BROKEN ARROW, Okla. – It was Lachlan Rutledge’s sixth birthday, but as he breathed heavily and blew out a candle, it was his mother who made a wish: a pediatric hospital bed in northeast Oklahoma.
Kindergarten child has connective tissue disorder, severe allergies and asthma. These conditions repeatedly brought him to the pediatric intensive care unit at Ascension St. John’s Medical Center in Tulsa, with collapsed veins and oxygen levels so low he was unresponsive to his doctor’s voice. mother.
But in April, the hospital closed its children’s floor to make way for more adult beds. So one September morning, after catching Covid for the fourth time and with what looked like bilateral pneumonia, Lachlan was struggling to breathe in a crowded emergency room at Saint Francis Children’s Hospital – the only remaining hospital pediatric option in Tulsa.
“We are always preparing for battle. It’s just a matter of where we’re going to fight,” said his mother, Aurora Rutledge, looking scared as she twisted the blonde curls that peeked out from under Lachlan’s Spider-Man headphones.
Hospitals across the country, from regional medical centers to small local facilities, are closing pediatric units. The reason is economic: institutions earn more money from adult patients.
In April, Henrico Doctors Hospital in Richmond, Va., ended its pediatric inpatient services. In July, Tufts Children’s Hospital in Boston followed suit. Shriners Children’s New England has announced that it will be closing its inpatient unit by the end of the year. Pediatric units in Colorado Springs, Raleigh, North Carolina and Doylestown, Pennsylvania, have also closed.
“They ask: should we be looking after children we don’t make money from, or use the bed for an adult who needs a bunch of expensive tests?” said Dr. Daniel Rauch, chief of pediatric hospital medicine for Tufts Medicine, who ran its general pediatrics unit until it closed over the summer. “If you’re a hospital, that’s a no-brainer.”
Many hospitals have converted children’s beds to adult intensive care beds during the pandemic and are reluctant to convert them back. Now staffing shortages, inflation – drug costs have risen 37% per patient from pre-pandemic levels – low Medicaid reimbursement and declining federal grants during the pandemic have left some health centers operating. with negative margins and eager to prioritize the most profitable patients.
Young patients like Lachlan, who has private insurance, occupy beds to recover from infections or asthma attacks, but don’t undergo lucrative, billable procedures — like joint or heart surgeries — that are more common among aging patients.
Doctors’ reimbursement through Medicaid, the insurance program for low-income people, is often only about 70 percent of the amount reimbursed through Medicare, the insurance program for seniors of all incomes. More than a third of children in the United States are enrolled in Medicaid.
There have been no aggressive legislative efforts to prevent hospitals from closing or downsizing their pediatric units. Democratic senators introduced a bill last year to provide funding to specialty children’s hospitals to improve their infrastructure, but it did not make it past the designated committee.
Health policy experts say an important solution would be to encourage hospitals to care for children by increasing Medicaid reimbursement rates. But even higher Medicaid and private rates wouldn’t come close to what hospitals can charge for adult-revenue procedures, and with many state budgets already stretched, experts say the regulatory move is unrealistic.
Hospitals that no longer admit children must transfer them to pediatric units in other hospitals. But when even the largest pediatric floors in the country are at capacity, the backlog of critically ill children in the emergency room can worsen patients’ conditions.
A crush in the emergency room
“Picu’s kids don’t belong here,” an overwhelmed ER doctor at a small Boston-area hospital wrote to his hospital’s chief medical officer two weeks ago in an expletive-laden text message. reviewed by The Times. (PICU stands for Pediatric Intensive Care. The text message was shared on the condition that the hospital is not identified.)
All of Boston’s children’s intensive care units were full at the time, and the closest open beds were in New Haven, Connecticut and Vermont. The doctor who sent the text considered intubating the child in the emergency room while waiting for a closer bed to become available.
As children return to school, waves of disease invade many remaining units.
“Forget the two-week January crush. We couldn’t find beds in May, August or September,” said Dr. Melissa Mauro-Small, chief of pediatrics at Signature Healthcare Brockton Hospital, near Boston. “There is no breathing season anymore. It is breathing season all year round.
A Plymouth, Mass. hospital that hadn’t transferred a patient to Dr. Mauro-Small’s hospital in a decade did so six times in 10 days recently, she said. ER staff at Lowell General Hospital outside Boston had to ask eight New England hospitals if they had room for an intubated 2-year-old, according to patient records reviewed by The Times. He transferred another patient to the nearest intensive care bed available – in Maine.
“At some point it was going to become a crisis,” Dr. Mauro-Small said. “And here we are.”
