Quality and Safety in Hospital Pediatrics During COVID-19: A National Qualitative Study

Two resources informed this study: the hospital disaster resilience framework (which outlines major domains of hospital resiliency) and the AcademyHealth report: “Health Systems Respond to COVID-19: Priorities for Rapid-Cycle Evaluation” (which identifies high-priority research questions for improving quality and safety of care during and after the pandemic).^18,19  We used these resources to identify key questions that we organized in a semistructured interview guide (see Supplemental Tables 2 and 3). The interview guide was pilot tested and refined over 3 interviews to ensure participant comprehension and ability to elicit descriptive, narrative answers. Data from pilot interviews were included in the final analysis. This study was reviewed and deemed exempt by our institution’s institutional review board.

We used The COVID Tracking Project database to identify the 6 US states with the highest incidence of COVID-related hospitalizations during the first quarter of the pandemic, from March to May 2020 (Connecticut, District of Columbia, Louisiana, Massachusetts, New Jersey, New York). In each of these states, we identified 1 community hospital and 1 children’s hospital. We sampled a first participant (pediatric clinician involved in inpatient care during the COVID-19 surge) by direct or indirect contact with our team members. That participant then helped identify additional knowledgeable participants (snowball sampling).²¹  We included participants with pediatric administrative and/or front-line clinical roles (nurses, physicians). We also interviewed caregivers who had used medical care during the pandemic from family advisory councils at 3 sites. We concluded interviews when we reached saturation amongst the cohort as a whole (ie, when new data became repetitive with no emergent themes generated).²² 

We conducted one-on-one interviews of participants via videoconference. After obtaining consent to record, we started with open-ended questions followed by semistructured probes from our interview guide. Interviews were transcribed, proofread, and deidentified.

We analyzed qualitative interview data in Dedoose 8.3.45 (Manhattan Beach, CA) using constant comparative methods.^22,23  Four authors simultaneously and independently analyzed the first 4 transcripts and developed a preliminary codebook. Subsequently, all members of the research team reviewed and finalized the codebook. Each transcript was then independently coded by 2 authors, who met periodically to verify consistency. Our team iteratively examined and discussed primary data to identify emerging common themes across the whole sample (both community and children’s hospitals). Five authors developed memos on the basis of these themes to facilitate further discussion and exploration by the larger team. We analyzed the data in parallel with ongoing interviews until we achieved saturation. To ensure study rigor, we used triangulation, reflexivity, and member-checking. Triangulation involved the use of investigators from multiple roles (eg, administrator, physicians, nurse, fellows, resident, student), to gain an in-depth understanding of relevant themes from different perspectives. All team members were engaged and encouraged to contribute their viewpoints through all stages of the study, so we could benefit from different perspectives (eg, trainees provided insights into workflow changes from the perspective of workers with up to 80 hours of duty per week). Team members promoted reflexivity throughout the study process by writing memos on and discussing their potential sources of bias (eg, professional role, experiences during the pandemic). We also used member-checking to strengthen the rigor of our analysis by returning data to 3 participants to check for accuracy; notably, we clarified that a particularly compelling passage about communication was intended to reflect safety concerns.^22,24 

We interviewed 30 participants from 12 hospitals (1 community and 1 children’s hospital in each of the 6 states). Fifteen participants had both administrative and clinical roles (6 nurses, 9 physicians), 9 were front-line physicians, and 6 were caregivers or parents (from 3 children’s hospitals). Duration of interviews ranged from 16 to 35 minutes for caregivers (average 27 minutes) and from 22 to 69 minutes for clinicians (average 41 minutes).

Below, we summarize the major themes that emerged, in order of highest coded frequency. Additional illustrative quotes for each theme are displayed in Table 1.

Participants reported a decrease in face-to-face interactions between clinicians and patients and caregivers due to fear of exposure to SARS-CoV-2 and the need to preserve personal protective equipment (PPE). Participants reported they were going into patient rooms less often, in smaller teams, and examining patients less frequently. PPE deterred clinicians from performing examinations and rendered examinations more difficult, which occasionally led to decreased clinical monitoring and to complications potentially going undiagnosed for longer.

Participants felt that halting FCR may have decreased patient and caregiver engagement (eg, involvement in decision-making, opportunities to clarify care plans). Many hospital leaders and clinicians raised concerns that these changes may have impacted patient safety by leaving caregivers less informed regarding care plans both during and after the hospitalization (eg, plans to ambulate regularly to prevent deep vein thrombosis, oral hydration goals). Some caregivers reported feeling “abandoned” and expressed decreased satisfaction. Other caregivers appreciated smaller rounding groups and fewer interruptions.

Caregiver, Hospital 5

Decreased direct interaction with patients impacted communication. In addition, participants described other communication challenges, including isolation status and PPE. Loud filtration systems, face shields, and masks impeded both verbal and nonverbal communication. Clinicians and caregivers alike reported difficulties exchanging information (ie, history, plan of care), especially with families whose preferred language was not English. This was exacerbated by restricted visitation policies, which left additional parents and caregivers out of direct communication. Participants raised concerns that these challenges to communication could compromise safety and patient and caregiver involvement in their child’s care.

