COVID-19 presents challenges to pediatricians, school nurses, parents and kids
Patient visits to all kinds of doctors dropped markedly after the COVID-19 national emergency was declared in March. Pediatricians were no exception.
“Practice managers around the country report that their caseloads are as low as 20-30% of their practices’ typical caseloads due to social distancing, shelter-in-place, and families delaying or foregoing care,” wrote Sally Goza, MD, FAAP, president of the American Academy of Pediatrics, in a letter to HHS Secretary Alex Azar in April. “At the same time, pediatricians are facing higher costs, including personal protective equipment and workforce training, as they transform their practices to meet the needs of their patients and families.
“The dramatic drop in revenue compounded with higher costs is forcing practices to confront furloughs and layoffs, cancel vaccine orders, and in many cases, consider permanent closure.”
At the same time, pediatricians can anticipate an influx of patients this fall, as parents and school administrators make sure their kids get the vaccinations they missed in the spring and summer. To accommodate them, practices will have to adjust their workflows and their workplaces for social distancing, isolation of patients with potential viral infections, etc. They may be called on to treat kids who, after months of staying at home and experiencing the frustrations of virtual learning, suffer from high levels of anxiety.
Mental health issues
The primary objective of annual physicals for kids – including “back to school” visits – is to monitor their social, emotional and physical well-being, Goza told Repertoire. But this year’s back-to-school checkup will be different.
“Mental health will be a big issue this year because of the pandemic and sheltering at home. Kids will have been out of school a long time. Did they miss much of their academics? How far behind are they? What kind of stress will that cause? Are they prepared for their schools to close again should a second wave arise? Change brings stress, and all of that will play into pediatric visits this year.”
Pediatricians will share that stress. Practices will need to enforce physical distancing in their offices, thoroughly wipe down exam rooms between visits, and stagger or extend office hours, says Goza. They may need to step up their efforts to communicate to families and schools the importance of keeping vaccinations up to date, and about keeping an eye on the social and emotional health of their children. Flu vaccines will remain a priority. “And we will have to figure out how to manage COVID-19 vaccinations, if they are available,” she adds.
What’s more, the Centers for Disease Control and Prevention cautions that given declines in routine pediatric vaccine ordering and doses administered during the pandemic, U.S. children and their communities face increased risks for outbreaks of vaccine-preventable diseases.
Telemedicine may help. The American Academy of Pediatrics strongly supported the use of telehealth during the COVID-19 pandemic. The technology is well-suited for monitoring mental, social and emotional wellness, but not for hearing/vision tests, physical exams or vaccinations, says Goza. “In the future, we may conduct more combination visits, with some being done over the phone, and the rest done in a shorter visit to the practice.”
Still, the pediatric community wonders what will happen when the pandemic ends. “Will telehealth be reimbursed at parity with all visits?” she asks. The issue could become important should a second wave strike.
The school nurse
As they do every year, school nurses will play an important role in keeping kids and their communities healthy this fall, says Laurie Combe, MN RN NCSN, president of the National Association of School Nurses.
“School nurses are sentinels who identify wellness and illness in the school community,” she says. “We engage in early identification of communicable disease; we collaborate with health departments to report and manage those illnesses to protect the entire school community. We manage immunization compliance and student access to immunizations. We use our health expertise to inform educational professionals about best practices and how to keep communities safe. We engage in health education. We coordinate care, and we translate medical plans for disease management for the classroom. And we collect and track data about students’ health.”
NASN members have some anxiety about the coming school year, says Combe. They question when schools will reopen, and the guidance from health and public authorities about safety precautions is in a state of flux. Teachers, custodians and other school staff share that anxiety, as do parents. “All this will probably result in more visits than ever to the nurse’s office this fall,” she says.
Part of the challenge facing school nurses and staff is the fact that most of the symptoms of COVID-19, as listed by the CDC, are the same symptoms kids display during non-pandemic times, says Combe. Students come to the clinic with stomachache for lots of reasons, many of them having to do with emotions they haven’t recognized or acknowledged, she says. Throwing up is not necessarily a sign of ongoing illness.
“The school nurse takes the health history, learns about the factors that might bear on that symptom presentation, and then, based on nursing education and training, makes the determination whether the student is fit for class or not,” she says. In light of COVID-19, that health history will address whether the student or someone in their family was exposed to the virus.
The Centers for Disease Control advises daily temperature and symptom screening of school children when feasible.
“‘Feasible’ is the big question,” says Combe. “When I last worked on a school campus, I had 3,600 students. What will that screening look like? How will schools reinforce social distancing while students wait to be screened? How much instructional time will be lost as schools conduct daily mass screenings?”
As they prepare for the school year, each school system will have to make decisions about screening based on the needs of their community, enrollment and availability of personnel. “Then there are the questions, ‘When is the best time to check temperature?’ Is it when students arrive at school? Is it before they get on the school bus? The logistics are confounding.”
School nurses also have concerns about maintaining the confidentiality of students during mass screenings. “If students are pulled out of line, will they be subject to stigma or bullying?” asks Combe. “I know schools will be addressing these issues.”
Some school systems may rely on parents to assess and be accountable for their children’s health, she continues. But if parents find it difficult to leave their children at home while they go to work, will they under-report symptoms for the sake of the family’s economic survival?
Meanwhile, teachers and staff may be asked to respond daily to an online survey before entering the building, verifying that they checked their temperature and do not display any symptoms of COVID-19. “It’s efficient, and it creates ownership and collegiality among school staff,” says Combe. Once students are seated, teachers will be challenged to manage physical distancing and the wearing of face masks while carrying on vibrant instruction.
School nurses always need PPE on hand in the course of their duties, for dealing with emergency situations, medication administration, diabetes care and help with toileting, says Combe. Because of COVID-19, they may need N95 respirators, face shields, even gowns if they are called on to perform a procedure that aerosolizes pathogens.
The American Academy of Pediatrics’ Goza says that pediatricians will have an increased need for gloves, face shields, cleaning supplies, needles and syringes, and more during this year’s “back to school” season. And they may ask their distributors for payment extensions, given the financial impact of COVID-19.
“What I would ask distributors to do is to see how they can help practices stay viable,” she says. “If pediatricians and other doctors can’t stay open to take care of the needs of children, we will be in big trouble.”