SCCM Resource Library-Administrative and Organizational Response to the Pandemic at a Large Children's Hospital

Video Transcription

Hi, Lara. I have Dr. Shekha Damian here with us. Lara, can you tell us a little bit about your practice setting and your role before COVID, and then we'll get into some of the  COVID things. Of course. Hi, Alex, and hi, everybody. It's great to be interacting today in an unusual  way, obviously. So I'm the chief of critical care at Texas Children's Hospital. Texas Children's  is a freestanding children's hospital. We partner with Baylor College of Medicine, our academic partner. We are a very large hospital, probably the largest freestanding children's  hospital in the United States, with more than 800 pediatric beds and 168 pediatric intensive care beds across three sites. So we actually have three campuses, and that's relevant  for the discussion that we're going to have. We have the main campus, which is in the medical  center in the heart of Houston, neighboring with many of the adult hospitals around town. And we also have two satellite freestanding hospitals, also with intensive care units  at the West Campus and at the Woodlands. Before COVID, I was the chief of critical care. I'm also vice chair of pediatrics at Baylor. And of course, we have a big, big  intensive care outfit. We have three locations, as I said, three intensive care units and incorporate subspecialty units that include a cardiac intensive care, neuro intensive  care, respiratory, hemlock, and surgical ICU. It's a little like the adult models of care.  And at West Campus, we also have a purpose-built, state-of-the-art biocontainment unit that was actually built on the back of the Ebola pandemic or the Ebola outbreak in 2014. And  the special isolation unit, we call it the SIU. It has eight but flexible up to 18 acuity adaptable beds, and it has its own BSL-3 laboratory. And it has, until several months  ago, been the place that we would always send children with highly communicable diseases and also young adults. Obviously, until COVID hit us, we would activate it infrequently,  usually a few times a year to care for one or two patients at a time. But when COVID  hit back last March, it really came into its own. So that's a bit of background, Alex. Thank you.  No, that's helpful. Thank you for sharing that, Lara. So when COVID was knocking at the door,  what was the ask from your administration and amongst your colleagues about how you guys,  your team was going to prepare? And what was the expectations for yourself?  So when we started to hear about COVID back even as early as January and February, of course,  none of us expected what was to come. But we were ready, of course, to receive any child that was  going to need our care. That's our mission at Texas Children's is to provide the best care to  every child who comes our way. And clearly, we were going to do exactly that with COVID, run towards this problem rather than look the other way. So we were ready. We had our first  patient under investigation, a PUI, who came to us actually at the end of February. But our first  bona fide COVID patient came to our care in late March of 2020. And as we are always prepared to  do, we activated the special isolation unit team and they were ready to care for the patient.  Clearly, in that buildup, we were hearing all the reports from Europe, from the East Coast,  and from Seattle, of course. So during that time, we were able to learn very rapidly from others  regarding treatment protocols, regarding PPE. And of course, we've been through a million  iterations of that between then and now. And also training the team. We were lucky it didn't hit us  unexpectedly. Our first patient came to us, we were ready. We'd done a lot of team training,  a lot of simulation, all the way from intubation to CPR to transport. So we were ready to care for  these patients as safely as we possibly could. I think that was one of the advantages of being  at Texas because we didn't see the beginning of the first wave. We certainly got a first wave,  but we got it kind of later in the day than our neighbors and our colleagues over on the East Coast of the United States. And with your traditional approach to pediatric population  with ARDS, did Hatwell have things change significantly from having your first COVID patient in a pediatric setting with ARDS to right now, 2021? Are you approaching things  quite differently or is it still similar? I think the biggest changes for us, of course, you could say ARDS is ARDS regardless of the etiology, a lot of management strategies are  similar. But I think what's changed with our own growing pediatric experience, and of course,  learning from adults, is the importance of hitting early. And of course, this is a type of ARDS we  have direct targeted treatments for. We have an antiviral that works, we have steroids that we  give really at the onset of any signs of impending respiratory failure. So increased oxygen  requirements equals dexamethasone for us now. But we didn't do that at the outset, of course.  The other changes in or additions to practice are the practice of proning or self-proning,  not just when patients are intubated, but really it's almost a preventive measure. So as soon as  if a patient is competent or cooperative, self-proning is part of our early protocol.  So I think the biggest change over the last year, the last 11 months, has been how aggressive we are  in the very early phases of treatment and using targeted therapies. And thank goodness we've learned from the adult experience with that. That's helpful. And Laura, I know you can't  share the specific details, but if you could give us some insight into pediatric population  in regards to ECMO, has your volume surged during the COVID surge? And how different is your  approach to placing a patient on ECMO in the COVID setting? So we have placed several patients on  ECMO, including with the adult population when we were helping our colleagues around the Med  Center who had reached their capacity with adult intensive care. We don't have a very different  philosophy. Clearly, there are a couple of kind of ground rules that we had to apply. One was an  agreement that to offer ECMO in the setting of CPR in patients with active COVID disease was something that we and pretty much most or all intensive care units that I had talked to  around the nation had adopted the approach to offer. So ECMO for severe respiratory failure,  but not in the setting of CPR. And the reason for that was we had to protect our team while doing  the best we possibly could for the patient. So with that aside, the actual strategy for ECMO for respiratory failure in COVID, not very different. I don't know that you could say we  offer it earlier. We certainly consider it earlier because, you know, it takes a lot of preparation  to calculate patients safely to get the right equipment and to get the right team members and potentially move them across campuses. So for example, our own