In December 2019, the coronavirus disease (COVID-19) epidemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was beginning in Wuhan City, China. By March 2020, COVID-19 was declared a pandemic by the World Health Organization. 1 As of July 27, 2021, there have been over 194 000 000 cases and nearly 5 000 000 deaths due to COVID-19. Reference Sohrabi, Alsafi and O’Neill2,Reference Dong, Du and Gardner3 With thousands of new cases daily, information has been constantly changing as researchers and the larger medical community attempt to better understand this pandemic and disseminate knowledge to the world.
To address the severe knowledge gaps that exist with COVID-19, many emergency departments (EDs) looked to their past experiences with pandemics such as the 2014 Ebola outbreak, the 2009 H1N1 influenza pandemic, and the 2003 SARS outbreak. Given variable and constantly changing practice standards, many institutions were forced to work through operational challenges on their own. Researchers in other countries hit particularly hard in the early months of the pandemic graciously shared lessons learned with the medical community. Reference Schwartz, King and Yen4–Reference Zhang, Liu, Locatis and Ackerman6 However, these do not always translate to the experiences here in the United States, particularly at pediatric hospitals.
Pediatric emergency departments (PEDs) have faced their own set of challenges that may not reflect the experiences of EDs that primarily care for adults. For example, PEDs initially saw a precipitous decline in the number of arrivals, at the same time seeing the acuity of those patients rise. Reference Isba, Edge and Auerbach7,Reference Dopfer, Wetzke and Zychlinsky Scharff8 Clinical and social complications, such as multisystem inflammatory syndrome in children (MIS-C) and child neglect, continue to challenge pediatric emergency medicine (PEM) providers throughout this pandemic. Reference Walker and Tolentino9
As PEDs plan a way forward, we must seek to understand the unique experiences and lessons learned throughout this pandemic. This study aimed to identify the early challenges and barriers that institutions have faced as the pandemic has evolved. The primary objective was to report on the drivers that interfere with the ability to provide high-quality medical care during a pandemic and to report on how institutions overcame those forces. The secondary objective was to identify areas of improvement for health care systems to consider when preparing for anticipated surges within this and the next pandemic.
Methods
Content analysis of social media postings, opinion pieces, and a PEM email distribution list identified COVID-19-related themes discussed by PEM physicians. These themes, as they related to the current COVID-19 pandemic, served as a framework, and guided the creation of semi-structured interview questions.
Participants, all PEM physicians, were identified using a purposive sample. The participants were working as frontline providers during the COVID-19 pandemic. Participants were identified using the researchers’ professional contacts at other institutions and are members of a network of disaster management leaders at PEDs around the United States. Participants were contacted via email and asked to participate. Willing participants were assigned a unique ID and asked to fill out a demographic survey prior to the interview. No personally identifiable data were collected. Consent was implied with survey completion. Participants could opt out anytime during the study. Survey data were securely stored using REDCap Reference Harris, Taylor and Thielke10 data capture tools hosted at Texas Children’s Hospital. IRB approval was obtained.
Interviews were conducted and audio-recorded using Zoom video conferencing software. They were auto-transcribed using Otter.ai (Los Altos, California) voice-to-text transcribing software, and transcription errors were corrected to create the raw data.
Given that these were semi-structured interviews, interviewers were provided a guide with suggested questions and topics with unscripted questions utilized to elicit further experiences and thoughts.
Two independent coders (TT, EMS) analyzed the raw data to summarize topics and form descriptions of interview answers to allow for investigator triangulation. Thematic saturation in the semi-structured interviewers was achieved when no new themes emerged in successive interview transcripts. The two coders developed mutually agreed-upon definitions for each code and established examples of each code to ensure reliability and trustworthiness. These members discussed the qualitative findings and developed themes from the codes. A third member of the research team (ND) was available to review any disagreements in coding so that team consensus could be reached. Memos of coding decisions were kept for consistency as analysis progressed. Member checking was performed to review themes and to check for accuracy and completeness of the findings. This thematic approach is a widely utilized process in the analysis of qualitative data Reference Ayub, Sampayo, Shah and Doughty11 and was used in our study to identify a conceptual framework of themes related to disaster management during the pandemic.
