Innovating Virus Care for Pediatric Patients

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Tom Haederle
Hospitals across the country have found innovative ways to increase their capacity, improve care and take care of health care workers while treating COVID 19 patients throughout this pandemic.

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Tom Haederle
Welcome to Advancing Health. A podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this episode, Jerrod Milton, Chief Clinical Officer and Senior Vice President of Professional Services at Children's Hospital, Colorado, joins Kathy Cummings, former communications lead for AHA’s Center for Health Innovation, to talk about COVID 19's impact on pediatric health care, and share lessons on managing the confluence of this unprecedented virus with RSV and the flu.

00;00;57;07 - 00;01;21;14
Kathy Cummings
Welcome Jerrod to AHA's Advancing Health Podcast. I'm really excited to have this time with you to talk about managing the triple threat that we've been experiencing lately of COVID 19, RSV and the flu. And we've got a lot to unpack here, but why don't we start out by talking about you? Tell us about yourself and your role at Children's Hospital, Colorado.

00;01;22;08 - 00;01;56;13
Jerrod Milton
Thank you, Kathy. Well, I am a formally trained pediatric pharmacy practitioner and I've practice at Children's Hospital, Colorado, for 32 years. I have the privilege of leading a diverse operating division of clinical and support services that are composed of pharmacy, pathology and laboratory medicine, precision diagnostics, diagnostic imaging, food and nutrition services, security, public safety and emergency management. I am a senior member of the hospital's executive team, and I'm really humbled to be invited to speak with you today.

00;01;57;02 - 00;02;18;05
Kathy Cummings
Well, that's terrific. I'm sure you've got a very busy schedule after hearing about all of those roles and responsibilities. So, again, this you know, we've seen the flu and RSV arrive earlier and hit harder this past year than ever before. Can you explain the impact this has had on your hospital?

00;02;18;26 - 00;02;49;24
Jerrod Milton
Well, sure, I'll try. I guess I'd like to break it down, just simply I kind of see hospital capacity is basically a function of three fundamental components, and that includes available physical space license to provide patient care, available medical supplies and equipment, as well as skilled clinical talent necessary to deliver the care. And this respiratory surge that we experienced during the fourth quarter of 2022 most definitely challenge pediatric providers across Colorado.

00;02;50;27 - 00;03;18;16
Jerrod Milton
The high demand created by children presenting to their primary care providers with serious respiratory illness warranting referral to a higher level of care was unprecedented and truly overwhelming. And beginning in September, our pediatric emergency departments quickly became overcome with a high number of young children presenting with respiratory distress, not to mention most often the two worried members of their family who accompanied them.

00;03;19;08 - 00;03;33;18
Jerrod Milton
And as the disease spread through our community in the following weeks, an escalating number of these children would meet the criteria for hospital admission, and many required intensive inpatient care and mechanical ventilation to support recovery from their illness.

00;03;34;12 - 00;03;52;23
Kathy Cummings
Yeah, you know, we've been hearing that COVID 19 has kind of fueled the devastation that we've seen with the flu and RSV among kids this year. We heard a lot about this immunity gap. Can you tell us a little bit more about that?

00;03;53;12 - 00;04;23;01
Jerrod Milton
Well, I think it wasn't necessarily a surprise. We were kind of anticipating this would be coming eventually. But due to the waning immunity, I mean, the exposure because people were isolating through the pandemic and the exposure that kids would of perhaps otherwise experience to give them some call it herd immunity waned. And so not terribly surprising, but I think that is the scientific sort of version of what caused this.

00;04;23;02 - 00;04;29;15
Jerrod Milton
And now that we've had so many kids exposed, hopefully we won't see this again ever.

00;04;30;07 - 00;04;45;08
Kathy Cummings
Right. So we see this confluence of COVID 19, RSV and the flu. And how has that impacted your hospital from an operational point of view? How are you overcoming those challenges?

00;04;45;22 - 00;05;27;28
Jerrod Milton
Well, I think we're well into 2023, and we have this in the rearview mirror, thankfully, But it definitely impacted us kind of on those three planes that I mentioned earlier. So staffing, supplies and bed capacity. And so, you know, preserving and obtaining medical supplies and some medication that we needed to treat these kids was a definite challenge. Supporting the resilience of so many team members, especially those who were at the bedside, who were facing burnout, became a much higher priority and responded to the surge of demand caused us to employ contingency measures that we developed early in the COVID 19 pandemic.

00;05;28;21 - 00;05;49;18
Jerrod Milton
And not to say that they were austere and we were using alternate sites of care, but internally we began to convert existing clinical care spaces so that we could provide inpatient level care to those in need. And we did that in spaces where we don't typically provide inpatient level care. So would you like me to talk about some of those details?

