could accomplish and the overarching crisis management happening on a system level in which few pediatric voices were present. We had a strong belief that we could provide high-quality care to a cultivated adult population as an intact team, and that belief powered us to create a unit despite initial resistance. That belief granted us the calm fortitude of vision to contribute all that we knew we could. Despite the constantly shifting landscape of clinical management and operations outside of our ward, there was a strong spirit of collaboration among nurses, residents, and attending physicians. Within the ward, our mission to care remained central and motivating. We leveraged our skills as pediatricians: a vast experience with complex respiratory conditions, an ability to forge strong doctor-patient relationships, and a keen skill to coordinate complicated care. This patient-centered mission to care for the sick inspired, motivated, and encouraged us.To further complement our skill set with the knowledge base of specialists in adult medicine, we invited the adult palliative care physician on service to join our morning rounds on a virtual platform. We discussed our comfort-measures-only patients as a team with input and expertise from the palliative care team whose members guided us through various aspects of managing dying adult patients and provided us with practical guidance and resources.5–7 Their presence also provided us the opportunity to process our own inner conflicts in challenging situations and talk about the personal emotional toll of seeing more patients die in a week than some of us had in a career. For an added layer of quality and safety, we had a member of the pharmacy team present on a virtual platform for the entirety of morning rounds. We also advocated for our addition to the daily adult infectious disease (ID) case discussion and question-and-answer rounds, adult hospitalist operations meetings, and electronic communications to stay current as the pediatrics team with respect to evolving clinical management protocols in adult patients and hospital operations. Although most of our interactions were with adult ID and palliative care subspecialists, we consulted other adult subspecialists as needed.We bore witness to dozens of stories of trust, compassion, innovation, and friendship: the nurse who gave us our headbands to attach our surgical masks more comfortably, the attending who gave a colleague a day off to rest, the boot camp that medicine-pediatrics faculty and residents designed to get pediatric colleagues up to speed. Residents arranging goodbyes on virtual platforms with family members unable to visit because of visitor restrictions. We made it a point to ask family members to tell us stories about their loved ones so that the fragile person taking agonal breaths in front of us felt more human and the mechanics of the process did not shade our empathy and compassion. We set up favorite audiobooks and music for our patients. Physicians took vitals, hung fluids, and helped patients to the bathroom to help our nursing colleagues. We were purposeful about stopping to reflect on each patient we lost individually and in groups.When we agreed to take care of patients who were comfort measures only, we knew that we had to be prepared to support our housestaff, hospitalists, and nursing staff. The physician staffing model was purposefully designed to be 7 days on and 7 days off to allow for decompression. Our graduate medical director for resident and fellow well-being led weekly virtual debriefings with housestaff to which nurses were also invited. To maintain a sense of connectedness, our hospitalist group set up biweekly informal virtual group check-ins and created a support group on social media. Attending physicians on service and nurses used a buddy model to check in with each other, and hospitalists took frequent trips with housestaff to our healing garden8 for reflection. Our child life team led group activities around bereavement, such as making crafts and writing cards to families of patients we lost, that brought multidisciplinary team members together. Unit physician and nursing leaders purposefully reached out in person or by phone to staff members whose patients died during their shift.A month after our hospitalist and nursing team returned to the children’s hospital, the key stakeholders reconvened for a debriefing with the quality and safety team. During a 6-week period of staffing the adult COVID-19 unit, we took care of 91 adults with COVID-19, of whom 33 died. We learned that no staff or clinician from our unit had been infected with COVID-19 and no serious safety events occurred on our unit. This was in part due to the work of our pediatric IP team who accompanied us and conducted frequent just-in-time trainings on appropriate donning and doffing of PPE and our culture as a high-reliability organization that includes 200% accountability and reporting of safety events. Our success was also in part due to the partnership and teamwork with adult subspecialty teams, our inclusion into the adult ID daily case conference discussions, internal medicine team meetings, and virtual daily rounds with the adult palliative care team. Anecdotally, each and every member of our clinical, nursing, and ancillary support teams, including our pediatric unit clerks and child life teams, felt the emotional impact of our experience in some capacity. Some staff sought therapy for their mental health and others relied on their social circles and unit leadership for support. The housestaff began compiling stories and visual art as a means to process their experience. Because of concerns about posttraumatic stress disorder, our unit leadership (medical director and nurse managers) and residency leadership still continue to check in with team members. The true extent of the emotional toll on our team members and impact of the support systems we created will never be fully understood, but after our team’s return to the children’s hospital, it is not uncommon for physicians and nurses to pause, share stories with each other, and reflect on the time we took care of adults.We identified opportunities for clearer communication during the ramp-up and ramp-down but recognized that urgency and uncertainty around the pandemic impeded clarity. For example, none of us had cared for patients with COVID-19, and on the first few days on the new adult COVID-19 unit, members of our clinician and nursing team decided to walk over to other adult COVID-19 units to learn about what the experience was like for the teams and unit leaders on the front lines and what resources they found most helpful day to day. Despite all the e-mail communications we were receiving, the one-on-one connection with other frontline teams proved to be more useful. Regarding ramp-down, after 6 weeks of staffing the adult COVID-19 unit, we started to see other adult COVID-19 units around us flipping back to non-COVID-19 and were not provided with a clear time line of when that would happen to our team and when we would return to the children’s hospital. Not knowing exactly when we would return to the children’s hospital was an added stressor to an already stretched team outside of their comfort zone.Looking back, our team of pediatric hospitalists, pediatric housestaff, and pediatric nurses, along with medicine-pediatrics hospitalists and medicine-pediatrics housestaff, came together in a crisis and successfully ran an adult COVID-19 unit during the peak of the pandemic in our hospital. We took care of dying patients honorably and supported families and each other during a historic and challenging time in our lives. Uncertainty remains around a second peak and the impact of COVID-19 on children. As future planning is underway, it is important to understand team dynamics, clinician experiences, and effects on patient care in 2 different models of clinician deployment in the pandemic. In one model, pediatric clinicians were deployed to other adult units and integrated into their teams compared to our model of deploying an entire pediatric team of clinicians and pediatric nurses to run an adult COVID-19 unit with guidance from medicine-pediatrics clinicians. For the next crises, whatever it may be, we will draw from these experiences, and face the future, together.We thank the medicine-pediatrics and pediatric housestaff, medicine-pediatrics and pediatric hospitalists, and pediatric nursing staff at Yale New Haven Hospital and the patients and families we had the privilege to care for.