International Committee November 2020 Update
Update on the Effects the COVID-19 Pandemic
Hospital da Criança e Maternidade (HCM), Sao Jose do Rio Preto
Our service has had very few pediatric cases suspected of COVID-19, and only one positive case (10 year old) with cardiovascular dysfunction, that was cared for in the main adult hospital. We have separated COVID-19 suspects and positives in specific areas (respiratory symptoms emergency area, ward FLOOR and ICU), regardless of the child’s basal illness. We have a monitoring committee for staff symptoms, in order to prevent spread of COVID-19 throughout professionals and patients, and advise staff to not come to work if they have any of the classic COVID-19 symptoms, and to get tested immediately at our hospital’s respiratory emergency area. The results are ready the next day and they will return to work only if negative. We have a special protocol on transport, care and management of these patients based on other sites/countries experiences so far that has helped us organize our logistics and staff.
We have suffered a little bit with the amount professionals testing for respiratory symptoms, but have managed to care for patients. Our pediatric congenital heart surgeries are reduced and had completely stopped for a couple of weeks due to shortage in some drugs such as sedation, neuromuscular blockade, and a few others (shortage in all of Brazil). We have not yet suffered with lack of PPE or equipment, but we are just now at the top of the curve of cases for the adult population in our region.
Professor, Head of Department
Department of Paediatrics and Child Health
University of Cape Town and Red Cross War Memorial Children’s Hospital
The direct impact of COVID-19 on children in Cape Town has been relatively mild, with people under the age of 20 making up less than 6% of cases confirmed on viral testing (as of 19thSeptember just over 6000 cases identified in the Western Cape province), and that translated into just over 624 hospital admissions and 24 deaths (most died with COVID, rather than as a consequence of COVID).
However the indirect impact on children has been substantial, with marked reduction in hospital access, immunization rates, and severe disruption of the educational system. The impact of severe economic disruption is likely to be felt for several years, and there are concerns about food insecurity for many families.
We have been faced with patients with Multisystem Inflammatory System related to COVID, and several of these children have required PICU admission for cardiac support (and other organ support).
Unfortunately, over this period we have been unable to maintain the usual rate of cardiac surgery, and probably the most direct impact of COVID-19 on the PICU has related to the number of staff members (both nursing and medical) who have acquired COVID-19 infections. The severity of infections has varied substantially, but it has impacted significantly on the number of staff available to care for children, as well as on staff morale. We seem to have passed the peak now, and are gradually working on re-escalation of clinical services (among others for cardiac patients).
National Cardiovascular Center Harapan Kita, Jakarta
Until recently, the COVID-19 pandemic did not show any sign of resolution in Indonesia as the number of new cases continued to increase each day. The effect of this problem can be felt in every aspect of life, including the provision of health services. Treatment of congenital heart disease (CHD) is among the services affected by the pandemic as both the patients and health workers are at risk of infection.
The Pediatric Intensive Care Unit (PICU) of National Cardiovascular Center Harapan Kita has enacted various standard operating procedures to prevent the transmission of COVID19 during the care of CHD patients. Among the procedures is the requirement for health workers to wear level 3-personal protective equipment when working in the unit. In addition, laboratory evaluations for COVID-19 using serological rapid test and polymerized chain reaction (PCR) are also conducted on patients that are to be admitted to the PICU.
Despite the various means to prevent the transmission of COVID-19, the risk of infection is yet to be eliminated. This is shown by the occurrence of pneumonia clinically suggestive of COVID-19 on a patient treated in the PICU despite negative PCR prior to admission. Questions arise on the need to review the screening procedure and whether immunology played a role in this phenomenon. Another problem also arises from the risk of transmission between health workers who may have contracted the virus not from the patients, but from external environments such as other health facilities and the community, considering the rapid increase of COVID-19 cases and the possible lack of screening effort in Indonesia. A surgeon working in the PICU is critically ill from COVID-19, despite no known contact with positive cases in the unit, possibly contracting the disease from other hospitals. All these difficulties, however, are not an excuse for any halt in the care of pediatric CHD cases that may also result in fatality if left untreated. Therefore, the PICU of National Cardiovascular Center Harapan Kita are committed to continue providing care of utmost quality without compromising the safety of all that are involved in its provision.