All participants described increasing use of telehealth, which offered opportunities for safe, distanced communication. However, participants reported important technical difficulties (eg, lacking electronic tablets, poor Internet connection). They also noted challenges with caregiver teaching via phone or video call (eg, feeding pump teaching over the phone feeling suboptimal) and interpreter services via telehealth (eg, accessing services; hearing and understanding speakers).

Administrator, Hospital 10

Participants described several changes in the hospital discharge process. Clinicians often tried to discharge patients earlier to minimize risk of COVID-19 exposure and optimize bed availability/access (eg, children with infections, respiratory illnesses, newborns/births). Some participants were concerned this could potentially lead to increased risk of hospital readmission, especially in the context of greater difficulties accessing timely outpatient follow-up. For instance, several clinicians described worries about expedited discharges of newborns impacting the risk of severe hyperbilirubinemia. Additionally, a caregiver described earlier-than-expected discharge of a child with febrile neutropenia (at lower cell counts than usual) and her concerns about severe infection risk. Participants described efforts to try to better leverage telehealth resources to arrange and ensure follow-up after discharge.

In addition, participants reported lacking appropriate facilities to transfer patients in need of specialized care (eg, psychiatric care, rehabilitation), especially when patients had COVID-19. Consequently, they described longer admissions in pediatric units while awaiting transfer, which increased exposure risk. They also described more time and effort spent on trying to find these specialized services. Some participants were able to newly harness telehealth services to provide mental health care on general inpatient pediatric units (which was not used before the pandemic).

Physician, Hospital 7

Quality and safety leaders and staff often had to take on key roles in planning COVID-19 response. Some participants reported that these shifts in prioritization led to lapses in ongoing quality and safety monitoring and stalls in starting new quality initiatives. However, other participants reported that decreases in inpatient volumes freed up time for leaders to launch new quality improvement tools (eg, clinical pathways) and initiatives.

Participants also reported mixed effects on safety events. Some noted increased safety events, such as pressure injuries and hospital readmissions, and they felt that these may be driven by changes in clinical monitoring and follow-up, respectively. Others described stable or decreased quality and safety events (eg, central line-associated bloodstream infections) and felt that decreased volumes led to improved patient-to-staff ratios and safety.

Participants reported challenges in ensuring quality and safety in the care of patients with COVID-19 and Multisystem Inflammatory Syndrome in Children due to the lack of evidence-based guidelines to define high-quality care and quality for these populations. They often relied on external resources to help navigate clinical care for children with these novel diseases (eg, POPCoRNetwork resources).²⁵ 

Physician, Hospital 10

Hospital policies on PPE use, patient isolation, and visitor restriction constantly evolved with emerging new evidence, leading to concerns that suboptimal evidence and policies put staff and patients at risk for exposure. Participants reported confusion and difficulty remaining up to date with policies, which were usually made with guidance from outside resources (eg, Centers for Disease Control). Caregivers feared getting infected in the hospital and appreciated strict guidelines.

Additionally, early in the pandemic limited testing access and supplies resulted in slow turnaround of results. This made it difficult to isolate potentially infected patients and staff, prevent exposures, and provide timely care. PPE shortages also contributed to the risk of exposure for clinicians and staff.

Nurse, Hospital 3

Surges in adult cases and COVID-19 exposures or illness led to staff shortages, prompting clinicians to take on new care tasks. Pediatric-trained clinicians were redeployed to adult care roles or new hospital units (eg, from surgical to new isolation units, from operating/recovery rooms to medical units, from acute to critical care units). As clinicians practiced out of their usual scope, safety and competency concerns arose. Some participants described increased safety events in units staffed with cross-covering clinicians. Helpful resources included consultation support from adult hospitalists, refresher training (eg, advanced life support), and educational resources.

Nurse, Hospital 5

Participants reported challenges meeting usual standards of care due to shortages in supplies (eg, PPE, oxygen delivery systems), clinical care spaces, and medications (eg, antibiotics), especially during the initial surge. Reallocation of resources to adult patients occurred in some children’s hospitals nested within larger hospitals.

Physician, Hospital 7

In this multicenter, qualitative study of children’s and community hospitals, we identified several challenges in clinical workflows and hospital operations during the pandemic that may have impacted quality and safety of inpatient pediatric care. Impacts on clinical workflows included decreased direct clinician-patient interactions, challenges to communication, and changes in the hospital discharge and transfer process. Operational changes included lapses in quality and safety monitoring, increased health risks for employees, and staff and supply shortages. Participants voiced concerns about several potential negative impacts, including increased risk of preventable safety events, decreased care quality, lower patient involvement and education, decreased patient satisfaction, and increased risk of readmission. Further quantitative research focused in those areas of concern is necessary to better define actual impacts. As hospitals return to normal operations, the quality and safety implications of these challenges will need to be closely measured, monitored, and addressed as needed.

