The COVID-19 push to evolve


Has anyone else noticed how slow it has been on your pediatric floors? Well, you are not alone.

Dr. Magna Dias, pediatric hospitalist, Yale University, New Haven, Conn.

Dr. Magna Dias

The COVID pandemic has had a significant impact on health care volumes, with pediatric volumes decreasing across the nation. A Children’s Hospital Association CEO survey, currently unpublished, noted a 10%-20% decline in inpatient admissions and a 30%-50% decline in pediatric ED visits this past year. Even our usual respiratory surge has been disrupted. The rate of influenza tracked by the CDC is around 1%, compared with the usual seasonal flu baseline national rate of 2.6%. These COVID-related declines have occurred amidst the backdrop of already-decreasing inpatient admissions because of the great work of the pediatric hospital medicine (PHM) community in reducing unnecessary admissions and lengths of stay.

For many hospitals, several factors related to the pandemic have raised significant financial concerns. According to Becker Hospital Review, as of August 2020 over 500 hospitals had furloughed workers. While 26 of those hospitals had brought back workers by December 2020, many did not. Similar financial concerns were noted in a Kaufmann Hall report from January 2021, which showed a median drop of 55% in operating margins. The CARES Act helped reduce some of the detrimental impact on operating margins, but it did not diminish the added burden of personal protective equipment expenses, longer length of stay for COVID patients, and a reimbursement shift to more government payors and uninsured caused by pandemic-forced job losses.

COVID’s impact specific to pediatric hospital medicine has been substantial. A recent unpublished survey by the PHM Economics Research Collaborative (PERC) demonstrated how COVID has affected pediatric hospital medicine programs. Forty-five unique PHM programs from over 21 states responded, with 98% reporting a decrease in pediatric inpatient admissions as well as ED visits. About 11% reported temporary unit closures, while 51% of all programs reported staffing restrictions ranging from hiring freezes to downsizing the number of hospitalists in the group. Salaries decreased in 26% of reporting programs, and 20%-56% described reduced benefits, ranging from less CME/vacation time and stipends to retirement benefits. The three most frequent benefit losses included annual salary increases, educational stipends, and bonuses.

Community hospitals felt the palpable, financial strain of decreasing pediatric admissions well before the pandemic. Hospitals like MedStar Franklin Square Hospital in Baltimore and Harrington Hospital in Southbridge, Mass., had decided to close their pediatrics units before COVID hit. In a 2014 unpublished survey of 349 community PHM (CPHM) programs, 57% of respondents felt that finances and justification for a pediatric program were primary concerns.

Responding to financial stressors is not a novel challenge for CPHM programs. To keep these vital pediatric programs in place despite lower inpatient volumes, those of us in CPHM have learned many lessons over the years on how to adapt. Such adaptations have included diversification in procedures and multifloor coverage in the hospital. Voiding cystourethrogram catheterizations and circumcisions are now more commonly performed by CPHM providers, who may also cover multiple areas of the hospital, including the ED, NICU, and well-newborn nursery. Comanagement of subspecialty or surgical patients is yet another example of such diversification.

Furthermore, the PERC survey showed that some PHM programs temporarily covered pediatric ICUs and step-down units and began doing ED and urgent care coverage as primary providers Most programs reported no change in newborn visits while 16% reported an increase in newborn volume and 14% reported a decrease in newborn volume. My own health system was one of the groups that had an increase in newborn volume. This was caused by community pediatricians who had stopped coming in to see their own newborns. This coverage adjustment has yet to return to baseline and will likely become permanent.

There was a 11% increase from prepandemic baselines (from 9% to 20%) in programs doing telemedicine. Most respondents stated that they will continue to offer telemedicine with an additional 25% of programs considering starting. There was also a slight increase during the pandemic of coverage of mental health units (from 11% to 13%), which may have led 11% of respondents to consider the addition of this service. The survey also noted that about 28% of PHM programs performed circumcisions, frenectomies, and sedation prepandemic, and 14%-18% are considering adding these services.

Overall, the financial stressors are improving, but our need to adapt in PHM is more pressing than ever. The pandemic has given us the push for evolution and some opportunities that did not exist before. One is the use of telemedicine to expand our subspecialty support to community hospitals, as well as to children’s hospitals in areas where subspecialists are in short supply. These telemedicine consults are being reimbursed for the first time, which allows more access to these services.

With the pandemic, many hospitals are moving to single room occupancy models. Construction to add more beds is costly, and unnecessary if we can utilize community hospitals to keep appropriate patients in their home communities. The opportunity to partner with community hospital programs to provide telemedicine support should not be overlooked. This is also an opportunity for academic referral centers to have more open beds for critical care and highly specialized patients.

Another opportunity is to expand scope by changing age limits, as 18% of respondents to the PERC survey reported that they had started to care for adults since the pandemic. The Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been a valuable resource for education on caring for adults, guidance on which patient populations are appropriate, and the resources needed to do this. While caring for older adults, even in their 90s, was a pandemic-related phenomenon, there is an opportunity to see if the age limit we care for should be raised to 21, or even 25, as some CPHM programs had been doing prepandemic.

Along with the expansion of age limits, there are many other areas of opportunity highlighted within the PERC survey. These include expanding coverage within pediatric ICUs, EDs, and urgent care areas, along with coverage of well newborns that were previously covered by community pediatricians. Also, the increase of mental health admissions is another area where PHM programs might expand their services.

While I hope the financial stressors improve, hope is not a plan and therefore we need to think and prepare for what the post-COVID future may look like. Some have predicted a rebound pediatric respiratory surge next year as the masks come off and children return to in-person learning and daycare. This may be true, but we would be foolish not to use lessons from the pandemic as well as the past to consider options in our toolkit to become more financially stable. POPCoRN, as well as the American Academy of Pediatrics’ listserv and subcommittees, have been a source of collaboration and shared knowledge during a time when we have needed to quickly respond to ever-changing information. These networks and information sharing should be leveraged once the dust settles for us to prepare for future challenges.

New innovations may arise as we look at how we address the growing need for mental health services and incorporate new procedures, like point of care ultrasound. As Charles Darwin said: “It is not the strongest of the species that survives nor the most intelligent that survives. It is the one that is most adaptable to change.” It is time for us to evolve.

Dr. Dias is a clinical associate professor of pediatrics at Yale University, New Haven, Conn., in the division of pediatric hospital medicine. She has practiced community pediatric hospital medicine for over 21 years in New Jersey, Pennsylvania, and Connecticut. She is the chair of the Education Working Group for the AAP’s section on hospital medicine’s subcommittee on community hospitalists as well as the cochair of the Community Hospital Operations Group of the POPCoRN network.

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