Medical Director of PICU
Leiden University Medical Center
How COVID-19 moved our PICU a few floors up, and down again.
It is March 16th 2020. The schools have closed their doors today. The whole world is increasingly grabbed by the COVID-19 pandemic. In the South of our little country, The Netherlands, adult ICUs are bursting at the seams and we are slowly watching SARS-Cov-2 march into our direction despite the lockdown. We are a 12-bed PICU in Leiden, which you may know for Factor V Leiden or the Leiden classification of coronary anatomy in TGA. Our PICU is embedded in a combined adult and pediatric academic hospital and focusses mainly on children with congenital heart disease with approximately 300 bypass cases a year and also admits general patients. We have our own comfortable and well-equipped unit, geographically very close to five adult intensive care units and have a very close and good relationship with our adult colleagues. We have an intricately combined ECMO program for instance and a large part of our nursing team rotates between adult and pediatric intensive care.
Two weeks later our adult ICU is full despite having expanded into the operating room complex. All dually trained (both pediatric and adult) intensive care nurses are working very hard in the now six adult units, leaving only few nurses in PICU. Retirees have been called back and help is coming from multiple former colleagues. Luckily, in PICU it is actually very quiet as all elective operations have been postponed and we also see far fewer children with infections or trauma due to social distancing. We are now down to four to six beds and because of the rising pressure on adult ICU beds, the decision is made to vacate our PICU and move to an alternate location to host adult COVID patients on our ward instead.
Two days later, after a team of very motivated people from all sorts of departments worked frantically to turn a pediatric day-care ward into a makeshift PICU we moved our remaining patients two floors up on April 2nd. We were warmly welcomed by our general pediatric colleagues and even the Minister of Health showed up in our now, very briefly, empty ‘old’ unit to see and appreciate how that is being turned into adult unit number seven.
It was not easy being in an unknown unit without any preparation. A general ward is not a PICU. Space was limited, especially when having to adhere to the new 1.5-meter society. The air-conditioning was not prepared for all the intensive care machinery and, most importantly, ‘stuff’ could not be found with your eyes closed anymore. Fortunately, we did not have to perform ECMO and nor did any adverse events occur while the occasional emergency patient was admitted (including a few with what is now known as MIS-C). Some of our pediatric intensivists worked in our ‘old’ unit, looking after adults with COVID-19. And then, in the beginning of May adult COVID slowly settled down. Operation rooms could be staffed again and a few elective congenital heart operations could gradually be performed again. On May 19th we packed everything and everybody up once more and moved back to our trusted unit on the fourth floor.
The unit has been busy since, catching up on postponed operations and dealing with preparations for the second wave which is on our doorstep as we speak. This time it is going to be different: schools and day-care centres are open and winter is coming which means PICU will be full with children with respiratory infections. So, a whole lot of COVID-suspicions are expected which will impact capacity. This time we are staying put; we cannot afford to limit PICU beds. All preparations are in place. We have buried down the hatches and are ready to face what’s coming….
