Impact of adapting paediatric intensive care units for adult care during the COVID-19 pandemic: a scoping review

Abstract

Objectives

The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research.

Design

Scoping review.

Methods

This study used Arksey and O’Malley’s six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate.

Results

47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges.

Conclusion

COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients.

Correspondence to Katie Hill; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Broad, comprehensive literature search and study selection yielding a wide range of results.

• The study used rigorous scoping review methods.

• The screening and data extraction were performed in duplicate.

• As this is a scoping review, no assessment of the risk of bias of the included studies was completed.

• All relevant studies may not have been identified or included as non-English studies were excluded.

Introduction

Paediatric critical and intensive care medicine have rapidly evolved into an extraordinarily complex and intricate medical field.¹ Paediatric intensive care units (PICUs) are high-acuity units that provide an increased level of clinical observation, invasive monitoring, specialised interventions and technical support to care for critically ill children with a range of medical conditions around the clock over an indefinite period.^{2 3} Within a PICU, there are multidisciplinary teams of highly skilled specialists and professionals such as paediatric physicians, nurses and physiotherapists, working together to deliver intensive care.¹

On 11 March 2020, the WHO officially declared (novel) COVID-19 a pandemic,⁴ and it placed an extraordinary demand on global adult critical care services, even causing some health systems to collapse.^5–7 This was evident early in the healthcare services in Spain and Italy, with clear evidence that other countries, including the UK and the USA, would face similar challenges.⁸ During the first 18 months of the pandemic, the ethical principles of fair resource allocation and the concept of doing all that is possible, required that the resources for caring for critically ill patients be shared,⁹ to ensure the maximum benefit from collective resources.¹⁰ This unprecedented demand for healthcare services had a substantial impact on children’s hospital services. These ranged from delays in presenting to the emergency department (ED) out of concern for contracting COVID-19, to a decline in healthcare visits, leading to serious health consequences for children.^{5 11–16}

As the demands on the resources of adult intensive care units (ICUs) increased worldwide during the pandemic, there were significant adjustments required in some PICUs, including transitioning into adult ICUs to meet the increasing demands of patient needs.^16–22 Lynn et al²³ found that in Ireland and the UK, the COVID-19 pandemic brought additional challenges to healthcare for children. Similar findings have been reported in additional studies in Ireland,^24–26 the UK^27–31 and across numerous other countries including, Italy,^32–35 the Netherlands,³⁶ Germany,³⁷ Canada,³⁸ the USA^39–41 and Australia.⁴²

The restructuring of PICUs and paediatric hospitals to accommodate critically ill adults must take into consideration the categories of children who are admitted to PICUs daily. Since the emergence of COVID-19 in December 2019, the experience in China and Italy suggested that 98% of all infections were in adults, with at least 5% of adults infected with COVID-19 requiring critical care admission.²² Only 2% of infections were in the paediatric population, with just 1%–2% of those requiring admission to PICUs.^43–46 In the initial surge of COVID-19, the occurrence of the disease in children was uncommon, with a reported mean age for most patients in adult ICUs being between 65 and 70 years.^47–51 Children who have presented with COVID-19 have not usually required PICU admission.⁵² In adults, the virus causes severe acute respiratory distress syndrome.⁶ In children, the disease appears to be milder, but a severe multisystem inflammatory syndrome has been reported.^{53 54}

The aim of this scoping review is to provide an overview of the organisation of care in PICUs during the first 18 months of the COVID-19 pandemic. The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of PICUs during the first 18 months of the COVID-19 pandemic. Additionally, this review sought to identify any knowledge gaps in the literature and to recommend areas for future research.

Methods

Scoping review design and data collection

As presented in the published protocol,⁵⁵ this scoping review follows the recommended framework introduced by Arksey and O’Malley.⁵⁶ At the consultation phase relevant experts working in PICUs were consulted to confirm that the keywords and inclusion criteria were appropriate. No further consultation was required throughout the process.

