On January 20 of this year, Tufts Medical Center it would be closing all inpatient pediatric care as of July 1. The current pediatric areas would be given over to adult services. The plan was to maintain the level 3 neonatal intensive care unit (NICU) to support obstetrics as well as the subspecialties (medical and surgical) that the NICU would require. Without a general inpatient unit or pediatric intensive care unit (PICU) to support training, our pediatric residency was pulled from the Match. Inpatient care would be transferred to Boston Children's Hospital and the current trainees would finish up there. At this time, the inpatient service was at or near full service capacity and had been for months. Like many pediatric units, "full" referred to our staffing capacity and not our certified bed capacity. As a result, although our rooms were full, we still did not show full occupancy because our single-patient rooms were originally double rooms.
After the initial disbelief that the institution -- over a century old, where , and where child life services and family presence in the hospital were championed -- would close, the reality of what that meant for patients and staff set in. Many of our families chose Tufts over other providers in the city for our style of care or insurance reasons. They were scared and confused, and did not understand how the medical center could choose to treat more adults over their children. For staff, it was equally traumatizing. Many had been at Tufts for their entire career. Others specifically chose Tufts over other workplaces for the same style reasons patients did. For them, in part due to style differences, the jobs offered with Boston Children's Hospital were substantially different from Tufts. As a result, most of the specialists left. Their departures started well before the closing date, so those who remained struggled to maintain the same standard of care. The loss of specialists reverberated around our larger network of care, which also depended on those specialists to support community hospitals and outpatient services. Additionally, the network had relied on having its own tertiary care referral center, rather than being part of a larger system. Many of the faculty and staff felt angry and disillusioned with what they viewed as a conscious choice to value other patients more than our kids. Business decisions seemed to lack heart.
Fast forward several months: We now have a crisis in pediatric care of too many sick children needing hospitalization and ICU level of care and not enough beds. For the last several weeks there have regularly been across New England, leaving children needing ICU level of care in community hospital beds or emergency departments, cared for by pediatric hospitalists or emergency medicine providers and staff who are not used to providing that level of care. Other parts of the country are seeing similar trends.
How can this be happening?
The surge is being viral infections. Respiratory syncytial virus (RSV) came early again this year (similarly to 2021), along with other more typical winter viruses. Having kids together again, unmasked, has promoted the spread. It may be that two winters of children masked and relatively isolated has made them more susceptible to more severe illness. Prior to COVID, the typical 1-year-old would have six to nine febrile illnesses over the course of the year, almost all virally mediated, as their maternal protection waned and they became more active explorers. These frequent minor infections helped prime the immune system, and that lack of exposure may be contributing to the current surge.
Whatever the cause of increased illness, there is certainly decreased capacity to hospitalize children across the country. There has been a steady loss of pediatric inpatient beds , and this decline accelerated during the pandemic as smaller units switched to adult units and larger units gave up beds to serve adults. Few of those beds have returned to pediatric use. This decrease in total number of beds has exceeded the relatively small decrease in over that same time. Some of the smaller units have closed due to lack of volume. However, the overwhelming majority of closures were due to money. Pediatric inpatient care is , both to the facility and provider, especially for the routine cases such as bronchiolitis and asthma that typically don't require ICU level of care. For hospitals operating on a thin margin, it makes no economic sense to sustain a small pediatric unit if those beds can be filled with adults. Even larger units, operating in the shadow of large children's hospitals, are making that decision. This was the case at Tufts.
The actual number of PICU beds across the country over the last decade or so. Meanwhile, the need for those beds has kept pace due to the increasing acuity of pediatric inpatients and the needs of medically complex children who are surviving longer. Additionally, the PICU beds are concentrated in tertiary and quaternary care centers and free-standing children's hospitals. The latter don't have the ability to quickly expand because they are already operating at capacity and there is no space utilized by other services to temporarily redirect. Furthermore, those centers with PICU beds are experiencing throughput problems because they now care for children who are transferred from places no longer providing inpatient care. Further crowding the pediatric hospitals are patients with mental health issues for which there are severely limited inpatient psychiatric options and equally limited outpatient treatment capacity. Therefore, a child in the PICU may no longer require ICU care, but there is no general inpatient bed to move them to, so the PICU remains full and can't accept new patients.
It is a national shame that we are not able to care for our children. There is no quick fix, and I fear that these challenging conditions will continue through the winter. We need to adopt some of the lessons from COVID.
We need to create regional centers that can monitor capacity and direct patient flow between institutions, overcoming institutional silos. It is hard enough to manage a critically ill child in a community hospital setting without the burden of having to call every hospital in the region individually to ask about accepting a transfer. We need to improve the ability of smaller centers to provide critical care by improving equipment and training, and then we need to be able to provide medical consultation to the bedside. Barriers to providing telemedicine, such as institutional credentialing and cross-state licensing, need to be removed. These barriers were targeted in the height of COVID, but many of the exceptions have since expired. We need to make sure our colleagues trained in adult care can help. There should not be an arbitrary age barrier to providing necessary care to adult-sized patients. There were no qualms about asking pediatricians to help with 30-, 40-, or 50-year-old patients during COVID, and most pediatricians did so proudly. In the near future, we need the ability to treat mental health issues out of acute care hospitals. In the long term, we need to ensure pediatric care is financially viable. Few states have Medicaid rates for pediatric care comparable to Medicare or Medicaid rates for adults. We need to value care for children as highly as we do for adults. Study after study has shown that not only produces healthier children but also has a long-term positive return on investment.
The current state is both a perfect storm of events and one that has been a long time coming. We need to turn this around and do better for our children.
is chief of pediatric hospital medicine for Tufts Medicine and chair of the American Academy of Pediatrics Committee on Hospital Care. The author's opinions are his own and do not necessarily reflect those of any institution with which he is affiliated.