Fortis Escorts Heart Institute, New Delhi
We faced, and continue to face innumerable challenges due to the pandemic. These include a precipitous drop in surgical volumes to 10 -12% of the usual caseload, sharply impacting departmental revenue. This was due to a harsh country-wide lockdown and an initial restriction on elective surgeries. The lockdown along with complete cessation of road, rail and air transport made it difficult for families to commute from long distances. Currently, despite the easing of the lockdown, the surgical volumes have picked up to only 30 to 40% of the usual caseload. We are also a COVID-19 hospital and even though COVID patients are admitted in separate designated wards and ICUs, most families are afraid to enter our hospital, because of the fear of contracting COVID. 80 to 85% of our admissions are emergencies like aortic arch interruption and are instances of desperate parents who have driven for 18 to 24 hours in their own vehicle unaccompanied by medical staff. The other challenge is that of having to work with a very lean and worn out workforce, a workforce being depleted daily, since nurses and junior doctors have been steadily diverted to the COVID wards. The third challenge has been that of a low staff morale, due to physical and mental exhaustion, fear after seeing their colleagues fall ill with COVID and additional challenges of having to deal with irate, stressed and frightened parents and pay cuts resulting from the economic downturn.
We are continuously learning to realign and recalibrate to deal with these challenging times with “no end in sight” and an economic depression with “no swift recovery”. We are trying to work differently, safely in a sanitized bubble, in a futuristic and dystopian manner, where there is strict restriction on families and parents visiting. Any family member who enters the pediatric area is COVID tested negative and if he or she leaves, cannot revisit without another COVID test. We are also supporting and helping each other as well as trying to work smarter and less expensively with leaner teams. During the period of April 2020 to September end (6 months), only 104 children underwent surgery as compared to our usual number of 300/6 months. More than 50% were RACHS1 3 and above including 10 arterial switches, with zero 30 day and discharge mortality, indicating the benefit of pulling together despite adversity.
The Hospital Garrahan is a Reference Center in Argentina serving patients with complex diseases from around the country. The last epidemiological report (08/30) showed that there were 328 admissions to the hospital with COVID-19 with a median age of 72 months (Ric: 15- 130). 44.1% had comorbidities and only 2 % had congenital heart disease. 5.3 % required intensive care. 62.5% of admissions were associated with acute infections and 37.5% with MIS-C. There was no mortality in our institution.
At the PCICU, we conducted a study whose objective was to describe the impact of the COVID-19 Pandemic on the cardiovascular surgery program and estimate the time to reduce the waiting list with different scenarios of increasing the supply of surgical shifts and/or temporary reduction in demand of patients. Finally, we analyzed the potential obstacles to the application of these strategies. A retrospective, descriptive study was carried out. The data of the patients operated and recovered in the unit, from March 23 to August 31, 2020 (COVID period) were analyzed and compared with the average of the same period of the last 2 years (Pre-COVID). The number of operated patients, the median age, the complexity of the procedure by RACHS-1, the days of hospitalization, the % of patients with ECMO and the immediate postoperative mortality (30 days) were compared. Results, from March 20 to August 31, 2020 (Period COVID) 80 patients were operated with congenital heart disease. This represents a reduction of 65% in relation to the average of the two previous years in the same period. The median age of the patients was 6 months (IQR 25-75 = 1.8 m to 2.9 a), with 17.5% of neonates. 14% of the patients underwent a highly complex surgery measured by a RACHS-1 score> = 4. The results of the surgery were similar in the two periods. We found no differences in the complexity of the procedures, but the median age was lower in the COVID period, consistent with the prioritization criteria applied by the institution. We found no difference in the origin of the patients, so it would seem that geographical barriers have not been insurmountable obstacles. Due to the reduction in surgical shifts in the 102 working days analyzed, 183 were not operated. The time necessary to eliminate this waiting list, assuming an increased operating capacity on September 1, varies between 10 and 19 months according to the different scenarios analyzed. In this period, priority was given to patients with indication for immediate surgery: newborns, patients with severe cyanosis, decompensated heart failure, patients with pathologies.
In Padova we stopped all elective cases from March 7 to June 3 2020. Whenever possible, we also transferred to other centers because our region was one of the most infected by COVID-19. We have been building back since June and are now working at full capacity including clinics. No children with COVID-19 were admitted. We still maintain all precautions and the separate pathways in the hospital for COVID-19 and non-infected patients. Activities are now back to normal and community infection rate is now under control. Hoping for the best.