Identifying the relevant studies

Full details of the search process are available in the published protocol.⁵⁵ The review took place between 15 and 20 June 2022. Five databases were identified to ensure a wide coverage of the literature. CINAHL (1981–), MEDLINE (1946–), PsycINFO (1990–), PsycARTICLES (1998–) and EMBASE (1966–). Grey literature was also included in the data search to ensure all relevant evidence in this arena was explored and was accessed via Opengrey and greylit.org. Manual searches of the reference lists from the included reviews were also carried out to cover the breadth of existing evidence. All results were exported into EndNote for deduplication and then into Covidence for screening. Our inclusion and exclusion criteria were, therefore, as broad as possible in terms of subject, but specific in that included articles must describe discussions around changes to activity in PICU during the first 18 months of the COVID-19 pandemic. Studies were included if they were published between December 2019 and May 2021, which covered the first 18 months of the COVID-19 pandemic. Publications that were not in English were excluded due to the non-availability of translators, which is recognised as a limitation of the review.

The first five data extractions and categorisations of articles were completed independently by two reviewers and were compared with pilot the tool, while also assessing if the results were consistent with the research question. Following the successful completion of these initial data extractions, the extraction and categorisation of data for each subsequent article was completed independently by two of the reviewers, while a third reviewer assessed the process, and completed spot-checks on 10% of the overall extractions. The third reviewer was also available to deal with any discrepancies which could have arisen. Each reviewer had previous experience with completing scoping reviews.

Analytical approach

Thematic analysis was used to analyse the findings of the studies, using qualitative descriptive methods to review the literature.⁵⁷ Findings were grouped into thematic categories and the key findings are presented.

Patient and public involvement

No patient involvement was sought for this review.

Results

The search resulted in 82 803 papers; with 47 631 left after the removal of duplicates. They included peer-reviewed academic articles, discussion papers, research studies, editorials and commentaries. Given the diversity of publication types, the assessment of methodological quality was not feasible in any meaningful way. This is a common feature of scoping reviews and makes them different from systematic reviews.⁵⁸ On reviewing and reading, 25 articles met the criteria for the extraction of relevant information (refer to figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for more details). The inclusion and exclusion of articles were discussed and agreed between the researchers.⁵⁷ The reasons for excluding articles included, those focused on non-PICU settings, including general wards in children’s hospitals or adult wards, some that explored healthcare professionals’ experiences not working in PICUs and some that related to the impact of COVID-19 on child health. A PRISMA flowchart (figure 1) was produced after the completed searches to ensure transparency of reporting⁵⁹ and outlined the process through which articles were included and excluded from the review.⁶⁰ The PRISMA flowchart was used solely for summarising and reporting of the findings.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the study selection process exploring the impact of adapting PICUs for adult care during the COVID-19 pandemic. CICU, cardiac intensive care unit; ICUs, intensive care units; PICU, paediatric intensive care unit.

Based on the articles found, a small number of PICUs retained their sole purpose, that of looking after children and did not admit adult patients.^{52 61–66} Articles dealing with this circumstance were subsequently excluded from this review as they did not meet the criteria. Other studies reported on the redeployment of staff from PICUs into adult ICUs, as a result of the pandemic, to increase the capacity for adult ICU beds.^{67 68} These studies were also excluded from this review as their aim did not meet the inclusion criteria.

Study types and countries

There were a variety of study designs and publication types included within the selected articles of this review. They were studies with primary data, commentaries, reviews and opinion pieces. Specifically, there were 11 studies with primary data, including retrospective chart reviews, and 14 review papers which included literature reviews, reflective pieces and discussion papers. The list of publications included articles from the USA (13), the UK (3), the UK and Canada (1), the UK and the USA (1), France (3), Spain (1), Australia (1), the Netherlands (1) and a study across a European Network (Ireland, Italy, Spain, Finland, the UK, Latvia, Poland, the Netherlands) (1). Interestingly, no studies were found from China or Italy that met the criteria, which were two of the countries initially worst affected by COVID-19.⁶⁹ Online supplemental appendix 1 provides the study characteristics of the included studies. The results illustrate the changes occurring within PICUs during the first 18 months of the COVID-19 pandemic. Three main themes emerged from the articles reviewed: (1) the reorganisation of space for increased capacity incorporating equipment and supply changes; (2) increases in staffing and support including training, clinical care and governance; and (3) the resulting challenges.

