Johns Hopkins Pediatric Hospital (Pediatric ICU — PICU)

Strategies to increase ICU Capacity: Convert a Pediatric ICU (PICU) into an Adult ICU (Johns Hopkins Case)

Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs

Levin, Amanda B. MD; Bernier, Meghan L. MD; Riggs, Becky J. MD; Zero, Stephanie D. BSN, RN; Johnson, Emily D. MSN, CPNP; Brant, Katelyn N. MBA, BSRT, RRT-NPS; Dwyer, Joe G. MAEd, RRT, EdD(c), CPPS; Potter, Caroline J. MS, CCLS; Pustavoitau, Aliaksei MD, MHS, FCCM; Lentz, Thomas A. Jr MS, MBA; Warren, Emily H. MSN, RN; Milstone, Aaron M. MD, MHS; Schwartz, Jamie McElrath MD

Series: Surge Critical Care Capacity Management (ICUs)


We outline the construction, logistics, supplies, provider education, staffing, and operations.

We share lessons learned of working with a predominantly pediatric staff blended with adult expertise staff while maintaining elements of family-centered care typical of pediatric critical care medicine.

Critically ill coronavirus disease 2019 adult patients may be cared for in a PICU and care may be augmented by implementing elements of holistic, family-centered PICU practice.

To the Editor:

The Johns Hopkins Hospital (JHH), a 1,003-bed facility with embedded 203-bed children’s center, is a National Emerging Special Pathogens Treatment Center with a dedicated biocontainment unit that quickly reached capacity with critically ill COVID-19 patients (11).

JHH was able to fulfill its pediatric mission as consequence of a lower patient volume but needed to expand adult ICU capacity to support a surge of patients (12,13).

We describe the conversion of half of our PICU into an adult negative-pressure COVID-19 ICU.


At the time of PICU conversion, JHH had increased ICU beds from 118 to 172 in both converted subspecialty ICUs and repurposed adult acute care spaces.

Yet, rising cases locally and transfers from affiliate hospitals necessitated additional capacity.
With a PICU census less than half of the available beds, the PICU was the next unit for conversion.
Transformation of the PICU into two units occurred over 10 days (Fig. 1).

Timeline of events leading to the opening of an adult coronavirus disease 2019 (COVID-19) ICU in repurposed PICU space in March 2020 and April 2020. A, Maryland state and institutional responses to the developing local outbreak by day of month. B, Dates of steps taken to convert the physical space of the PICU and ready staff for opening of the negative-pressure adult COVID-19 ICU. WHO = World Health Organization.

Physical Plant

Construction included building a separation wall, sealing of pneumatic tube stations and doorways, and creation of one donning and two doffing anterooms, one accommodating patient transport.
The main ventilation system was converted, so patient rooms were negative pressure to the hall and portable high efficiency particulate air fans made the donning and doffing anterooms positive pressure to the unit and outside corridors. Pressure monitors were installed ensuring donning and doffing areas sustained a positive pressure relationship to adjacent spaces.

Conference rooms and workrooms were repurposed in the neo-PICU to accommodate six-foot distance between staff.
With significant visitor restrictions, unused family kitchens and waiting areas were repurposed for staff respite areas. Offices were moved outside the PICU.


PICU providers were recalled to the BioDome from deployments and blended with additional staff. The BioDome staffing was with PICU attendings, fellows, nurses, and RTs. Housestaff was intentionally augmented with senior residents from Medicine/Pediatrics, Anesthesiology, and Emergency Medicine to strategically blend in providers with adult experience. The primary PICU BioDome team was supported with a daytime adult intensivist from the launch team, and an adult ICU resource fellow and nurse were on site 24/7 for a week. A standing JHH resource is the central intensivist (CI), a 24/7 roving adult intensivist supporting the hospital in ICU bed management and crisis care. After the first week, we relied on the CI with either phone consultation or could immediately be present in the unit if needed. These adult colleagues provided patient management support, especially in patients with complications unable to be managed with published resources or those with advanced disease (14). All staff were cleared by hospital epidemiology and infection control to work in both COVID-19 units and non-COVID-19 units. Physician, fellow, and resident scheduling allowed for dedicated around-the-clock BioDome staff separate from the PICU, whereas nursing and RT staff were assigned on a shift by shift as needed basis to not only our BioDome but multiple COVID-19 units throughout the institution.

A PICU social worker with adult medical ICU experience, adult critical care pharmacists, physical and occupational therapists (PTs/OTs), pediatric palliative care nurse practitioner, and dietician participated in virtual rounds with occasional in-person support. All consults were made to adult subspecialists.

Centralized COVID-19 teams were available for additional support:

  • an anesthesia airway team performed intubations;
  • the CI-led emergency response team assisted in emergencies;
  • an ICU nurse, RT, and PT/OT assisted with prone positioning;
  • and a transport team ensured safe transports.
  • A procedure team was available, but PICU fellows completed all procedures.

