Children’s hospitals across the nation have been overwhelmed by the current surge of patients with acute respiratory illnesses.1 The unprecedented demand for acute care has caused critical inpatient bed and staffing shortages. The closing of inpatient pediatric units in community, rural, and critical-access hospitals across the country over recent years has further worsened the shortages by decreasing overall pediatric bed availability and straining emergency transport systems with increased transfers.2 Given the urgency of the current surge, hospitals have been left scrambling to develop strategies to increase capacity and focus resources on those most in need.
Helen DeVos Children’s Hospital (HDVCH), a 234-bed quaternary referral center that is part of Corewell Health (formerly known as Spectrum Health), is affiliated with 13 regional and critical-access hospitals across West Michigan, most of which have closed their pediatric inpatient units over the last several years. As the pediatric surge across the state of Michigan ramped up, these regional hospitals were unprepared to admit pediatric patients as they no longer employed pediatricians or pediatric nurses. As cases of viral illnesses climbed, so did the number of requests for transfer to HDVCH. We rapidly increased our capacity by doubling up many patient rooms, shifting to team-based models of nursing care, and adding an additional hospitalist team. Despite these efforts, it became evident we could not continue to accept all transfer requests due to our own staffing and bed shortages. We have never had to close our doors to outside transfers, and we grappled with how to best care for the growing number of sick children in the community. It was clear that, to decrease the demand for transfers, we needed to find a way to treat children locally by supporting the teams in community hospitals and emergency departments (EDs).
To meet this need, our pediatric hospitalists began a virtual hospitalist outreach program to facilitate local management of select patients in our affiliated regional hospitals’ EDs using a telemedicine approach in place of transfer to the children’s hospital. We collaborated with ED leadership to expand upon their already established pediatric ED observation programs by providing the ED teams 24/7 access to our virtual pediatric hospitalists for consultation and rounding support during the surge. We offered both phone and video visits when capacity limitations made transfer to HDVCH impossible. Patients were kept in the ED, and video visits were conducted using the Cisco Jabber application interface with telemedicine carts located in each of the hospitals. We provided recommendations for the management of feeds and hydration, management and weaning of supplemental oxygen and high-flow nasal cannulas, selection and dosing of antibiotics, management of chronic medical problems, and other common inpatient pediatric issues. These visits were performed with the goal of providing support to those on the front lines in community spaces during a time of crisis, and therefore no billing was submitted. With further development, these visits could be billable encounters if the hospitalist gets privileges at each of these regional hospitals where patients are located.
With the implementation of this program, we have been successful in managing lower acuity inpatients in regional EDs through their illnesses (and many to discharge), allowing us to use beds at our children’s hospital for the patients of the highest acuity and those with medical complexity. The video component of the consults increased our triage accuracy, giving a clearer picture of which patients needed transfer to the children’s hospital general-care floor versus intensive care, and which patients could remain in place locally. We were able to establish rapport with the patients’ caregivers early on as well as communicate directly with the nurses and respiratory therapists managing the patient in the ED setting. The ED teams have been outstanding collaborators and stepped outside their normal workflows to help manage these patients successfully.
Telemedicine use increased significantly during the COVID-19 pandemic. Previously, the benefit has been described for use in adult hospital medicine, especially across rural and smaller hospitals.3 Telemedicine has also been described as beneficial during the transfer request process in pediatrics,4,5 but little is known about its use for managing patients remotely in the field of pediatric hospital medicine. More research is needed to determine the effects on patient safety, clinical outcomes, and patient experience. However, our experience suggests that virtual visits can be an impactful tool for triage, patient management, and capacity planning during times of extraordinary need.
Dr. Hadley (@AndreaHadleyMD) is an internal medicine and pediatric hospitalist at Corewell Health in Grand Rapids, Mich., chief of pediatric hospital medicine at Helen DeVos Children’s Hospital (HDVCH), and assistant professor of internal medicine and pediatrics at Michigan State University College of Human Medicine. Dr. Kessenich is a pediatric hospitalist at Corewell Health in Grand Rapids, Mich., associate program director of the Pediatric Hospital Medicine Fellowship at HDVCH, and associate professor of pediatrics at Michigan State University College of Human Medicine. Dr. Arnos is a pediatric hospitalist and physician informaticist at HDVCH in Grand Rapids, Mich., and an assistant professor of pediatrics at Michigan State University College of Human Medicine. Dr. Kort is a pediatric hospitalist at Corewell Health in Grand Rapids, Mich., and assistant professor of pediatrics at Michigan State University College of Human Medicine. Dr. Inclan is a pediatric hospitalist at Corewell Health in Grand Rapids, Mich., and an assistant professor of pediatrics at Michigan State University College of Human Medicine. Dr. Synhorst (@dsyn08) is a pediatric hospitalist at HDVCH in Grand Rapids, Mich. His previous work focused on the financial stability of children’s hospitals and the impact of observation-status stays.
- Bean, M. ‘It’s the perfect storm’: Capacity issues intensify at children’s hospitals amid RSV surge. Becker’s Hospital Review website. https://www.beckershospitalreview.com/care-coordination/it-s-the-perfect-storm-capacity-issues-intensify-at-children-s-hospitals-amid-rsv-surge.html. Published October 20, 2022. Accessed December 9, 2022.
- Baumgaertner, E. As Hospitals Close Children’s Units, Where does that Leave Lachlan? The New York Times website. https://www.nytimes.com/2022/10/11/health/pediatric-closures-hospitals.html. Published October 11, 2022. Accessed December 9, 2022.
- Gutierrez J, et al. A systematic review of telehealth applications in hospital medicine. J Hosp Med. 2022;17(4):291-302.
- Rosenthal JL, et al. Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods. Telemed J E Health. 2021;27(4):459-463.
- Curfman A, et al. Implementation of Telemedicine in Pediatric and Neonatal Transport. Air Med J. 2020;39(4):271-5.