In the News

Reflections on the Tripledemic and Our Path Forward

Published March 10, 2023

The following narrative describes Dr. Chris Newton and Dr. Jonathan Kohler's tripledemic experience and suggestions for action to be taken to mitigate shortfalls found during the response in future events. It was developed during the latter weeks of the pediatric surge, was submitted to various media outlets for publications, and reflects an accounting of the events at that time. It is being posted on the PPN website to encourage reflection and learning from this event, in the hopes that PPN and our many partners leverage the challenges of the past 3 years to improve our collective readiness for future emergencies, crises, and disasters.

Even now, months into the surge, the calls are coming in. “3 month-old, RSV, requiring high-flow nasal cannula, needs a Pediatric Intensive Care Unit bed.” “2 week-old, RSV, tiring out, will soon need intubation, needs Pediatric ICU.” “3 year-old, COVID Positive, rural emergency department with no pediatric capabilities, needs Pediatric ICU.”

With every call, we review our children’s hospitals’ abilities to accept transfers of critically ill children. Some children will die without the resources that only a specialized pediatric facility can provide. And in recent weeks the answer has often been something we have rarely said before: we can’t take the child.

We explain to the physicians on the other end of the line that the recent surge in RSV, influenza, and COVID-19 cases, the so-called “Tripledemic,” has stretched pediatric critical care resources to the breaking point. Where once our hospitals could stretch our resources to find a bed for every child who needed our resources, we now find ourselves with no flexibility. This epidemic of respiratory viruses is “our COVID” for children and those who care for them. But our explanations are little comfort to the physicians, nurses, parents, and patients who need pediatric specialty care that is not available. And turning away kids who need us is devastating to the staff of children’s hospitals, who desperately want to help.

It’s hard to know how many patients in the months of this tripledemic needed a pediatric critical care bed but couldn’t get one. We lack the data systems needed to collect this data, but to judge by the number of times we and our regional partner facilities say no, the number is in the thousands nationwide. What is clear is that there has been an undeniable erosion of pediatric healthcare infrastructure since before the start of the COVID-19 pandemic, with loss of pediatric capabilities at community and adult general hospitals, and dangerously overcrowded conditions at pediatric referral centers. No one has calculated the current extent of the erosion in pediatric capacity, but it is apparent every day and it needs to be addressed emergently.

Pediatric ICUs (PICUs), where we can deliver specialized care to the sickest children, are a precious commodity. A large children’s hospital might have 25 beds in their PICU. The state of Oregon has 40. And in many children’s hospitals some of those desperately needed beds sit empty because there is no nurse to care for a patient in it. Specialized PICU nurses have become a critical and endangered resource, with wealthier children’s hospitals paying traveling PICU nurses many multiples of the standard salary just to maintain staffing - when they can find one at all. These market forces pull nurses away from already underserved areas, worsening the glaringly apparent disparities in health care with which we’ve become too familiar in the pandemic-era.

The capacity crisis at children’s hospitals has received most of the attention during this viral surge. However, children fortunate enough to find a bed at a children’s hospital are likely to receive good care, even if resources are stretched. The true crisis is at the many community and rural hospitals, lacking critical pediatric resources and expertise, where children must shelter in place waiting for a transfer to a pediatric referral center.

All indications suggest that the demand will continue to grow even as the supply shrinks. What can be done to address the unprecedented demand for acute care beds for sick children at appropriately resourced centers? How do we not only address childrens’ immediate needs in the coming weeks, but also prepare for next year’s inevitable surge? How do we make this capacity and resource crisis a single crisis and not an annual event? The federal government has responded with several programs focused on these challenging issues. These include the widely celebrated permanent White House Office of Pandemic Preparedness and Response Policy, three Administration for Strategic Preparedness and Response (ASPR) pediatric centers of excellence, the Health Resources and Services Administration (HRSA) funded Emergency Medical Services for Children Innovation and Improvement Center (EIIC), and the HRSA funded10-hub site Pediatric Pandemic Network.

As children’s hospitals attempt to navigate the coming weeks and prepare for the years to come, it’s clear that we need help. Federal emergency declarations, such as the COVID-era protections recently extended to include the current surge, offer financial and legal protections to hospitals to create flexibility where it did not previously exist. But they are set to expire soon, and it is not clear how we will maintain that vital flexibility when they do. State level emergency declarations provide similar critical flexibility in the worst of times. Unfortunately, only 10 states have issued public emergency declarations related to the current pediatric surge. Clearly, there is widespread fatigue when it comes to pandemic health measures in America. But the need for flexibility that comes with these federal and state declarations cannot be overstated.

We also need better national data sources, and then we need to put those data to good use. In response to the COVID-19 pandemic, the state of Washington developed the Washington Medical Coordination Center, a statewide collaboration between hospitals and the Department of Public Health that in surge situations can act as a sort of air traffic control for patient transfers, with insight into bed availability across the state. A few other states have made similar efforts, but most have not invested in such widespread response capability. It is extremely challenging to reliably know bed availability in real-time, much less direct patients intelligently based on that data. And pediatric bed requests don’t stop at state lines - hospitals routinely field transfer requests from out-of-state. A regional or national solution is critically needed.

Finally, we need to re-establish and expand pediatric capacity in our children’s own communities. Building new PICU beds and finding the people to staff them will take years. Creating financial incentives from Medicaid and commercial insurers for smaller communities to rebuild and expand their pediatric capacity will take political will. But there are things we can do today to help smaller hospitals take care of children, at least keeping them safe until they can be transferred to a pediatric bed. With the help of regional children’s hospitals offering telehealth consults, our specialists can help children in small emergency departments without pediatric specialists or substantial expertise. Hospitals also need equipment that is sized for children, and emergency personnel need to know how to use it. The Pediatric Ready Program outlines what hospitals should have on hand to care for children and will soon be part of the widely adopted American College of Surgeons Trauma Center verification system. In the meantime, we are doing our best to be a resource to the physicians on the other end of the line, sharing our expertise from a distance as best we can.

For now, we don’t have the beds we need. So we need to make children safe in the beds they have.

Dr. Kohler and Dr. Newton are pediatric surgeons and physician administrators in Northern California. Dr. Newton leads the Western Regional Alliance for Pediatric Emergency Management (WRAP-EM) and is a Co-Principal Investigator of the Pediatric Pandemic Network (PPN). Dr. Kohler is a specialist in health communication. The contents are solely the responsibility of the authors and do not necessarily represent the official views of ASPR, HRSA or the Department of Health and Human Services.

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