isolation unit does not,  it's not a unit where we will keep patients on ECMO. So where possible, we would transfer to  the campus that does offer ECMO preemptively. Some of those patients get better, others require  ECMO and that's an acceptable arrangement. Once on ECMO, I mean, typically in our unit,  we place respiratory failure ARDS patients on veno venous ECMO most often with a single double  lumen cannula. And again, that's institutional preference. Occasionally they place additional  venous cannulas. We have had a couple of patients, for example, on VA ECMO where they had  cardiovascular instability too. But the ECMO management, not very different. A lot of attention  obviously to anticoagulation and keeping them well anticoagulated because we know that there's a higher  risk of thrombosis and pulmonary embolism in patients with COVID disease. Other than that,  not very different. And decannulation would be similar to a non-COVID patient. Use of tracheostomy,  again, similar if patients require respiratory support or post-ECMO are going to require  chronic support, we would consider tracheostomy too. All right. Thank you for sharing. I wanted  to follow up on one thing you mentioned earlier in the discussion, which was your team who primarily practices pediatric critical care being called on to the adult population.  How was that transition? And also a second part of the question is, has any of the adult  providers come over to help out with pediatrics? So, you know, as I said before, we are a freestanding  children's hospital. We have the luxury of being part of a huge medical center surrounded by  adult experts in adult intensive care. And we do have a pavilion for women, so we do have some  access to adult providers there too. But, of course, everyone is busy. And to expect people  whose units are overflowing to come and be able to help out in the PICU was not a reasonable  expectation. So as the numbers were going up in Texas, and particularly around the Texas Medical  Center in June and in July, we decided to be prepared to accept adults. We weren't reinventing  the wheel. Massachusetts did it. Boston did it beautifully. They centralized all their pediatric  care and then flipped one of their PICUs into an adult ICU, as you probably know. New York did it.  And around the country, many units for adult patients. So we kind of, again, like so many  things COVID, this was collaborative learning. We learned from the experience of others. And  essentially, we were ready to help out. We did have capacity. Of course, this was at a time where  elective procedures were minimal or canceled. So we certainly had our capacity to care for some adult overflow. The way we approached it was not necessarily to say, well, we'll take  under 30s, but not 31 plus. We didn't impose strict age criteria, but we tried to create criteria that would be least likely to require skills and expertise that we weren't able to  provide. So a single organ failure was going to be okay. We also realized early on that a lot of  the demand was for non-COVID patients, too. So we were not just about admitting COVID adults. It  was non-COVID adults, too. We got together with all the service chiefs, obviously, from around  Texas Children's to agree on a commitment to do the best we possibly could for these adults. This  is not routine medicine. This isn't a situation where people are thinking, well, I'm not covered.  I'm not certified. Am I going to get sued? These were extraordinary measures that everyone's using  all around the country. And it went well. We had, as soon as the, and this was obviously agreed upon  at the highest level. This was CEO level. It's obviously, these things are political. They have  a lot of ramifications and we had to get it exactly right. So when the CEOs around the med center  agreed that it was time to pull the trigger, the trigger was pulled. And within hours, we had our  first adult patients referred to us. Triage was really important. And I think we did it  as right as we possibly could. We triaged all the calls at leadership level, whether it was intensive care, which was myself or one of our senior medical directors,  or if it was acute care, the chief or one of his delegates from hospital medicine took all the  calls just so that you could really dissect the referrals and figure out the best possible  strategy. And in the end, we took over about a five or six week period around sort of 35 adults  who were not going to get care anywhere else in the med center. A lot of these patients  had been in emergency departments for many hours, some of them up to 72 hours. There are patients  who've been on inotrope infusions in emergency departments, intubated in ECs for days. I mean,  in your practice, this has become your bread and butter, obviously, as an adult intensive care  PA. But, you know, for us, this was new. So we all believed that anything we could do to help  was better than nothing. We had a group of physicians, some of whom had med peds training.  So we did have some adults expertise who were willing to, in their own time, help and consult the rest of the intensive care team on these patients. We put adult protocols together  very quickly. We also have the benefit of having adult congenital heart as a big part of our heart center. So again, physicians and workflows and protocols within that service,  we could sort of adapt, if you like, into the practice that we were introducing into the PICU.  And all in all, it went well. We didn't have any surprises, really. Minimal needs to kind of  bring expertise in from elsewhere or transfer. And if it happens again, we'll be even more ready  this time. That's right. And then if I could ask another one is, what was the biggest challenge,  would you say, jumping from the pediatric into the adult? You probably haven't done that in a  while. Was it vent management, presser management, fluids? What did you need most refreshers on?  A little bit of everything, I think. Okay. You know, from fluid, nutrition,  presses. I think some of the things that, you know, for example, not prescribing everything  per kilo, you know, just doing it for doses, for example. It wasn't completely new to us because we  do have populations of adults that we care for in the ICU. And of course, you know, older children  and adolescents and young adults who are part of the TCH system, we would treat using adult  algorithms, adult dosing, et cetera. So it wasn't completely new to us. And we were able to  adapt protocols pretty quickly for use. I think some of the challenges are in adults, the kind of, if you like, the sort of hidden comorbidities, you know, healthy four-year-old.  Well, if you add in, I mean, I'm just making up a patient here, of course, add in the history of  smoking or, you know, sort of borderline glycemic control, et cetera. When you add those in, they become more than just single organ failure. And that's probably the challenges,  the kind of... And then, excuse me, of course, there's the issues with, you know, social,  the social side, the disposition, where do they go to if they're going to need longer-term care?  