Reorganisation of space for increased capacity

Several PICUs reorganised their structures to accommodate both child and adult patients within the same physical space,^{6 16 22 41 70–75} with others refocusing to care for adult patients only.^{9 20 76–81} These hybrid models, of caring for both children and adults by the same staff and within the same space required significant adaptation to manage these two very different cohorts of patients.⁷¹ The transformation of PICUs to accommodate critically ill adults occurred rapidly, usually in less than 2–3 weeks, with some units transforming within as little as 10 days.¹⁶ In some hospitals, the restructuring of departments and units occurred alongside the cancellation of non-emergency theatre lists to free up critical care capacity to accommodate caring for children alongside adults on ventilators.⁷⁴ Several other studies during this period reported on this hybrid model of caring concurrently for children and adults in the same physical space,^{16 71} because of the declining needs of children for elective surgeries and the low disease burden associated with COVID-19 in children. The reported benefits of transforming PICUs when a children’s hospital was situated within an adult hospital, included shared administration, management, resources and supply chains. Although preparation time was very short, strong multidisciplinary team cooperation helped to maximise the effective transformations from PICUs into adult ICUs.²²

Numerous studies reported on hospitals completely converting their PICUs to care for adults instead of sending their resources to adult hospitals,^{9 19–21 76 77 81} and moving children out of PICUs to other locations including the operating theatre recovery rooms.⁷ Within these reorganised PICUs, the physical space was adjusted to care for adults.^{75 76} This involved creating different areas for donning and doffing personal protective equipment (PPE) for staff,^{16 22} and included major construction such as building additional walls to restructure units to accommodate increased patient loads⁷⁰ and changing ventilation systems.¹⁶ The introduction of telemedicine and telehealth services were implemented across all hospitals to improve care delivery,⁷³ and as reported across other studies, clinical support to staff in PICUs was extended.^{71 82}

Wolfe et al⁸³ recognised that although staff from PICUs and adult ICUs are not entirely interchangeable, many staff from PICUs could provide safe care to adults with common diseases also seen in PICUs, mirrored in findings by Sachdeva et al.⁷² Likewise, a retrospective chart review by Gist et al⁷⁸ explored the experiences of repurposing a PICU into an adult critical care unit and compared the outcomes for adults admitted to a paediatric (n=9) and adult medical ICU (n=140). The average age of those admitted to the PICU was lower than those admitted to the adult ICU and those admitted to the PICU presented less complex cases, and fewer to no comorbidities, allowing the PICU to function with relative independence. The outcome for patients cared for in the PICU was no worse than for those in the adult medical ICU. Since this was an observational study with a small number of patients within a single PICU, this limits the generalisability of the conclusions. However, it suggests that careful assessment of critical illness considering the age and comorbidity type, are the most appropriate for PICUs in general hospitals, which corresponds with the aforementioned studies.^{72 78}

The task of caring for adults within a PICU required not only the reorganisation of physical space, but also a redistribution of equipment and supplies. Several studies reported on operational changes made to space to accommodate this change in patient load, including, PICU stockrooms being restocked with adult appropriate equipment.^{7 9 22} Other studies highlighted PICUs stocking adult and paediatric equipment and medications together,⁸² including easily recognisable adult and child resuscitation equipment.^{16 22} In addition, modes were changed on ventilators and monitors in the PICUs to accommodate both child and adult variables.^{16 72} However, Jansen et al¹⁰ highlight that the reallocation of resources and reorganisation of space is not simple in practical terms, due to the increased risk to patient safety, creating overall challenges in extending the scope of practice for staff and changing previously functioning systems.

