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A Hybrid Model of Pediatric and Adult Critical Care During the Coronavirus Disease 2019 Surge: The Experience of Two Tertiary Hospitals in London and New York

Deep, Akash FRCPCH1; Knight, Philip MRCPCH1; Kernie, Steven G. MD2; D’Silva, Pam MRCPCH1; Sobin, Brittany MSN3; Best, Thomas FRCA4; Zorrilla, Maria PharmD3; Carson, Lydia BSN3; Zoica, Bogdana MRCPCH1; Ahn, Danielle MD2

Author Information
Pediatric Critical Care Medicine: February 2021 - Volume 22 - Issue 2 - p e125-e134
doi: 10.1097/PCC.0000000000002584
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Abstract

On March 11, 2020, the World Health Organization officially declared the novel coronavirus disease, or coronavirus disease 2019 (COVID-19), a pandemic (1), with unprecedented demand on global adult critical care services (2), confirmed by the experiences of our Spanish and Italian colleagues. It was clear that the United Kingdom and United States would face the same challenge (3,4). In the United Kingdom, the pediatric and adult intensive care societies released a joint statement that PICUs would care for critically ill adults while providing high-quality pediatric critical care (5). Although the severe presentation of COVID-19 seemed to vastly spare pediatric patients (6), children’s health services were at risk given the reallocation of resources.

In roughly the same 6-week period between March and May, the COVID-19 pandemic led to a “super surge” of critically ill adult patients in London and New York. Our two hospitals were faced with the challenge of supporting our adult colleagues, while also caring for critically ill children. Although many PICUs across the globe converted their units to provide care exclusively for adults, a few PICUs expanded services to both pediatric and adult patients. This latter hybrid model required drastic adaptation to manage two very different cohorts by the same staff in the same space. In this report, we share the perspectives of two busy PICUs at the King’s College Hospital (KCH) London, United Kingdom, and the Morgan Stanley’s Children Hospital (MSCH) in New York, NY. We also describe the strategies adopted by our respective hospitals with adjustments in staffing, education, equipment, and medication use. The varying clinical, emotional, and social needs required by the staff to take care of the youngest and oldest patients on the same unit were unique challenges. We compare our approaches (Table 1), the lessons learned, and implications for the future.

