key: cord-0870175-y5foi9r5
authors: Abulebda, Kamal; Ahmed, Rami A; Auerbach, Marc A; Bona, Anna M; Falvo, Lauren E; Hughes, Patrick G; Gross, Isabel T; Sarmiento, Elisa J; Barach, Paul R
title: National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic
date: 2020-12-18
journal: World J Crit Care Med
DOI: 10.5492/wjccm.v9.i5.74
sha: 10b122cc3df2a228321b272af30f012a7431dcec
doc_id: 870175
cord_uid: y5foi9r5

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.

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.

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.

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 December 18, 2020 Volume 9 Issue 5 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.

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. 

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.

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

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 .

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) .

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 ).

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 ). December 18, 2020 Volume 9 Issue 5 

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 ).

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 December 18, 2020 Volume 9 Issue 5 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] [19] [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.

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 December 18, 2020 Volume 9 Issue 5 

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.

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.

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

The Impact of Coronavirus Disease

COVID-19 PICU guidelines: for high-and limited-resource settings

Overcoming COVID-19 Investigators; CDC COVID-19 Response Team. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents

Critical Care Clinician Reports on Coronavirus Disease 2019: Results From a National Survey of 4,875 ICU Providers

Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective

Just-in-Time Simulation to Guide Workflow Design for Coronavirus Disease 2019 Difficult Airway Management

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

Kissoon N; Task Force for Pediatric Emergency Mass Critical Care. Supplies and equipment for pediatric emergency mass critical care

Task Force for Pediatric Emergency Mass Critical Care. Neonatal and pediatric regionalized systems in pediatric emergency mass critical care

Pediatric Resuscitation Practices During the Coronavirus Disease

Improving Pediatric Acute Care Therapy Simulation (ImPACTS)

Guidance on Medical Students' Participation in Direct In-person

Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation

In situ simulation in continuing education for the health care professions: a systematic review

COVID-19 Outbreak Response for an Emergency Department Using In Situ Simulation

Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies

Personal Protective Equipment Supply Chain: Lessons Learned from Recent Public Health Emergency Responses

Infection preventionists' experience during the first months of the 2009 novel H1N1 influenza A pandemic

Hospital preparedness for severe acute respiratory syndrome in the United States: views from a national survey of infectious diseases consultants

Health workers should be top priority for vaccines -nurses' group

COronavirus Pandemic Epidemiology Consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

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

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

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.

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.

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.