Staffing and support

The studies within this review emphasised the changes that occurred with respect to staffing when accommodating adult patients in PICUs, both alongside children and in units solely dedicated to the care of adults. Providing care to critically ill adults in PICUs produced staffing considerations that included the assessment of the clinical experience, skills and capabilities of staff.⁷ Changes in staffing requirements, involved employing more staff, adjusting rosters, implementing staff shadowing systems, cooperation between hospitals and the redeployment of staff.^{9 17 20 21 74 75 82}

Staff in PICUs cared for adult patients in close consultation with adult clinical teams, although specific service delivery models varied across PICUs.²² All PICUs operated a supervised staffing model, with paediatric staff supported by adult staff, whether virtually or in-person^{41 81} and dual-trained healthcare professionals were used where available⁷¹ to safely accommodate adult patients within the reorganised physical space in PICUs. Cooperation and collaboration between adult and paediatric teams was regarded as fundamental. Given the anticipated knowledge and skills gap, the assistance from adult healthcare professionals offered a reframing of the clinical models of care and allowed for consultative and collaborative processes to be implemented between adult and paediatric staff.^{21 22 78} Siva et al⁷⁵ and Wasserman et al⁸¹ reported on the importance of adult ICU staff and services remaining readily accessible to assist the PICU team and to provide subspeciality consultations.

Poncelet et al⁷⁹ conducted a questionnaire in seven COVID-19 ICUs (two PICUs and five adult ICUs), to investigate whether changes in care conditions for the staff in PICUs that switched from caring for children to adults, during the first wave of the pandemic, caused increased job stress. The results of the study found that despite the drastic changes required due to the pandemic, and the resulting revisions to clinical practice, the prevalence of job strain was like that reported by Dodek et al⁸⁴ in 13 Canadian adult ICUs under usual pre-pandemic conditions. Poncelet et al⁷⁹ conclude that PICUs can be used to admit adult patients, without an increased risk of additional job stress among staff in PICUs.

Some hospitals opted for nurses to operate within a team or shadow system, pairing those with adult experience together with a PICU nurse.^{71 78 81} Similar findings were reported by Mcnamara et al,⁷⁴ where multidisciplinary collaboration with a neighbouring adult ICU, facilitated a consistent approach to management, and adult and paediatric clinicians could work cohesively to share skills and knowledge. Responding to the surge in patients with COVID-19 also involved developing a multi-stakeholder team consisting of paediatric and adult leaders to discuss how best to respond to the needs of patients.⁸²

Keeping PICU teams together in a familiar environment while caring for adults, mitigated certain patient safety risk factors and encouraged resilience during this emotionally and physically challenging time.⁷¹ Kneyber et al¹⁷ discussed the experience in the Netherlands of retaining their PICU capacity but expanding it to include adults and finding their main hurdle was how to staff the unit. PICU staff wished to stay in their familiar environment to care for adults, with some contracts upgraded to full-time equivalents and leave of absences revoked until further notice.

Similarly, Yager et al²⁰ reported that PICU nurses and physicians, rather than redeploying to other areas, opted to stay in their familiar environment and take advantage of the years of established relationships to optimise performance, despite caring for a different patient cohort. Chomton et al⁹ reported that caring for adult patients was easier within the staff’s own familiar unit, instead of being redeployed to a unit with unfamiliar colleagues and equipment.