TABLE 1. - Essential Components of Managing the Coronavirus Disease 2019 Surge in a Hybrid Unit
Component Shared King’s College Hospital Morgan Stanley Children’s Hospital
Baseline hospital characteristics Children’s hospital within an adult hospitalHospital within a larger hospital system 151 pediatric beds, 16 PICU beds, National Health ServiceSouth East London, United KingdomMajor trauma center, supraregional center for pediatric liver transplant, one of 3 centers in the United Kingdom 299 pediatric beds, 41 PICU beds over 3 ICUs, NewYork-PresbyterianUpper Manhattan, New York, United StatesLevel 1 trauma, extracorporeal membrane oxygenation, full transplant programs for bone marrow and solid organ
Organizational changes Centralized pediatric careCentralized triageElective operations postponed Adults admitted March 27 to May 10All adults were COVID negativeRing fence 25% beds to pediatrics Adults admitted March 25 to May 14Increased capacity for pediatric critical careConverted 13 beds into negative pressure rooms, in addition to the 3 existing
Operational meetings Daily updates from the chief executive’s office, live recorded webcastWeekly hospital wide meetings to answer any queries and updates Gold and bronze commandTactical leader—adult ICU consultant, key role in daily tactical team meetings Three-tiered huddle system, nursing basedDedicated triage attending and fellow pairAd hoc townhall meetings to address real time operational issues (i.e. personal protective equipment)
Staffing changes Redeployment and training of general pediatric medical and nursing staffAdditional staffing added to evening hours Dual trained MICU/PICU nurses, cross pollination of pediatric and adult residents and fellowsSplit day and night shifts on the weekends MICU attending oversightRedeployed pediatric physicians from hospitals within our hospital system
Infection prevention and control Centralized occupational health guidance for quarantine and return to work policiesWork from home when possible, particularly vulnerable employeesFrequent updates regarding PPE, protocol changes, and testing Daily discussions regarding infection status of adult and pediatric patients on the same unit (pediatric transplant patients, COVID pediatric patients, and adults with multidrug resistant organisms) Strict guidelines on testing, how to treat persons under investigation, and confirmed COVID patients
Ventilators Frequent assessment of the availability of ventilatorsUtilization of alternative ventilators (neonatal, portable, transport) for children to free up machines for adults Proactive training on the ventilators Utilization of transport ventilators to manage patients with ARDS
Equipment Shared equipment supply with the adult hospital including CRRT, nitric oxideStockpiling of medications and PPEPICU nurses initiated, supported and trained adult staff on the use of PICU CRRT machines Allocation of available CRRT and nitric oxide to adult units while reserving for PICU patients Less frequent changing of equipment such as in-line suction catheters
Pharmacy Daily assessment of commonly used drugs to identify shortages earlyAlternative drugs used within the same class when certain drugs were unavailable Pediatric and adult pharmacists working together much before the surge to create easy to use protocols Flat-based dosing with nursing-initiated titratable dosing for adult patientsIncreased expiration dates of IV tubing and aseptically prepared medications (7).Shared protocols, virtual lectures, and ad hoc consultations with adult pharmacy parallels
Clinical management, teaching, and education Involvement of adult colleagues (medical and nursing) virtual teaching sessions for the pediatric colleaguesJust in time teaching huddles by unit-based nursing educators Multidisciplinary crash course for doctors and nurses on the common clinical issues of adult patientsIncorporation of simulation in teaching sessionsDevelopment of a free online application developed by King’s College Hospital with adult protocols Utilization of adult COVID ARDS guidelines and protocols Quickly developed protocols for delirium inadults Readily available protocols from our adult colleagues in centralized digital locations
Staff mental health Support Identification and ongoing discussions regarding emotional health during a pandemic and burnout Well-being hubs with psychology support Promoting well-being engagement and resilience (POWER) − a department wide initiative
Research Trials initially started in adults were soon extended to include children such as the remdesivir trial (both), or Randomised evaluation of COVID-19 Therapy (RECOVERY) (King’s College Hospital) All COVID-related research prioritized by weekly meetings and trials prioritized at the medical director level Clinical trials limited to COVID related or life-threatening conditions (all others on hold)Centralized data collectionBiobanking of unused COVID patient specimens to be discarded
COVID = coronavirus disease, CRRT = continuous renal replacement therapy, MICU = medical ICU.

At MSCH, patient chart review was performed under the supervision of the Columbia University Irving Medical Center Institutional Review Board, with a waiver of informed consent due to minimal risk as described in protocol AAAS9622. At KCH, since the project involved retrospective review of already collected clinical records, ethics approval was not required, and this project was registered as an audit with our Service Improvement Team (CH071). Death was counted if it occurred within the study period.

Over a 6-week period, KCH admitted 23 adult patients with a median age of 53 years and 25 critically ill children, the smallest weighing just 2 kilograms. Nine liver transplants were performed, and two pediatric organ donations were facilitated. The PICU at KCH was converted to accommodate non-COVID adult ICU (AICU) patients. Over a very similar time period, MSCH admitted 30 adult patients with a median age of 33 while caring for 40 children with positive severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2) polymerase chain reaction or serologies and 125 non-COVID patients. In this time period, two heart and two liver transplants were performed. Patient characteristics, outcomes, and quality indicators for both adult and pediatric patients admitted at the two hospitals is described in Table 2, including common adult complications (8). The adult and pediatric COVID-19 experience was unique at MSCH (Table 3). Despite reports elsewhere (9), mortality of ventilated patients with COVID acute respiratory distress syndrome (ARDS) was low. Further detail regarding pediatric patients hospitalized at MSCH with COVID-19 or COVID-related multisystem inflammatory syndrome is described in other reports (10,11).

