This will be the shortest of a two-part series on the 2022-2023 respiratory virus season so far, which has been brutal for the nation’s infants and toddlers. I’m going to focus mainly on RSV, the infamous (at least among pediatricians and family physicians) initials for respiratory syncytial virus, because it has been causing the most problems. In this post, I will discuss the current situation in hospitals across the country and give a personal perspective. Next time, I’ll go into more detail about RSV and the potential of a new vaccine that shows promise in reducing the risk of severe disease in the most vulnerable population.
The 2022-2023 season got off to an unusually early start for pediatric service providers in the United States, with reports in July of unusual RSV activity that serves as a harbinger of a particularly bad fall and winter ahead. I also saw this in my patient population, and our summer in the Boston area was definitely a bit busier in inpatient service than expected. As fall approached, admissions for lower respiratory tract infections continued to rise, and we saw a strange but not entirely unexpected increase in rhinoviruses and other respiratory enteroviruses that caused wheezing and asthma flare-ups requiring hospital care.
i wrote about a specific enterovirus that is linked to cases of polio-like illness in young children in mid-September. At the time, we were very busy and had easily surpassed the total number of similar admissions in all of 2020 and 2021 combined. Still, it was manageable. But in the month leading up to the midterm elections, which have understandably now taken center stage, news of hospitals overrun by pediatric patients infected with viral lower respiratory tract infections, particularly RSV, began to circulate in the media. .
In early October, NBC reported in five states (California, Illinois, Massachusetts, North Carolina, Rhode Island) with significant capacity issues. On October 21, Axios reported that the increase had passed the peak of 2021 and presented the situation in Connecticut and Colorado. on October 24 Article NPR focused on Texas, Washington, DC, Maryland, and Washington, all of which were grappling with having more children requiring hospital or ICU care than there were pediatric beds available. It was clear, and it still is, that this is not an isolated problem.
I’ve been a pediatrician since 2003 and have generally been on top of medical issues since I started medical school in 1999, and personally have never experienced a month like the one we’re having. Before the pandemic-related hiatus in the last two seasons, RSV had always kept us busy. After all, it is the most common reason babies are admitted to a hospital each year. But I have never seen admissions come in at this rate, which has far exceeded any previous busy winter.
So what happens when a child is in the emergency department and needs to be admitted to an inpatient unit, but there are no beds available in that facility? Well, they can be transported from the emergency department to a pediatric inpatient bed at a different facility. Easy, right? Not so fast.
What if there are no pediatric inpatient beds available at a nearby facility? It’s not a big deal, you can just transport them to a facility that’s not that close, and in some cases these kids are moved hundreds of miles away from where they entered the system. And if no beds are found, the child has to stay in the emergency room, sometimes for days, waiting for a bed to open up. None of this is ideal. It increases expenses and, more importantly, the possibility that a mistake will be made at some point.
It gets worse. Not only is the number of children requiring admission historically high, but these patients tend to be sicker than usual. Traditionally, most children with RSV infections have a mild, self-limited illness that is essentially a case of the common cold. Children under 2 years of age are more likely to develop lower respiratory tract involvement, but most do not. And when they do, most don’t need to be in the hospital. When admitted for RSV, they usually only need supportive care for 2 to 3 days with IV fluids, oxygen, and perhaps a short period of feeding through a nasogastric tube.
Some children, especially young or premature babies and children with underlying heart or lung disease, need help with high flow nasal cannula or even CPAP, and some will even require mechanical ventilation. However, the vast majority of admitted patients can be cared for in an inpatient unit. This year has been very different. Children are arriving sicker. And in addition to the babies we are used to handling, older children also require admission in unusually high amounts.
When a child needs a higher level of care than can be provided in an inpatient unit, he or she is transferred to a pediatric intensive care unit. Never before have I seen so many in need of dispatch. So what happens when there are no beds available in the PICU…anywhere? We do the best we can. For the first time in my career, I have seen children sitting in an inpatient unit receiving critical-level care because there is literally nowhere else for them to go. Not only is this less than ideal for the patient, it causes extreme physical, emotional, cognitive, and moral fatigue for those providing care.
I practice in the Boston area, a region that is home to Boston Children’s Hospital, Massachusetts General for Children, the University of Massachusetts Children’s Medical Center, and a handful of community hospitals with pediatric inpatient capacity to varying degrees. So even though we’re not in Houston, there are a lot of inpatient and PICU beds around here. But for the last few weeks, and particularly the last month, we started most days with no availability for new admissions or transfers anywhere.
I work in a decent sized community hospital with a 12 bed pediatric unit. We’ve been at 100% capacity for weeks now and manage 20+ patients some days, about 75-80% with RSV. Our ED is struggling to keep up. My partners and I have been working a lot of overtime, even staying overnight, to help each other out. We’ll make it, but it’s been hard. In the Boston area today (11/10/22), there were 7 of 142 staffed PICU beds available to start the day. That’s better than some days, but still not great because they can fill up fast.
Next time, I’ll go into a little more detail about RSV. I will also discuss possible reasons why this season is so bad and it has nothing to do with “immune debt”. Finally, there is hope just around the corner (in a year or two) as a promising vaccine is close to being ready for release.