I'm very debilitated by COVID, you know, this is not the bread and butter of pediatrics. So lots of  little things that we were less expecting. But of course, the main thing is to do your best, and we did. And we are very proud of what we managed to achieve during that time.  And without nurses, of course, it's not a job. We have nurses who are trained in adult intensive  care. We have PAs, APPs who are trained in adult intensive care, which was a huge win for us.  Excellent. Sounds like it was all hands on deck. Everyone stepped up.  I wanted to ask one more, maybe we'll make this our final question,  is if you... We talked a little bit offline before, but if you could kind of summarize for everyone  at SCCM over the last six months or so, you know, what has been your experience with the census,  mortality, the age range of the patients you're seeing, newborn, infant, and then  also, if I could put one more and not to overload you, but out of Wuhan early, we had thought we  were going to see all of this, these cardiomyopathies associated with COVID, which we didn't end up seeing, at least in the adult population, to the degree that we were planning on.  Have you seen that in your congenital heart disease population?  Maybe I'll take the last one first and then talk about just the generic kind of patient  population that we've encountered. So the cardiac has been surprising. We've had a percentage,  actually, when we dissected the data of patients who had congenital heart disease and COVID, but  really many of, it was very few of those who were sick from COVID respiratory disease.  So we didn't see a significant rate of cardiovascular impairment in patients with COVID and congenital heart disease. We do see, obviously, some patients with COVID disease who  develop monthly shock, circulatory collapse, in addition to the COVID, and possibly a kind of,  you know, MIS-C, of course, is separate, but possibly that myocarditis-like picture, but not  congenital heart disease, which was a surprise for us all because we all usually think that  congenital heart is a risk factor for anything. You know, think of RSV, congenital heart disease.  We have not seen that touchwood. Obviously, MIS-C, we have seen a lot of because we've had a huge  volume of COVID patients. We've had well over 60 children now, and I'm sure by the time this  is broadcast, it'll be even more with MIS-C. And of course, they present typically with circulatory  disturbance as well as, typically for us, GI symptoms as well. In terms of the patients that  come to us with acute COVID disease or acute COVID separate from the MIS-C, we've had several hundred, I will say that, probably well into the 400s now, and a third to a half are  ICU level. And we're in the middle of a huge surge now, as are you, obviously, in California.  I think it's not good to be an epicenter. We've been there. I think you're there right now,  but we're really seeing a surge right now. And our current impression is that we're seeing  sicker children now with COVID disease than we did back in the summer or right at the start in  March, April. I'm sure by the time we talk live at the meeting, we'll have a little more insights  into that data that we can discuss. The ICU level patients almost all get better, obviously, as we reported, as everybody has reported. Comorbidities or chronic medical underlying  medical conditions are typical in the patients that get sick with COVID. But of course, we have  a population of asymptomatic patients or patients who are diagnosed on routine surveillance, because like everybody else, we swap, we do PCRs on everyone that comes into hospital.  So we do have a population of ICU patients or acute care patients who are in with something else and never really become symptomatic from the COVID standpoint.  The proportion of intubated patients is relatively low, but we do a lot of non-invasive ventilation,  high flow, self-proning, et cetera, to try and ward off intubation. We don't have a different  approach to intubation for COVID as we would for other diseases. I remember in the early days,  there was two camps in the adult world, intubate early, intubate late. We just intubate at the point  a patient requires a child needs intubation. Sure. Well, that's all very interesting. I'm primarily in the adult population. Just to get some insight from that is great to hear.  I wanted to say thank you for everything you're doing for the adult population as well.  Like you said, I think this is going to end up being a lot longer than everyone thought.  We've learned so much already. It'll be interesting in a year's time what we know looking back.  Hopefully, we'll be looking back in an in-person meeting with a little bit of luck. I think the  last thing I would point out, and you have lived this even more than we have probably for the last  year, is the impact it's having on the workforce. Not, of course, the risk of physical infection,  which fortunately with a vaccine is becoming much less of a concern  unfortunately. It's really taking its toll, I think, on the whole workforce. We all know some,  we've either had it, know someone who's had it. Many of us now actually know someone who has not  survived COVID. We're all social animals, particularly in the ICU and this life we're  living where we can't quite socialize. We can't socialize, we can't practice the way we used to.  I think that's been one of the hardest things. I think a lot of us hope that by 2021,  we'd be able to do more in person, maybe beyond this kind of tidal wave that we saw in the summer  into the fall. Keeping morale up, I think, is going to be our biggest challenge for the next  few months. I think vaccination will provide a lot of relief individually, but then we all have  families and our spouses, kids, whatever, they're not necessarily going to be as lucky as we are to  get vaccinated. It's just kind of keeping the morale going, I think, as leaders or as team  members, it's going to be a big challenge for us in the next few months. But I'm hanging in there,  holding out for later this year, maybe something closer to normality. And this is going to be audits, so you can hold me to that. Yeah, that's such an important point you made is  keeping everyone's spirits up. We went through the first surge with some exhaustion, had a lull.  And it seems like even outside of the providers and the physicians and the advanced practice  providers, the nursing too, I mean, everyone feels it at every level. And yeah, hopefully, like you said, you know, we have some light coming here with the vaccination as those  numbers increase. But thank you so much for taking the time, Lara. I'll see you  again at the virtual meeting. And if you have any other closing remarks you'd like to add?  I think we've covered a lot and hopefully we can have a discussion at the meeting too.  Excellent. Thanks. Thank you. Thank you.