TABLE 2. - Characteristics of Pediatric and Adult Patients Admitted During the Coronavirus Disease 2019 Surge With Performance Indicators
King’s College Hospital Morgan Stanley Children’s Hospital
Characteristics Adults Children Adults Children
Admissions, n 23 25 46 149
Mortality, n (%) 4 (17.3) 4 (16.7) 1 (2.2) 8 (5.4)
Male: female 1.5:1 1.75:1 2.3:1 0.91:1
Median age, yr (range) 53 (19–77) 3.0 (0.5–17) 24.4 (18–52) 3 (0-17)
Median PICU length of stay, d (range) 3 (1–40) 2.5 (0.8–21.5) 8 (1–61) 4 (1–78)
Diagnosis Respiratory 6Neurology 6Sepsis 4Post liver transplant 2Neurosurgery 8 Respiratory 8Neurology 5Neurosurgery 5Liver/GI 11Sepsis 6Hematology/oncology 2Other 1 Respiratory 32Cardiac 4Liver/GI 1Endocrine 2Sepsis 1Hematology/oncology 4Ingestion 1Other 1 Respiratory 40Cardiac 40Neurology 8Neurosurgery 4Liver/GI 8Endocrine 2Renal 3Sepsis 6Hematology/oncology 7Ingestion 2C-MIS 26Other 3
Number of COVID polymerase chain reaction+ 0 4 30 29
C-MIS NA 2 NA COVID + 15 COVID (–) 11
Posttransplant 2 admitted with severe liver disease 9 liver transplants NA 2 heart and 2 liver transplants
Neurosurgical emergencies 2 3 NA 4
Emergency admissions unable to admit 0 0 2 6
Readmissions after being discharged from PICU 0 1 3 1
Cardiopulmonary arrests 1 1 1 7
Major bacteremias 1 0 3 2
Accidental extubations 0 1 2 2
Major serious untoward incidents 0 1 0 1
Stroke 1 0
Gastroenterology bleed 2 1
Atrial fibrillation 2 1
Skin breakdown 2 7
Moderate-severe delirium 2 16
Review of pacemaker 1 0
COVID = coronavirus disease, C-MIS = COVID-related multisystem inflammatory syndrome, NA = not available.
Admission characteristics of patients admitted to the King’s College Hospital PICU from March 27 to May 10, 2020, and the Morgan Stanley Children’s Hospital PICUs from March 25 to May 14, 2020, inclusive. Admissions represent the number of unique hospitalizations during the study period. Deaths and all other events were counted if they occurred during the study periods.

TABLE 3. - Characteristics of Coronavirus Disease Positive (Viral and Serologic) Pediatric and Adult Patients at Morgan Stanley Children’s Hospital
Characteristics Adults Children
Number of admissions 30 40
Patients still admitted, n 6 2
Mortality, n (%) 0 (0) 1 (2.5)
Male:female 23:7 20:20
Median age, yr(range) 32 (18–52) 9 (0.16–17)
Median PICU length of stay, d (range) 14 (1–41) 5 (1–43)
Remains hospitalized 13 6
Transferred to medical ICU 6 NA
Readmitted 1 0
Diagnosis ARDS—26Acute on chronic respiratory failure—1Diabetic ketoacidosis—2Hypoxic ischemic encephalopathy post arrest—1 ARDS—5Acute on chronic respiratory failure—3Hyperkalemia—1Heart failure—3Tracheal stenosis—1Progressive brain tumor—1Coronavirus disease–related multi system inflammatory syndrome—26
Illness severity IMV—26CRRT—6ECMO—3 IMV—8CRRT—1ECMO—1
ARDS = acute respiratory distress syndrome, CRRT = continuous renal replacement therapy, ECMO = extracorporeal membrane oxygenation, IMV = invasive mechanical ventilation.
Admission characteristics of patients with positive severe acute respiratory syndrome coronavirus 2 viral polymerase chain reaction or serum antibody in the Morgan Stanley Children’s Hospital PICUs from March 25 to May 14, 2020, inclusive. Admissions represent the number of unique hospitalizations during the study period. Deaths and all other events were counted if they occurred during the study periods.

