Effie Schnacky became lethargic and wheezy instead of her usual, rambunctious self on a February afternoon. Her blood oxygen level was dangerously low at 80% when her parents checked it.
Jaimie, her mother, rushed Effie with asthma to a Hudson, Wisconsin emergency room. She was diagnosed quickly with pneumonia. Schnacky was quickly diagnosed with pneumonia after a few hours of oxygen, steroids, and nebulizer treatment. A doctor advised Schnacky that she needed to transfer her daughter to a children’s hospital in order to receive better care.
They didn't know that it would take them hours to find a suitable bed for her.
Although the last respiratory crisis that flooded hospitals and doctor's offices last fall has ended, parents such as Schnacky still have trouble getting their children into a pediatric hospital or pediatric unit.
Overworked health care workers still suffer from the mental and physical burnout caused by the Covid-19 pandemic. Experts say that there are increasing shortages of skilled nurses and doctors, as well as technicians. This, along with a shortage in nurses to train them and rising costs of hiring, is leaving hospitals without pediatric beds.
There are many reasons that have been building since long before the pandemic. We are not investing in children's health care as the future. Hospitals in difficult situations may place adults in pediatric beds because Medicaid reimburses doctors at a lower cost for children. Children with mental health issues are more likely to be admitted to emergency rooms for weeks or months. This allows them to fill beds that may not be available to other children.
"There might be a bed available right at the time you need it. Schnacky said that he believed there was enough.
According to Dr. Daniel Rauch (chair of the Committee on Hospital Care of the American Academy of Pediatrics), the decline in pediatric beds has been a problem for at least ten years.
According to Rauch's 2021 paper, almost 25% of American children had to travel further to get to pediatric beds in 2018, compared to 2009.
Rauch, who has been studying the subject for over ten years, said that "this was predictable." People who have studied the data on the decline in bed capacity know that this is not surprising.
How it began - and how it got worse during the pandemic
Before the Covid-19 pandemic, the number of children in need of care fell. This is due to improvements in pediatric care. According to data from the US Department of Health and Human Services, there were approximately 200,000 fewer pediatric discharges than in 2017.
Dr. Matthew Davis, pediatrics chair at Ann & Robert H. Lurie Children's Hospital in Chicago, stated that pediatrics has improved the ability to care for children with chronic conditions like cystic fibrosis and sickle cell. He also said that vaccination programs have helped prevent previously common diseases like meningitis and pneumonia.
Pediatrics also has a seasonal nature. There is a drop in summer patients and an increase in winter patients during respiratory virus season. Davis stated that schools and daycares were closed when the pandemic struck, which reduced the spread of Covid and other diseases in children. There was less demand, which meant that there was less demand for beds. Children's beds were replaced by adult beds in hospitals that had been overwhelmed by Covid cases.
According to the American Hospital Association, only 37% of US hospitals offer pediatric services. This is down from 42% a decade ago.
Although there are pediatric hospitals in the area, Greater Baltimore Medical Center is the only one that offers pediatric emergency care in Baltimore County, Dr. Theresa Nguyen (the center's chair in pediatrics) said. She said that all the other hospitals in the county of 850,000 people have closed in recent years.
MedStar Franklin Square Medical Center, a nearby hospital, consolidated its pediatric ER and the main ER in 2018. MedStar Health cited a 40% decrease in pediatric ER visits over five years, according to CNN affiliate WBAL.
In the six months prior to Franklin Square's closing of its pediatric ER, GBMC saw an average of 889 children admitted each month. This monthly average rose by 21 patients over the following year.
Nguyen stated that he now sees the majority of pediatric ED patients who would otherwise go to a nearby community hospital.
The Tufts Medical Center, Boston, converted 41 of its pediatric beds to be used for adult ICU and medical/surgical patients in July. This was due to the urgent need to provide care for severely ill adults.
Davis stated that in other instances, it was the hospitals with fewer than 10 pediatric beds who started asking tough questions.
"Those hospitals said, "You know what?" On average, we have one or two patients per day. This is absurd. It is impossible to sustain a nursing staff that has received specialized training in pediatrics. Davis stated that we are going to shut it down.
According to CNN affiliate KBOI, Saint Alphonsus Regional Medical Center Boise shut down its pediatric inpatient unit in July due to financial reasons. The closure means that patients are now overflowing nearby St. Luke's Children's Hospital. This is the only children's hospital located in Idaho, Katie Schimmelpfennig, the administrator of St. Luke's Children's, told CNN. According to the American Board of Pediatrics, Idaho is last in the United States for pediatricians per 100,000 children.
Saint Alphonsus was closed just months prior to the fall. RSV, influenza, and other respiratory viruses had caused an increase in pediatric patients who needed hospital care. The season began earlier than usual.
The rising tide of demand has engulfed the already depleted supply of pediatric beds. This means that there are fewer beds for children who come in for common conditions like asthma, pneumonia, and other illnesses. It has been particularly difficult to recover from additional challenges.
Insurance pays less for doctors who treat children.
Another factor that is reducing bed capacity is the fact that caring for children costs less than caring for adults. These beds are often needed when there is a shortage of adult care. Hospitals may not be able to afford them due to lower insurance reimbursement rates.
