P3A220: Experiencing the "Tripledemic": A Community Hospital Perspective

Background: In the fall of 2022, there was an early and robust RSV surge, an early influenza A outbreak, and the ongoing COVID-19 pandemic.2 The confluence of these viruses, called the “tripledemic,” led to a large number of pediatric patients seeking care in emergency departments. Children requiring critical care services needed to remain in community settings given limited pediatric inpatient capacity.

Methods: This is a retrospective study of patients ≤ 18 years old presenting to a community hospital ED from September – December 2021 (COVID-19 pandemic year 2) and September – December 2022 (COVID-19 pandemic year 3). We included all patients 18 receiving critical care as identified through billing and order data. The primary outcome was the number of patients receiving pediatric critical care over the study periods. Secondary outcomes included: 1) median ED length of stay (LOS) (ED rooming time to ED discharge time); and 2) patients with a prolonged ED LOS (>5 hours) We obtained data on viral testing results for the study periods to compare with ED volumes for patients receiving critical care. We reviewed the 4S’s (staff, space, stuff and structure) needed to care for children in our community hospital during this time period. This study was deemed exempt from review by the Institutional Review Board.

Results: For all pediatric patients 18 years old, there were 5758 ED encounters from September-December 2021 and 7085 ED encounters from September-December 2022, a 23% increase (p < 0.01). Between the two periods, the proportion of pediatric patients receiving critical care increased by 72% (314/5758 (55%) vs 540/7058 (76%); p< 0.01), and the proportion of patients who received critical care and had prolonged ED LOS increased by 69% (87/5758 (15%) vs 147/7058 (21%); p=0.02). For patients receiving respiratory-specific critical care, the proportion of patients increased by 83% (229/5758 (4%) vs 419/7085 (6%); p < 0.01); the median ED LOS increased by 7% (3.6h vs 3.9h; p=0.04); and the patients with a prolonged ED LOS increased by 88% (51/5785 (0.9%) vs 96/7085 (1.4%); p=0.03). The number of patients testing tested positive for RSV, COVID-19, or influenza increased between the study periods (Figure 1).
With regard to the 4S’s, we increased staffing shifts, ensured staff received pediatric critical training, facilitated discharges for children on low-level oxygen nasal cannula, increased supplies of high-flow nasal cannula circuits, and created policies to provide critical care for pediatric respiratory illnesses.

Conclusion: During the fall 2022 “tripledemic,” our community ED saw an influx of pediatric patients needing critical care especially those with respiratory-specific conditions with longer lengths of stays. Applying the disaster framework (4S’s) to develop strategies to manage high volumes with high acuity can be useful to other community hospitals for future pediatric ED volume surges.