A pediatric ICU nurse's warning about the crisis at kids’ hospitals

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Too many patients, too few beds: A pediatric ICU nurse on the crisis facing kids’ hospitals

A double-punch of staffing shortages and an early surge of respiratory viruses is pushing many children’s hospitals to the brink — a slow-moving disaster that has been deepening for weeks, if not months.

Viruses kept in check by social distancing for the last two years have come back with a vengeance since late summer, filling up hospital beds much sooner than normal. Many have been operating at or near capacity. Some have set up tents to deal with the overflow, and the Children’s Hospital Association and the American Academy of Pediatrics recently called on President Joe Biden to declare a national emergency because of the crisis.

The viruses — respiratory syncytial virus (RSV), enteroviruses, rhinoviruses and others — are exploiting a population of youngsters who either haven’t been infected or whose immunity has waned during the pandemic. With protective measures largely abandoned, there’s ample opportunity for the viruses to spread, driving abnormally high levels of infection.

That surge is colliding with a thinned-out workforce that’s exhausted nearly three years into the pandemic. Clinicians, especially nurses, have left the bedside in record numbers, leaving fewer staff to tend to the influx of patients. With potential flu and covid surges looming, those who remain could be facing their toughest pandemic winter yet.

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Grid spoke with Hui-wen Sato, a pediatric ICU nurse at a children’s hospital in Southern California, to get an on-the-ground perspective of the surge. Sato works both as a bedside nurse and as a charge nurse who oversees the department and helps coordinate care.

This interview has been edited for length and clarity.

Grid: What is it like right now in your hospital?

Hui-wen Sato: We are absolutely seeing a surge of respiratory illness in kids. It’s been going on for six or eight weeks. The bulk is definitely RSV, but we have kids who are coming in with other respiratory illnesses like the common cold, but they either were so young that they got hit really hard, or they have other health issues that made them a little more susceptible to needing more support. We also have a handful of covid kids that have come in.

G: What kind of care does the average RSV patient need?

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HS: There are some who just need a simple nasal cannula, the little light prongs in the nose [that emit oxygen]. They could go to the regular medical surgical floor. But because RSV hits young infants a lot more, they’re smaller, and their airways are smaller. And so those kids often need to come to the ICU for a high-flow nasal cannula, which pushes pressurized oxygen through their nose into their lungs and helps to keep those teeny tiny lungs and airway passages more open.

Sometimes they might need a next level up CPAP or BiPAP, which is even more pressurized airflow. And there are some extreme cases who need the entire breathing tube that goes down into their trachea.

G: Many hospitals are experiencing a shortage of staff, especially nurses. How has this been at your hospital?

HS: Our capacity has really taken a hit since covid. By and large, everyone is short-staffed. That impacts everything. There might be a long line of patients coming into the ED [emergency department], and we have to transfer patients out of our ICU to a regular medical surgical floor, but if those floors are short-staffed, it impedes our ability to get patients out of our ICU in a timely fashion, which impedes our ability to admit patients from the ED. The overall flow is impaired because capacity is lower. Our hospital has been doing less non-urgent, elective surgeries since we just don’t have as much capacity.

In our ICU, we physically have 24 beds, but because of our staffing, we only have adequate staff for 20 or 21 occupied beds. Just because there are three more physical beds open doesn’t mean that we can safely staff them. We also typically have to hold space for what we call the code bed, that’s used for a code blue [a hospital-wide alert that a patient needs immediate emergency care, often for a cardiac or respiratory arrest]. We try to keep one bed open for when someone inside the hospital has an emergency, or someone comes through the ED and is terribly, critically ill, not just needing oxygen for RSV but they got slammed by a car and need that bed.

Because of the respiratory surge, there’s so many who show up in the ED who need oxygen right now. And we take them, but I always have to think about the other things that can happen. There are still car accidents. There are still patients on the regular floors who suddenly have a medical crisis. Those kinds of things don’t stop just because this respiratory surge is happening. How do you plan when you don’t know when those emergencies are going to happen, and you don’t want to come up short, but you’re always short-staffed?

