'Most children’s hospitals are struggling,' says John Nickens, president and CEO of Children's Hospital New Orleans

Modern Healthcare reporters take a deep dive with leaders in the industry who are standing out and making a difference in their organization or their field. We hear from John Nickens, president and CEO of Children's Hospital New Orleans, about how the organization has responded to staffing needs and the pediatric behavioral health crisis.

What are some of the biggest challenges you’re facing right now at Children’s Hospital New Orleans?

If you look at today’s world, I think most children’s hospitals are struggling, and we certainly are, with staffing. [One problem] is nurses, but we’ve had a nursing shortage before, and we have creative solutions for that, which sometimes include adjusting our care model. This time, [the shortage] includes respiratory techs, lab techs, imaging technicians. One crazy story from New Orleans is, as tourism has come back, we opened our own little coffee shop, and we haven’t been able to find a barista to help us.

In Louisiana, we had Hurricane Ida [in 2021]. We refer to that time frame as “COV-Ida” because we were battling COVID-19, [while] we had a hurricane with Ida. We didn’t have power for almost 10 days.

More recently, I think a lot of people have heard about the triple threat of viruses with COVID, RSV and flu. Kids have really been sick. Hospitals have been full.

How has that so-called “tripledemic” affected Children’s Hospital?

You always have, in the winter, the opportunity for kids who have medical complexity to possibly get RSV and add some sort of breathing challenge or flu—just really tearing down the immune system. But the fact that you have both of those, and COVID, [increases] the impact.

We normally see about 200 kids in any day in the emergency room. We’re seeing 400 every day. We’ve never actually been 100% full before, and we have been multiple times in the last couple of months. It’s forced us to reallocate resources: “Is this the right time to do a surgical procedure, or should we wait?” That’s always a concern and creates anxiety because obviously that kid needs to have surgery, but maybe we can’t provide that care right now.

How do you navigate capacity issues?

There are all kinds of mechanisms that we talk about regularly as children’s hospital groups. One of those is you take your operating rooms and turn those into acute-care inpatient rooms. So you might have 10 operating rooms, and then you might have 20 post-surgery rooms: You take those rooms and convert them.

We have our ambulatory center on site, which has five floors of physician office clinics, about 80 rooms. We have some creative ideas in the emergency room. We triage, and if you’re not at [a certain] level of sickness, we take you over to our clinic space after 5 o’clock, when the clinics are closed.

Regarding the tripledemic, do you see any improvement in the near future?

I don’t think it’s going to improve. We talk to our infectious disease doctors, and they try to use all the preliminary data they get from the Southern Hemisphere, which gives them an idea of how flu might spread. As an administrator, I’m just hesitant to feel confident that it’s going to get better. Kids are going to get back in school. They’re going to spread the flu between themselves. It’s difficult for those who choose to mask to keep a mask on a kid. I think we’ve got another couple of months of navigating through this.

Can you expand on those staffing challenges you’re seeing at this point?

The boomer generation … [made up] a big number of nurses whom we saw leave the workforce. And then, unfortunately, we’re not seeing the same numbers signing up in nursing school that we have in previous years. That’s something we feel accountable [for] and have to work on. We need to make nursing attractive, but as I mentioned earlier, [the need includes] more than just nursing right now.

In New Orleans, we’ve been very aggressive about partnering with all our affiliated schools. The last six months has [seen] our lowest turnover rate since prior to COVID. That does give me some hope.

How much contract labor are you using for nursing?

We have about 800 nurses, and we’ve peaked at around 25 contract nurses, which is a pretty small number compared to our peers. But we’ve been very purposeful. We’ve asked many of our nurses who have left the clinical environment—maybe gone into clinical trials in the research world, or maybe they’ve gone into administration—we’ve asked all of them to come back to the bedside for a period of time to help us out.

How do you stay competitive on compensation and benefits?

Wage inflation has been significant. We are in a competitive environment, where we need to pay nurses or they can go right down the street. But we’ve tried to balance that with the kinds of benefits we provide. In the last two years, we’ve opened our own daycare on site and provided that free to our employees. We’ve opened our own gym area. We have a dry-cleaning place—anything that you need to make your life a little easier. Our cafeteria offers take-home meals for the entire family.

We’ve never actually been 100% full before, and we have been multiple times in the last couple of months."

Mental health has become a huge topic in healthcare. What has the recent mental health crisis looked like in pediatrics?

It’s been devastating. We’ve seen teen suicide rates bump back up for the first time in a decade. The trauma of loss, whether it’s through COVID or crime rates, has really forced us to take a new, deep look at the way mental health is cared for.

In New Orleans, we’ve set aside eight rooms in our emergency department that now create a safe environment for those who are struggling with mental health. They’re patterned after our behavioral health and mental health building. A year and a half ago, we built a 51-bed inpatient behavioral health psychiatric unit for kids.

We were fortunate to get the TAG, or trauma and grief, program. It’s in Detroit, Houston and now in New Orleans. It really goes after [the question]: In the school system, can you identify those kids who are struggling, early on, and get them the help they need?

How are you balancing supply with demand for pediatric mental health services?

The demand is exponentially higher than the supply. We have the healthcare advocates in the school system, liaisons who try to identify [children in need], so that you don’t have a psychologist or psychiatrist who’s constantly going through triage. We can train social workers and others to be the eyes and ears. That’s helped some, but what you find is more kids who need help.

We’ve tried to go big with a more robust outpatient program. We have an outpatient eating disorder program, where the whole family participates. For autism and those who are on the spectrum, we have a robust outpatient program.

We’ve tried to pivot a little bit and use the preventive approach, but I think our providers would say they’re a little outmanned. They’re not able to catch up to the demand right now. If you look at our next available appointment, it’s in months, not days.

I feel a responsibility, as a business guy, to run better operations in support of the effort to see every child. I’m not sure that we’ve maximized our ability to bring health inside of the school system. Kids are there, and we want to keep kids in school. I think there’s some encouraging opportunities there, and we’re certainly investing big in that platform.