Photo by Annie Spratt | Unsplash
On January 30, 2020, the WHO declared the novel coronavirus a public health emergency of international concern. Many have noted that the greatest disease burden of COVID-19 is seen in adults, but children of all ages are also susceptible. Research in China indicates that over 90 percent of children have mild, moderate, or asymptomatic disease.
We work in a large health care trust in Northwest London, delivering secondary care to children across three boroughs. In line with the impact of previous epidemics such as SARS, MERS and Ebola, we expected a reduction in non-epidemic related health care use by children, as families follow national guidance to stay home for minor illnesses but also delay genuine emergency presentations.
While the health impact of COVID-19 is disproportionately adult, the social impact of COVID-19 may be disproportionately pediatric: All children are losing months of education. For the most vulnerable, without the safety net of school, hunger and maltreatment are predicted to rise during the national lockdown.
We must also acknowledge the impact the pandemic is having on health care staff. They face risks to their own health, the uncertainty of job relocation, changes to work patterns at short notice, and burnout. Some are also coping with family bereavement.
Our goals were to address the concerns of both our pediatric patients and our staff:
Right place, right time care for sick children in the acute setting.
Continuity of safe care for the most vulnerable patients.
Resiliency of a workforce who are trained and able to assist colleagues in adult medicine in a timely fashion.
Support and Adaptation
In line with local and national guidance, leveraging our connectivity with the network, we eliminated and safely postponed elective work and reorganized our pediatric services from the front door onwards to keep children with suspected COVID-19 apart from those without.
We collaborated with primary care colleagues to ensure children with both suspected COVID-19 and other acute illness do not present with late or missed disease. We accelerated innovation, coproducing a four-stage approach to open access:
A direct phone line to the pediatric Emergency Department (ED) team for urgent cases
A phone line answered by a senior staff member for advice
An email address for written case queries with a 48-hour response time
Video consultation capabilities between pediatricians, sick children and primary care doctors for collaborative consultations.
We were able to rapidly upscale telehealth for triage of suspected COVID-19 cases during the containment stage of the pandemic. A telephone triage proforma was developed for nurse use. All children under five and case identified as of special concern went on to have video consultations with pediatricians, thus preventing hospital admission in most cases. We then moved to widespread use of video consultations for all pediatric clinics, including allowing self-isolating doctors to continue holding clinics from home, and serving vulnerable children or those identified being at risk of harm.
With the need for more space to accommodate increasing numbers of COVID-19 cases, the adult medical teams took over the pediatric daycare and outpatient areas. A new area was repurposed and made child-friendly within seven days. Repeated in situ multi-professional simulations increased staff confidence in pediatric resuscitation using new protocols for COVID-19 in unfamiliar environments. Latent errors in equipment and process were analyzed and remedied to improve patient safety.
Out of a workforce of 50 pediatric junior doctors, to date 22 have been relocated to adult medicine after rapid induction and shadowing. We put in place a novel structure of staff supervision and a “buddy system” to pair experienced adult physicians with pediatric doctors to care for adult patients in the new areas. To facilitate this shift of workforce, we accepted leadership from all levels and the junior doctor team coproduced a flexible new work pattern with built-in resilience days for staff to recharge, back-up personnel to step in at short notice to cover staff sickness, and a skeleton staff of senior doctors to continue to support pediatric care. To date, this has been tested to good effect with 16 junior and six senior doctors needing time off for sickness or self-isolation.
Local pockets of innovation have sprung up to support joy in work. One example is the ED’s “Tea at Three” – a daily tea and cake break for all staff on shift.
We have tried to build sustainability into all our innovations, in particular through robust but rapid agreement across teams to create governance structures to support the open access initiative and telehealth. By building in evaluation mechanisms and a means to capture clinical activity we have facilitated ongoing review and improvement of novel services.
During the COVID-19 pandemic, telehealth is transforming how we care for our pediatric patients. However, accessibility is limited for some families as this requires WiFi, a smart phone with sufficient data, and a level of English fluency.
COVID-19 remains a significant focus for the service, but we remain concerned about reluctance from families to bring their children to the hospital. The most pressing need is to develop more methods on a local and national level to allow children to receive safe and timely care.
Lucy Pickard Sullivan, Gabriella Watson, and Bhanu Williams are pediatric physicians at London Northwest University Healthcare NHS Trust.
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