Keywords
children - health care system - infrastructure - modifiable factors - pandemic - systems
approach
Introduction
The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome
coronavirus 2, is thought to largely spare the children. Data from China and the United
States suggest that pediatric COVID-19 constitutes just ~2.0% of all reported positive.[1]
[2]
[3]
[4] Children of all ages are susceptible to COVID-19, including newborns.[5] Among them, those with respiratory failure due to severe acute respiratory infection
(SARI) or multiorgan dysfunction syndrome due to multisystem inflammatory syndrome
in children (MIS-C) require critical care.[3]
[4]
[6]
[7]
[8]
[9] In a scenario of 5% cumulative pediatric infection proportion, the projected estimate
of sick children requiring hospitalization is just ~0.2%.[10] World over, several pediatric intensive care units (PICU) are converted to medical
ICUs due to the disproportionately severe illness and progression in adults.[3]
[11]
[12]
The COVID-19 pandemic supposedly started in late November 2019 from the Chinese city
of Wuhan. India reported its first case on January 30, 2020 in a student returning
from Wuhan. The World Health Organization (WHO) declared COVID-19 as a pandemic on
March 11, 2020, and around this time, India accounted for just ~350 cases.[13] China, Korea, and the United States reported their first pediatric case on January
20, February 19, and March 2, respectively.[3] On April 26, 2020, the National Health Service of the United Kingdom gave the first
alert on children presenting critically ill with overlapping features of toxic shock
syndrome and Kawasaki disease, later described to be temporally associated with COVID-19.
On May 14, the Centers for Disease Control and Prevention, United States, released
the MIS-C advisory.
A pandemic leads to disruption and stretching of an existing health care system and
its resources to its limit. Pediatric cases span from neonates to adolescents with
different requirements. We discuss the importance of preparedness of the health care
system for children based on systems approach, in the background of evolving knowledge
of a pandemic and its outcome.
Preparedness to COVID-19 Care
The department is part of an academic institution based in coastal Karnataka, Southern
India. We worked out the optimization of the services of the pediatric department
to meet the following objectives:
-
To diagnose, isolate, and manage COVID-19 infected.
-
To reduce the risk of transmission to health care workers (HCW).
-
To rationalize the management of assets and resources.
-
To partner with the public health system.
-
To continue uninterrupted non-COVID services.
Infrastructure Changes
Fever clinic was established at the emergency department as the single-entry point
to triage and segregate all children with fever, respiratory, and other COVID-19-compatible
symptoms. We undertook infrastructure changes ([Fig. 1]) in the Children’s Critical Care Complex as follows:
-
Separate entrance and exit for HCW and patients.
-
Donning and doffing areas for personal protective equipment (PPE).
-
Earmarked areas for stable and unstable COVID-19 suspect and COVID-19 positive, pediatric
and neonatal (born to COVID-19-positive mother) beds.
-
Labor theater for COVID-19 suspect/ positive mothers.
Fig. 1 Floor plan of Children’s Critical Care Complex showing infrastructure changes for
coronavirus disease 2019 admissions.
The ICU had high-efficiency particulate air filtering system and negative pressure.
We relocated the non-COVID-19 neonatal and pediatric beds for both regular and intensive
care in other hospital areas. An inventory and stocking of medical products along
with allocation of equipment like ventilators between the COVID-19 and non-COVID-19
areas were executed.
Human Resources and Training
A task force comprising of clinicians, intensivists, epidemiologist, microbiologist,
biomedical engineering, and a member of the hospital administration board formulated
the health system requirements and compiled the patient management protocols of individual
departments.[14] It monitored the training of the HCW and support staff. Faculty and residents were
reoriented to infrastructure changes, donning and doffing of PPE, changes to treatment
protocols, especially intubation and ventilation strategies for minimizing aerosol
generation.
Duty rosters for all HCW were reorganized into teams in a lean way, ensuring minimal
staff exposure, no cross over between COVID-19 and non-COVID-19 areas, and adequate
reserve staff. Ongoing changes to infrastructure and processes, clinical management
guidelines, and government notifications were updated continuously and broadcasted
using virtual platforms. The hospital board also focused on psychological support
for the HCW and COVID-19-related biomedical waste disposal.