Aga Khan University
We had a major decrease in census at the hospital after stopping elective cases and clinics for three months. Now we have restarted with proper SOPS, Pre-op Covid-pool testing is done to check every patient (COVID-19 testing laboratory center is far) .We test each individual patient 72 hours before surgery and ask them to stay in the same city till discharge .
We have a separate area to admit COVID-19 patients including pediatric and adult population from critical care facility till special and ward care in a separate portion in hospital campus.
Our infection control team is active in managing social distancing and utilization of proper PPE. The hospital has also launched a SEHAT (HEALTH) app and staff have to report on it before starting duty. It screens for all symptoms of COVID and if any are present staff cannot work at the hospital.
The reduction in pediatric cardiac ICU workload left many PICU staff surplus to need in our own units, so many of us went to Adult ICU’s (AICU) in other London hospitals. Task shifting, the delegation of specialist work to “less qualified” personnel, has become an established tool in global health emergency response and the COVID-19 version of the concept not only involved PICU nurses becoming AICU nurses but also an army of “ICU helpers” – speech therapists, community physiotherapists, dentists, dieticians and others – working as basic ICU care assistants, enabling us to take a heavier workload than any PICU nurse is accustomed to. Typically we looked after 2-3 ventilated patients each, in a 10 bed ICU now occupied by 20 COVID cases. Adaptations happened as fast as they could, but with many extra staff in already cramped conditions, changing areas were at times a social distancing contradiction that could not be fully mitigated. PPE was in good supply for us inside ICU, but this was before “community” mask wearing had become commonplace and we were probably at more risk from each other than from our patents.
We were supported and welcomed, by an amazing host ICU team – already exhausted by the “tsunami “ of cases that had hit in late March, we were around 2 weeks late, but we were not too late – as things did not lighten up until the end of May. We were also supported by out of work airline crews – (facing their own financial hardship and uncertainty) – who set up a “first class lounge” in an empty corner of the staff restaurant area providing refreshments, newspapers, calm music and listening ears. We saw firsthand the pandemic impact on the “public facing” section of the population with bus drivers, taxi drivers and other hospital staff amongst our patients. Mortality was initially high, but later spontaneous rounds of applause became more commonplace as more and more patients were discharged from ICU. The experience was intense but we were well supported both during and after, and the facilitation of such a mass secondment of staff was an impressive achievement organizationally.
Great Ormond Children’s Hospital, London
Pediatric cardiac surgical care is centralized in the UK, with 11 specialist centers taking care of around 3000 operations per year in ‘normal times’. The Royal College of Surgeons, England, issued guidance to be used in the major springtime COVID 19 epidemic in the UK, this contained explicit priorities, which were to maintain emergency surgical services; protect and preserve the surgical workforce; fulfill alternate surgical roles and lastly to fulfill alternate non-surgical roles.
The elective cases were suspended, but there continued to be referral of newborns requiring immediate cardiac care/interventions and also other children needing urgent interventions due to worsening of the clinical status and we continued to receive offers of organs for cardiac transplantation. These cases were discussed at a regular multidisciplinary triage meeting and priority was assigned according to the RCS guideline. The triage meetings were virtual consultations between the cardiology, cardiac surgical and the intensive care teams.
Just prior to the national lock down in the UK in March 2020 (lasting until July 2th 2020), we had to close all cardiac admissions for 14 days (other than salvage procedures and transplants), as one of our key personnel tested positive for the coronavirus at a time when social distancing measures were not completely implemented. In order to protect the existing workforce (and any new patients) from acquiring a new infection, Public Health England recommendations were implemented for the employees. The staff were trained in safe systems of working, including donning and doffing of personal protective equipment. Visiting guidelines were updated to restrict one caregiver per patient. All patients and parents were tested for coronavirus with PCR, within 72 hours of planned admission irrespective of the symptomatology. For children, whose procedure could not be planned in advance, the testing was still done on arrival at the hospital and patients were isolated till the results were available. If emergent surgical intervention was required, separate earmarked theatres and intensive care areas were used to provide the appropriate care. Measures were taken to prevent cross movement of treating personnel between the COVID (presumed and proven) and non-COVID patients.
