Every morning at about 7 a.m., staff members in the transport department at Children’s Mercy Hospital in Kansas City, Missouri, start calling dozens of hospitals in the region.
They’re looking for information from hospitals that provide pediatric care in Iowa, Kansas, Missouri and Nebraska – the states that make up the U.S. Department of Health and Human Services (DHHS) Region 7.
Specifically, they ask: “How many pediatric ICU beds do you have available?”
This became an urgent question for hospitals that treat children when the so-called “tripledemic” of RSV, COVID-19 and flu cases began to fill hospitals in the fall.
Dr. John Trapp, chief medical office at Nebraska’s Bryan Health in Lincoln, said finding the right treatment for acutely sick children remains urgent.
“If I don't have a critical care bed for one pediatric child, to me that's a crisis. Our primary resources are Omaha Children's Hospital. When they cannot go to Omaha, Omaha's full. What happens? They go to Des Moines or Kansas City, or further away.”
Douglas County, home to the city of Omaha, Nebraska, reported a child’s death from the flu on Dec.16. Nationwide, more than a dozen children have died from the flu this year.
Weekly or bi-weekly calls among the region’s hospitals and government agencies have become a regular feature of battling the tripledemic.
“The meetings between leaders of children's hospitals throughout the region, healthcare emergency management professionals, and state and federal partners have been invaluable,” said Dr. Kari Wellnitz, a pediatric critical care physician at University of Iowa Stead Family Children’s Hospital. “People have shared novel ideas on how to address the ‘space-staff-stuff’ issues that are confronting all hospital systems right now. Members have also shared just-in-time pediatric care and medication resources, hopefully preventing the need to reinvent the wheel multiple times.”
Transferring sick kids
At Children’s Mercy in Kansas City, when transport department staffers complete their round of phone calls to find pediatric ICU beds, they compile data about which hospitals can take patients and send it out to colleagues across Region 7. Then, when needed, Children’s Mercy dispatches a helicopter to make the transfer.
“We have a phenomenal critical care pediatric transport team,” said Dr. Jennifer Watts, chief emergency management medical officer at Children’s Mercy, which serves both Kansas and Missouri. “We offered our services to other hospitals to take a child from a referring hospital to Omaha for example, if they were the ones that had the bed.”
Alexa Lewis, director of women and children’s services at Bryan Health, said the hospital system is seeing both sides of the transfer process.
“We have had to accept patients from Iowa. We've had to transport out as well,” Lewis said. “We’ve been grateful for partnerships throughout the whole region to expand our abilities and our capacity.”
At a time that’s already stressful and distressing for families, moving a sick child to another city or state is far from ideal, Trapp said.
“It’s a tremendous challenge for those families to manage a sick child rapidly,” he said. “Trying to say, ‘how do we navigate that when they're 200 miles away?’ We know how important families are for the decision making medical decision, making and care of those children.”
Medication shortages
While one group of Children’s Mercy employees is working to get acutely sick kids the care they need in the four states, other teams at the hospital have a different quest: Finding enough medicine for those who need it.
Vital prescription and over-the counter medications are scarce because of supply chain hiccups and high demand. For example, supplies of amoxicillin, the go-to antibiotic for treating infections in children, are running low across the country, Watts said.
And it’s not just prescription drugs in limited supply. The nation's two largest pharmacy chains – CVS and Walgreens – are restricting purchases of children's pain relief medicine amid the tripledemic of respiratory infections. That includes staples like Children’s Tylenol and Children’s Motrin.
Watts and her colleagues identify sources of vital antibiotics and other medicine then share that information with Region 7 partners. There are tough choices about how and what to prescribe.
“We have developed alternative suggestions for how to decrease our strategies, how to decrease usage and conserve the supplies that we do have,” Watts said.
This might mean prescribing amoxicillin for an infection for five days instead of seven. Hospitals also look at other antibiotics that could do the job and work with primary care physicians and insurance companies to educate them on the alternatives.
University of Iowa’s Stead Family Children’s Hospital adopted new practices to deal with low supplies at its own pharmacy.
“We have contingency plans in place to address these shortages until the national supply has stabilized. Our pharmacies are limiting purchases of over-the-counter supplies to one bottle of acetaminophen and ibuprofen per day,” said Dr. Patrick McNamara, director of inpatient services.
It’s only December
Like Children’s Mercy, SSM Cardinal Glennon Children’s Hospital in St. Louis is a treatment destination for children from around the Midwest. Even as part of a leading hospital system that boasts 120 pediatric beds, Cardinal Glennon is not immune to the forces of the tripledemic.
“We are having a really, really difficult time,” said Dr. Ken Haller, a professor of pediatrics at Saint Louis University School of Medicine who practices at Cardinal Glennon. “Our offices are full, our emergency rooms are full, our urgent cares are full of kids with upper respiratory infections.”
Haller said Cardinal Glennon remains flexible and nimble to care for sick children, just like its regional colleagues.
“At times like this, sometimes we have kids who are spending time in the emergency room because there are no beds up on the floor, because the kids are just sick enough that they can't quite go home, and those rooms are not empty yet,” he said.
And it’s only December. Haller said rates of flu in the St. Louis area are about three times higher than their normal peak, and that peak has come about two months early.
While experts say it’s hard to pinpoint exactly why there’s been an early peak in the Midwest and elsewhere, the steep drop in flu cases due COVID-19 masking and social distancing regimes may have played a role.
“Reduced population immunity, particularly among young children who may never have had flu exposure or been vaccinated, could bring about a robust return of flu,” the CDC said on its website in October.
At the Stead Family Children’s in Iowa, a routine in critical pediatric admissions has emerged during the influx of respiratory infection cases.
“The pattern where Children’s Hospital is very full in the evening but by the morning there are open beds has been a consistent theme,” McNamara said.
Still, he said, there are staffing shortages to contend with.
“The impact of this challenging respiratory illness season on frontline staff, who are already tired after working harder than ever before, is not ideal,” McNamara said. “We are fortunate to have an amazing team that continues to show up and deliver high-quality care amidst these challenges.”
So far, Stead Family Children’s Hospital has not had to transfer pediatric patients to other hospitals. Even so, the hospital is bracing for what could come.
“We have developed a comprehensive surge plan, which has not yet been activated,” McNamara said. “The necessary preparations have been made to ensure the team can flex up if needed to maximize our care potential. These preparations include expansion of our pediatric intensive care services and adding clinical staff to support these beds.”
Haller, in St. Louis, summed up the sentiments about the tripledemic shared by many of his colleagues around the region.
“Whether we have reached the peak, and now it's going to start falling off, or whether that peak is just going to be much longer and continue, I think is kind of anybody's guess,” Haller said. “So we're sort of holding our breath and crossing our fingers and hoping that things are going to start heading back down again.”
Jackie Ourada of Nebraska Public Media News contributed to this report.
This story comes from the Midwest Newsroom, an investigative journalism collaboration including Iowa Public Radio, KCUR, Nebraska Public Media News, St. Louis Public Radio and NPR.