Challenges in Health Care Delivery
Optimization of services and safety of the HCW took precedence over cost and long-term
repercussions on the department budgeting. We revisited the annual budgeting of the
department. Issues with medical product companies, especially PPE, were the greatest
challenge to the hospital. Telemedicine was expanded to provide continuity of treatment
to chronic patients. Networking with community industries that could manufacture PPE
coupled with existing buffer stock and rational use helped to tide over amidst the
country-wide lockdown and underpreparedness very early on in the pandemic.
We worked in mutual cooperation with the district public health system. Our facility
was part of the state contingency plan. We utilized the government facility for COVID-19
diagnostics until we established our own. The state also helped with contact tracing
and surveillance. Google Spreadsheets working like an application were created to
update ICU beds and ventilators in real-time across the district for adults and children.
Outcome
Our first admission of a critical case was on March 23, 2020 within 24 hours of the
country going for a lockdown. He was a 10-month-old infant, presenting with SARI,
hyperpyrexia, and seizures. He was designated as P06, the sixth case in the state,
in the daily bulletin released on the COVID-19 information portal by the government.
He was probably one of the first few infants with a severe disease in the country.
Over 6 months, between April and September, 22 children required in-patient care for
an influenza like illness or SARI. We promptly recognized and managed MIS-C associated
with COVID-19, in a 6-year-old girl presenting with myocarditis and shock in the second
week of October.
A total of 33 (6.5%) pregnant women tested positive for COVID-19; only 17 of the newborns
were tested due to lack of consent of whom two (11.8%) were positive. Two newborns
had a severe transient tachypnea of newborn and had uneventful recovery. Their COVID-19
status was unknown. All babies were nursed at the mother’s side.
The preparation also helped to manage childhood poisoning and trauma without cross-infection.
Poisoning constituted 4.8% of PICU admissions in comparison to 2.1% during the corresponding
period in 2019. Trauma constituted 4.2% of PICU admissions that were comparable to
the corresponding period in 2019.
Discussion
In a health care system, the relationship between an operator, tasks, and contexts
is dynamic. A pandemic like COVID-19 exposes the imbalance in exponential time; the
health care facility requires rapid and drastic changes to infrastructure and functioning.[15] However, we had difficulty assessing the extent to which these adaptations were
needed very early in the pandemic, especially as the knowledge was scarce for the
pediatric population. Children are generally a part of the family cluster. Dong et
al from China, in one of the most extensive case series comprising of 2,135 children
with COVID-19, reported that ~43.9% had moderate-to-severe respiratory illness, and
0.6% had a critical illness with multiorgan dysfunction syndrome.[6] The proportions of severe and critical cases were 10.6 and 7.3% among infants and
children aged between 1 and 5 years. The authors reported only one mortality in the
series.
Restructuring the health care system to deliver specialized COVID-19 care, the decline
in routine services and regular office visits has led to losses amounting to hundreds
of billion dollars for the hospitals.[16] We adapted the systems approach and looked into the independent and interdependent
modifiable factors.[17] The key initiatives were to identify our objectives, bring out changes to the organizational
processes, and integrate the same into the existing system. The strong commitment
and reassurance to all employees' safety by the hospital board helped the department
execute the infrastructure changes, reallocation of resources from its annual budgeting,
roles and responsibilities of HCW, and handholding.
Our prior experience during Nipah virus outbreak in the neighboring state helped us
quickly establish the fever clinic and protocols for segregation and triage.[18] Our critical care unit with high-efficiency particulate air filtering system and
negative pressure was best suited for management of COVID-19.[19] Increase in indigenous manufacturing and innovations during the latter part of the
pandemic ensured no imbalances in demand and supply. The management protocols relevant
to our health care system were adopted.[14]
[19]
[20]
[21] This preparedness helped us manage COVID-19-positive children and neonates efficiently
very early in the outbreak without collateral issues.
Conclusion
The preparedness of the health care system is crucial in a pandemic like COVID-19.
This requires addressing all aspects of the system, namely, infrastructure, human
resources, medical products, funding, leadership, and governance. Though the health
system is mostly open, acting upon the modifiable factors using a systems approach
gave better preparedness in a short time. Children also need prioritization as they
are susceptible to the disease.