G: How do you navigate that?

HS: It’s really case by case, hour by hour, day by day. You’re just trying to make the best decisions and triage your patients with as much wisdom as you can, but it’s not perfect, we don’t have a crystal ball, and sometimes we have to deny admission.

We talk very closely with our physicians about all the scenarios. So, there might be three respiratory patients in the ED that would normally go to the ICU, but if they’re stable in the ED and the ED is OK managing them for the foreseeable future, maybe they stay there to protect our ICU beds.

Or maybe we can take these two respiratory patients from the ED, but if we do, that means that we only have enough staff and beds for one more very critically sick kid, and the code bed — that’s all I have. So doctors, you need to make the decision: Do you really want to occupy the space this way?


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G: What is that like personally, having to manage this large influx day by day and provide care when staffing is so limited?

HS: It’s just really distressing. When staffing gets limited, that means that you just have less hands to do all the things that either critically need to be done or the things beyond the absolute essentials. I wish I could be more present with the families, or I wish I could even just clean up my patients better. Sometimes I may have managed all their respiratory support and their medications fine, but they just need a really good bath. But I only had time to do a quick wipe down, and that’s the really good patient care that I wish I could provide. But I have to choose what my priorities are. In some ways, it feels like you lower your standards, and you try to always protect safety as the highest goal. But there’s a different level of quality nursing that we all feel generally less able to provide because we just don’t have as much time on our hands to do it.

From a charge-nurse vantage point, there’s just always this push to turn around beds. I know how stressful it feels as a bedside nurse when you have two patients and need to transfer one upstairs, but you’re still responsible for your other patient’s care. You barely get to catch your breath, and then you have to admit another patient and get them all tucked in while still keeping up with your other patient.

Those make for really exhausting shifts. And they just happen a lot more these days because of the push for beds. I care a great deal about my staff, and I want to take care of them from the charge nurse role, but I also just have to push them, and that feels terrible. I’m just constantly apologizing and hoping that they can manage their time in a way that they can get a full break and have a moment to breathe. Sometimes they can, and sometimes they can’t.

G: That all sounds like so much to bear. What is the mood like among nurses in your unit?

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HS: It’s weary. And it’s not just weariness, but a sort of resigned sense that this is just how it is. People come in these days just expecting it generally to be more hard. We don’t have high expectations to be luxuriously staffed and not so pressured.

G: You’ve been dealing with this surge since early fall, and it’s only November. How are you feeling about the coming months, where we might see surges of flu and covid, too?

HS: There is concern that it certainly isn’t going to lighten up any time soon, with the weather getting colder and the holidays. I think that we’re already operating at just a really high pressure point. I say this with some fear and trembling, but I can’t imagine any more pressure. We will continue to do the best we can with what we have. What’s hard is just accepting that what we have isn’t always enough to meet the overwhelming needs. That’s just going to be where we sit and how we function for the next few months.

I don’t know how else to say it except that it’s just really hard. And to say, well, you know, we nurses and physicians and respiratory therapists all just need to hunker down and hang in there, I mean, yes, but it’s a weary crew. And it’s a really big ask of people after we’ve all gone through the pandemic.

Nurses are at the end of all this, bearing the greatest stress and seeing the consequences of all this happening to our patients. It’s like, we’re still here. I can’t go and ask people to mask anymore, quite honestly. It would be helpful, but I realize the historical moment to plead for masking is behind us. I don’t know what else to do, to raise a societal plea for more support anymore. It’s like, well, the world has moved on, and we’ll do our best.

Thanks to Lillian Barkley for copy editing this article.

  • Jonathan Lambert
    Jonathan Lambert

    Public Health Reporter

    Jonathan Lambert is a public health reporter for Grid focused on how science, policy and the environment shape our collective well-being.