PC2141: Barriers in Transitions of Care for Adult Patients with Childhood-onset Conditions in the Inpatient Setting: A Case of an Adult Patient in the Pediatric Hospital with a Bronchopleural Fistula

Introduction: Adult patients with childhood-onset conditions face numerous barriers in their medical care, which has been exacerbated by resource availability during the COVID-19 pandemic. This case provides several examples of barriers facing this population, and highlights the need for improved transition processes.

Case Description: A 32 year old patient with spastic quadriplegia presents to the hospital for management of worsening dyspnea. She has a history of hypoxic ischemic encephalopathy, restrictive lung disease secondary to scoliosis, chronic pleural effusion, gastrostomy tube dependence, and epilepsy. She had been treated by her primary care physician for pneumonia with ciprofloxacin without improvement, and subsequently was brought to a large academic center with both free-standing pediatric and adult hospitals that are part of an integrated health system. The adult hospital had reached maximum capacity due to high COVID-19 census. Because of the critical need for adult capacity, she was identified as appropriate for admission to the pediatric hospital given her age and childhood-onset conditions. On admission, she was requiring 2 liters of supplemental oxygen via nasal cannula, and over the next day she developed worsening hypoxemia, reaching the pediatric floor maximum for oxygen supplementation. Given both her age and weight, she was deemed inappropriate for admission for the pediatric intensive care unit due to more limited capacity. Therefore, an adult rapid response was initiated, and she was transferred to the adult hospital. The process of having the patient accepted to Internal Medicine from Pediatrics and transferred between hospitals took approximately 4 hours.

Further work-up revealed a right-sided bronchopleural fistula with extensive herniation of the small bowel through the esophageal hiatus, and a loculated empyema, which necessitated chest tube placement for 10 days. Pleural fluid cultures grew Pseudomonas aeruginosa and possible Mycoplasma salivarius. She was ultimately discharged home with a four-week course of piperacillin-tazobactam and azithromycin. Since discharge, she has continued to show clinical improvement, therefore surgery has been deferred, given the risks due to her complex anatomy.

Discussion: As patients with childhood-onset conditions age into adulthood, they encounter unique barriers in medicine. This case in particular highlights a delay in care that resulted from resource allocation during the COVID-19 pandemic, as this patient likely would have been admitted to Internal Medicine if there were bed availability. Insufficient processes exist for the transition of care from pediatric to adult providers in the acute hospital setting, particularly during clinical decompensation such as in the case of this patient. Additional barriers include limitations in communication between providers and nonverbal patients, as well as caring for patients dependent on medical technology.

Conclusion: As these patients grow older, there is an increasing need for improved communication and efficient transition processes between pediatric and adult care providers.