This document provides recommendations for the management of paediatric patients requiring intensive care during the COVID-19 pandemic and will be revised as the situation evolves. It should be used to inform local policies and procedures which should be current and reviewed regularly.
The purpose of this document is to provide guidance to managers and clinicians for the critical care management of paediatric patients during the COVID-19 pandemic.
The goal is to maintain existing best practices for the
management of respiratory conditions, while alerting
clinicians and managers to the additional complexities
and changes to practice that will be necessary. This
document also aims to identify alternate strategies that
should be considered during the COVID-19 pandemic
when existing resources are nearing or are at capacity.
This document aligns to existing NSW Health
documents and is designed to complement these, while
providing specific COVID-19 advice. In addition, it
supports local best practice guidelines, policy and
emerging evidence.1, 2, 3
At a very high level, this document identifies three key
elements that are core to the critical care management
of paediatric patients requiring respiratory care during
the COVID-19 pandemic:
A paediatric intensive care unit (PICU) provides state of
the art intensive care services to critically ill children.
In NSW PICUs are located at three facilities: Sydney
Children’s Hospital Randwick, The Children’s Hospital
at Westmead and John Hunter Children’s Hospital.
Private hospitals in NSW do not provide paediatric
intensive care services.
Table 1. PICU Bed Capacity in NSW
* as per 2019–20 Service Agreements
Options for increasing ICU capacity are limited, but the
following strategies apply equally to adult and
The following points should also be considered as options for creating additional PICU capacity if appropriate.
All patient movements at the three PICUs can be tracked by the patient flow portal (PFP). Staff must update the PFP at least every four hours to ensure accurate information on current bed status is available across NSW.
Specific information requiring frequent updates to include; facility and ward short-term escalation plan (STEP) level colour, bed availability by nursing dependency (Nur Dep), respiratory support status (Resp), ventilation vs non-ventilation, Bi-PAP/CPAP and the name and contact details of PICU consultant on duty.
Figure 1. Patient Flow Portal dashboard
Where current guidelines exist in relation to the ages and weights of children and where these children are best managed, consideration should be given to where exceptions can be safely made to these guidelines.
These include children younger than 16 years, for problems without specific paediatric therapy implications e.g. neurosurgery for head injury. There may be a need to manage some patients for longer locally that is outside of a children’s hospital as retrieval services may be overwhelmed. Children’s hospitals should consider how to better assist paediatric services providing intensive care in those referring hospitals, with telehealth support.
All paediatric medicine level 35 sites and above will need to be aware of the number of ventilators they have available, including the number of transport ventilators and what suggested weight ranges the ventilators are capable of ventilating, maintenance cycles and availability of associated equipment and consumables. (Appendix 1).
It will also be important to understand unit configurations and variables for specific clinical management.
Consideration should be given to the:
The ANZICS COVID-19 Guidelines recommend that COVID-19 patients be treated in a Class N negative pressure single room.8 If a Class N room is not available, a Class S single room should be utilised. Class S rooms require demarcated areas for donning and doffing of personal protection equipment (PPE).
When both these options are exhausted hospitals will need open bays and to convert the unit to a COVID-19 unit and moving non-COVID-19 patients to different areas of the hospital. The patients will remain under the care of staff with appropriate critical care skills.
During a pandemic-related surge it will be important that consistent decisions are made regarding both admission to PICU and continuing care when a meaningful recovery is unlikely, with the use of end of life plans where appropriate. Triage will be enacted at the same level across the state, to promote equity of access of patients to intensive care. It is important that the triage principles to maximise access to PICU are used for all potential admissions, not just infection-related admissions.
The ANZICS COVID-19 guidelines recommend that admission to intensive care should reflect routine practice and be open and transparent and incorporate a shared decision-making model which includes the treating intensivist, other clinicians and the family.8
During the COVID-19 pandemic, children will continue to present to hospital emergency departments with other respiratory tract problems.
ANZICS COVID-19 Guidelines advises against the use of non-invasive ventilation (NIV). The guidelines state, ‘… deteriorating patients should be considered for early endotracheal intubation and invasive mechanical ventilation.’8
In the presence of suspected or confirmed acute respiratory viral illness, including COVID-19, aerosol generation increases the risk of virus transmission to other people. Additional precautions are required in the way care is delivered. The routine use of NIV forCOVID-19 patients with deteriorating respiratory failure is not recommended.9
If NIV is to be used, this should be administered in a negative pressure single room with full PPE to protect staff from aerosolising procedures. If negative pressure rooms are exhausted, patients on NIV should be kept in units with other COVID-19 positive patients. Staff should wear PPE appropriate for aerosolising procedures.
Children with pre-existing chronic respiratory disease will need to be managed as per existing protocols with appropriate infection control precautions.
Emergency departments will be required to manage respiratory patients in line with existing COVID-19 protocols.
Other considerations for emergency departments will be the safe transportation of the patients through the hospital to the required ward.
Protocols will need to be developed for:
Other considerations for emergency departments will be in relation to:
Currently the time for returning results for COVID-19 tests is variable. The requirement to expedite COVID-19 tests should be identified as urgent and communicated to the testing laboratory.
Patients should be assessed and screened in line with the latest national recommendations for COVID-19.8
If the patient is identified as ‘at risk’ the patient should be isolated and tested for COVID-19 until results confirm otherwise.
If a child is requiring transfer to another facility for care, it is ideal that the results of the COVID-19 testing are available prior to transport.
There will also be a requirement to advise families that only one carer will be permitted to visit the patient.
Every effort should be made to protect siblings and extended family, particularly those individuals identified as high risk.