Hospital for Sick Kids, Toronto
At SickKids we initially stopped all “elective” or non-urgent surgery, which resulted in about 50% decrease in volume and most outpatient activity was cancelled. We’ve been building back up since June and are now at full cath lab capacity and 90% OR capacity. Clinics are mostly back to normal but we’ve markedly increased our capacity for virtual care. We have not identified any cardiac patients who have suffered significant morbidity or mortality from the change in volumes. We’ve had next to no COVID or MIS-C in the ICU here and no MIS-C with cardiac involvement. We’re still mostly working from home when not on clinical service. Ontario and Toronto are in the midst of a second wave that’s going to be much worse than the first in terms of identified infections. We’re not sure how it will compare in terms of hospitalizations and deaths because so far, the demographic is very different (i.e. younger). That said, the government seems much less interested in acting this time around, so infections inevitably get to the most vulnerable and we’re still uncertain what the outcomes will be this time around.
Children’s Mercy Hospital, Kansas City
At Children’s Mercy Hospital in Kansas City all in person appointments were cancelled till August and only limited telehealth appointments were offered throughout the organization except at one outpatient facility where in person appointments continued at 50% of usual. Since August the hospital is working at 66% of the usual in-person workload and additional telehealth appointments. The total workload is around 70% of the usual. Only urgent procedures (cath/surgeries) were offered till end of July or mid-August and back to about 70% of usual. No urgent visits or procedures were denied.
Children’s HeartLink, USA
Children’s HeartLink is a nongovernmental organization based in Minnesota, USA. We are focused on improving access to pediatric cardiac care in low- and middle-income countries through capacity building partnerships with hospitals to become centers of excellence, and through advocacy for policy changes. We currently have 18 hospital partners and 2 government technical advisory projects in Brazil, China, India, Vietnam and Malaysia. While travel restrictions and health risks have temporarily suspended our in-person training exchanges, Children’s HeartLink is increasing remote engagement, and redesigning our training to be delivered via remote technology. Our programs team is exploring how this blended approach of in-person training and remote education will continue into the future post-pandemic, without compromising the end goal of the partnerships. We have also started a listserv with relevant information on COVID-19 and pediatric cardiac care, and engaged with International Quality Improvement Collaborative to begin webinars on the same topics relevant to low-resource environments.
Among our partner hospitals, some hospitals fight COVID-19 by treating patients directly. Others don’t have COVID-19 patients but have to cope with the challenges that arose from the pandemic. The most common concerns we hear from our partners are providing timely access to care for children and also the morale of health care workers on their team. Most hospitals were providing only emergency surgeries, and waiting lists have ballooned but many have now began resuming operations. Things were difficult in India where the lockdown was very severe and impacted even public transportation between cities. At one hospital in Coimbatore, India, families had to travel up to 250 km to reach the hospital and that placed a significant financial burden on them. For many, communication with their patients is a challenge. Our partner hospital in Kochi, India shared that when patients’ families could not come in person, the medical team resorted to talking to them on the phone. Our partner hospital in Fortaleza, Brazil said that many families do not have cell phones, and that further complicated the communication.
However, technologies also opened up educational opportunities to others, and medical teams are becoming more comfortable using these technologies, like the team in Sao Jose do Rio Preto who did daily visits in the ICU via FaceTime or Zoom. Some partners have instituted special staff accommodations and specific shifts to reduce the risks of infection, such as the two hospitals we work in Bangalore and Kolkata.
The global coronavirus pandemic and the changing economy put a lot deal out of our control but we remain committed to our mission, to improving pediatric cardiac care. No matter what is happening in the world, children with congenital heart disease are being born, and they need high-quality care.