The strain on pediatric hospitals from a triple epidemic of RSV, COVID and the flu continues unabated

With the triple threat of RSV, influenza, and COVID having materialized much earlier than previously predicted (usually arriving in December or January after the holidays), instead of spending Thanksgiving weekend at home with extended families many children will be huddled with their parents in emergency rooms across the United States seeking medical attention for their respiratory ailments.

The triple threat of infections is devastating a health care system that is already in free fall, as described by a letter sent to the White House by organizations of doctors, nurses and health care providers earlier this month, urging the president to address the crisis faced by emergency departments (EDs). Wait times for admissions or transfers are extending far beyond the four-hour limits recommended by health authorities, risking the lives of the patients both in the EDs and hospital wards.

Most of the Atlantic seaboard, Southeast, Midwest, and Southwest states are registering high levels of influenza-like illnesses (ILI). The Centers for Disease Control and Prevention (CDC) has reported that influenza activity in the US is higher than it has been in more than a decade, exceeding their epidemic thresholds. As of November 18, more than 4.4 million flu cases had been registered. There have been 38,000 hospitalizations and over 2,100 deaths across the country.

A critical care nurse administers an anti-viral medication to a COVID-19 positive patient at Kootenai Health regional medical center in Coeur d'Alene, Idaho, on Sept. 6, 2021. [AP Photo/Michael H. Lehman/DVIDS U.S. Navy/via AP]

With approximately an average of 8 people per 100,000 population being placed in hospitals, children under the age of five are only behind adults 65 and older at 13.6 per 100,000, nearly twice the national average. Many in the corporate press had claimed these were a byproduct of a so-called “immunity-debt” that left many children vulnerable because they had gone two years with essentially no exposure to these respiratory pathogens. 

Such pseudo-scientific explanations facilitate the current back-to-school policies heavily promoted by the Democratic Party. The claim is that such infections have clinical benefits to children, meaning that the limited measures against COVID that saved millions of lives were somehow harmful to children. In actuality, COVID has killed far more children than flu and RSV, despite very limited mitigation measures.

Immunology professor at the University of Surrey Deborah Dunn-Walters told the Financial Times, “Immunity debt as an individual concept is not recognized in immunology. The immune system is not viewed as a muscle that has to be used all the time to be kept in shape and, if anything, the opposite is the case.”

Indeed! Pediatric hospitals have been strained for several weeks from an onrush of young infants infected by RSV and other respiratory illnesses. For newborns in particular, RSV is quite dangerous, due to their narrower upper respiratory tracts and fragile condition. In fact, RSV-related hospitalization rates for babies under six months has reached 145 per 100,000 and those six to 12 months of age at 63 per 100,000.

Travelling nurse Dana Free, who was working in a pediatric intensive-care unit in Danville, Pennsylvania, explained to the Wall Street Journal, “If you think of it [the small airways] as a straw, and that’s your normal breathing, that’s fine. You coat it in congestion, essentially snot and mucus, you’re making that airway much smaller.” 

What Free is describing is tantamount to suffocating. A sign of serious illness is a wheezing cough that sounds like a barking seal. The squeaking noise when babies inhale is called stridor. These are accompanied by retractions in their chest walls as they gasp for air. Lack of oxygenation will turn their fingers, toes, and lips blue, critical signs of impending respiratory collapse.

Hospital occupancy rates have continued their steady climb since early August and have reached a rate of 76 percent capacity for pediatric inpatient beds across the US. The Department of Health and Human Services reported that 80 percent of all pediatric intensive-care beds are full. In states like Massachusetts, Pennsylvania, and Texas, the occupancy rate for pediatric ICUs is over 90 percent.

Demand for hospital beds is also being compounded by higher rates of mental health and suicidal ideations/attempts among children of all age ranges. As one emergency room physician, speaking on condition of anonymity, told the American College of Emergency Physicians, “We are a 28-bed pediatric ED, with a catchment area of 2.8 million children. I came into shift yesterday morning. We had 15 children on psych holds, many of them waiting in the lobby for 24 to 72 hours stays so we could use our beds to see medical patients. One of those patients had been in the ED for more than 150 hours.” 

He added, “We had ten admission boarding, seven on high-flow oxygen, four of which were Peds ICU level. There are no open Peds ICU beds in our four closest counties, including our own. We had 35 patients in the waiting room in addition to the 20 medical patients being managed by the ED. We had seven transfers pending from outside facilities to the ED, plus more awaiting direct admission from an outside ED to an inpatient bed whenever a bed became available. One that left another hospital’s ED against medical advice and came to our ED had been waiting three days for transfer. They had an arterio-venous malformation [a vascular condition] that needed urgent surgery.”

Two hospitals in Oregon, Doernbecher Children’s Hospital & Science University and Randall Children’s Hospital at Legacy Emanuel, which provide the vast majority of intensive care treatment for children for their region, have been forced to implement crisis standards of care that allow hospitals to decide which patients will get treatments without facing legal repercussions.

Moreover, the implementation of crisis standards of care also allows hospital administrations to loosen patient to staff ratios, meaning nurses would be obligated to assume care for more patients despite the risks in terms of patient safety and well-being. The burnout of health care workers has reached epidemic proportions. The well-being and mental health of these professionals have been eroded by overwork in a setting where risk of exposure to infectious disease and violence remains high. 

The US Bureau of Labor Statistics has projected that the US will need more than 203,000 new registered nurses annually to 2026 to close the gap created by just the retiring workforce. However, nursing schools turned away over 90,000 qualified applicants last year due to lack of faculty to train them and rooms in nursing school to chair them. Meanwhile, up to 40 percent of nurses in practice are strongly considering leaving.

Michelle Collins, dean of the College of Nursing and Health at Loyola University in New Orleans, told reporter Mariel Padilla, “The pandemic exacerbated a situation that was already becoming dire. So many nurses left the profession during the pandemic because of burnout. We have a huge number heading towards retirement and a shortage of nursing faculty to teach new nurses, making for a perfect storm.” 

She also noted, “There’s a huge spike in the number of nurses who are leaving their career in the first three months of being a nurse. And not like going to another job—they’re leaving nursing, which is astounding to me. That’s horrible.”

Nurses aren’t leaving the bedside because they are disinterested in their professions. Rather, the conditions under which they are forced to work, their unmet concerns over patient safety, the monetization of health care, are deeply troubling, creating hardships and chronic distress for them and their profession. Worse, they are being scapegoated for the errors and safety violations that are inherent to the dangerous conditions created by demands by hospital systems to operate under the principle of doing more with less.

The crisis in health care will continue to grow more appalling as economic realities—labor costs, supply chain issues, and inflation—continue to erode the capacity of health systems to deliver care to their patient populations. A recent report in Fierce Healthcare noted that upwards of 60 percent of hospitals across the country will end 2022 “with their operations in the red versus the 34 percent reported in 2019.” The projections were made by Kaufman Hall on behalf of the American Hospital Associations. 

Senior Vice President at Kaufman Hall Lisa Goldstein said at a press conference last week that financial margins in 2022 will remain depressed while expenses remain above pre-pandemic levels. “Hospitals will lose billions,” she said.

John J. Lynch, president and CEO of Main Line Health in Philadelphia’s suburbs, warned, “The numbers are all going in the wrong direction, and I’m concerned we’re going to see more healthcare providers close as a result of the current financial reality, which will impact access to care.”

He noted somberly, “In my 35 years as a healthcare leader, this is the most fragile I’ve ever seen the American healthcare system.”