Joshua Gottlieb, associate professor at University of Chicago Harris School of Public Policy, says that Medicaid is an important part of the story. It provides health care coverage for people with low incomes.
He stated that medicaid was an important payer for children and is also the most generous. "Medicaid is responsible to insuring a large portion of pediatric patients. It is also very difficult to manage due to its low payment rates.
According to the Children's Hospital Association (a national association representing 220 children's hospital), Medicaid reimburses children's hospitals on average 80% of the cost of care. This rate is much lower than what private insurers reimburse.
According to Kaiser Family Foundation data, more than 41 million children are enrolled under Medicaid and the Children's Health Insurance Program. Census data shows that this is more than half of the children living in the US.
According to Dr. David Wessel, Children's National Hospital's executive vice president, approximately 55% of children use Medicaid at Washington, DC.
"Children's National has a higher Medicaid rate than other hospitals for children, but it's because there's no other safety net hospital than Children's National in this area," said Wessel, who is also the chief physician officer and physician-inchief.
Wessel stated that it costs more to take care of a child than for an adult. Sometimes special equipment that is suited for smaller persons is necessary. A routine exam or test for an adult can be approached differently for a child. A CT scan or MRI can be done while an adult is still, but a child might need to be sedated. A child life specialist can often be found to calm and explain the situation.
He said that there are many services that can be rendered, but most of them are not covered by insurance. "There is no child life expert who ever sent a bill to see a patient.
Hospital administrations also have to consider the impact of low insurance reimbursement rates on their financial decisions.
Gottlieb stated that when insurance pays more, people tend to build more hospitals, employ more workers, and treat more patients.
"Everyone may be squeezed but it's not surprising pediatric hospitals, who face [a] lower and more difficult payment environment generally, will find it particularly hard."
The number of rural hospitals and pediatricians is declining, which forces families to travel for medical care.
Dr. Benson Hsu, a pediatric critical care provider, has been serving rural South Dakota for over 10 years. He has witnessed firsthand the unique challenges rural communities face in their health care.
According to the American Board of Pediatrics, many rural areas don't have a pediatrician. Hsu stated that family practice doctors treat children in their local communities with the aim of keeping them out the hospital. Hospital care can often require you to travel outside your community.
Hsu said that Hsu has patients from South Dakota, Iowa, and Nebraska. This is a predominantly rural population that also includes Native American reservation residents.
Hsu stated that these children are travelling 100 to 200 miles within their state to see a subspecialist. This refers to Sioux Falls patients. They are looking at traveling 200-400 miles to reach Omaha, Minneapolis, Denver if we transfer them out, which is what we do.
According to the 2021 Pediatrics paper, the number of pediatric units in rural areas fell by 26% between 2008-2018.
"It's terrible, and it's only getting worse." Rauch stated that the hospitals with safety nets are at greatest risk of closing.
Hsu, who chairs the American Academy of Pediatrics' critical care section, stated that in major cities, a child with a serious illness would receive the care they need within one hour. This is what clinicians refer to as the golden hour.
He said, 'The rural population doesn't have that golden hour.' It's the golden hours because I must dispatch a plane to land and pick up, stabilize, drive back, and fly back.
He said that when his patients travel from far away, it can cause chaos in the entire family. He spoke of families that would camp at the bedside of their child for several weeks. They may be hundreds of miles away from their families, but this is not the case when the patient is in their local community. Parents can also take turns at a hospital.
Hsu stated that he knows farmers who miss harvest time and that is as devastating as it gets. These are not office workers who take their computer with them. These are people who live and work in their local communities.
Patients with mental health issues are spending longer in emergency rooms
According to Nguyen, an adolescent with depression, suicidal ideastion, and eating disorders was admitted to GBMC, Maryland for 79 days. Nguyen said that no facility offered pediatric psychiatric beds or could accept a patient who required this level of care for months. The patient was on a feeding tube.
Before the patient was transferred to Nguyen in March, Nguyen stated that her team of social workers, physicians and nurses spent a lot of time trying to reach out to Maryland as well as the nation to find placements. I need your help.
Nguyen's case is one of many cases of teens and children with mental health problems who are being treated in hospitals and inpatient beds.
This problem began before 2020, and it grew during the pandemic. Studies show that the number of children who came to emergency rooms with mental disorders rose dramatically.
"If we don’t address the growing pediatric mental health crisis it will directly affect how we can care and treat other pediatric illnesses in our community.
There is a shortage of beds nationwide for children in need of mental health care. A federal survey in 2020 revealed that there are fewer residential treatment facilities for children than 2012.
Nguyen stated that children at GBMC are often waiting two weeks on average for placement. According to hospital data, the average number of behavioral health patients in the pediatric emergency department was 42 per month between July 2021 and December 2022. This is 13.5% more than the same time period in 2017-2018, before the pandemic.
Hsu stated that mental health patients who are admitted to the emergency room can cause a ripple effect and can flood other areas of the hospital.
"For example, if a child cannot be transferred from a general pediatric to a specialist mental health center, it prevents a pediatric ICU child from being transferred to the general bed. This prevents an emergency department from admitting a child into the ICU. Hsu stated that health care is often interconnected in such a way.
"If we don’t address the growing pediatric mental health crisis, it can directly impact how we care for other pediatric diseases."