This will be the shorter 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 will mostly be focusing on RSV, the infamous (at least among pediatricians and family docs) initialism for respiratory syncitial virus, because it has been causing most of the problems. In this post, I’ll discuss the current situation in hospitals around the country and give some personal perspective. Next time, I’ll go into more detail on RSV and the potential for a new vaccine that is showing 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 providers in the United States, with reports in July of unusual RSV activity serving as an omen of a particularly bad Fall and Winter ahead. I saw this in my patient population as well, and our Summer in the Boston area was definitely a bit busier on the inpatient service than expected. As Fall approached, admissions for lower respiratory infections continued to increase, and we saw an odd, but not entirely unexpected, surge in rhinovirus and other respiratory enteroviruses causing wheezing and asthma flares that required inpatient management.
I wrote about a specific enterovirus that is linked to cases of a polio-like illness in young children in mid-September. At that point, 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 understandably have now taken center stage, news of hospitals being overrun with pediatric patients infected with viral lower respiratory infections, particularly RSV, began making the media rounds.
In early October, NBC reported on five states (California, Illinois, Massachusetts, North Carolina, Rhode Island) having significant capacity problems. On October 21st, Axios reported that the surge had blown past the peak of 2021 and featured the situation in Connecticut and Colorado. An October 24th article from NPR focused on Texas, Washington, D.C., Maryland, and Washington, all of which were dealing with having more children that required inpatient or ICU care than available pediatric beds. It was clear, and remains so, that this is not an isolated problem.
I have been a pediatrician since 2003, and generally aware of medical stuff since starting medical school in 1999, and I have never personally experienced a month like the one we are having. Prior to the pandemic-related lull over the past two seasons, RSV had always kept us busy. It is the most common reason for infants to be admitted to a hospital every year, after all. But I have never seen admissions come in at this pace, which has far surpassed 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 aren’t any beds available in that facility? Well, they can be transported from the ED to a pediatric inpatient bed at a different facility. Easy, right? Not so fast.
What if there aren’t any pediatric inpatient beds available at any nearby facility? No big deal, you can just transport them to a facility that is not so nearby, and in some cases these children are being moved hundreds of miles away from where they entered the system. And if there are no beds to be found, the child has to board in the emergency department, sometimes for days, waiting for a bed to open up. None of this is ideal. It increases expense and, much more importantly, the chance that a mistake is going to be made somewhere along the line.
It gets worse. Not only are the numbers of children requiring admission historically high, these patients are trending sicker than usual. Traditionally, most children with RSV infections have a mild and self-limited illness that is essentially a case of the common cold. Children under the age of 2 years are more likely to develop lower respiratory involvement, but most don’t. And when they do, most don’t end up needing to be in the hospital. When they are admitted because of RSV, they usually just need supportive care for 2-3 days with IV fluids, oxygen, and perhaps a brief period of feeds through a nasogastric tube.
Some kids, particularly young or premature infants 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. The vast majority of admitted patients, however, can be cared for in an inpatient unit. This year has been very different. Kids are coming in sicker. And in addition to the babies we are used to managing, older toddlers are requiring admission in unusually high numbers as well.
When a child needs a higher level of care than can be provided on an inpatient unit, they are transferred to a pediatric intensive care unit. I have never seen so many need to be sent out before. So what happens when there are no PICU beds available…anywhere? We do our best. For the first time in my career, I have seen children sitting on 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 the people providing the care.
I practice in the Boston area, a region that boasts Boston Children’s Hospital, Massachusetts General for Children, University of Massachusetts Children’s Medical Center, and a handful of community hospitals with inpatient pediatric capacity to varying degrees. So, while we aren’t Houston, there are a lot of inpatient and PICU beds around here. But for the past several weeks, and particularly in the past month, we start most days with none available for new admissions or transfers anywhere.
I work at a decently sized community hospital with a 12-bed pediatric unit. We have been at 100% capacity for weeks and managing 20+ patients some days, about 75-80% having RSV. Our ED is struggling to keep up. Myself and my partners have been working numerous extra hours, even staying overnight, to help each other out. We will make it, but it has been rough. 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 bit more detail on RSV. I will also discuss the potential reasons for why this season is as bad as it is, and it has nothing at all to do with “immune debt”. Finally, there is hope around the corner (in a year or two) as a promising vaccine is close to being ready for prime time.