Results
Participants
A total of 14 PEM fellowship-trained physicians from academic centers with rotating fellows and residents participated. More than half were women with the median years of experience after fellowship being 15 years. Half held leadership roles within their institution, almost all were part of their institution’s disaster or emergency management department, and the majority had received specialized disaster management training (Table 1). Member checking was accomplished using a Zoom focus group of 4 participants.
Table 1. Participant and institution demographics
ED, emergency department; PEM, pediatric emergency medicine.
a Number of years practicing following the conclusion of fellowship training.
b Disaster management and emergency preparedness are used interchangeably.
c Northeast (ME, NH, MA, RI, CT, VT, NY, PA, NJ, DE, MD), Midwest (OH, MI, IN, IL, MO, IA, WI, KS, NE, SD, ND, MN), South (WV, DC, VA, KY, TN, NC, SC, GA, FL, AL, MS, LA, AR, OK, TX), West (NM, CO, WY, MT, ID, UT, AZ, NV, CA, OR, WA, AK, HI).
d Estimated annual census of emergency departments prior to the COVID-19 pandemic.
e Divisions of pediatric emergency medicine under the leadership of either the department of pediatrics or emergency medicine.
Themes
Many used the semi-structured interviews as an opportunity to share their frustrations, and what did and did not work well. Four primary themes emerged from these interviews: communication, leadership and planning, clinical practice, and personal adaptations (Figure 1). The following are the summarized themes with select quotes that highlight the codes elicited from the interviews (Table 2). Solutions and recommendations to these challenges mentioned by participants are summarized in Table 3.
Figure 1. Themes and codes identified from semi-structured interviews.
Table 2. Identified themes from interviews with example quotations to demonstrate underlying codes
Table 3. Commonly discussed challenges based on identified themes and ways participants addressed these challenges
Communication
Early in the pandemic, multiple participants remarked they “don’t spend as much time as I used to (with patients) because getting in and out of the room is challenging with all the gear I have to wear.” This makes building rapport difficult, especially when the children think “we look like monsters sometimes coming in these rooms.” Additionally, the personal protective equipment (PPE) makes hearing difficult, not only for the provider, but also for the patient and their family. These communication challenges make ED visits “not as a personal experience as it used to be.”
With ever-changing recommendations, participants identified difficulties reaching providers within their division about new processes, whether related to PPE, testing, or return-to-work guidelines, to name a few examples. One participant remarked, “We have over ninety plus practitioners plus over 200 nurses, and all these rotating residents. How do you communicate all the changes when they change so fast?” Emails were viewed as a necessary means of information dissemination, but institutions and leaders “had to figure out what’s the cadence of sending those things (emails) out. If you send 3 of them and someone doesn’t get a chance to look at them daily, they’re flooded.” To address the overwhelming number of emails, several institutions incorporated town hall meetings with leadership, shift huddles, and designating an ED point person to consolidate the information coming from incident command (IC). Internal websites were created for providers to reference changes.
Traumas and resuscitations that require closed-loop communication, precision with medications and orders, and multiple people working in concert, posed new communication challenges. With the extra layers of PPE, “no one can hear the team leader very well.” Resuscitation teams limited their numbers to prevent potential exposures to an entire department, and as a result have “gone to virtual or partly virtual resuscitations with a limited team in the room.” To address this issue of limited personnel, institutions have incorporated radios or tablets; in some centers, a new role, the “gatekeeper,” was created to communicate with those outside the trauma or resuscitation bay.
Leadership and Planning
As frontline providers, participants stressed the importance of ED representation within IC. One participant put it plainly: “Taking the IC side, I mean, the hospital leadership view, they had to deal with like, the entire hospital. Right, not just the ED but the ED is like a unique organism. So, I think it was hard for them to see what the needs were in the ED when they didn’t have ED representation on the hospital leadership team.” To address this challenge with ED representation at the hospital leadership level, it is key to “identify a group of people interested in pandemic and disaster preparedness” and develop a “leadership COVID team within the ED…” These leaders “would communicate with ED staff, and kind of filter out or filter through all the different messages that were coming out and making sure everything was synced,” which ensures bidirectional communication with IC.