Success within PICUs was highly dependent on collaboration and support from the adult care team⁸² and through the preservation of team composition by minimising unnecessary personnel changes.²⁰ To provide the necessary resources to deliver safe care to adults at the bedside, there was a need for a clear chain of command, in addition to excellent leadership and constant support.⁷ PICU physicians were well situated to care for adult patients in this pandemic and reported this opportunity as building greater collegiality within their teams.⁷⁶

As a result of the reorganisation of care within the units and required staffing changes, significant upskilling of staff occurred across all of the hospitals.^{21 22 76 81} Adult competencies of staff were addressed with appropriate training arranged where necessary.⁸² Gaps in knowledge were identified and adult ICU nursing educators provided education and coaching.⁷¹ These training sessions, including the donning and doffing of PPE⁷⁰ and simulation training of clinical scenarios,⁸² enhanced the ability of staff to safely care for critically ill adults.²¹ The training was reported as reducing anxiety and promoting a sense of preparedness within teams.⁷¹

A joint statement from the Statutory Regulators of Health and Care Professionals⁸⁵ provided reassurance to paediatric healthcare workers that working in cooperation with adult specialists and using the best available evidence was acceptable to the relevant regulatory bodies.²² The development of adult-specific guidelines, including checklists and quick guides, were rapidly distributed and regularly updated to support the management of critically ill adults.^{22 80}

Fernandes et al²¹ reported good clinical outcomes for patients when the PICU staff were supported by adult colleagues and dedicated operational processes were implemented. Sinha et al²² also found that paediatric teams can give excellent care to adults with outcomes comparable to adult ICUs, provided there is effective communication and strong leadership. Despite the provision of training and the techniques implemented to support staff, there were numerous challenges with the transition of patient loads and the changes required within PICUs to accommodate adult patients.

Challenges associated with the reorganisation of PICUs

Although most studies reported a positive experience when caring for adults within their PICUs, it was not without its challenges. The establishment of adult COVID-19 ICUs within PICUs was demanding and required coordinated multidisciplinary efforts to convert the space, equipment and teams to adequately care for adult patients.¹⁶ The rapidly evolving clinical management of patients with COVID-19 was testing for staff, but the creation of cohesive guidelines helped.⁷¹ Effective communication with staff, patients, families and the wider paediatric hospital community was critical in overcoming challenges.⁷

Deep et al⁷¹ reported on the difficulties associated with maintaining team morale during these challenging times. Staffing changes and redeployment caused additional stress, due to non-PICU staff requiring significant oversight from adult ICU staff in ensuring safe delivery of care and adherence to adult ICU protocols.⁹ There were issues around the availability of ventilators and where safe, neonatal and portable ventilators were used for children, to free up ventilators for adult use.⁷¹ Additionally, some units reported medications and supplies running low, with aseptically compounded medications being used beyond their expiration dates, and intravenous tubing changed less frequently, which was against standard hospital procedures.⁷¹

Furthermore, challenges arose around specific issues in adults that were unfamiliar to paediatricians, including, various comorbidities and anatomical differences⁹ and a difference in practices between adults and children, such as sedation.¹⁶ Inexperience with specific equipment and pharmacy protocols also caused distress for staff.⁷⁵ Other challenges included PPE shortages, and fear, relating to PPE availability,^{70 76} and the rationing of essential medical equipment.⁷⁶

The quick transition within these units left staff little time for emotional processing, giving rise to feelings of relief and pride, mixed with severe anxiety, stress and fear.⁷⁶ As a result of visitor restrictions, staff reported concerns, particularly around end-of-life care, because of the high degree of isolation for patients who were alone and without family members.⁷⁶ Discussions regarding advanced directives and resuscitation were held with family members over the phone, which was a major deviation from normal family-centred care practices in the PICU. The requirement to provide care as quickly as possible to protect healthcare professionals was challenging, as this could not be further away from the normal environment of care in PICUs.⁷⁶ The normal ethos within paediatric healthcare is, ‘to care for a child is to care for their family’, and the absence of family was ‘unsettling’ and ‘heart-breaking’ for staff (p2).⁷⁶ Staff reported the ways in which they tried to make the best of these difficult situations, using video conferencing, and allowing one person a compassionate visit if death was imminent. This helped somewhat with improving practices during end-of-life situations.⁷⁶

