Table 1.

Summary of challenges faced by paediatric services during COVID-19 outbreak

Challenge	Details	COVID19 Responses	Proposed future strategy
Personal protective equipment (PPE)	Unfamiliarity with PPE, including donning and doffing procedures Time required to train all of workforce Adequate stores/logistical issues	Real-time training of staff (time consuming) Some trusts chose not to complete recommended training/fit-testing due to time constraints Lack of trust from frontline healthcare workers in employers/public health bodies with impact on staff retention	New strategy for fit-testing of healthcare workers – for example, mandatory fit-testing of selection of FFP3 masks at start of job for all healthcare staff, variety of fit-testing methods employed Regular donning and doffing training and simulation of caring for patients wearing PPE Hub and spoke approach to training, supported by HCID centres
Workforce Planning	Shortage of staff working in frontline areas (A+E, Critical care etc) No centralised record of staff skills and vulnerabilities Staff in ‘wrong place’, no NHS passport, difficulties in mobilising staff	Line-managers contacting staff to gather information re skills/vulnerabilities Occupational health overwhelmed by staff requests Unclear guidance for ‘vulnerable’ staff Complex discussions between trusts at executive level to arrange memorandum of understanding	Regularly updated records of staff skills and vulnerabilities to allow rapid and appropriate deployment of healthcare workers (HCW) NHS passports for all HCW– rapid mobilisation between trusts if necessary Standardised and transparent guidance for deployment/protection of vulnerable staff
Maintenance of essential services	Primary care overwhelmed by increased patient load and staff self-isolation/illness Community services not adequately in place to support hospital at home Frontline community workers/carers not initially provided with PPE or training to use Parental fear of attending healthcare settings to receive vaccines and so on	Elective procedures cancelled to free up space and workforce Slow change in configuration of community services Slow delivery of information /reassurance to public re services	Pre-planning for back up of essential services for example, pharmacy/school nurses to deliver primary immunisations and so on Early clear public information regarding which services will continue Pre-identification of ‘pandemic free’ clinical areas to conduct clinical work for these services Recent recognition of importance of basing paediatric services in the community should be expanded and established more permanently
Paediatric Critical Care	Unavailable real-time information of level 2 and level 3 critical care capacity Limited back up work force available for rapid expansion Limited adult critical care skills within paediatric workforce Children with life limiting conditions, often very vulnerable to such viruses with poor outcomes, not having had appropriate discussions about emergency care planning with their home clinicians. This had led to sometimes inappropriate, stressful and occasionally futile PICU admissions	Regional leads for paediatric critical care (PCC) calling all PICU daily for updated admission information, capacity inaccurately published Rapid webinar-led training of other hospital staff – uncertainties, anxiety and possible inadequate care Difficult conversations with families under extremely stressful circumstances, limited visitors due to COVID and sub-optimal end of life care Difficult conversations over telephone regarding end of life care with families Shortages of certain medication and access to renal replacement therapy and loss of PIC beds and staff to meet AICU demand – required rapid modelling based on previous PICANET data to ensure enough PIC capacity ring fenced for any critically ill children at this time.	NHS digital support for real-time information of level 2 and 3 critical care capacity all the time, not just during pandemics. All hospital based healthcare training (medical and nursing) should include at least one placement in critical care; adult and paediatric ICU staff should have shared learning Early community led discussions with families of those children for whom critical care may be unsuitable with support from hospital teams Premade e-learning packages as well as simulations and resources to aid rapid critical care learning for non-intensivists Templates for “cheat sheets” – for day to day management of critically ill children or adults that can be rapidly modified to meet need. Continue to improve modelling based on paediatric critical care needs to ensure appropriate PIC capacity maintained Early joint discussions with AICU, pharmacy, nephrology network to plan cohesively for future pandemics
Protection of Vulnerable Populations	Over-inclusion of many patient cohorts into high-risk populations High level of anxiety	Centralised definitions of at risk populations, rather than by specialist clinicians/societies Mixed messages from NHSE/PHE versus specialist groups/societies	Early involvement of specialist groups/societies to identify at risk groups & unified single response to avoid confusion/anxiety National registry for chronic conditions to allow rapid information dissemination to relevant populations
Communication	Top down communication with poor cascading Unclear routes of dissemination Centralisation of decision making, without involving those at the frontline eg junior doctors, nursing staff and so on Poor initial use of tele/video communications	Delayed recognition of importance of regular transparent messaging to frontline staff High level of anxiety, concern re concealment of truth, lack of trust in those in positions of authority Development of daily communication emails, information on intranet Eventual recognition of importance of in-person or face-to-face information delivery	Recognition that although information is limited at the start of the outbreak, transparency about decision making crucial to gain trust of frontline staff Early regular conveyance of information, even if caveats about need to be flexible included Early use of established networks to disseminate information and share decision making process
Time	Clinical and nursing staff involved in planning doing so on top of usual work commitments	Exhaustion and over work	Early recognition that those in planning/organising role need to rescind other responsibilities for duration of outbreak
Innovation	Extraordinary ability to make decisions and act during ‘major incident’ mode Multiple competing research studies for same patient cohort Rapid roll out of funding, ethics and regulation to allow appropriate research to be done Initially poor standardisation of clinical management	Extraordinary leaps due to need Dormant studies with ease to ‘awaken’ re opened Standardisation of treatment - utilise established networks to share guidance nationally and internationally Shared experience internationally – learning from those countries who entered the pandemic first	Early centralised approach to research to minimise duplication More important to get accurate results than early results into literature – peer review still necessary Continue rapid rate of innovation and clear decision making pathways after outbreak Retrospective review of data to inform future outbreaks Review of which management strategies were effective and which were counter-productive
Response to pandemic	Didn’t think big enough early enough	Planning for next two phases, rather than for the next ten phases	When preparing guidance write for today, tomorrow, this week, this month and this year at the same time – consider all worse case scenarios