00;05;49;26 - 00;05;50;20
Kathy Cummings
Yes, please.

00;05;51;10 - 00;06;34;24
Jerrod Milton
Okay. At our largest hospital, we have four hospitals in our pediatric system of care. Our Anschutz Medical Campus. We creatively used initially our PACU space that was associated with our procedure center, where we do minor procedures, typically ambulatory procedures, and then discharge kiddos. We use that space, the PACU space after hours when the emergency department was busiest. So really think of it as late into the evening or overnight when kids were presenting to the ED for care in the middle of the night into the early morning hours and we were able to provide more observation level care for those those patients who were waiting for inpatient beds to open up, through this surge the many weeks that it endured.

00;06;34;24 - 00;07;05;02
Jerrod Milton
We made the decision to postpone many non-urgent surgical cases that we had previously scheduled, and that included those surgical procedures that required short in-patient bed placement postoperatively so that we could free up those inpatient beds for kids who needed bronchiolitis care. We set up temporary respiratory care units, inpatient units in our procedure center because we postponed those non-urgent procedures. And across our system of care, we did some other reorganization.

00;07;05;03 - 00;07;30;11
Jerrod Milton
We temporarily reorganized many operational clinical sub units that allowed us to create space for both inpatient care beds and ED and observation care spaces. We maximize the use of already licensed beds. And this was a really important tactic that we employ that allowed us to expand our pediatric intensive care unit capacity by roughly 50%.

00;07;30;23 - 00;07;57;14
Jerrod Milton
I mentioned that a number of those kids needed mechanical ventilation and more intensive care, and so that was really pivotal to our ability to get these kids out of the EDs and into the proper bed space. And then obviously, for us to be able to creatively use these dead spaces, we had to quickly apply for and obtain waivers from our state health departments to enable us to do that and be compliant with regulation.

00;07;58;01 - 00;08;25;10
Kathy Cummings
Terrific. So it sounds like you've been making room for high quality care for the kids who are at greatest risk. And that seems to me that that would have a positive impact on the health care teams, you know, maybe taking some of that strain or lifting some of the strain and stress of dealing with the challenges here. Is that true?

00;08;26;11 - 00;09;08;10
Jerrod Milton
Well, you know, I think we always we've existed to serve our community for more than 100 years. And so, as we continue to grow and evolve and expand our capabilities to serve our mission, we have made very careful and strategic decisions to maintain our capacity. This one really was quite overwhelming. And I think when you look at the challenges that I think all of us have been facing with respect to labor and the labor market, this came at a very difficult time, really, truly on the heels of an Enterovirus D68 outbreak that drove kids to the hospital through the summer.

00;09;08;17 - 00;09;36;20
Jerrod Milton
And really on the heels of that came this RSV surge. So we had to pay very close attention to our capacity constraints and make some difficult but very important decisions related to resourcing staff to provide care. I think our team members, many of them are so committed to the mission and they love what they do. At the same time, we're all human and we need time away from work to be resilient.

00;09;36;20 - 00;09;49;29
Jerrod Milton
And so we had to be very mindful of those things and do what we could to bring in additional resources to help relieve some of the pressure so that we could provide safe and certainly high quality care.

00;09;50;23 - 00;10;03;10
Kathy Cummings
So you're adjusting operationally, you're taking care of the caregivers, your staff. What does that meant to the patient family experience there?

00;10;04;04 - 00;10;39;20
Jerrod Milton
That's a great question. We definitely take that very, very seriously. We know that these sort of changes are disruptive. We know that patients and their families travel oftentimes from far distances to come to receive the care that they have planned to get with us. And so, you know, I mentioned the postponement of those non-urgent surgical procedures. We had to be very thoughtful about how we message that and how we accommodated and recovered from that and worked with our teams that actually lead that front.

00;10;39;20 - 00;11;04;23
Jerrod Milton
We have a dedicated patient, family and experience team that really focused on the impact that this would have on our patients and families. There were measures that we took just recognizing how uncomfortable it is for parents to sit in a crowded emergency department for oftentimes many, many hours waiting to be seen based on the level of acuity that their child had presented with.

00;11;04;23 - 00;11;29;18
Jerrod Milton
And so comfort rounding was something that we employed. We had volunteers and other team members who would basically regularly round through our emergency departments and offer measures that we put together. Think of them as comfort measures that could be food. It could be things that would distract kids, toys, coloring books, things like that to help ease that difficult situation.