Despite the highlighted difficulties and challenges, there did not appear to be any adverse adult patient outcomes reported.^{71 76} Staff described finding it rewarding, and an opportunity for growth.⁹ Teams reported coming together to provide excellent care for those admitted to their PICUs.^{16 76} The reorganisation and sharing of staff and equipment was easier in children’s hospitals that were already physically part of larger centres.⁸³ In stand-alone hospitals, this sharing of resources required additional planning and was more challenging than in facilities where child and adult hospitals were in close proximity.⁸³ Despite different logistical issues, the ethical issues remained the same. Wolfe et al⁸³ also highlight that although there were strong ethical grounds for justice, fairness and social utility, in treating all general ICU resources as equal during a pandemic, there were correspondingly strong grounds for considering that paediatric healthcare professionals may need to practice outside of their usual scope of practice and comfort zone to care for critically ill adults.

Discussion

The COVID-19 pandemic has changed professional practices in adult ICUs and PICUs due to the sudden and increased number of critically ill patients.⁷⁹ PICUs have been significantly impacted by the pandemic, providing care not only to children but also to adults, which is outside of their normal daily functioning.⁷² The themes identified within this review are consistent with published recommendations about repurposing adult ICUs to care for critically ill adults.^{86 87} PICU involvement in caring for adults during the current COVID-19 pandemic may constitute a reliable option for expanding the adult ICU bed capacity beyond the traditional boundaries.⁷⁷ However, a ‘one size fits all’ approach, is not universally effective, as different hospitals will implement alternative scenarios based on the availability of resources.

The consensus across studies was that it may be easier for PICUs to set up their own adult unit instead of redeploying PICU staff to the unfamiliar setting of an adult ICU, and in some areas, this was a necessity as many adult ICUs were out of space.^{9 88} Preserving the PICU team ensured a rapid transition and boosted staff morale, while creating a strong relationship between adult and paediatric critical care medicine within the hospital.¹⁷ Globally, the transformation of a PICU into an adult ICU was based around clearly outlined principles, applied to local requirements, to allow several adult critical care patients to be successfully cared for by PICU teams.⁸⁸ Interprofessional working and collaboration between teams were critical to the success of care delivery. This enabled potential barriers to be identified and allowed solutions to be created which was essential to the daily functioning of the units.¹⁹ Critical to the success of the transition into caring for adult patients in PICUs was collaboration between key stakeholders, rapid training, oversight and support from adult physicians to ensure competency.^{19 81}

Adaptation to create hybrid models of care successfully facilitated an expansion into caring for critically ill adults, while also providing essential services for critically ill children.^{16 71} Simultaneous care for children and adults within the same ICU space can be sustained, if teams of healthcare professionals work collaboratively, exhibit clear leadership, and provide ongoing support and training for all staff.^{16 71} By implementing a dynamic, hybrid model, the services remain responsive to the rapidly changing demand for critical care beds, provide increased capacity for critical care adults at the right time, and can continue to provide ongoing specialist paediatric services.⁷¹ This flexibility ensured that the PICUs have been upskilled to care for adult patients, which is a valuable resource for any additional surges with unpredictable demands and outcomes.⁷¹

A large body of research is emerging concerned with the physical, mental and emotional impact the pandemic is having on staff.^89–91 However, these features were not predominant during this scoping review. Despite the challenges, it was reported that adult patients were cared for effectively and safely in PICUs. Staff reported finding their experiences rewarding, with opportunities for professional and personal growth while caring for adults in a PICU.⁹ Staff reported positive experiences of effective team working and successful collaboration, which is consistent with the wider literature reporting on the concepts of strong teamwork, camaraderie and fulfilment that were associated with working in adult ICUs during the pandemic.⁹⁰ Future research into the reorganisation of care within PICUs during subsequent waves of the pandemic and exploring staff experiences within these units is essential to ascertain any ongoing challenges that may arise. Future research should specifically explore challenges faced by staff in PICUs that adjusted their units to care for adult patients during the pandemic. Changing situations may present themselves within different time periods of the pandemic.