A CHILDREN’S HOSPITAL WITHIN AN ADULT HOSPITAL—ORGANIZATIONAL CHALLENGES

Children are generally cared for in either a standalone hospital for children or within an established adult hospital. The chosen model depends on local needs, type of children’s services provided, and agreements within the regional teams. The benefits of a children’s hospital within an adult hospital include shared oversight, administration, resources, and supply chains. Two examples are KCH and MSCH, both major referral centers for pediatric services within larger hospital systems. Both the National Health Service (NHS) London and New York Presbyterian (NYP) decided to increase capacity and centralize pediatric critical care. In London, this was done in standalone children’s hospitals such as Great Ormond Street Children’s Hospital. Within the NYP system in NYC, this was tasked to MSCH, with the addition of a fourth PICU unit. This increased capacity was used to offload other PICUs that had ceased pediatric services completely to convert to adult units (12,13).

As KCH is one of the busiest adult critical care centers in London, all nonspecialist critical care pediatric patients were transferred to other standalone children’s hospitals. However, as a designated subspecialty supraregional center for liver transplant, neurosciences, and trauma, great consideration was taken to determine which specialty services to retain. After regional consultation, KCH decided to allocate 25% of their beds for pediatric speciality services. In New York, MSCH was able to increase pediatric critical care capacity to decompress other hospitals within the NYP system and still has capacity to care for critically ill adults. This was accomplished by the creation of 19 additional PICU beds through the conversion of a stepdown unit and transitional nursery. For both institutions, all elective surgical and nonessential work was postponed, although trauma and select transplant services were maintained.

The identification of patients for admission to the PICU was determined by a tactical lead from the adult team who would discuss individual patients for admission with the pediatric critical care lead. Initial triaging intentions to care for patients similar to pediatric age and diagnosis were abandoned as the demand for assistance increased. As reflected in the differences in median age of the adults at MSCH and KCH (Table 2), the triage decision making was highly dependent on the circumstances of the individual institution, with cohorting of COVID+ patients playing a major role. At MSCH, only adult COVID+ patients were admitted to all locations compared with KCH which remained one of the last non-COVID-19 critical care areas within the whole hospital. At MSCH, younger adult patients with fewer comorbidities were preferentially transferred. The original plan at KCH was to admit non-COVID patients below 30 years old, but very few patients fit these criteria. The age limit was therefore lifted, leading to higher median age, diverse presenting pathologies, and more co-morbidities.

LEADERSHIP AND COMMUNICATION—KEY DRIVERS FOR SUCCESS

In both institutions, regular updates were provided from local leadership via e-mail, teleconferencing, and live streaming. Technology was used to maximize effective communication, while minimizing unnecessary in person meetings and exposure. MSCH used a nursing-centered, tiered huddle system, which included nursing leadership, environmental services, supply, equipment, transport, radiology, nutrition, infection prevention and control, and facilities. KCH employed a similar established emergency structure, led by a tactical leader that disseminated updates to the clinical team. The tactical leader would meet with the PICU team daily, providing clinical advice and addressing all operational issues including staffing, bed availability, equipment, and consumables. Communication with adult consultants in critical care medicine was in-person or over the phone, daily and as needed.

The approach to subspecialty consultation was divergent at the two institutions. At MSCH, pediatric subspecialties handled all consults regardless of age and would independently decide if extra assistance from their adult counterparts was needed. At KCH, consultative services were requested based on the patient’s age. In general for both institutions, in-person consultations were discouraged, and video conferencing or phone calls were used when possible.

