ABSTRACT
BACKGROUND: During Wave 3 of the COVID-19 pandemic, 15 community hospital paediatric inpatient units (comprising 167 beds) in Toronto were directed to close by the Greater Toronto Area (GTA) Hospital Incident Management System (IMS) Command Centre to increase adult inpatient bed capacity. All paediatric patients from closed inpatient units were redirected to a single tertiary care paediatric hospital, which increased capacity to accommodate these additional patients through activation of surge plans, while community hospitals redeployed resources to fill much needed gaps in adult care. OBJECTIVE(S): The objective was to describe patient characteristics of all transfers during the closure to explore the impact of community paediatric inpatient unit closures on transfers to the tertiary hospital. DESIGN/METHODS: A chart review of all transferred patients was conducted during the mandated closure and subsequent reopening. Transfers excluded ICU-level transfers as these were not impacted by IMS mandated closures. All transfers were categorized as requiring tertiary care (i.e. would typically be transferred) or not requiring tertiary care (i.e. only transferred due to the closure). Variables collected included sending hospital, admitting diagnosis, patient age, hospital disposition, and length of stay. Data was collected until the last paediatric unit reopened. Quality improvement project approval was granted by the institution. RESULT(S): A total of 858 patients were transferred to the tertiary hospital during the 67 day closure;of those, 530 were transferred solely to increase adult bed capacity (i.e. were categorized as patients requiring non-tertiary care). The majority of patients were admitted to general paediatrics (52%), and 39% went to a surgical inpatient unit. Most patients (68%) admitted had a length of stay between 24 and 72 hours. A third of patients admitted were under 2 years old, and a third were over 12 years old. The top three diagnoses for admission were infections, gastrointestinal issues, and general surgery. Two-thirds (60%) of transfers from closed sites came from three sites. CONCLUSION(S): More than half of the transfers occurred solely due to the mandated closures, and transfers returned to a stable volume once all sites re-opened. The GTA hospital system was able to respond to the mandated closure effectively through clear high-level communication, escalation processes and structures as well as responsive, real-time problem solving. Closures increased potential adult inpatient capacity by 6740 bed days and demonstrated an unprecedented system-wide approach to the provision of integrated paediatric care across the region.
ABSTRACT
BACKGROUND: Enhanced health and safety measures, such as symptom screening, physical distancing, cohorting, masking, and asymptomatic testing for children have been introduced into schools to prevent SARSCoV- 2 transmission. Although asymptomatic testing has been considered a measure to reduce in-school transmission, it has not been broadly implemented or evaluated. To address this, a pilot project with public health, school boards, and hospital-based testing partners was established to assess the feasibility of offering on-site and low barrier SARS-CoV-2 polymerase chain reaction (PCR) testing across schools in the Toronto region. OBJECTIVE(S): The primary objective of this study was to assess the feasibility of offering on-site and low barrier PCR asymptomatic testing across schools in the Toronto region. DESIGN/METHODS: A six-week testing pilot across the Greater Toronto Area took place. Schools were selected to participate in expanded testing to determine case prevalence in high-risk settings of school-based SARSCoV- 2. Students and staff were excluded if they had tested positive for COVID-19 in the last 3 months. Different testing opportunities were offered based on the testing partner and school preference including location and modality. Descriptive methods were used to assess the uptake of testing and case positivity by individuals recommended to be tested. RESULT(S): Eighteen schools participated in the pilot testing. All students and staff were invited to participate in asymptomatic testing. Testing was offered to 9282 students and 1000 staff, and testing uptake was 29% (2729 students) and 54% (544 staff), respectively. Forty-eight percent of tests (1645) were oral nasal tests, 18% (622) were NP swab tests and 33% (1120) were saliva tests. Of the saliva tests, 52% (590) were on-site saliva tests and 48% (530) were take-home saliva kits. The staff and student positivity rate for on-site testing was 1.9% and 4.9% for tests completed at the COVID-19 Assessment Center at SickKids. CONCLUSION(S): Results from this pilot project demonstrate that on-site PCR testing uptake remained low despite offering in-school testing, specialized support, and reduced barriers by using non-invasive testing with the use of saliva/ oral nasal/PCR testing kits. Results highlight the challenges of asymptomatic testing and the balance of resource utilization for low case counts. Future studies should examine alternate means of symptomatic testing.