This pandemic is not unprecedented. Previous pandemics include the Spanish Flu in 1918–1919, the Asian Flu in 1957–1958, the SARS pandemic in 2002 and the Middle East Respiratory Syndrome (MERS) in 2012. Interestingly, there is very limited data available on the impact of paediatric experiences, including care delivery in PICUs during the SARS pandemic in 2002 and MERS in 2012.^{92 93} This might be because children were reported as being less commonly and less severely affected by these infections than adults.⁹⁴ Reports about care delivery in paediatric EDs identified similar themes, with decreased visits and reduced lengths of stay due to the pandemic,⁹⁵ with no literature available around caring for adults in PICUs during these pandemics. Al-Dorzi et al⁹⁶ report the use of an old PICU to care for adults, but this was merely for extra space, as the PICU had been vacated when a new paediatric hospital had been opened. However, the consistent message from the SARS and MERS experiences, in common with COVID-19, was that although children were affected by these diseases, overall, the greater disease burden and higher mortality rate was in the adult populations.^{97 98}

Following these pandemics, previously proposed strategies to provide surgical capacity if adult ICUs were overwhelmed, was to use the availability of PICUs.^{99 100} Children’s hospitals must work with public health agencies to determine the best way to support adult hospitals and the wider community when these situations arise.¹⁰¹ This scoping review offered a valuable opportunity to learn from the COVID-19 pandemic. The reports on the experiences of PICUs caring for adults prompt recommendations for future global pandemics in a PICU setting—something that is absent from the research literature. This scoping review will contribute to ensuring that future research in this area can be planned appropriately to address any gaps in the scientific knowledge and continue to provide recommendations for best practice, beginning with exploring healthcare professionals’ experiences of working within these restructured PICUs during the pandemic.

Limitations

The studies included in this review were all in the English language. Due to the nature of the scoping review, there is a potential that relevant articles and policies or guidelines may have been missed, and this is recognised as a limitation to this review. Another limitation of this review is the potential lack of generalisability given each site was quite different and the included studies were very heterogenous. This review only focused on the initial 18 months of the pandemic. This review only explored changes to care delivered within PICUs and excluded other changes within the hospital setting because of COVID-19 including redeploying staff to adult ICUs and those PICUs which did not admit adult patients. Additional findings could have been reported in the period since then, as the pandemic evolved, and hospitals have continued to adjust and manage this increased burden of care.

Conclusion

COVID-19 has strained institutional resources across the globe. This scoping review examined the reorganisation of care within PICUs during the first 18 months of the COVID-19 pandemic. To relieve the burden on adult ICUs, some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The findings highlighted the complex requirements to effectively care for adults in the PICU, including the reorganisation of space, staffing adjustments and the resulting challenges that arose.

Building relationships between adult and paediatric services can strengthen health systems and healthcare communities beyond this pandemic. Through educating staff and retaining many elements of paediatric practice, healthcare teams can meet pandemic demands and provide excellent, safe patient care. This scoping review has contributed beneficial knowledge in the event of further waves of COVID-19, but also in the face of other inevitable, future healthcare crises. Further research exploring healthcare professionals’ experiences of working in PICUs during COVID-19 is critical to build on the knowledge gained through this review, to give the nurses and physicians who are working in these areas a voice to share their experiences.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Ethical approval is not required for this scoping review. However, this study is part of the European Research Council (ERC) TechChild project where ethical approval was previously obtained from the relevant academic and clinical Research Ethics Committees, nationally and internationally. The results from this study will be disseminated through interdisciplinary paediatric intensive care conferences and in peer-reviewed academic journals related to intensive care.

Footnote

Contributors All authors contributed to conceptualising and designing the study. KH, MB and CM independently performed screening. KH and MB independently performed data extraction. KH performed initial data synthesis and MB and CM refined it. KH drafted the manuscript. MB and CM made revisions. All authors read and approved the final manuscript. KH is responsible for the overall manuscript.

Funding This project has received funding from the ERC under the European Union’s Horizon 2020 research and innovation programme (grant agreement no. 803051).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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