All patients were transferred to a specific ICU for extracorporeal support if needed, with streamlined consultation and activation.

Equipment/Supply/Medication Preparation

Personal Protective Equipment

Electronic Medical Records



Unit Function

In addition to nursing, at least one physician and RT were always present inside the BioDome. All staff staggered frequent breaks to respite areas. Physician handoffs were staggered and occurred outside the unit, whereas nursing and RT handoffs occurred on the unit.

We created workflows to limit BioDome traffic, PPE use, and separate movement of staff and patients from the neo-PICU. For example, staff carried supplies in, helped with cleaning, and transported trash to doffing areas.
We relied on point-of-care ultrasound to reduce need for portable radiography. Specialists consulted by phone, entering the unit only when physical examination was required. We optimized teleconference rounding utilizing a headset, video camera, and speakers.

Uniquely Pediatric

Unit Closure

Additionally, the need for PICU beds steadily increased as delayed procedures became urgent, and we began admitting critically ill pediatric patients with multisystem inflammatory syndrome.

The PICU BioDome was open for 3 weeks and was the second converted adult BioDome ICU space to return to pre-COVID-19 functions.
Initially, the negative pressure system was turned off, the separation wall and adult supplies/medications remained, and the unit was slated to support adult non-COVID-19 ICU patients to be staffed by our adult colleagues. However, the adult patient ICU census was manageable without our space, so the separating wall was eventually removed.
As we look forward to uncertain and likely changing need, our unit is now prepared to adapt to future increased ICU needs, either pediatric or adult. Adult supplies are maintained in a separate storage location, and monitors and message systems are set to pediatric presets, but we now have ready operations to convert back to adult mode.
In anticipation of a second wave in the fall of 2020, no other modifications were undone and the BioDome can be rapidly reinstituted.

After BioDome physical closure, PICU attendings, nurses, and RTs continued to support the other institutional adult COVID-19 ICUs as independent staff for an additional 7 weeks.


  • We rapidly established an independent PICU run and led BioDome considered equal to the other institutional COVID-19 ICUs.
  • Working in the BioDome required increased staff to facilitate breaks for hydration and rest, reduce PPE facial pressure injuries, and hand-deliver medications and laboratory specimens.

Our greatest growth was our ability to connect with patients and each other.

  • We used iPads and speakers in each room to link with families.
  • Staff members wore cleanable photo buttons with their picture, name, and title enabling patients to see behind the PPE.
  • We established routines of communication with families thrice daily with an early identified decision-maker.

We experienced growing pains as well.

  • Ascertaining practice styles and reconciling variations while learning COVID-19 medical care took time.
  • Although we appreciated the launch team’s expertise and knowledge, chains of command often blurred between the PICU attending/fellow and the resourcing adult attending/fellow.
  • This required direct, clear, and consistent communication regarding ultimate patient management responsibilities belonging to the PICU attending.
  • Having a dedicated and small PICU BioDome attending cohort assisted in keeping consistency.
  • Additionally, the PICU attending was physically present in the BioDome or the work space more frequently than normal to ensure open and uniform communication.
  • Whereas PICU physician staff was supported with colleagues from the adult divisions of our Department of Anesthesiology and Critical Care Medicine, our nursing colleagues were supported with resources from outside their department.
  • Despite PICU nurses gaining familiarity with adult ICU bedside nursing and personnel from redeployments, there were instances of strain between adult and pediatric nursing practices such as sedation and pressor titration.
  • Our PICU relies heavily on physician-guided protocols rather than nurse-driven, which is common in our institution’s medical ICUs.
    At times, the physician-driven practices and increased presence were interpreted as overbearing from the adult ICU resource nurses.
    Once there was an openly stated shared mental model of practice style, tensions eased.
  • Additionally, learning the nuances of working in the adult system, such as extracorporeal membrane oxygenation activation or dialysis initiation, sometimes occurred in real time, as these therapies were needed.
    After occurring once, lessons learned were shared with the whole team, making the next instance easier.

Overall, the pandemic fostered a collaborative and “all-hands-on-deck” spirit throughout JHH with all disciplines assisting each other freely.


  • Establishing an adult COVID-19 ICU in a PICU was a challenge requiring coordinated multidisciplinary efforts to convert space, equipment, and teams.
  • Nevertheless, by educating PICU clinicians in COVID-19 medical practices and retaining many elements of pediatric practice, we meet pandemic demands and provided excellent patient care.

Edited for Brazil by

Joaquim Cardoso

Senior Advisor for Health Care Strategy to BCG
Boston Consulting Group

Chief Researcher for Health Transformation to HTI
Health Transformation Institute



Senior Advisor for Health Care Strategy to BCG — Boston Consulting Group

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Joaquim Cardoso @ BCG

Senior Advisor for Health Care Strategy to BCG — Boston Consulting Group