It happened fast. Johns Hopkins Children’s Center had more pediatric patients in the fall of 2021, when kids began going back to in-person learning. “We started seeing the normal viruses again, but at much higher volumes than normal,” says Eric Biondi, M.D., associate chief medical officer for the Children’s Center and the director of the pediatric hospital medicine division. “Every day was an adventure. While the Children’s Center was often full of patients, and we were pulling in emergency staff and getting creative about finding additional beds, the previous COVID peak at the Children’s Center was only about eight to 10 patients. Over the holidays though, our COVID volumes more than doubled, from 10 to 25 in just a few days. At that point, we needed to contend with already near full capacity and a need for additional negative pressure beds that we didn’t have at the time.”
Biondi and his colleagues, Meghan Bernier, M.D., medical director of the pediatric intensive care unit (PICU), and Lisa Fratino, M.S.N., assistant director of nursing at the Children’s Center, jumped into action to dust off plans they developed back in the summer of 2021, when they were tasked with thinking about what the next COVID-19 surge would be. “At that time, pediatrics was not the population that was significantly hit,” Fratino says. “More adults were contracting COVID-19 then, and we were able to extend our help to The Johns Hopkins Hospital by caring for some of their adult patients with the illness.”
In August, the team anticipated what the upcoming fall would bring. “We knew we would likely see a rebound of patient volumes, also flu and RSV [respiratory syncytial virus], which impact people every fall and spring,” Fratino says. “What if our occupancy is up, and we do or don’t see an increase in COVID-19, in addition to flu and RSV cases? That was all built into our surge plan.” The plan they created — Code Tangerine — put into place a series of actions for how the Children’s Center would build capacity for an increase in COVID-19 cases.
“To be honest, back then, we didn’t think the plan would be necessary, to a certain extent,” Bernier says. “For the most part, we didn’t have an increased need for children requiring admission for the delta variant of COVID-19. The plan sat in our COVID-19 fall surge 2021 folder until mid-December and the arrival of the omicron variant.”
As the holidays approached, the plan became pivotal regarding how the Children’s Center responded to what would be the most challenging COVID-19 wave for pediatrics since the start of the pandemic. “I think this surge caught everyone somewhat off guard with its rapidity and timing around end of the year holidays,” Bernier says. “Staffing was slated to go to holiday coverage, with people taking time off while retaining enough staff and providers to safely care for our patients. And then we saw this sharp uptick, first, on the adult side in the emergency department, with more patients needing to be admitted.” The increase in pediatric COVID-19 cases soon followed.
The team, working closely with Dawn Luzetsky, D.N.P., senior director of pediatric nursing, and Stacey Mann, M.B.A., assistant administrator of the Children’s Center, began putting its plan in place and troubleshooting challenges.
In late December, units needed to be converted to biomode — patient rooms in some areas were switched to negative air pressure to care for patients with COVID-19. The group worked with providers, nursing shift coordinators, other staff members, and many departments including infection prevention, facilities, nutrition services and pharmacy, to bring Code Tangerine to life. Long hours were spent preparing. New walls and doors were built overnight. And workflows were changed.
On Dec. 31, as the world was readying to ring in the new year, nine beds in the infant and toddler unit — 9 South in the Charlotte R. Bloomberg Children’s Center Building — were flipped to biomode. Those patient rooms quickly filled, and with the anticipation of more serious cases of COVID-19, the decision was made to create an additional seven-bed biomode space in the PICU, which took 24 hours to convert. Soon after, on Jan. 10, an ambulatory biomode space was created in the nine-bed pediatric clinical research unit for outpatients with COVID-19 needing specialty care such as transfusions or oncology treatments.
At the surge’s peak, the Children’s Center had 25 pediatric inpatients with COVID-19 more than twice the number during the previous peak of 10 patients in the fall. “We originally had about 15 negative pressure beds in the Children’s Center,” Biondi says. “Adding these biodomes — units with negative air pressure rooms — has increased our capacity to 28. If hospitalizations were to start trending up, we would flip the next unit. It’s a game of Tetris.”
Nursing shift coordinators have been the triad’s right-hand team to help make important patient placement decisions. “They are working on the front lines on a daily basis and regularly providing the upfront detail to us so that we can make the right changes,” Fratino says.
“That’s the hardest part to balance,” Biondi says. “I don’t want people to feel like they are getting whiplash. We are listening to those working the front lines and doing everything we can to accommodate their feedback. Dr. Bernier and I also work clinically, so that gives us firsthand experience with the changes.”
Fortunately, rather than continuing to worsen, the COVID-19 surge plateaued and began to recede. The number of pediatric patients with serious cases of COVID-19 has lowered, and the PICU biomode beds were deactivated and returned to their normal status on Jan. 18. The deactivation of the remaining biomode spaces followed, with the last deactivation taking place in February.
But, as this COVID-19 wave recedes, the next concern may be multisystem inflammatory syndrome in children (MIS-C), a serious and often life threatening condition in which organs become inflamed, including the heart, lungs, kidneys and brain. MIS-C typically appears weeks to months after a COVID-19 infection. “Emerging literature shows vaccines are helpful in preventing MIS-C, so we are preparing, but we are hopeful that the immunizations will protect many children from getting this illness,” Bernier says.
The triad understands that its work won’t end any time soon. “We’ll put the surge plan away sooner or later, but we will continue looking at any challenge that tests our capacity,” Fratino says.
The triad is confident that it has great teams on its side that are ready to address any concerns, so that providers and staff members at the Children’s Center can offer the best care possible for their young patients.