In cases where infection is present the following should be communicated to the family.
International trends identify that the paediatric population is less likely to require admission to PICU. This may create some capacity in the PICUs.
Accessing PICUs for adult patients will need to be undertaken in consultation with the director of the PICU and hospital management. The Childrens Hospital executive will need to decide if the consultation is local or coordinated state-wide. While it adds another layer, state-wide management may enable more equitable access to limited resources.
There may also be a need to consider ways to safely manage co-located adult and paediatric patients in PICUs and ICUs. This could include both patient groups being COVID-19 positive and both groups being COVID-19 negative.
There are existing historical cross border practices but no formal agreements for the management of patients requiring access to a PICU.
For NSW these include Southern Local Health District (LHD) with Canberra, Northern NSW LHD with Queensland, Far West LHD with South Australia and Southern NSW LHD with Victoria.
The processes for activating these pathways should be reviewed to ensure there are minimal barriers to accessing the right people to initiate the transfers when required.
Rural and regional facilities have limited ventilation capacity. With some additional support from the newborn and paediatric emergency transport service (NETS), or their networked hospital, patients could be managed for longer periods of time in these facilities. Consideration will need to be given to operational staff requirements and workload and any additional equipment requirements.
Early consultation with NETS and PICU to enable shared
decision making will be required on a case by case basis.
Telehealth should be considered as an enabler to increasing ICU capacity across NSW. Effective telehealth models of care could reduce patient transfers, keep patients closer to home longer, and support medical, nursing and allied health staff to provide critical care to patients who are assessed as suitable for this model.
Telehealth can be used to:
NETS is the statewide emergency service for medical retrieval of critically ill newborns, infants and children in NSW. The expectation is NETS may receive higher than normal call volumes for both clinical advice and patient transfers. Although this will most likely involve patients not needing ICU, and many will be for possible pandemic related infections rather than other clinical considerations. Children’s hospitals should ensure that accepting clinicians are aware of the patients infectious status and this information is provided to NETS prior to transfer.
NETS staff will need to have the same access to appropriate PPE and training as hospital staff to ensure staff safety.
It is important not to duplicate or create alternate pathways to the existing NETS procedures.
This can be achieved by:
Other considerations for supporting NETS during a pandemic include:
The Public Health Workforce Surge Guidelines have been identified to assist LHDs understand when and how to identify, recruit and use surge staff in the event of a pandemic.6 These guidelines should be used in conjunction with local PICU pandemic or disaster policies.
Consideration for the types of staff required, potential pools of staff, logistics and staff wellbeing will also be important.
Planning for surge capacity staffing will need to cover at least the next 72 hours, with monitoring for staff fatigue and stress, and include hospital or LHD strategies to mitigate these. Staffing in the middle of the respiratory pandemic will need to consider a team orientated approach if lesser experienced staff are used in the PICU to support more skilled staff. This is an appropriate response for phase 4 of a pandemic.7
Hospital managers will be required to consider if PICU staff will be deployed to other wards during times of low occupancy. Assigning a patient load to PICU staff deployed to other units could negatively impact the availability of PICU beds and expanding into PICU at short notice.
Consideration will need to be given to where staff are deployed based on their clinical experience and qualifications.
Alternatives to deployment might include starting education and upskilling of staff. Then, if there is an influx of PICU patients, there is a skilled workforce to care for them. This could also be extended to the respiratory wards, so they are able to manage a deteriorating patient while waiting for a PICU bed.
There are other potential considerations to both maintain and increase the access to front line staff during acute times of need.
The following options should be explored at a statewide and local level.
There will be a need to review and provide additional training to clinical staff managing infected patients and all other staff who will be near infected patients.
Each facility will need to review the training requirements of staff depending on their skill level and recent experience. The following would be considered essential skills clinicians are required to demonstrate proficiency in:
Consideration also needs to be given to the development of training and educational materials and how staff access these resources. Information should be available in a variety of modalities to meet varying needs including:
There will also be a need to identify a mechanism where new information can be published and accessed by those who need it in a timely way, with the use of an collaborative platform.
The Clinical Excellence Commission (CEC) and the Health Education and Training Institute (HETI) have resources to assist with staff education.
Simulated training should not deplete scarce stock that is essential for minimising infection and protecting staff.
All inpatient facilities providing paediatric medicine services must take an inventory of the following resources to inform their local critical care surge response.
Facilities should also identify the number of children with NIV in the local community.
Ventilation capacity is most relevant to rural sites that may need to manage a child while a more appropriate bed is being identified.
All facilities should have an accurate oversight of all ventilators available to clinicians and their limitations. This includes number of:
During a pandemic a communication framework, with clearly defined channels to ensure timely and accurate information sharing between pandemic response authorities and all intensive care service providers, will be used.
The NSW Minister of Health will engage and obtain strategic advice from the Secretary of Health, ACI, NETS, the Sydney Children’s Hospitals Network (SCHN) and the John Hunter Children’s Hospital on the prioritisation and delivery of intensive care services for adults and children during a pandemic.
The Secretary of Health, as Incident Controller, will have overarching responsibility for NSW Health’s response to a pandemic and will establish an incident management team to oversee the response across the NSW Health system. Core members of the State Pandemic Management Team include:
The below table identifies the activities that should be undertaken in preparation for an increase in cases by PICU’s, LHD’s and Networks.
What to do when NSW Health reaches a critical point and the ongoing actions required by PICUs.
ACI Intensive Care NSW.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.
Paediatric Intensive Care Advisory group co-chairs
To support paediatric intensive care staff with surge in COVID-19 pandemic.