When COVID-19 spread to the United States in January 2020, Texas Children’s Hospital was ready. While many hospitals raced to isolate the highly contagious patients and to train staff on protective protocols, Texas Children’s transported patients suspected of having COVID-19 to its Special Isolation Unit at Texas Children’s Hospital West Campus. There, well-trained staff already knew how to prevent spread of the infection.
The Special Isolation Unit (SIU) opened in 2015 as part of Texas Children’s preparation for highly infectious communicable disease outbreaks like Ebola, which spread from West Africa in 2014. The Centers for Disease Control and Prevention (CDC) designated the hospital as a pediatric Ebola treatment center. At that time, there were no pediatric biocontainment units in the United States, and today only a handful exist.
Texas Children’s SIU features intensive infection control equipment, unit design and protocols. Just as important as the space is the SIU’s Special Response Team, which trained every three months on critical skills such as putting on and taking off personal protective equipment, and practicing the specialized protocols and procedures involved in safely caring for these patients. The multidisciplinary health care team includes nurses, providers, respiratory therapists, environmental services, laboratory technologists and waste management.
“The team of doctors and nurses at Texas Children's was absolutely amazing,” said Shayne Baker, who stayed in the room with her son, Jaxon Baker, 17, while he was treated for COVID-19. “I can't say enough wonderful things about them. All of them did their very best to make us feel comfortable, engaged and cared for.”
Jaxon went to Texas Children's Hospital West Campus on what he called the worst day of his life. He tested positive for COVID-19 two days before. Mild asthma made his lungs highly reactive and breathing difficult.
“I wanted to sleep so bad because I was so tired, but I couldn't because I would wake myself up coughing every 20 minutes. It took every ounce of my strength just to move, just to roll over in my bed,” Jaxon said.
Breathing treatments and oxygen began immediately in the Emergency Center. After a diagnosis of pneumonia caused by COVID-19, Jaxon was moved to intensive care in the Special Isolation Unit.
Hospitals in 2020 faced a new disease without clear treatment guidelines for children.
“We’ve tried to be data driven on how we use therapies,” said Amy S. Arrington, MD, PhD, medical director of Texas Children’s Special Isolation Unit and section chief of Global Biologic Preparedness in the Department of Pediatrics at Baylor College of Medicine. ”It’s been a steep learning curve on which therapies are most useful, as well as how and when they are most effective in caring for pediatric patients.”
Collaborating with colleagues across the medical center and the country provided key input into developing best practices.
“Informal communication with colleagues was important, particularly with those from institutions in Seattle or New York, which were hit with the pandemic early,” said Ricardo Quinoñez, MD, chief of Pediatric Hospital Medicine at Texas Children’s and associate professor at Baylor.
To coordinate a comprehensive multidisciplinary approach, Texas Children’s established a COVID-19 immunomodulation team chaired by Eyal Muscal, MD, MS, chief of Pediatric Rheumatology at Texas Children’s and associate professor at Baylor, and co-chaired by Lisa Forbes-Satter, MD, medical director of Texas Children’s Center for Human Immunobiology and assistant professor of pediatrics-immunology. The Pediatric Hospital Medicine team cared for most COVID-19 patients. But some patients in the ICU required subspecialist consults in such areas as hematology, infectious diseases, rheumatology, cardiology, pulmonology and immunology.
Initially, Texas Children’s SIU held eight beds, in which the level of care could be raised to intensive care or lowered to the acute care of a regular hospital unit. Increasing numbers of COVID-19 patients required expansion to 22 beds.
Because Texas Children’s Hospital West Campus does not have all of the subspecialties that Texas Children’s Medical Center Campus has, a small isolation unit was established at the Medical Center Campus.
“We had our first patient in April, because a baby had severe heart failure,” said Matthew Musick, MD, senior medical director for Pediatric ICUs at Texas Children’s and assistant professor of pediatrics-critical care at Baylor. “We thought the baby needed to be in the Medical Center next to the cardiac ICU doctors, the cardiac surgeons and the cardiac catheterization lab. It just grew from there.”
As the patient population continued to increase, the COVID-19 patients were cohorted in isolated areas of other ICUs and acute care units at the Medical Center, West Campus and The Woodlands. Staff received additional training, and strict infection control measures were implemented.