As COVID-19 cases increased, institutions initially prepared by looking to their past experiences with pandemics. At some institutions, these plans were helpful in terms of “PPE readiness,” developing a “command center,” and deploying “bio response teams.” However, as several mentioned, past experiences did not apply or help with the response to COVID-19 because simply “it’s a different disease.”
For most, planning for COVID-19 began as early as January 2020. Some institutions “started discussing strategies in late January, and, started doing simulations toward the end of February.” Others began to prepare for a surge: “We knew pretty early on, or we had heard earlier on, there were not many pediatric cases. But, you know, again, we just didn’t know at that time, so we were ready for a pediatric surge.” Alternative care sites (ACS) to receive the anticipated surge were built at some institutions only to discover that at least, prior to any variant-led surges, space was not a limiting factor. “In the first, I’d say three, four months of the pandemic, we had five COVID positive kids. And so, we had the tent set up, and I don’t regret doing it…But we definitely didn’t use it like we thought we would.” Several institutions chose to wait before setting up ACS based on experiences elsewhere: “The initial indication of that was from the New York experience. As we know, the adult hospitals got hit hard. Early in the pandemic, pediatric hospitals were relatively spared. And we had no reason to think then that our experience would be any different.”
As the pandemic progressed, participants reflected on challenges working across health care systems. Several mentioned challenges collaborating with other hospitals: “But even regionally, every hospital was kind of building its own fort. And there was very little collaboration with one another.” Even within their own institution, participants expressed frustration working with other departments. “It was harder to get people on board, to not think of themselves as needing special privileges…” To address these challenges, participants recalled methods to improve command structure and leadership within their institution. This included establishing a centralized command quickly and using “the information officer to keep things consistent,” opening command to physicians and “allowing physicians to have a voice,” and establishing collaboration across health care systems because it can “result in innovations.”
Additionally, the early COVID-19 pandemic had other unintentional consequences, especially when it came to hospital finances and patient volumes. Initially, many institutions began to cut cost as “they saw numbers go down and elective surgeries being shut off.” For them, the easiest thing to do was “furlough nurse practitioners” and “cut shifts back.” To relieve the overstressed nearby adult hospitals, pediatric centers also began admitting adult patients or accepting their pediatric patients to free up more space for adults. Instead of preparing for a surge, centers “created plans to care for adults.”
Managing the supply chain became the focus of many leaders within their institutions’ command structure to ensure adequate amounts of PPE, ventilators, and testing materials. Institutions that created real-time “dashboards” and “calculators” could keep constant inventory control. Collaborating with other industries such as liquor distillers ensured some institutions had enough hand sanitizer.
Clinical Practice
Aerosol-generating procedures (AGP) created their own set of challenges as institutions looked to contain the infectious droplets created. Part of the struggle was defining AGPs and how these procedures “affected spread.” In response, institutions with the capabilities moved these procedures into “negative pressure rooms”; in 1 instance, the entire ED was able to change the air flow in the rooms to negative flow. Others enforced mandatory use of powered air purifying respirators (PAPR) in resuscitation rooms or during intubations.
Before in-house testing was commonplace, “tests were controlled by the CDC or through public health…and every potential patient had to be run by public health before we would be allowed to test.” ED providers were also frustrated by inpatient units refusing patients until results returned: “We tell people that they don’t have to do that, that it is ok to admit at least an asymptomatic patient to the floor pending a result.” Operating rooms and inpatient psychiatric units also demanded test results before accepting patients, so institutions employed rapid tests that would provide results within 1 hour. Several institutions were able to deploy “drive-thru testing” and any patient who visited the ED could get tested once the supply was secured. Three-dimensional printing was able to create swabs that were in short supply nationwide. Overall, participants thought liberalizing testing was a necessity in addressing the pandemic.
