• Article
  • August 3, 2020

COVID19: Pandemic to Permanently Change How Children's Hospitals Deliver Care

Despite the darkness of the COVID-19 pandemic, bright spots have begun to emerge. Children’s hospitals have quickly changed processes, policies and systems, which will affect how health care is delivered in the future.

By Megan McDonnell Busenbark

As the world faces the COVID-19 pandemic and the fear, anxiety and uncertainty it brings, children's hospitals are finding aspects of hope amid the crisis. Out of necessity, hospitals are thinking and working in different ways—from enhancing care and leveraging technology, to improving communication with staff, patients and families. Many of these changes the pandemic has brought to children's hospitals will be here to stay even in a post-COVID-19 world. Here's a look at the developments we've seen so far.

1Improved collaboration with community physicians

Team members at Children's Hospital at Erlanger in Chattanooga, Tennessee, say they are seeing several promising outcomes from COVID-19. One is a renewed and strengthened connection and collaboration with community physicians. "A big transition point over the last couple of years has been a lot of community doctors no longer want to come to the hospital to do well-baby checks because it takes a lot of time, and they can see kids in their offices a lot faster, so very few community physicians come to the hospital anymore," says Don Mueller, M.D., who at the time of this interview was CEO at Children's Hospital at Erlanger.

"We lost that connectivity, but COVID gave us that back—now, they want to be here," adds Mueller. "They want to be connected to the hospital, they want to know what our current testing is, they want to know what we're seeing in the community. They're interested in our emergency department and what's going on there. We have a participation level with our community physicians that we haven't had in the last five years."

Mueller says this connection will last long beyond the pandemic, especially because there's a new, ongoing communication practice in place: a weekly, half-hour phone call with more than 50 community pediatricians to talk about COVID-19, patient policies, how to handle newborn babies with COVID-positive parents, how to do pre-surgical testing for COVID-19 patients and a range of other topics.

Mueller says these calls will continue post-pandemic, even if only monthly. "It's been a great connectivity point, and probably the biggest benefit of COVID-19 has been bringing the community closer together like this," he says. "The community physicians are very busy but holding these calls in a structured way—where it's at lunchtime for half an hour on a certain day of the week—is very efficient."

2Connecting patients with loved ones

COVID-19 affected hospital visitations—and it was exacerbated by statewide shutdowns that forced parents to split time between their children in the hospital and other children who were no longer in school. Maria Fareri Children's Hospital, a member of the Westchester Medical Center Health Network in Valhalla, New York, used electronic tablets and devices to help families communicate with loved ones who would otherwise be at the bedside but could not be present due to COVID-19.

Through FaceTime or Facebook, families were together even when they were apart. And it's something that will stick in a post-pandemic world. As a result of the pandemic, the hospital is considering adding cameras in the NICU so parents can see their babies from home. "Communication with families has always been key to their experience," says Michael Gewitz, M.D., executive director and physician-in-chief at Maria Fareri Children's Hospital. "We will continue to look at ways to enhance that process."

3Accelerated telemedicine capabilities

Children's hospitals have been building telehealth programs for some time, and COVID-19 gave them a real shot in the arm. One long-term challenge for telehealth is the payment model; often hospitals are not reimbursed at comparable rates and payments vary by state. But as an alternative way to receive care at the height of the pandemic and during a social-distancing era, more providers, patients and families have embraced it, and many payers adapted their models. While it remains to be seen if these changes will stick for the longer term, there could be more opportunity within the continuum of care in the future.

Before the pandemic, Texas Children's Hospital in Houston conducted anywhere from 10 to 20 telehealth visits a day, mostly for maternal-fetal medicine and ambulatory pilots. When the coronavirus hit, telehealth visits increased to more than 2,000 visits a day. That meant teams at Texas Children's Hospital had to scale with lightning speed to accommodate the surge—and they did.

Pre-pandemic, about 10 to 15 providers at the hospital were trained to conduct telehealth visits. Now, more than 1,500 of its providers, or about 90%, are trained, credentialed and seeing patients across the care spectrum—sometimes with up to nine providers connecting into a video visit so patients and families never had to leave their homes. "The only patients who were having in-person visits were those who required a procedure or physical examination," says Paola Alvarez-Malo, vice president of innovation at Texas Children's Hospital.

While the growth of telehealth came on fast, the adoption and use of telehealth services is expected to grow from pre-pandemic norms based on the experience coming out of COVID-19, according to Alvarez-Malo. Still, children's hospitals need to remain mindful of when and how telehealth visits will work best for patients and their care needs.

"The silver lining for those of us who are zealots about e-health is that it was a forced immersion for both patients and providers into this modality," says Robert Ball, M.D., medical director of eHealth at Texas Children's Hospital and professor, Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology at Baylor College of Medicine/Texas Children's Hospital. "We shouldn't lose track of the fact it is just one tool of many when it comes to patient care. There's going to be responsibility that we don't just throw this at patients, but we have the responsibility not to degrade their experience compared to an in-person visit... the telehealth visit must be at least as good."

According to Alvarez-Malo, an area of telemedicine that has proved surprisingly beneficial since COVID-19 hit is physical therapy. Particularly because now, telehealth visits can take place with patients in their own homes instead of in a provider's office.

"Physical and occupational therapy sessions are done in person because you need the equipment, you need the gym," says Alvarez-Malo. "But what our therapist found was it was beneficial to see the home environment to help families figure out what equipment they could use in their homes to do the exercises in between visits." Alvarez-Malo adds: "As our president of primary care says, 'Telemedicine is here to stay. This is the way that families have been asking to receive care, and the ones who weren't asking didn't know they wanted it. Now, they just absolutely love it.'"