ABSTRACT
BACKGROUND: Children living with chronic comorbid conditions are at increased risk for severe COVID-19 disease, though there is limited evidence regarding the risks associated with specific conditions and which children may benefit from targeted COVID-19 therapies. Age-specific baseline indicators of COVID-19 severity are also needed to evaluate the effectiveness of SARS-CoV-2 vaccination strategies in the paediatric population. OBJECTIVE(S): In this study, we aimed to 1) identify factors associated with severe COVID-19 in children, and 2) describe rates of hospitalization, intensive care unit (ICU) admission, and severe COVID-19 within specific pediatric age groups. DESIGN/METHODS: We conducted a national prospective study on hospitalized children with microbiologically confirmed SARS-CoV-2 infection via the Canadian Paediatric Surveillance Program from March 2020-May 2021. Cases were reported voluntarily by a network of >2800 paediatricians and paediatric subspecialists. SARS-CoV-2 hospitalizations were classified as COVID-19-related, incidental infection, or infection control/social admissions. Severe disease was defined as intensive care, ventilatory or hemodynamic requirements, select organ system complications, or death. Outcomes were described among children aged <6 months, 6-23 months, 2-4 years, 5-11 years, and 12-17 years. Risk factors for severe disease were identified using multivariable Poisson regression, adjusting for child age and sex, coinfections, and timing of hospitalization. RESULT(S): We identified 541 children hospitalized with SARS-CoV-2 infection, including 329 (60.8%) with COVID-19-related disease. Median age at admission was 2.8 years (IQR 0.3-13.5) and 42.9% (n=232) had at least one comorbidity. Among COVID-19-related hospitalizations, severe disease occurred in 29.5% of children (n=97/329), including a higher proportion of children aged 2-4 years (48.7%) and 12-17 years (41.3%) (Table 1). Comorbidities associated with severe disease are described in Figure 1, and included technology dependence (adjusted risk ratio [aRR] 1.96, 95% confidence interval [CI] 1.31-2.95), neurologic conditions (e.g. epilepsy and chromosomal/genetic conditions) (aRR 1.87, 95% CI 1.34-2.61), and pulmonary conditions (e.g. bronchopulmonary dysplasia and uncontrolled asthma) (aRR 1.66, 95% CI 1.13-2.42). CONCLUSION(S): While severe outcomes were detected at all ages and among patients with and without comorbidities, neurologic and pulmonary conditions as well as technology dependence were associated with increased risk of severe COVID-19. Children aged 2-4 years more commonly experienced severe COVID-19 in this study, which was conducted at a time when no children were eligible for SARS-CoV-2 vaccines. Notably, this high-risk group remains without access to approved vaccines. These findings may help guide vaccination programs and prioritize targeted COVID-19 therapies for children.
ABSTRACT
BACKGROUND: COVID-19 testing for symptomatic individuals is a key public health measure for infection prevention and control. However, COVID-19 testing can be uncomfortable without appropriate supports and can lead to testing hesitancy amongst certain populations such as children with medical complexity (CMC) and those with underlying neurological and respiratory conditions. To support COVID-19 testing, a specialized initiative was developed for CMC and their families onsite at The Hospital for Sick Children to enhance testing uptake, reduce barriers to access, and support a safe and accommodated testing environment for families. Multiple modalities of testing were involved and could be completed in their personal vehicle, with specialized support from nurses and child life if needed. OBJECTIVE(S): The objectives of our study were to investigate the characteristics of CMC and their families who underwent COVID-19 testing through our program, evaluate indications for testing, and collect case positivity rates. DESIGN/METHODS: Prospective data, including testing and population characteristics, were collected from December 2020-August 2021 through a centralized system, and was analyzed using descriptive methods. RESULT(S): 335 children (Table 1) with medical complexity came to the COVID-19 Assessment Center for testing. Of those who were tested 88% (294) had neurodevelopmental conditions with highly challenging behaviours (e.g. autism, developmental delay), and 12% (28) were classified as CMC (i.e. those with active use of medical technology e.g. tracheostomy, G-tube etc.). Of those tested, 6% (21) tested positive for COVID-19. Sixty percent (199) were tested due to having symptoms consistent with COVID-19, 27% (90) had a COVID-19 exposure, 8% (26) were exposed and tested as part of outbreak management and 5% were of an unknown criteria. The majority of completed tests (74%) were nasopharyngeal (NP) swabs, 18% completed saliva tests and 6% completed anterior nares/throat swab tests. Thirteen percent (43) of families requested additional supports such as extra nurses, child life specialists or other accommodations. All patients had a dedicated paediatric nurse and received testing in their personal vehicle. CONCLUSION(S): CMC and their families face unique barriers to COVID-19 testing. A specialized testing centre for CMC was able to support families by providing unique opportunities for testing, revealing a 6% COVID-19 positivity rate. NP swabs that can be painful were supported through in-vehicle testing with dedicated pediatric nurses. Robust health and safety measures, including a coordinated testing approach, are necessary to ensure accessible testing opportunities for CMC and their families. Further research is needed to be able to support this unique population.