To limit the spread between infected persons and other patients, some institutions divided their EDs between cohorts: COVID PUIs (patient under investigation) and the non-PUIs. Cohorting required rooms and pods to be redesignated “COVID assessment areas” and equipment was removed to prevent contamination. Many participants expressed that dividing patients was unnecessary as they “came to the realization that almost everyone who lives in the community could be a PUI even if you didn’t have symptoms.” To address the asymptomatic PUI, institutions adopted practices such as “triage in the room” to limit exposure of non-infected patients. Institutions that built ACSs re-purposed areas for screening.
PPE posed unique challenges as recommendations changed frequently. N95 face masks were especially difficult to obtain early in the pandemic, so several institutions chose to reserve their use based on the prevalence of COVID-19 in their community. One participant said, “We only have a seven-day supply of N95s, do you want to use them up? Now? When the incidence is so low, the prevalence of it in the community is so low, or do you want to use the N95s when the prevalence is higher, and you really do need the N95?” To address supply chain issues with N95 masks early on, some institutions developed sterilization procedures involving “hydrogen peroxide vaporization” or “UV light sterilization” to render N95s safe for reuse. To ensure staff was wearing the appropriate PPE correctly, some employed strategies such as “PPE spotters” to ensure staff was properly donning and doffing PPE while in the ED. As individuals became more proficient at wearing PPE, institutions could link videos to proper donning and doffing technique on their website for review. PPE guides were posted on patients’ doors to instruct providers on what PPE was required for that patient.
Personal Adaptions
Early on, individuals did not feel safe coming to work and participants discussed challenges with addressing the fear COVID-19 struck in the entire ED staff. One individual said, “…there was irrational fear, even with the degree of reassurance that we tried to provide, it seemed like there were those individuals who, during normal times, are very rational people who then became very hard to convince that it’s safe to be at work.” At an institution where a team member became ill due to COVID-19, fear was an even bigger challenge to address: “We actually had one of my division members in mid-March, at the beginning of this, who actually got very, very severe COVID. That impacted our division significantly… And he didn’t have any reasons to be so sick, just unlucky. That made all of us a little more cautious.” To address this fear and anxiety throughout the ED, participants reiterated the importance of communication, setting an example for others to follow, involving all staff in shift huddles, being flexible with scheduling and securing, or at the least planning for a robust PPE supply.
In addition to securing adequate PPE, leaders discussed challenges keeping their colleagues and workforce safe throughout the pandemic. Even within departments, there were personnel who at times “took it a little less seriously” than others and would do things such as “sit with their goggles off and mask partly down their chin” or share workstations meant for 1 individual to use. “Burnout” was mentioned by several participants as providers were constantly dealing with changes to PPE, testing, and management of COVID-19 patients and people were “feeling the stress of this long process.” “Safety monitors” were useful in ensuring that individuals followed regulations. To keep exposure at a minimum, non-clinical staff such as registration or research staff utilized in-room phones and tablets to interact with families. Employees were tested frequently, and institutions “moved away from in-person screening of every employee” to using cellular phone applications. By employing these methods, nearly every participant mentioned they had very little spread within their workforce.
All participants discussed changes they made to their routine at work or when coming home to keep themselves and their families safe. Most participants reflected that perhaps they did not wear adequate PPE for patient encounters prior to COVID-19. Many mentioned “changing in the garage” and “showering before seeing family” as ways to protect one’s family from exposure to the virus. Wardrobes have changed as “everyone has ditched the white jacket,” and even providers who used to dress professionally are now wearing scrubs. To limit their exposures and preserve PPE, several mentioned they “make judgements from the doorway” or “rely… on residents and fellows who have been in the room” to re-evaluate patients.
