The coronavirus disease pandemic caught many pediatric hospitals unprepared and has forced pediatric healthcare systems to scramble as they examine and plan for the optimal allocation of medical resources for the highest priority patients. There is limited data describing pediatric intensive care unit (PICU) preparedness and their health worker protections.

To describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a set of PICUs within a simulation-based network nationwide.

A cross-sectional multi-center national survey of PICU medical director(s) from children’s hospitals across the United States. The questionnaire was developed and reviewed by physicians with expertise in pediatric critical care, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through a long-established national research network. The questions focused on six themes: (1) PICU and medical director demographics; (2) Pediatric patient flow during the pandemic; (3) Changes to the staffing models related to the pandemic; (4) Use of personal protective equipment (PPE); (5) Changes in clinical practice and innovations; and (6) Current modalities of training including simulation.

We report on survey responses from 22 of 35 PICUs (63%). The majority of PICUs were located within children’s hospitals (87%). All PICUs cared for pediatric patients with COVID-19 at the time of the survey. The majority of PICUs (83.4%) witnessed decreases in non-COVID-19 patients, 43% had COVID-19 dedicated units, and 74.6% pivoted to accept adult COVID-19 patients. All PICUs implemented changes to their staffing models with the most common changes being changes in COVID-19 patient room assignment in 50% of surveyed PICUs and introducing remote patient monitoring in 36% of the PICU units. Ninety-five percent of PICUs conducted training for donning and doffing of enhanced PPE. Even 6 months into the pandemic, one-third of PICUs across the United States reported shortages in PPE. The most common training formats for PPE were hands-on training (73%) and video-based content (82%). The most common concerns related to COVID-19 practice were changes in clinical protocols and guidelines (50%). The majority of PICUs implemented significant changes in their airway management (82%) and cardiac arrest management protocols in COVID-19 patients (68%). Simulation-based training was the most commonly utilized training modality (82%), whereas team training (73%) and team dynamics (77%) were the most common training objectives.

A substantial proportion of surveyed PICUs reported on large changes in their preparedness and training efforts before and during the pandemic. PICUs implemented broad strategies including modifications to staffing, PPE usage, workflow, and clinical practice, while using simulation as the preferred training modality. Further research is needed to advance the level of preparedness, support staff assuredness, and support deep learning about which preparedness actions were effective and what lessons are needed to improve PICU care and staff protection for the next COVID-19 patient waves.

The coronavirus disease 2019 (COVID-19) pandemic has forced healthcare systems to examine the judicious allocation of scarce medical resources to the highest priority patients, including the pediatric population[1]. Recent studies report pediatric populations have a lower incidence and typically, a less severe presentation, as compared to adults[2]. Some children, particularly with co-morbidities, are more likely to develop critical illnesses such as respiratory and cardiac failure or shock that may require invasive respiratory support or extracorporeal hemodynamic support[3]. Recently, emerging data are suggesting, however, a more serious illness in kids, with hundreds of children sickened with severe illness due to COVID-19, now named multisystem inflammatory syndrome in children[4].

Diagnostic and therapeutic guidelines used for children are commonly extrapolated from studies conducted in adults. The Society of Critical Care Medicine published a national survey of more than 4500 intensive care specialists to assess adult intensive care unit (ICU) preparedness. This survey demonstrated that adult ICU settings are preparing for COVID-19 patient care by enacting a myriad of measures including: Preparing in-hospital non-ICU space, canceling elective surgeries, and preparing temporary spaces and external facilities[5]. Reviews of adult ICU preparedness for pandemics have focused on concepts of infection control and optimal ways to increase staffing and surge capacity[6]. Pediatric preparedness for COVID-19 is distinct from adult preparedness due to important physiological and equipment differences, distinct differences in pediatric COVID-19 presentations, the child’s stage of development, and the intimate need for parent involvement as part of the care delivery model.

It is important to assess pediatric ICU preparedness to identify gaps and inform improvements as we prepare for present and future waves of the COVID-19 pandemic. Most children’s hospitals in response to the pandemic have rapidly escalated their health systems preparedness and implemented innovative processes to prevent disease transmission and prepare their staff to care for COVID-19 patients[7,8]. Despite a widely accepted standard of care and national accreditation for pandemics and mass disasters for neonatal and pediatric critical care in the United States, recent data suggest that the United States system lacks adequate surge capacity and would benefit from a well-organized, nationally directed and cohesive approach[9,10].

There are limited data describing the extent of the actual changes implemented by pediatric ICUs (PICUs) and their approaches to improve pandemic their preparedness[11]. This survey aims to describe the current: (1) Preparedness efforts by a group of leading United States children’s hospitals’ PICUs; (2) Changes in policies/procedures /guidelines; and (3) Training modalities and innovations including use of simulation for COVID-19 care.