ABSTRACT
BACKGROUND: Child and family-centered care, a partnership approach to health care decision-making, is central to paediatric practice. To reduce transmission of SARS-CoV-2, healthcare institutions implemented policies to protect staff, patients and families. Family presence at the bedside was reduced to one caregiver, except in special circumstances requiring pre-approval by hospital leadership. OBJECTIVES: We explored the impact of the COVID-19 pandemic on paediatric healthcare delivery, focusing on family presence. We describe the clinician's experience of restricted family presence during the COVID-19 pandemic in a paediatric hospital. DESIGN/METHODS: Physicians, trainees, and nurses at The Hospital for Sick Children completed surveys between March-August 2020 to identify patients they perceived to have experienced a suboptimal quality of care or health-outcome related to changes that had occurred as a result of the pandemic and describe the impact. Data were analyzed via case report and thematic analysis. As part of a larger study, here we report on cases related to family presence in the hospital. RESULTS: A total of 212 clinicians reported 116 cases;eighteen cases specified an impact on child and family-centered care. Nine cases related to patient experiences and nine to family experiences of the restricted family presence policy. Clinicians reported a perceived distress in patients due to family members not being present. 6267 family restriction exemption requests were received. Cases described families who opted for a different location for end-of-life care so that extended family could be present. Further cases highlighted how important conversations such as disclosure of diagnosis involved one parent present and the other joining remotely. Siblings were also reported to be impacted by visitor restrictions and closure of the sibling play area. Exclusions were also reported to be challenging for children with complex medical needs and technology dependency whereby two-caregivers were often required. Clinicians reported experiencing stress and moral distress as part of being required to support family restriction policies, impairing their ability to provide care. CONCLUSION: Family presence policies are a critical component of child and family-centered care and have been impacted by the pandemic as described both by family and clinician stress. Recommendations based on these findings would include: facilitating two-caregiver presence to support shared decision making, regular remote meetings to communicate information with families in cases where they cannot be physically present;using remote technology or implementing allotted visitation time for siblings, reviewing exceptions to caregiver restrictions, and mental health supports for clinicians such as peer-support groups, or wellness workshops.
ABSTRACT
BACKGROUND: The coronavirus (COVID-19) pandemic has broad implications for children and families. Healthcare experience and delivery has changed significantly, and changes will likely continue for some time. Particular attention has been paid to delays in accessing timely pediatric care leading to unintended morbidity. OBJECTIVES: This study aimed (1) to describe the broader spectrum of unintended negative consequences by describing the courses of care altered by the COVID-19 pandemic from the clinician's perspectives and (2) to identify thematic similarities to inform clinical practice change. DESIGN/METHODS: All full-time doctors, dentists, and nurse practitioners working at a tertiary care children's hospital in Canada were surveyed every two weeks throughout the initial phase of the COVID-19 pandemic. We asked them to identify and describe clinical cases in which they perceived a negative outcome associated with hospital or societal changes due to the COVID-19 pandemic. Analysis followed a qualitative case series methodology using a narrative synthesis approach to determine similarities and associated themes. RESULTS: Two-hundred and twelve clinicians reported 116 cases. Several broad themes emerged, including (1) timeliness of care, (2) disruption of child and family-centred care, (3) new pressures in the provision of safe and efficient care and (4) inequity in the experience of the COVID-19 pandemic. Within each of these themes, subthemes emerged, highlighting its impact on (1) patients, (2) their families and (3) healthcare providers. Table 1 provides examples of cases within each theme. CONCLUSION: The broad consequences of the COVID-19 pandemic impact patients, families, healthcare providers and the healthcare system. Understanding this breadth is necessary as we strive to deliver safe, high quality, family-centred pediatric care in this new era. As the pandemic continues, we need to consider carefully how to provide elective and ambulatory care, including surgery, in this era of social distancing. Particular attention is needed to understand particular aspects, including vulnerable children and the clinician experience of the COVID-19 pandemic.