Discussion
Since late 2019, the world has been at war with COVID-19, Reference Zhou, Yang and Wang12 and EDs have continued to be the first line of defense for many health care systems where they serve as the primary access points for many patients. Reference Venkat, Asher and Wolf13,Reference Markwell, Mitchell, Wright and Brown14 Despite initial drops in overall pediatric patient volumes and low mortality, as of August 16, 2021, COVID-19 has affected more than 4 000 000 children nationwide, with numbers increasing daily due to new variants that are changing the landscape of COVID-19. Reference Isba, Edge and Auerbach7,Reference Team15–Reference Cull and Harris19 PEDs’ experience with COVID-19 has forced many leaders to re-evaluate their pandemic planning and approach to disease outbreaks. We set out to understand those issues faced by PEDs due to the early COVID-19 pandemic and provide possible solutions to improve the emergency response.
As emails were flooding mail servers, the way we communicated early during COVID-19 highlighted challenges with reaching large, multi-disciplinary departments. While interdepartmental communication was challenging, so was speaking with patients and colleagues during traumas and resuscitations. In a national survey of 25 PEDs, mass email messaging was utilized by 96% of the institutions during the COVID-19 pandemic. Reference Auerbach, Abulebda and Bona20 Email is a quick and easy communication modality that can be utilized to update departments and reiterate important information that is rapidly evolving. Reference Jain, Fahlgren, Giovanni and Dowd21,Reference Meier, Jerardi, Statile and Shah22 However, as our participants discussed and as mentioned in previous studies, the number of emails received per day can be overwhelming. Reference Hartford, Keilman and Yoshida23 By limiting the number of emails sent and highlighting the most important changes within the text of the emails, important updates are better received. In addition to adjusting the number of emails, our participants echoed the utility of virtual town hall meetings with leaders, shift huddles, internal web pages, and opening divisional meetings to non-physician staff. Reference Meier, Jerardi, Statile and Shah22,Reference Diskin, Orkin and Agarwal24 For traumas and resuscitations, participants recommended using technology and team members to communicate with consultants, pharmacists, and other team members outside of the trauma bay. Tablets with video conferencing capability, baby monitors and 2-way radios, secure network cell phones, and white boards are all ways to enhance communication during the care of these complex patients during a pandemic. Reference Turer, Jones and Rosenbloom25–Reference Dharamsi, Hayman and Yi27
Disease outbreaks and other public health emergencies highlight the necessity of strong hospital and departmental leadership, as well as having a flexible plan for addressing the emergency. The top-down leadership approach during a pandemic or other disaster is often not well-received by ED physicians who wish to participate. Reference Markwell, Mitchell, Wright and Brown14 As mentioned by participants and described by others sharing their institution’s experience with COVID-19, developing multi-disciplinary ED leadership teams not only helps improve communication, but also can be useful in surge planning, improving collaboration with other institutions, streamlining logistics, and setting up IC structure within the ED. Reference Jain, Fahlgren, Giovanni and Dowd21–Reference Hartford, Keilman and Yoshida23 Additionally, by being physically present in the PED, leaders are able to better understand the workforce’s concerns and provide reassurance to address those concerns. Reference Shanafelt, Ripp and Trockel18 Following the 2009 H1N1 outbreak, the Institute of Medicine developed the crisis standards of care, emphasizing the importance of early preparation and management of resources during a disaster to maximize patient care and minimize harm. Reference Auerbach, Abulebda and Bona20,28 This framework for disaster preparedness was discussed by several of the participants and was evident in discussions around ACSs, re-deploying staff to care for adults, Reference Walker and Tolentino9,Reference Beno, Ross and Principi26,Reference Bressan, Buonsenso and Farrugia29–Reference Levine, Fraymovich and Platt32 keeping plans up-to-date, and knowing the supply chain. While it is challenging to predict the need, having those ACSs available and knowing how to re-purpose them is invaluable to an institution’s pandemic preparation. Reference Hartford, Keilman and Yoshida23
