"I'm sorry, we are out of that..."

How many times during the last two years did you order something at a restaurant or store only to be told, "I'm sorry, we are out of that item..."?  It's incredibly unfortunate that many physicians at outlying emergency departments are being told the same thing when they need to admit a sick child to the hospital.  It's happening all over America right now as we are moving into the busiest time of year for children's hospitals with a recent surge of viral respiratory illnesses.  

Today is the last day of my week of taking care of patients on our inpatient pediatric hospital medicine service.  I always enjoy these weeks of service - it's a good break from the administrative aspects of my job and after all, I spent several years of education and training in order to be a physician.  I still love taking care of patients.  It certainly feels like Autumn outside this morning, but inside the hospital it feels like the middle of winter.  We are at the tail end of one surge of respiratory illnesses associated with rhinovirus and enterovirus D68 (see the CDC report here), and we are starting out the typical late fall/early winter respiratory syncytial virus (RSV) season a little earlier than usual this year! 

Every winter, doctor's offices and hospitals around the country see more children with respiratory illnesses.  In other words, those of us in pediatric medicine experience this every winter, and we should be adequately prepared to handle an increased number of emergency department (ED) visits and hospital admission requests.  Things are different this year though.  Our health care delivery system in this country is struggling.  We've experienced supply chain disruptions and labor shortages just like every other industry.  What's so different about children's hospitals then?  In order to answer that question, we have to go back several months to the early days of the COVID-19 pandemic, because that's when our struggles really began.

We were fortunate that, for the most part, the vast majority of children infected with SARS-CoV-2 weren't very sick.  COVID-19 was the hardest on adults over the age of 50 years, and when adult hospitals were filling up with critically ill patients with COVID-19, most children's hospitals weren't very busy at all.  As a result, hospitals around the country converted their pediatric beds to adult beds in order to accommodate the surge in adult patients with COVID-19.  Children's hospitals often sent over staff and supplies to their adult counterparts, as well as increasing the maximum age of patients that they would admit to lend a hand.  As one of my colleagues, Scott Krugman points out in an article in the Health Affairs blog "An Unexpected Shortage: Hospital Beds for Children", most of these pediatric inpatient units never re-opened, despite a drop in COVID-19 numbers.  

All of us in health care like to argue that medicine is not a business, but that is just not the case.  Health care administrators have to generate revenue and decrease costs, just like any other business.  Unfortunately, the unique calculus of health care finance incentivizes adult medicine over pediatric medicine.  Hospitals are reimbursed more for admitting adults instead of children.  As Dr. Krugman writes, "With current models of hospital and physician payment that incentivize high-cost volume adult medicine, there is a high risk of further closures of pediatric units across the country...Unless there is a dramatic change in how we pay for and prioritize inpatient care - for all age groups - the cost to organizations to care for children will exceed any community benefit and more hospitals will be pressured to close their (pediatric) inpatient units."

Two additional articles appeared within the last week or so on this issue.  Emily Baumgaertner wrote about this issue in a New York Times article last week ("As Hospitals Close Children's Units, Where Does That Leave Lachlan?").  Ms. Baumgaertner writes that the decline in pediatric beds began even before the COVID-19 pandemic, though undoubtedly the pandemic greatly accelerated the problem.  She writes, "Between 2008 and 2018 - the most recent national data available - pediatric inpatient units in the United States decreased almost 20 percent, and nearly a quarter of children found themselves farther from their nearest pediatric unit."

As community hospitals and even large academic medical centers close their pediatric inpatient units, free-standing children's hospitals will have to fill the gap in order to meet the demand for inpatient care. One of my pediatric critical care colleagues, Dr. Deanna Behrens, recently wrote an Op/Ed piece in the Chicago Tribune.  Dr. Behrens specifically addresses our current predicament that there are just not enough pediatric beds to meet the current demand.  She writes, "Here is what can happen when the system gets overwhelmed: The emergency rooms are full of children who need a hospital bed. Emergency department providers must spend time calling various hospitals to look for rooms on the general floor or in the PICU. The pediatric floor is full. We cannot transfer children who have improved to the floor from the PICU, so the PICU is full. It is more difficult to transfer to the PICU children on the floor who get sicker — because the PICU is full. Children in the emergency room end up staying for much longer than normal. Hospitals in the area and in surrounding states trade patients depending on who has which type of bed available at any given time."

It is indeed a perfect storm - critical staffing shortages, supply chain disruptions, an early respiratory viral season, and pediatric bed closures - all of which are placing an unprecedented strain on children's hospitals across the country.  But as the proverb says, "A smooth sea never made a skilled sailor."  I see these challenges as an opportunity for all of us to really take a look at how we practice pediatric medicine and improve. 

While we certainly should look at how pediatric health care is financed in this country, the reality is that the system that currently exists isn't likely to change quickly, if at all.  We need to look elsewhere for help.  First of all, pediatric health care organizations are going to have to take a leadership role in addressing the disparities that currently exist.  We have to find ways to keep children out of the hospital whenever possible.  Children's hospitals are working with local government and community organizations to address the social determinants of health.  Second, we have to continue to leverage existing technology to prevent unnecessary admissions and/or expedite discharge from the hospital.  COVID-19 accelerated several advances in remote patient monitoring and increased the utilization of telemedicine care.  While technology will require investment, if we can prevent hospitalization or shorten the length of stay when children do get admitted, it will be well worth it.  Third, children's hospitals need to develop and/or expand existing partnerships with community hospitals in order to extend their reach and provide localized pediatric expertise.  Fourth, we are going to have to change our existing models of care.  Staffing shortages aren't going to go away anytime soon, so we will have to be creative on how we design care delivery systems to provide safe, effective, evidence-based care.  I also think that children's hospitals need to build closer relationships with community colleges and universities to develop workforce pipeline as early as possible, similar to what they have done with medical schools.  Finally, we are going to have to address the concurrent mental health crisis.  We just don't have the capacity to hold kids in emergency departments or inpatient beds while they await definitive mental health treatment.  

 These next few years are not going to be easy, but I do think we will get through them and be a better and stronger pediatric health system as a result.  Dr. Behrens ended her Op/Ed piece with the following statement, which I think applies universally.  "Be kind to each other, be patient with health care providers as we work to help your children...With everyone's help, we will get through this."