Children’s Hospitals Caring for Adults During a Pandemic: Pragmatic Considerations and Approaches

Med-Peds physicians and advanced practice providers are the foundation of the clinical care provided to adults at our institutions. Our Med-Peds providers practice in both the free-standing pediatric hospital and an affiliated adult health system. They offer expertise in adult clinical care and navigate between pediatric and adult systems when the need arises (eg, adult requiring urgent intervention for an acute myocardial infarction). Adult competencies of other staff must be addressed. For example, our cardiac ICUs include nurses with adult clinical care experience because critically ill adults with congenital heart disease are admitted. Advanced Care Life Support (ACLS) training is also required for staff caring for adults throughout the hospital.

There are many ways, even during a crisis, to develop an adult care model in a pediatric setting. Depending on workforce availability, internal medicine, Med-Peds, family medicine, critical care, and emergency medicine physicians could serve on either a primary service or as a consultant to support pediatrics-trained providers in caring for adults should the patient volume and acuity require staffing restructuring. Adult subspecialty access must be addressed. Telehealth may play a significant role in extending clinicians in all of these clinical roles both during the current crisis but also in underresourced settings.⁸ A clear process and indication for emergency or temporary credentialing and privileging necessitates understanding and addressing such challenges early. Training in adult care, or lack thereof, for other staff, such as nurses and respiratory therapists, is also crucial to consider.

Adults are more likely than children to have comorbidities and clinical deterioration while hospitalized. At our institutions, when a rapid response team is called for an adult patient, an adult care–team provider responds to aid in clinical management and determines the appropriate care setting. Additionally, given that the incidence of coronary artery disease increases starting at age 35 years,⁹ our systems have developed procedures for managing time-sensitive conditions seen more commonly in adults, such as acute myocardial infarction, stroke, and pulmonary embolism. Despite simulation training for pediatric providers and staff, it is clear that implementing these procedures is highly dependent on involvement of the adult care team.

With the urgency of implementation, pediatric systems should consider increasing the number of providers and staff with ACLS training, especially for rapid response and code teams. Many pediatric systems may need to evaluate how their code carts are stocked and ensure they are equipped with appropriate medication dosages and sizes of supplies. Emergent and accessible adult care will be needed, especially for issues with time-to-intervention criteria like acute myocardial infarction and stroke. Hospitalized adults with COVID-19 may also have a higher incidence of arrhythmia, cardiac ischemia, and stroke.¹⁰ Consider proactively simulating common COVID-19–related scenarios to build interdisciplinary teamwork in emergency scenarios. Interhospital agreements and pathways exist for sharing medications. Outreach to pharmacies may be indicated to ensure accessibility for medications not commonly found in pediatric systems.

Our children’s hospitals care for certain adult populations with chronic conditions of childhood origin because of the availability of subspecialty clinical expertise. Our adult care team aids in contingency planning to help determine place of admission (adult vs pediatric hospital) depending on patient clinical needs and system expertise. For instance, an adult with congenital heart disease may have two cardiologists—one for congenital heart disease and one for coronary artery disease. Patients with an acute issue such as new-onset arrhythmia may be admitted to our pediatric hospital; however, for a stroke they would be admitted to the adult hospital.