Much has evolved in our clinical approach to COVID-19 regarding PPE, testing, triaging patients, AGPs, and airway management. Aggressive, early PPE practices were almost universally recommended by participants as droplet and enhanced precaution (addition of N95 mask or respirator) guidelines were refined, as was using negative pressure or negative flow rooms for AGPs and using video laryngoscopes for intubations. Reference Auerbach, Abulebda and Bona20,Reference Morgan, Kienzle and Sen33,Reference Tan, Ong and Chong34 PPE champions and interpersonal accountability for properly wearing and disposing of PPE helped ensure that staff were donning and doffing correctly, as well as helping mitigate supply shortages. Reference Auerbach, Abulebda and Bona20,Reference Jain, Fahlgren, Giovanni and Dowd21,Reference Morgan, Kienzle and Sen33 As testing capabilities improved and institutions developed their own in-house testing, it became evident that we could not test everyone without running out of supply. Reference Hartford, Keilman and Yoshida23 While it is crucial to have widespread testing available for the community during a pandemic, testing those deemed “high-risk” based on symptoms, risk factors, or those being admitted to the hospital or going to the operating room should be given priority within the PED. Reference Auerbach, Abulebda and Bona20,Reference Jain, Fahlgren, Giovanni and Dowd21 While some participants discussed eventually moving away from cohorting patients in favor of treating everyone like a PUI, having the capability to physically separate PUIs from the rest of the patient population is crucial to infection control during a pandemic. The wide array of symptoms observed in pediatric patients, including not only respiratory but also gastrointestinal, musculoskeletal, and cardiovascular symptoms, persuaded many centers to treat everyone like a PUI and institute universal PPE procedures for all patients. Reference Beno, Ross and Principi26,Reference Parri, Lenge and Cantoni35–Reference Yasuhara, Kuno, Takagi and Sumitomo37
During a pandemic or other public health disaster, health care workers routinely put themselves in danger as they are filled with a sense of duty to assist. This lack of regard for personal safety does not extend to the fear health care workers have of transmitting illnesses to their families or to other patients. Reference Markwell, Mitchell, Wright and Brown14,Reference He, Stolarski, Whang and Kristo38 Recommendations for protecting the PED workforce, especially those with higher risk of severe disease go beyond adequate PPE supplies and include introducing new strategies to appropriately minimize interactions with potentially infected patients. Reference Jain, Fahlgren, Giovanni and Dowd21 By using phones in patient rooms to provide updates, coordinating with trainees and nurses to do exams together, and having cardiac monitors visible from the doorway, PED providers can limit their exposure. Participants took this further and recommended having changes of clothes available and showers at the hospital for providers to use before going home. By being transparent about PPE supply, providing child care and mental health resources, and allowing personnel to get tested when they desire, leadership will boost confidence in the workforce and help alleviate some of the stress and anxiety felt during a prolonged pandemic. Reference Shanafelt, Ripp and Trockel18,Reference Siddle, Tolleson-Rinehart and Brice39
Our study is not without its limitations. Two independent coders were used in the evaluation of the qualitative data, which may have introduced bias. However, utilizing a third coder to resolve discrepancies allowed for investigator triangulation and ensured trustworthiness. Furthermore, member checking was performed to confirm consistency and dependability of the findings. Despite only 14 PEM providers participating in this study, thematic saturation was reached. This relatively small number may not be generalizable across all PEDs. However, we were able to capture responses from institutions of varying sizes and geographic locations. Additionally, we only spoke with PEM physicians with disaster management experience who may have different perspectives than junior physicians or leaders who work at institutions that primarily care for adults and limits generalizability.
As the Delta variant of COVID-19 is spreading and future disease outbreaks are likely to occur, by collectively sharing our biggest challenges we faced as pediatric emergency centers and providing recommendations to overcoming those challenges, we may be better prepared for the next disaster.
Author contributions
All authors contributed to study design, development of data collection tools, data analysis, and manuscript writing and editing. Thomas Tanner was the primary data collector. Thomas Tanner and Esther Sampayo coded the data, and Nichole Davis was the tie breaker should there be a discrepancy. Erin Endom and Nichole Davis participated in member checking session with Thomas Tanner and Esther Sampayo.
Funding statement
Presented at American Academy of Pediatrics national conference on October 7, 2022.