At MSCH, the creation of a dedicated triage attending and fellow trainee team allowed optimization of the triage of inbound patients, bed management, transport safety, and disposition of ICU graduates. Centralizing these duties allowed clinicians to focus exclusively on the clinical demands of the patients. At both institutions, frequent multidisciplinary meetings with clearly identified leadership roles allowed for early identification and resolution of issues.

TRANSITION TO ADULT CARE—EDUCATIONAL CHALLENGES FOR THE PEDIATRIC STAFF

Gaps in knowledge with age appropriate equipment, medication dosages, and adult-based policies were identified early in the hospital’s response to COVID. KCH was able to use a unique pool of providers that were dual-trained in adult and pediatric medicine as well as AICU trainees that had rotated previously in the PICU. Both teams had the valuable resource of unit-based nursing educators to provide just in time education and coaching of all bedside nursing staff and PICU providers. An oversight system was established at MSCH, where an advisory adult critical care attending was assigned to be available for urgent consultation and review of daily management plans. Training in AICU practices, ahead of the surge, reduced anxiety and promoted a sense of preparedness. Providing education for the rapidly evolving clinical management for COVID patients was a particular challenge at MSCH, often causing distress in providers. Individuals stepped up as needed to provide cohesive guidelines for specific problems such as delirium and anticoagulation. However, designating a dedicated education lead would have helped specialists to quickly understand the concerns of the critical care team, provide ad hoc education sessions, and ensure timely dissemination of the up-to-date guidelines.

TEAM FACTORS—CHANGES IN STAFFING

Keeping the PICU teams together in a familiar environment while caring for adult patients mitigated certain patient safety risk factors, but also encouraged resilience of the team in an emotionally and physically challenging period of time. Doctors and nurses willingly worked in COVID-19 units, so that vulnerable staff could be deployed elsewhere or shielded. At MSCH, emphasis was placed on minimizing trainee fatigue leading to staggered scheduling. At both institutions, frequent changes in physician staffing led to impaired continuity of care due to fragmented availability. In the future, innovative ways to establish a more consistent cross cover schedule, while also taking into account the potential for staff illness and fatigue, will have to be developed.

Shadow or team nursing supported nurses with previous ICU experience or noncritical care nurses. At KCH, this was named a “Return to PICU” model whereby ex-PICU nurses were recalled to shadow rosters. Deployed senior noncritical care staffs were used in a tier of senior staff members, dedicated to updating families on a regular basis to allow clinical staff to focus on direct clinical care. Every effort was made to maintain 1:1 nursing for level-3 ICU patients, and threats to staffing were anticipated but rarely violated (14).

EQUIPMENT, SUPPLY AND PHARMACY CHALLENGES

One major challenge throughout the world was the availability of ventilators. To free up ventilators for the adult surge, multiple innovative approaches were used. Neonatal, portable, and home ventilators were used when possible and safe for pediatric patients to free up ventilators for adult patients. MSCH shares a supply and equipment depot with the adult hospital allowing adult supplies including beds, turning devices, and code carts to be obtained with ease. Commonly used medications and consumables frequently ran low and required close daily monitoring of available supplies. To conserve medication and related supply usage, expiration dates for aseptically compounded medications were extended (7), and IV tubing was changed less frequently. There were no adverse events attributable to this with no increase in catheter-related bloodstream infections rates at MSCH. It is likely that continued relaxation of these constraints in nonpandemic times will reduce waste without significantly impacting patient safety. There was also an unexpectedly high need for continuous renal replacement therapy (CRRT) which put constant pressure on supplies of related consumables. In general, both institutions used lower CRRT clearance rates within safe parameters to allow for conservation of fluids. In certain instances, due to lack of supplies, dialysate fluid from one company was used on an incongruent machine.