St. John’s Medical Center in Tulsa had been a community treasure for nearly a century when Ascension acquired it in 2013. The closure of the pediatric unit sparked opposition from families and referring pediatricians.
Dr. Michael Stratton, a pediatrician in Muskogee, Okla., said Ascension St. John had been “the first place to send a child” and that the closure of his pediatric unit had been “such a disservice to the whole East Oklahoma”.
A spokeswoman for Ascension St. John, where Lachlan had been admitted to intensive care three times before the shutdown, declined to be interviewed but said in an email the shutdown was prompted by a request for more adult beds. She also pointed to earlier statements that Saint Francis Children’s Hospital was “more than capable of picking up the slack.”
A spokeswoman for Saint Francis Children’s Hospital said it has at times reached full capacity and staff have transferred about 23 patients to other facilities, including in Arkansas, so far This year.
The ER “was busy even before the pediatric unit in St. John’s closed,” she said. Still, she said the hospital did not become overcrowded. “The volume is pretty consistent with what we usually see on a seasonal basis,” she said.
Some Oklahoman families with chronically ill children say they regularly travel to Memphis, St. Louis and Rochester, Minnesota, for care. The distances cause financial hardship and, in the worst-case scenario, force them to forgo care, said Katy Kozhimannil, director of the University of Minnesota’s Center for Rural Health Research.
For those in rural communities, the pediatric closures have made travel to what Dr. Rauch calls “bread and butter pediatrics” untenable. Johnny, 16, of Childress, Texas, had to be home-schooled so he could travel eight hours to Dallas for dialysis treatment three times a week, according to his doctor.
Jamaal Bets His Medicine, a 2-year-old with an autoimmune disease in Fort Kipp, Montana, regularly makes an 11-hour trip to Billings, Montana to receive infusions, his mother said, Patricia.
“Children are not small adults”
The largest decline in the number of pediatric inpatient beds has been seen in rural areas, where large health systems have acquired community hospitals and consolidated pediatrics on one campus.
Centering pediatric care in specialist centers can erode a local hospital’s ability to care for a critically ill child, say doctors.
“Children are not small adults,” said Dr. Meredith Volle, a pediatrician at Southern Illinois University School of Medicine in Springfield, Ill., who regularly sees patients who travel two to three hours. The number of pediatric beds in Illinois has declined, and 48 of its counties no longer have a pediatrician at all.
“When nurses and respiratory therapists become less comfortable with children’s cases, when units don’t have child-friendly equipment,” Dr. Volle said, “at a certain point you shouldn’t really don’t treat the kids anymore because you don’t treat them often enough to be good at it.
Critically ill children are four times more likely to die in hospitals and twice as likely to die in trauma centers that scored low on a “pediatric readiness” test, according to research. Only a third of children in a national research survey had access to an emergency department deemed highly “pediatrics-ready,” and of these, nine in 10 lived closer to a less-ready department.
A parent who is unaware of the wide variability, said Dr. Katherine Remick, executive director of the National Pediatric Readiness Quality Initiative, “could make a split-second decision that would change their child’s fate.”
The Rutledge family lives in Broken Arrow, a sunny suburb of Tulsa with an ice cream shop and a dentistry called Super Smiles. Their front porch is home to potted succulents, an abandoned scooter, and a 140-pound Great Dane named Thor.
But their life is far from ordinary. The last time Lachlan needed to see an allergy specialist, her mother packed the car with her nebulizer and medication for a 14-hour drive to Denver, leaving her husband, their two other sons and her mother, who was undergoing chemotherapy for two weeks. . Later, when doctors told her Lachlan’s disease seemed to be causing stomach ulcers — but Saint Francis’ only pediatric gastroenterologist was unavailable for months — she began planning a trip to Dallas.
On the September morning when Lachlan was in St. Francis struggling to breathe, the ER was so busy that Ms. Rutledge hooked him up to a pulse oximeter herself, quieting the monitor settings so it wouldn’t startle her. each time his heart rate increased. .
Lachlan tugged at his collarbone, his chest looking drawn in. Five hours later, he still hadn’t been admitted. Mrs. Rutledge’s hands were shaking and tears were streaming down her face.
“I know you’re exhausted in this hospital, and I understand,” she cried, leaning over Lachlan’s bed to level her eyes with the attending physician on the other side. “But you’re not sending this child home so he can see his own vital signs drop.”
Lachlan was discharged from the emergency room after 10 hours on a course of steroids to combat inflammation in his lungs. He sleeps in his parents’ room so they can check his oxygen level and administer nebulizer treatments every few hours throughout the night.
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