Video Summary

Dr. Lara Shekha-Damian, Chief of Critical Care at Texas Children's Hospital, discusses her experience in managing pediatric COVID-19 patients. Before COVID, Texas Children's Hospital had three campuses with a total of 168 pediatric intensive care beds. They were prepared to receive COVID patients and had their first case in late March 2020. They learned from others' experiences and rapidly developed treatment protocols for COVID-19. The approach to pediatric ARDS changed to include early targeted treatments such as antivirals and steroids. Proning became a preventive measure, even for non-intubated patients. ECMO volume surged during the pandemic and patients were transferred to campuses offering ECMO support. The approach to ECMO management for COVID patients was similar to non-COVID patients, with attention given to anticoagulation. The hospital also provided care for adult patients when adult ICUs reached capacity. The transition involved collaboration and triaging patients that required specialized pediatric care. The biggest challenge was managing adult-related comorbidities and coordination with adult care providers. The hospital also experienced a surge in pediatric patients with MIS-C. COVID-19 had a significant impact on the healthcare workforce and morale, and the challenge was to keep morale high while waiting for the vaccine and return to normalcy.

Asset Subtitle

Crisis Management, Pediatrics, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

These educational sessions present a wide range of critical care topics discussed by faculty from SCCM sections and are moderated by In-Training Section leaders.

Lara S. Shekerdemian

Alexander P. Lukic

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Area Pediatrics

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Tag Facilities Management

Tag Resource Allocation

Year 2021

Keywords

pediatric COVID-19 patients

treatment protocols

ECMO support

adult patients

pediatric patients

healthcare workforce

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