00;11;30;26 - 00;12;03;12
Jerrod Milton
We also use technology to communicate, and so we know that helping people understand the rationale, the why behind what's going on, some difficult changes oftentimes is just all they need to do to cope with it and and manage through it. And so communication is absolutely critical. How we communicate with them, how it's perceived not to sound manipulative, but it's how do we manage the expectation that they have for the care that they're receiving or need to receive.

00;12;04;06 - 00;12;18;02
Kathy Cummings
Boy, I really like that. You know, I mean, it's in the midst of this logistical nightmare. You're still focusing on patients as people and not just illnesses. And that says a lot.

00;12;18;23 - 00;12;19;08
Jerrod Milton
Thank you.

00;12;20;13 - 00;12;47;29
Kathy Cummings
So recently we just heard that the Biden administration announced the end on May 11 to the declaration of COVID 19 as a national and public health emergency. That's a testament to the progress that hospitals and health systems like yours have made in this fight against COVID 19 and and these other viruses, too, that that kind of had disrupted what was already this incredible time of uncertainty and disruption.

00;12;48;18 - 00;12;51;11
Kathy Cummings
What are your thoughts on that declaration?

00;12;52;03 - 00;13;11;25
Jerrod Milton
I'm not terribly surprised. I think, you know, many of us are anticipating that this will be sort of veering off into the distance, a distant memory, if you will, and that I think many of us want to put behind. But it's definitely changed the way we do business. And I think some of those things will still need to persist.

00;13;12;03 - 00;13;40;08
Jerrod Milton
The vigilance that we need to have measuring and monitoring for outbreaks. This is still, I think, a very serious virus that can make many people very sick. And so we don't know what the future will hold with respect to new variants and what that will mean. But I'm happy to see that we've hit that point. I think it's a turning point now ... after I'm kind of losing track like three years of dealing with this almost.

00;13;40;20 - 00;13;53;13
Jerrod Milton
It's time. And I think we have the technology with the advent of these novel and highly effective and safe vaccines to respond if we see a resurgence with a different variant.

00;13;53;25 - 00;14;20;28
Kathy Cummings
Yeah, mean, it's interesting, you know, like you said, we may talk about the end of this pandemic, you know, nearing, but there have been so many uncertainties leading up to this point, and we could continue to see these uncertainties down the road trying to figure out how to navigate that, the unexpected. What is your message then, to your staff?

00;14;21;20 - 00;14;53;22
Jerrod Milton
I think what we'll definitely want to reinforce the positive sides of the this message that we've made it through it, and we have to continue to maintain our vigilance. It's time to recover. I think that is a very critical component of all disasters. I mean, it's a fundamental element of the emergency management response is recovery. And that is, you know, returning to some, if not former baseline, a new baseline and moving forward.

00;14;53;22 - 00;15;24;20
Jerrod Milton
And so we're certainly grateful for the dedication, the commitment that our team members make. They choose Children's Hospital, Colorado as their employer of choice and we value that. And so there will be things that I think many people will want to see go away. And I'll speak about some of those changes that have come through the pandemic. We have a very rigorous daily health screening that we have used and we have not let up on, because we really need our team members to, when they come to work, to be well.

00;15;25;02 - 00;15;49;26
Jerrod Milton
And if they're not well, to stay home and get well. And so it's an extra step in everyone's day. I think at some point we will probably phase that out. But, you know, kiddos are very sensitive to illness through our winter respiratory season, RSV influenza and all of the other viruses that tend to impact children's health through the winter.

00;15;50;06 - 00;16;17;28
Jerrod Milton
And we need team members to be healthy. And so we want these that are probably until we feel it's safe to do that and we're also still doing very rigorous visitor management. So we know that's not required, but we have chosen to do that. So we, we screen all visitors coming in. Anybody who is in a public area or in a patient care area encountering patients or the public is expected to wear a mask.

00;16;18;13 - 00;16;31;09
Jerrod Milton
And so we'll have to manage those expectations again. What's the why behind it? I don't think people will be terribly surprised, but we're all sort of ready to take the masks off and go back to what normal was pre-pandemic.

00;16;32;02 - 00;16;54;29
Kathy Cummings
You know, it's great you know, you talk about looking back and learning from everything that has happened during this pandemic, how it's changed health care, how it's changed how we care for patients in some of these new programs that have come to fruition because of it. Is there kind of the proudest moment in all of this that you can share?

00;16;56;02 - 00;17;25;14
Jerrod Milton
There are several very proud moments, I think. The work that we did on, gosh, several things leading up to our ability to independently perform SARS-CoV-2 testing in our clinical laboratory. We've rolled that out on March 16th of 2020. It was very early. I think we were one of the first clinical laboratories in the country, certainly one of the first children's hospitals in the country to advance that technology.

