Some are calling it a “tripledemic.” An extraordinary convergence of severe respiratory viruses—fueled primarily by respiratory syncytial virus (RSV), COVID-19 and influenza—is overwhelming the pediatric health care system.
“What we're seeing does match the description of a ‘tripledemic,’” says James Fortenberry, M.D., chief medical officer at Children’s Healthcare of Atlanta (CHOA). “What makes this different than a typical virus surge is that we have hit historically high admissions volumes and maintained that peak for a number of months.”
Earlier this month, the Centers for Disease Control and Prevention (CDC) issued an advisory warning of the strain on health care systems caused by the circulation of multiple respiratory viruses. On Nov. 15, the Children’s Hospital Association and American Academy of Pediatrics sent a letter to the White House and the Department of Health and Human Services urging them to make an emergency declaration. According to the letter, more than 75% of pediatric hospital beds are occupied and some states seeing occupancy rates over 90%.
While COVID-19 cases are still being reported, RSV cases around the country began increasing in late-spring and throughout the summer—months earlier than normal. And the flu season has arrived early and severely—CDC reports flu-associated hospitalization rates for children are at their highest point in more than a decade compared to the same time periods during previous seasons.
“It is really taxing the pediatric health care system in the country right now,” says Frank Belmonte, D.O., M.P.H., chief medical officer and pediatrics chair at Advocate Children's Hospital in Park Ridge, Illinois. “There’s simply not enough bed capacity for all the kids needing hospitalization.”
Greater incidence and higher acuity
The concurrent timing of the viral surges is only part of the problem. Belmonte and Fortenberry say they’re also seeing a higher incidence of severe respiratory illness compared to prior years. It’s too early to determine exactly why that may be the case, but the signs point to immunity debt.
RSV and the flu virus circulated at very low levels during the COVID-19 pandemic, so children have had little exposure to those viruses over the last two years. Many of those children returned to daycare or school this year for the first time without masking precautions and no immunity to these respiratory viruses.
“The number of kids who had not had any significant exposure previously to these viruses has certainly been a factor in filling up our emergency departments (EDs), ICUs and general pediatrics floors,” Fortenberry says.
Strategies for the surge
Fortenberry describes the primary challenge as a “supply/demand mismatch.” He and his team have deployed strategies to mitigate patient demand while bolstering the availability of care across several categories:
- Beds. Opening overflow patient areas and repurposing non-clinical spaces to add capacity.
- Providers. Ramping up staffing, particularly in EDs.
- Admissions. Leveraging area adult hospitals to care for some older pediatric patients and limited non-essential surgical procedures.
- Flow. Earlier rounding to expedite discharge process.
- ED support. Adding surge tent outside one facility’s ED, configuring overflow waiting room space at another.
- Communications. Guiding parents toward appropriate care facilities for their sick children through proactive community outreach.
The hospital also established a capacity planning group that meets regularly to assess and adjust the surge response plan as needed. While COVID-19 continues to be a primary source of concern for Fortenberry’s team and a contributing factor to this latest surge, it has also helped them prepare to meet this challenge.
“If the pandemic taught us anything, it is that we don't know what's going to come next and to prepare for the worst,” Fortenberry says. “We're confident that the work we’re doing now is going to help prepare us for whatever happens.”
Advocate Children’s Hospital is also addressing the surge of respiratory illnesses with a multi-tiered approach. Belmonte says two aspects of his team’s plan have proven especially effective:
- Disaster privileging. An internal disaster declaration has enabled the hospital to credential about 50 primary care physicians to provide care for lower-acuity patients, freeing up ED doctors to attend to sicker children. “Our throughput and wait times have improved and we’ve been able to see more patients with this program in place—it’s been a great win for us,” Belmonte says.
- Chief triage officer. A senior hospitalist or critical care physician monitors all patients across the hospital’s network of community sites daily, providing guidance to ED physicians at those sites and prioritizing patients to move into beds as they become available.
Communication is crucial
The glue holding the response plan together, according to Fortenberry, is a solid line of communication across the organization. “When we’re able to gather our leaders together, we can very quickly identify what's working, what's not and what the need is,” Fortenberry says. “We have the right people at the table so we can make decisions quickly and they’re able to run with them.”
As critical as clear and direct communications are to the community and within a health care organization, it’s also important to nurture relationships with peers.
Belmonte has a standing weekly meeting with other CMOs in his area to discuss how their institutions are dealing with the patient surges. “We’re processing results, how everyone is doing, what’s working and sharing best practices,” Belmonte says. “I’m really proud of the work we’re doing collectively on behalf of the kids in our region.”
For more information on capacity management, Children’s Hospital Association has launched a group discussion page for its members.