key: cord-0925392-liibe9n6 authors: Jain, Priya N.; Finger, Leron; Schieffelin, John S.; Zerr, Danielle M.; Hametz, Patricia A. title: Responses of three urban U.S. children’s hospitals to COVID-19: Seattle, new York and new orleans date: 2020-06-11 journal: Paediatr Respir Rev DOI: 10.1016/j.prrv.2020.06.002 sha: 85143a7872d2e78c3e2e39d05139f42b95c26e19 doc_id: 925392 cord_uid: liibe9n6 Since January 2020, there has been a worldwide pandemic of COVID-19, caused by a novel coronavirus--severe acute respiratory syndrome coronavirus 2. The United States has been particularly affected, with the largest number of confirmed cases in a single country in the world. Healthcare systems for adults as well as children have dealt with challenges. This article will reflect on the experiences of selected children’s hospitals in Seattle, New York City, and New Orleans, three of the “hotspots” in the US and share common aspects and lessons learned from these experiences. This article discusses testing and cohorting of patients, personal protective equipment utilization, limiting workplace exposure, and information sharing. In January 2020, a novel coronavirus--severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 1was identified, and by March 11 th the disease it causes, COVID-19, was declared a worldwide pandemic. 2 The United States has been particularly affected, with more than 1.7 million cases as of the end of May, the largest number of confirmed cases in a single country in the world. 3 The country has been in a state of emergency since the 13 th of March 4 , and by mid-March all fifty states, the District of Columbia, and four U.S. territories had reported cases of COVID-19. 5 Although the majority of severe illness has been seen in adults, leading to immense challenges for hospitals and healthcare systems, COVID-19 also has profound impact on the healthcare systems for children as well. Seattle, New York City, and New Orleans were three "hotspots" of COVID-19 infections in the US [Table1], each with unique epidemiologic features contributing to their case rate [ Figure 1 ]. King County (Seattle) 6 New York City 7 Orleans and Jefferson Parish (New Orleans) 8 Overall the Bronx, the borough in which our hospital system is primarily located, given that it is one of the poorest areas of the state and the rates of obesity, asthma, and other co-morbidities thought to exacerbate COVID-19 are very high. 16, 17 Although ultimately the Bronx did experience a disproportionate number of cases and death in adults, 7 pediatric ED visits and admissions remained low, and dropped even further after NYC public schools closed and non-urgent procedures were cancelled. Efforts were made in the Bronx to consolidate pediatric admissions at the Children's Hospital at Montefiore in anticipation of the need to increase capacity for adult patients across NYC. 18 The Children's Hospital at Montefiore (CHAM) is a part of a large health system and is situated within the main Montefiore Hospital campus. In order to help alleviate some of the burden on our adult colleagues and in preparation for an anticipated peak in the first two weeks of April, pediatric leadership met with institutional leadership regularly, and surge plans were put into place. Pediatric providers, nurses and staff employed a "surge in place" model, creating and staffing an adult COVID-19 unit; 19 increased the age limit on pediatric med-surg units to 30 years; and deployed multiple providers and staff to units run by adult providers. The first case of presumptive COVID-19 in the greater metropolitan area of New Orleans was identified on March 9 th , approximately one week after the first case in NYC. Over the next week, several more cases were identified in individuals who had no significant travel history and were unrelated to each other, suggesting that there was previously unrecognized existence of disease and presence of community transmission in the area. New Orleans had recently celebrated Mardi Gras during the last two weeks of February, when nearly one million visitors from around the country and world visited the area. It has been suggested that the Mardi Gras celebration may have significantly accelerated transmission within the community and possibly led to the virus's spread around the country. 20 Currently available sequencing data 21 indicate that a small number of closely related strains were introduced, likely in late February or early March, and those strains spread rapidly within the New Orleans community. Within a week of the first case, state and local officials moved to decrease transmission. Schools were closed on March 16, 2020 and restrictions on business activities followed shortly thereafter, leading to a predictable decline in visits to the pediatric Emergency Room at Children's Hospital New Orleans As COVID-19 spread across the United States, there were factors unique to each city which influenced the individual experiences. Seattle was the first major US city to experience COVID-19, and therefore faced the need to implement COVID-19 policies immediately. New York City, with its high population density and delayed implementation of strict social distancing, had a rate of spread and acute surge that challenged hospitals and healthcare systems to an extent not seen in other US cities. New Orleans hosted a highly attended event in February before the threat of transmission in the US was fully appreciated, and thus likely had an increase in community spread that may have been initially underrecognized. 5 Despite these different starting points, the three children's hospitals shared many similar experiences. All three institutions faced limited testing capabilities. 