Our findings largely align with previous research. In a single-center qualitative study, Diskin et al¹⁶  describe similar impacts of the pandemic on the quality of inpatient pediatric care in a free-standing children’s hospital. They describe how visitor policies and changes in communication decreased patient and family engagement and discuss the limitations of telehealth. Previous quantitative studies have described the declines in inpatient pediatric volumes reported by our participants.^10–14  Additionally, a study by Masonbrink et al early in the pandemic found an increase in preventable safety events.¹⁵  Some of our participants described concerns regarding potential increases in hospital readmissions, which were not demonstrated in a previous quantitative study by Markham et al. However, this previous study focused on children’s hospitals early in the pandemic; thus, may not represent the full spectrum of the pandemic’s effects.¹²  Future research is needed to quantitatively analyze the impacts of the pandemic on pediatric quality and safety metrics, including how those impacts may differ by hospital type.¹⁷ 

Our participants reported decreases in the quantity and quality of direct interactions and communication with patients and families, with potentially concerning implications for quality and safety. It will be important to safely resume and increase direct interactions with patients by applying growing evidence around SARS-CoV-2 transmission to inform hospital policies, maximizing vaccination efforts, and ensuring adequate PPE and testing supplies. To optimize care quality and safety, it will also be essential to continue developing and refining innovative communication strategies that include verbal (eg, talking without PPE through windows and tablets; clear masks) and nonverbal communication (eg, exaggerating nonverbal cues when wearing PPE) to maximize patient and caregiver involvement in their care.²⁶  Additionally, hospitals will need to continue to enhance infrastructure for successful technology-enhanced communication (eg, videoconference, phone, E-mail) to mitigate the negative impacts of decreased patient-clinician interactions. This includes ensuring availability of functioning, user-friendly equipment (eg, tablets, workstations-on-wheels/in-room computers, smartphones), server capabilities for videoconferencing, information technology support personnel, and staff training. Furthermore, implementing safe practices for resuming and maintaining FCR can maximize patient and family involvement, as these rounds have been associated with decreases in harmful medical errors.²⁷  Our findings also indicate that when planning patient and caregiver education, it may be important to prioritize resources for equipment and skills teaching to be done in person for optimal understanding (eg, feeding pump management, drain management, dressing changes).

Our participants sometimes reported lapses in quality and safety monitoring as quality and safety staff took on new COVID-19-related tasks. Ensuring staff are reallocated to resume prepandemic monitoring will be important, given our participants reported concerns of increased safety events during the pandemic, as was also reported in a study by Masonbrink et al.¹⁵  It will be essential for hospitals to rebuild quality and safety infrastructure and monitoring, including close monitoring of hospital readmissions (since they can potentially increase when discharges are expedited). The pandemic also prompts us to consider expansion of quality and safety monitoring in certain areas. Participants noted a lack of quality and safety measures related to the care of children with COVID-19 or Multisystem Inflammatory Syndrome in Children.

Those developing evidence-based guidelines and pathways focused on these novel diseases might consider developing associated quality and safety measures to monitor care quality, such as receipt of recommended treatments. We also currently lack robust metrics for capturing patient and caregiver education and engagement, which our study indicates may have been adversely affected by the pandemic. An important future area of focus is the development and implementation of new monitoring strategies for patient and caregiver engagement.²⁸ 

Although our participants expressed concerns about potential links between the challenges they reported and quality and safety outcomes, this qualitative study is hypothesis-generating and cannot establish causality. Likewise, our stated aim was to investigate quality and safety challenges related to the pandemic and as such our study did not reveal the positive changes that may have occurred. Furthermore, our study was not designed to compare experiences between community and children’s hospitals. Additionally, we sampled hospitals in US states with high COVID-19 rates (located predominantly in the Northeast and South), so our findings may have limited generalizability to other geographic areas or those with lower COVID-19 rates. Also, despite optimizing triangulation with team members from 6 different disciplines and 4 different states, our team did not comprise members from disciplines such as respiratory trainees, therapists, child life services, or pharmacists. Furthermore, our study team members’ experiences may have introduced bias into our analytic process (for instance, 4 team members worked in one of the selected states with high COVID-19 incidencethe selected and high COVID-19 states during the pandemic, which may have increased their tendency to focus on data that aligned with their own experiences). However, we tried to minimize this risk through triangulation of our analytic process across our whole study team and reflexivity. We interviewed English-proficient caregivers only and, therefore, did not capture the experience of patients who might have encountered added challenges in communication. We also acknowledge that some of the patterns we observed varied by hospital. For instance, some participants reported staff shortages while others reported improved patient-to-staff ratios due to lower pediatric case volumes. Such differences were likely a reflection of the varied experiences of this diverse group of hospitals. For example, staff shortages were reported more often by hospitals in which pediatric clinicians were commonly redeployed for adult care.

In conclusion, we identified several challenges in clinical workflows and hospital operations during the pandemic that may have impacted quality and safety of inpatient pediatric care. These findings indicate that hospital leaders should quickly reestablish robust quality and safety monitoring and consider development of new areas of monitoring. Further research is also needed to quantify the quality and safety impacts of the pandemic on the whole spectrum of inpatient pediatric care, including community hospitals.

COVID-19

coronavirus disease 2019

FCR

family-centered rounds

PPE

personal protective equipment

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2