“We have been very diligent, making sure that even the patient’s path from the parking lot is secure and without anybody else around to share their airspace,” Dr. Forbes-Satter said. “For stable patients with COVID-19 who needed life-saving infusions in our outpatient setting, we devised a plan in which a nurse designated to care for the patient puts on appropriate PPE and actually goes to the parking lot and gets them. The elevator and back hallway are secure; there are no patients in the area when they’re brought in. They’re not allowed to touch a door handle or elevator button. The nurse opens and closes everything for them until they get into the room. It’s a methodical, detailed protocol to protect our staff and our other patients.”
A parent or guardian accompanying a patient must always wear a mask. Only one parent or guardian at a time is allowed in the patient’s room. They may switch parents every 72 hours.
Although COVID-19 generally is not as serious in children as in adults, in 2020, Texas Children’s treated more than 600 COVID-19 patients hospitalized on three campuses. About 35 to 40 percent needed intensive care during hospitalization, primarily because of severe pneumonia, multi-system inflammatory syndrome in children or cardiac disease. Like Jaxon, many of those patients required oxygen administered by CPAP or BiPAP, non-invasive machines that push air into the lungs. Some required intubation and greater breathing support from a ventilator.
Risk factors for becoming ill enough to need the ICU include:
As cases in Houston surged in late June 2020, other hospitals in the Texas Medical Center were running out of beds, and patients were waiting in emergency rooms for two or three days. The hospitals requested that Texas Children’s accept adult patients. Thirty-four adult patients were admitted after referral from Medical Center hospitals.
Caring for adults was not new for Texas Children’s. The hospital routinely cares for adult patients with congenital heart disease and for young adults with complex medical needs, diabetes or transplants who are transitioning to adult care.
For the care team, treating a new disease brought special challenges:
First: “Fear of the unknown has been the hardest thing about these patients,” Dr. Musick said. “To take a brand new disease process that needs the ICU, and we don’t know the infection risk to ourselves, is incredibly emotionally exhausting for the teams.”
In response: Volunteers staffed an emotional support hotline to listen and refer to professional support for those who needed it.
Second: “Every couple of days, there was some new information or a change in workflow that would make people’s heads spin. How to keep up with that information overload was extremely challenging,” Dr. Musick said.
In response: The ICU developed frequent information sharing sessions. Every two weeks ICU town halls would offer updates and opportunities for questions.
“ICU team members have scientific, questioning minds. We’re always doing assessments and reassessments, asking, ‘Why is this happening to the patient?’ or ‘Why are we doing that?’ So, the more information we could share and the thought process behind it, made it easier for them to understand and to do their jobs,” Dr. Musick said.
Third: Limiting the number of people in a patient room made communication difficult, especially when the patient was being seen by physicians in multiple subspecialties.
In response: Staff created virtual rounds. The medical staff who are in the patient room use a computer or iPad with a camera to allow those outside the room to see and communicate with the patient. Since only one parent is allowed in the room at a time, cell phones or other technologies enable medical staff to communicate with both parents at once.
Fourth: An additional aspect has been learning on the fly about the science of COVID-19 and how to treat it. The ICU team already knew how to use ventilators, medicines like adrenaline to help the heart, and blood thinners for a disease that seems to promote blood clots. But new investigational medicines presented a lot to learn.
In response: Dr. Arrington created a “how to” guide for treatment. It answers such questions as when to use steroids, remdesivir and convalescent plasma; what to look out for; and when to discharge patients from the hospital.
Like most pediatric COVID-19 patients, Jaxon went home after 10 days in the hospital. After a two-week quarantine, he returned to school.
“Jaxon is an incredibly strong athlete,” Mrs. Baker said. “He was a varsity football starting running back. Because of COVID-19, he is still on heart protocol.”
Three months after his release from the hospital, Jaxon still got winded easily. He was still being monitored by a cardiologist and restricted from doing extensive workouts. Adhering to follow-up rules ensures that he returns to everyday life in the safest manner that he can.
Advance preparation, dedication and teamwork enable Texas Children’s to overcome the difficulties of COVID-19 patient care.