EMOTIONAL CHALLENGES—SUPPORTING PATIENTS, FAMILIES AND ICU STAFF

The hybrid model has the unique challenge of responding to the very different physical, medical, and emotional needs of two different patient groups. This often led to high levels of anxiety over differences in adult nursing care, medical management, equipment, and medication dosing leading to unintentional patient harm. However, as recently reported, we shared the subjective benefits and emotional resilience of keeping the pediatric team in familiar surroundings during this rapid transition (15).

Visitation policies in pediatric versus adult patients were very different based on compassionate and pragmatic grounds. For adult patients, visitation was limited to preterminal visits, and for parents of pediatric patients, alternation of caregivers for respite was prohibitive. The long-term negative effects of restricted visitation have yet to be quantified. Social isolation has been proposed as an additive risk factor for delirium, increased length of stay, and mortality in adults (16). The frequency of moderate to severe delirium (Table 2) was higher in adults at MSCH (16/43; 37%) compared with KCH (2/23; 9%). Although social isolation contributed, delirium in adults with COVID ARDS was more frequent than expected and likely multifactorial (17). A systematic approach for prevention and treatment of delirium was used, with video calls between adult patients and family members when possible. Conversations with family members regarding end-of-life care and advanced care directives including facilitating organ-donations, challenging at baseline, often occurred on the phone or over video conferencing.

In both institutions, a major focus was placed on the mental health and well-being of providers. At KCH, mental health teams set up well-being hubs that provided much needed psychologic support. At MSCH, the Promoting Well-being Engagement and Resilience (POWER) initiative organized easy to access resources for provider mental health and virtual meditation, mindfulness, dance and yoga sessions. Recognizing and acting upon the need to manage staff welfare was critical to optimize our ability to care for patients in these most challenging of times. Despite this, maintaining the morale of team members was difficult. In the future, greater effort should be taken to provide holistic support to staff members.

There are several limitations of this study. Our results include two different cohorts of adult patients with differing underlying pathologies and baseline demographics, and therefore outcomes cannot be directly compared. We present our experience using this hybrid model, to offer the PICU community insight into an alternative model of care. We recognize fully that our approaches may not be generalizable to all institutions. Since our hospitals operate within adult organizations, the collaboration with our adult colleagues was facilitated with relative ease. Our goal was to present unique successes, challenges, and short comings for this specific model. There are many obstacles such as staffing shortages, lack of equipment and medications, fear of resource allocation, and rationing that were universal to the global ICU community, not fully discussed here. The strengths, weakness, opportunities, and threats analysis discussed in this article are summarized in Figure 1. Finally, the number of adult patients treated at both centers was relatively small; hence, we cannot proclaim proficiency in managing all aspects of adult critical care.

Figure 1.
Figure 1.:
A strengths, weakness, opportunities and threats analysis of the hybrid model of ICU care.

CONCLUSIONS

The advantage of a dynamic hybrid model is that it remains responsive to the rapidly changing demand for critical care beds, providing increased capacity for adult patients at the right time while providing ongoing specialist pediatric services. This flexible modeling also means our units have been upskilled to care for adult patients, a valuable resource for future surges with unpredictable demands. Using a hybrid model, both institutions were able to maintain large numbers of transplants, as well as high-level trauma and neurosurgical emergency services during the COVID surge. However, with a strong probability of future peaks occurring during the winter months and the potential to affect high numbers of pediatric patients, additional consideration should be taken in the planning of specialist services and the available critical care capacity. With this cooperative model, the collective critical care family is better poised to successfully navigate global crises such as COVID-19 through enhanced communication and teamwork.

ACKNOWLEDGMENTS

The authors from MSCH would like to thank Jason Zucker, MD, and Magdalena Sobieszczyk, MD, MPH, for spearheading the institution wide effort to prospectively collect data on our COVID patients. The authors from KCH would like to thank the medical, nursing, and allied health professionals from the PICU and AICU for their collaborative work during the pandemic and Dr. Rupesh Bhimani for proofreading the grammatical part of the article.

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Keywords:

children; coronavirus disease 2019; coronavirus infection; critical care; pandemic

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