As COVID-19 cases threaten capacity, children's hospitals resist taking adults

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As the COVID-19 outbreak threatens to overwhelm hospitals in the U.S., many children's hospitals are united in the message: Don't send your adult patients here.

That's the essence of guidelines the Children's Hospital Association, which represents 200 children's hospitals, made public Tuesday. After fielding questions from hospitals, governors and mayors about whether children's hospitals could take adult patients, the organization said adults can't safely be treated in children's hospitals, given the equipment and staff is centered around caring for kids.

"If my family wanted COVID care, I'd want them to go to an adult hospital," said Mark Wietecha, CEO of the Children's Hospital Association.

Rather than accept adult patients into children's hospitals, the CHA said hospitals that treat adults should send their children and adolescent patients to children's hospitals, which typically are focused on treating seriously ill children with multiple chronic conditions. That should free up capacity for those hospitals, he said.

"It's easier for children's hospitals to create surge capacity for kids, just as it's easier for adult hospitals to create surge capacity for adults," Wietecha said.

The equipment, calibrations, medication dosing and staff in children's hospitals are all designed for treating children, Wietecha explained. Some of the oxygen masks are smaller than the palm of one's hand and the surgical gowns and booties are made for small patients, as are the "teeny tiny needles" used. Neonatal and pediatric intensive care unit beds are much smaller than those in adult hospitals, he said.

More importantly, the physicians, nurses and other staff members are accustomed to working with babies and children. Treating adults, especially older adults, would be a dramatic shift. Bringing adult patients into children's hospitals would necessitate also bringing in providers who are used to treating adult patients, Wietecha said.

Wietecha said the CHA already sent its directive to the CMS, which is reviewing the document. The CMS did not immediately respond to a request for comment.

Despite the CHA's directive, some children's hospitals said they're willing to be flexible and are preparing to welcome adult patients if needed.

Among them is Rainbow Babies & Children's Hospital in Cleveland, part of the University Hospitals system. Hospital leaders say Rainbow Babies is already preparing to take on adult patients.

"I would leave the door open as to what would be best for patients, and we'll have to do that as a team," said Dr. Marlene Miller, University Hospitals' pediatrician-in-chief.

Hospital President Patti DePompei said adult patients could be housed on the same floor as Rainbow Babies' pediatric intensive care unit as well as next to University Hospitals' women's hospital.

Rainbow Babies is uniquely positioned in that it is located on the same campus as its larger integrated health system, which allows it to move people and resources more easily than a standalone children's hospital, DePompei said.

Children's Hospital Colorado is alerting community hospitals in its seven-state coverage area that it is accepting patients up to age 30 amid the outbreak, said Dr. David Brumbaugh, the hospital's associate chief medical officer. Administrators at the hospital, located in the Denver suburb of Aurora, realized they would still have excess capacity even if they admitted all the children from other hospitals in their coverage area, which stretches from Billings, Montana to Albuquerque, New Mexico.

"Nobody is going to be comfortable in this pandemic," Brumbaugh said. "We are going to have to stretch as an organization taking patients that are older than our usual age range because that's what the circumstances call us to do. We feel it's our duty."

Despite the expanded patient age range, Children's Hospital Colorado still is not accepting patients who are pregnant and have other medical diagnoses or patients with significant substance use and psychiatric disorders because those are outside of its providers' expertise, Brumbaugh said.

Brumbaugh expects most of the new patients will not have COVID-19, given data that show low hospitalization rates among people younger than 30. Administrators made 30 the age limit because patients older than that tend to have conditions more typical of adults like chronic lung conditions and type 2 diabetes, he said.

"At some point the balance tips where the quality and safety of pediatric care in a pediatric institution is not the same as in an adult institution," he said.

Mount Sinai Kravis Children's Hospital in New York City appears to be taking a similar position. In an emailed statement, Dr. David Reich, president of The Mount Sinai Hospital and Mount Sinai Queens, said the organization will be flexible in its contingency planning "to use all clinical areas of The Mount Sinai Hospital and Mount Sinai Kravis Children's Hospital to accommodate the expected influx of patients of any age that require acute care."

New York City has been particularly hard hit by COVID-19. The city had about 14,900 confirmed cases just before 3 p.m. on Tuesday.

Several children's hospitals, by contrast, described plans that align with the CHA's guidance.

That includes UCSF Benioff Children's Hospital, whose spokeswoman, Suzanne Leigh, wrote in an email that the hospital is not preparing to accept adult patients, but that it would accept pediatric patients from other hospitals to allow them to dedicate more space and resources to their own adult patients.

Lurie Children's Hospital of Chicago, Nationwide Children's Hospital in Columbus, Ohio and Oregon Health & Science University's Doernbecher Children's Hospital in Portland sent similar statements.

The CHA said it consulted with the American Academy of Pediatrics and the Association of American Medical Colleges to craft its guidelines. The AAP declined to comment for this article.
Dr. Janis Orlowski, the AAMC's chief health care officer, said she thinks the guidelines make sense.
"Children's hospitals don't have the equipment and they really don't treat the vast majority of adult conditions," she said.

A UBS analyst last week predicted that children's hospitals won't be as hard hit by COVID-19 as general acute-care hospitals. Wietecha disagreed, noting that in the first quarter his members are estimating losing 20% of their total cash flow, mostly from deferring elective procedures. Guidance from the White House urging hospitals to defer elective procedures did not differentiate between adult and children's hospitals, so children's hospitals followed suit, despite the fact that they haven't seen as many seriously ill COVID-19 patients as their general acute-care counterparts, Wietecha said.

The COVID-19 situation is rapidly changing, and Wietecha conceded that scenarios may arise where children's hospitals have to take on adult patients.

"Then so be it," he said, "but I think we probably want to start out thinking that rather than start out saying all the beds are equal. Just put anyone where they've got a seat kind of musical chairs."