00;17;25;14 - 00;17;57;29
Jerrod Milton
And really we leverage that to serve our regional needs because the state health department, CDC were overrun. And so we offered that very early on. We also were one of the very first blood banks to actually basically manufacture convalescent plasma. And we really stepped out of the niche that we serve pediatric patients and lent the hand to our adult partners who we knew were struggling all over the nation and certainly in our region, wherever we could.

00;17;58;18 - 00;18;31;18
Jerrod Milton
And to that end, we also did the same thing when it came to vaccines. As you can imagine, you know that the vaccines were not initially indicated for children under the age of 18 generally. And so it was mostly adults who needed to get vaccinated. And so we stepped up and after we vaccinated our own team members and the pediatrician community, we extended our resources to help all of the educators in our reach, other EMS providers, daycare providers.

00;18;31;18 - 00;18;57;07
Jerrod Milton
So we were really trying to help our community get through this pandemic. And there are many, many proud moments. But I think the fact that we were able to maintain our our continuity of care, to take care of kids, I'm thankful that this did not impact children as it would have been just horribly, horribly disruptive to try to manage that alongside everything else that the world was dealing with.

00;18;57;07 - 00;19;04;26
Jerrod Milton
And so that was maybe a bit of a silver lining for us, but I'm glad to see it in the rearview mirror. Let's just say that.

00;19;05;03 - 00;19;34;22
Kathy Cummings
Yeah, we all are. You know, you you mentioned the importance of hospitals being good communicators, and I know you guys have a fantastic podcast charting pediatrics and what a great way that is to share accurate and timely information with the people of your community. Can you tell me about that podcast and how you've leveraged it during this pandemic to reach people across the communities you serve?

00;19;35;14 - 00;20;01;24
Jerrod Milton
Oh, absolutely. This is definitely a proud moment, something that we actually put up on a pedestal in terms of a product that we've advanced through the pandemic. You know, we I mentioned our pediatric partners. And so being a pediatric freestanding children's hospital, we often work with referring pediatricians. We support them with educational programing and try to help them however we can.

00;20;02;22 - 00;20;26;16
Jerrod Milton
It's part of our universe. And so the the podcast that was developed really got legs quickly because the pediatricians and folks in the community all over the world, not just in our Colorado region, were really looking for expert guidance and kind of an outlet to stay in touch with what was happening, what was advancing, what were we doing, what were we recommending?

00;20;26;29 - 00;20;55;12
Jerrod Milton
And I think it really took root and we've continued that. It's a great way. It's a great medium to advance that sort of information to those type of stakeholders. And so really very proud of that work as well. I certainly don't take any credit for that. Our chief medical officer, Dr. David Brumbaugh, and his colleagues that support those initiatives have done an amazing job.

00;20;55;23 - 00;21;01;03
Jerrod Milton
It's very timely content. It's accurate, it's targeted, and it's useful.

00;21;02;03 - 00;21;26;28
Kathy Cummings
Jared, thank you so much for sharing this time with us and all the great work that you and your teams have been doing during this pandemic and its aftermath. And it just gives us so much hope when we think about the advances, big and small, that hospitals and health systems have been making during these very tough times and what the future of health care looks like.

00;21;27;18 - 00;21;30;08
Kathy Cummings
Very, very promising. Any final thoughts?

00;21;31;05 - 00;21;54;13
Jerrod Milton
I think we've all learned a lot through this hopefully once in a lifetime, maybe never again, experience. And I think there's a lot to look forward to. How we approach sensitivity to operations, I think is one of the underpinnings of highly reliable organizations. And in those organizations, leaders pay attention to early warning signs and remain vigilant.

00;21;54;13 - 00;22;22;12
Jerrod Milton
I think we've learned that deftly through this experience. I think we need to continue to use data with more rigor and regularity, and those data points often inform important decisions. And so when the next disruptive or disastrous thing occurs, it's okay to say no and to really organize and make our response to that disaster a top priority for the organization.

00;22;22;21 - 00;22;28;04
Jerrod Milton
And that's what doing the right thing for our mission is all about. So thank you again for this opportunity.

00;22;28;28 - 00;22;41;07
Kathy Cummings
Thank you. Terrific final thoughts. For more information on COVID 19 and the triple threat, please visit aha.org/vaccineconfidence.

00;22;42;00 - 00;23;10;01
Tom Haederle
This podcast was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention. The contents of this resource do not necessarily represent the policy of CDC or HHS and should not be considered an endorsement by the federal government.