22 Each region initially relied on testing through local Public Health or Department of Health (DoH) centers, which pragmatically prevented widespread testing. When testing capability was expanded to include in-hospital and commercial laboratories, limited supplies of reagent and swabs threatened testing ability. Each institution employed strict criteria aimed to allow testing of patients most at risk for severe disease or of transmitting disease. Although each site used a different algorithm, initial criteria at all three included fever, cough/shortness of breath, and risk of exposure (travel to certain areas, known exposure to someone with confirmed or highly suspected disease). Children with certain chronic medical illnesses who presented with respiratory symptoms were given preference for testing as well. As the understanding of disease transmission and the recognition of the possible constellation of presenting symptoms evolved, and availability of rapid testing improved, criteria for testing were expanded. Currently, all three institutions are performing COVID-19 testing on a broader population, including all patients presenting for surgeries or those requiring aerosol-generating procedures, admitted patients, and a subset of patients presenting to the emergency room. Patients are prioritized to either in-house or commercial-based tests, depending on urgency of need for results. The number of patients being tested remains highly variable between the three sites [ Table 2 ]. Simultaneous with rapidly changing recommendations, all three institutions also faced concern over supply shortages, an effect of both increased utilization and a shrinking pipeline. Each institution employed different strategies to ensure adequate protection. 22 First, Seattle Children's had previously switched from routine use of N95 masks to multi-use powered air purifying respirators (PAPRs) as the primary source of respirators. With a shortage of isolation masks, PAPRs were preferentially used for care of patients with any respiratory symptoms or signs. In addition, re-use strategies for PAPR shields and face shields were employed, and extended use strategies were initiated for PAPRs, face shields, and isolation masks. CHNOLA implemented similar PPE conservation measures nearly immediately during the first week of local disease recognition in order to preserve their supply. At CHAM, PPE inventory information across the health system was shared at the leadership level on a regular basis, and both reuse and multi-use strategies were employed. At the unit level, critical items including N95 masks and face shields, were stored in a central location with controlled access. Through the three hospitals' experiences, several strategies for managing PPE shortages emerged as promising: controlling access immediately, monitoring supply closely including tracking utilization, and implementing conservation strategies that may need to change frequently to reflect degree and type of shortages. In addition, capitalizing on appropriate opportunities for PPE discontinuation was recognized as an important strategy. 24 In order to ensure effective use of available supplies, all three sites made PPE references, including donning and doffing protocols, 24 easily accessible and interpretable by all frontline clinicians. Once adequate PPE supplies were ensured, each site was able to successfully implement universal masking. Limiting workplace and nosocomial exposure to COVID-19 required a coordinated institutional response. 25 For example, in order to identify potentially infected people quickly and contain the risk of transmission, strategies for screening all staff prior to entering the hospital were implemented at each hospital. All three centers also implemented institutional policies to limit those at the bedside of admitted pediatric patients, in alignment with official recommendations 26 to one parent or primary caretaker. All three institutions suspended team rounds at the bedside, which had previously been a daily part of the workflow, in order to limit staff and patient exposure, and to maintain social distancing. 25 Technology was increasingly utilized, for example calling or face-timing patients and families to obtain histories and answer questions so that PPE could be conserved and movement in and out of patient rooms limited. 27 To minimize overall crowding in buildings and offices, institutions changed prior policies to allow a work-from-home option for non-clinical work. Ambulatory settings in each hospital have seen a marked increase in the use of telemedicine in an attempt to limit unnecessary visits to the hospital campus; this is a strategy that merits further exploration in the inpatient setting. Timely and accurate communication was crucial within each hospital to avoid any confusion or misinformation that might be potentially generated by the multiple streams of information existing within a complex hospital. All three institutions mitigated this risk by using a centralized system to collect and disseminate information such as treatment protocols, clinical trial information, and epidemiologic data. This allowed each hospital to maintain alignment throughout the organization, and for Disease Control and Prevention. Coronavirus Disease World Health Organization. Rolling updates on coronavirus disease (COVID-19) Bringing resources to state, local, tribal & territorial governments Geographic Differences in COVID-19 Cases, Deaths, and Incidence -United States King County Department of Health. Daily COVID-19 outbreak summary New York City Department of Health. COVID-19: Data Louisiana Department of Health. 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The New York Times Genomic epidemiology of novel coronavirus -Global subsampling Innovation and Knowledge Sharing Can Transform COVID-19 Infection Prevention Response Strategies to Optimize the Supply of PPE and Equipment Finding the Value in Personal Protective Equipment for Hospitalized Patients During a Pandemic and Beyond Implementing Physical Distancing in the Hospital: A Key Strategy to Prevent Nosocomial Transmission of COVID-19 Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. 2020 Choosing Wisely in the COVID-19 Era: Preventing Harm to Healthcare Workers The authors would like to thank Dr. Margaret Aldrich for providing data regarding COVID-19 testing at CHAM.