4Cross-training and role flexibility

Agility and flexibility have never been more important than they have been since the pandemic struck—especially because some departments do not have as much work as others due to the COVID-19 crisis. Children's Hospital at Erlanger cross-trained nurses in at least one other area during the pandemic.

For example, an emergency department nurse may train with the intensive care unit, which works well because they are such similar environments, with very sick or injured children, says Mueller. The cross-training has enabled the teams to flex to another area when needed. And it has enabled the hospital to float nurses in ways that maximize employee work hours, give the teams the hours they need, and cut overtime costs.

"For the last six weeks, we've eliminated all overtime for our system," Mueller says. "A designated group gets together and works out the staffing plan for the week. Financially, knowing we eliminated something as costly as overtime while still meeting the needs of our employees by giving them good full-time jobs... this has been a great thing."

COVID-19 brought flex opportunities to Maria Fareri Children's Hospital. Gewitz re-assigned a cardiology nurse, whose patient appointments were limited due to the pandemic, to assist with a clinical trial examining whether a medicine used for other conditions could block some of the effects of inflammation in acute COVID-19. "This flexibility, looking at how people who are providers in one area can pitch in and help out in other areas, is something we'll look at into the future," says Gewitz.

5New awareness about supplies

The biggest change at Children's Hospital at Erlanger, according to Mueller, is there is now a culture of conservation when it comes to supplies and equipment. "I heard from our supply chain team members about the amount of waste we had pre-pandemic, and the culture was that we had an abundant supply of everything, so we didn't worry about it," says Mueller. "Now, we're talking about conservation.

A great example: the gowns in the operating rooms. We used to have stacks where people would grab gowns as they needed them—but COVID-19 has made people think, 'Do I really need to break scrub right now? That means I have to get a whole new set of personal protective equipment.' So, they have enough, but we're eliminating a lot of waste."

Improving the management and optimization of PPE also is a priority at Maria Fareri Children's Hospital. Sourcing is another priority. Especially given how hard COVID-19 hit the New York area, and how hospitals burned through PPE so quickly, the team is making permanent changes.

"We're looking at how we can stockpile better and have more flexibility in vendors so we can reach out quickly to various alternatives," says Gewitz. "COVID-19 clearly demonstrated the need to have flexibility in the rapid procurement of critical supplies."

Mueller agrees going forward, children's hospitals need multiple sources for supplies—even though that has not been the norm, and it is not without drawbacks. "Sole sourcing, while you get pricing benefits, also gives you a lot of risk," he says. "We're sourcing from multiple places now, and we never used to do that. We're very cognizant now of our supply chain whereas before, we just assumed things would be there."

6Managing essential patient care

What’s next?

Regional spikes in COVID-19 cases during the late spring affected more children and young adults than earlier stages of the pandemic. And with schools examining their options in the coming weeks, children’s hospitals are preparing for potential additional COVID-19 impacts, including:

Modeling. Children’s hospitals are allocating resources for possible spikes in COVID-19 patients, as well as the usual fall virus activity and an expected surge in births following the stay-at-home period in early spring.

Behavioral health. The onset of the fall semester could stoke further anxiety and depression, especially if schools delay opening, continue with virtual learning or have ongoing disruptions.

MIS-C. While rare, children’s hospitals continue to monitor research around Multisystem Inflammatory Syndrome in Children (MIS-C); as of July 15, more than 340 cases had been reported nationally.

At the onset of the pandemic, it was anything but business as usual—and that meant a disruption to planned procedures and routine care due to legitimate fears from families and clinical staff about exposure risks and how to handle them, says Gewitz.

This prompted Maria Fareri Children's Hospital to form a workgroup that will develop and analyze strategies for operating as normally as possible in the face of a pandemic. "We're looking at ways to, in the future, continue doing what needs to be done on a regular basis in addition to what we need to do for acute emergencies like COVID-19," says Gewitz.

"And we're looking at strategies for how to better assure people, families in particular, that some of the care that still needs to go on... can still safely go on." The work group is in its early days at the hospital—but it is already looking at things like more flexible hours of operation and how to better arrange the pediatric floors, in terms of both personnel and space, to care for all children more effectively during a pandemic, whether they are infected or they are there for other kinds of critical care.

Maria Fareri Children's Hospital isn't alone in this re-assessment. As a result of COVID-19, Children's Hospital at Erlanger is performing scheduled surgeries on Saturdays to accommodate families concerned about COVID-19 exposure in the hospital environment—and the team plans to maintain that practice moving forward for patient and family convenience.

"COVID-19 has provided the opportunity to improve processes that the hospital couldn't work on before," says Mueller. "Many associates and physicians did not want to do things differently before COVID-19 because that was not how they were done in the past. The new processes during COVID-19 forced people to think differently and do things differently to improve efficiency and patient care."

7Re-engineering the operating room

As the team at Children's Hospital at Erlanger monitored PPE in the face of the pandemic, they discovered they could reduce the number of staff going in and out of the operating room. "Before, you might have one person who would go into six different operating rooms, which may mean they have to change PPE during that process," says Mueller. "We learned there were a lot of people circulating through the operating room and changing PPEs—but they didn't need to. So, we re-engineered the way the operating room staff works."

Megan McDonnell Busenbark is a writer and founder and principal of Encore Communications LLC in Omaha, Nebraska. Send questions or comments.