A total of 35 PICUs within the network were identified. Responses from 22 PICUs (63%) were received (Table 1).

COVID-19 has placed extraordinary and sustained resource demands on critical care services. This survey provides a first snapshot of the current preparedness efforts among a set of leading PICUs in the United States during the first months of the pandemic. The majority of surveyed PICUs implemented dramatic changes to their workflow and adapted their staffing models, with 43% creating dedicated COVID-19 care units. Additionally, medical trainees with different professional backgrounds were either limited or prohibited from participating in direct patient care, posing significant workload burdens on PICU staff.

In March 2020, during the peak of the pandemic in New York City, The Association of American Medical Colleges and The Liaison Committee on Medical Education issued guidance that medical students should not be involved in the care of COVID-19 patients or persons under investigation, and many medical schools near the early epicenter of the pandemic discontinued clinical rotations[13]. Surveyed directors reported that they conducted extensive training on the proper use of enhanced PPE among their providers, while a third of surveyed programs reported regular shortages in PPE. Even 6 months into the pandemic, PPE shortages continue to be reported across the United States. Beyond this, more than two-thirds of PICUs implemented innovative training for their providers targeted at modified clinical practices for airway and cardiac arrest management, while only one-third implemented surge management training. Simulation conducted in situ is a well-established method for effective team training and was the most common training modality in our survey and was frequently utilized to support interprofessional team training and improve team dynamics in the ICU setting[14,15].

Our survey results are the first nationwide reports from pediatric ICUs with that have active simulation programs about their state of preparedness[7,16]. PICUs initiated rapid cycle planning and implementation of changes to established childcare models to ensure that safe and effective care was being maintained. Although many adult ICUs have reported on current approaches to improve preparedness, this is the first survey outlining the detailed preparedness steps and response efforts adopted by PICUs[17].

Many PICUs encountered a dramatic decrease in the number of non-COVID-19 patients as the pandemic evolved, which has likely helped balance the need for additional resources and training for all bedside providers to care for COVID-19 patients. In this survey, one-third of PICUs reported a consistent shortage in PPEs, which is similar to what has been reported in previous pandemics and which continues to put healthcare workers at risk[18-20]. This ongoing shortage of PPE is notable given the high risk of PICU staff exposed to aerosol-generating procedures, with recent data suggesting over 3000 healthcare workers have died caring for COVID-19 patients, including several intensive care providers, and at least 500000 healthcare providers reported infected worldwide[21,22].

The findings of the survey are a reflection of the overall preparedness efforts among the participating PICUs and the changes completed in operational policies by the surveyed PICUs. These changes translate into clinical and occupational benefits and can help in optimizing the clinical services of PICUs nationwide who are under resource constraints. These benefits include protecting healthcare providers and patients from the virus exposure to reduce the infection risks, establishing a community of practice among PICU clinical services and medical directors to avoid “reinventing the wheel” during the current pandemic, and more importantly identifying how best to prepare and implement more effective operational plans for predictable future pandemics. Furthermore, this survey serves as a guide to highlight and address present PICU system vulnerabilities. It supports PICU leadership and bedside providers in providing the highest quality of care and a laser-like focus on the safety of healthcare providers.

This survey has several limitations. While 22 of 35 major leading PICU medical directors responded, this represents only a sample of all United States PICUs, which may impact the generalizability of our findings. Additionally, this survey targeted PICUs that have active simulation programs, which may reflect more well-funded facilities. The survey, nonetheless, can provide deep insights into how PICU directors and programs are adapting their training, staffing, and workflow to address the ongoing, shifting pandemic demands. Additionally, the survey responses are inherently prone to bias and may not always accurately reflect the actual practice of clinical performance but rather the policies and intent. Lastly, we did not capture certain data such as the percent decrease in non-COVID-19 patients seen or visitors’ policy to the PICUs.

We conclude in this first national survey that the current preparedness efforts among PICUs in the United States during the first few months of the COVID-19 pandemic have been highly variable, with one-third lacking adequate PPE. PICUs have implemented several strategies including modifications to staffing and workflows, changes in their acute resuscitation and airway management, treatment protocols, limiting personnel’s exposure to contagion, while using simulation as the preferred training modality to support protocol changes in response to COVID-19. Our findings highlight the importance of sharing experiences among PICUs, particularly during these challenging times. Future research is needed to better appreciate the effectiveness of better PPE preparedness, workflow, and training changes. We also need to better understand what are the impacts of limiting trainees’ exposure to COVID-19 care on their clinical competencies in preparation for ongoing and future pandemics.