How a children’s hospital set up an on-campus daycare in 72 hours during COVID-19

Rocking babies to sleep, logging kids onto Zoom school lessons, and coloring with preschoolers – these activities were all in a day’s work for CHOC Children’s child life team as they ran a pop-up on-campus daycare center for children of hospital staff during the COVID-19 emergency this spring.

“It brought me back to my early days as a parent,” says Amber Chavez, a special programs coordinator for the Cherese Mari Laulhere Child Life Department.

That the child life department could ultimately be tasked with setting up on-campus childcare for hospital staff in the event of a large-scale disaster or crisis was well-known among the team. They had long planned for that possibility, stocking up bins of activities and supplies carefully marked by age group – just in case.

So, when schools in Orange County, Calif., began closing on-campus instruction in mid-March, the team sprang into action immediately.

A survey conducted through CHOC’s emergency communication system revealed that nearly 600 staff and physicians did not have backup childcare. Then, the child life team, in collaboration with executive leadership and other departments, scurried over the weekend to establish an on-campus daycare for physicians and staff who directly support patient care and throughput and had no other childcare options.

A child life specialist sits with two children enrolled in CHOC's on-campus daycare for staff.
Child Life Specialist Peggy Mok with a CHOC staff member’s child

Just in time

Within 72 hours of receiving notices of school campus closures, the center had an emergency operating license, and was open and available in a conference center of the main hospital campus.

In addition to a robust programming schedule, the compound featured a space for naps, a play area, computer stations for school-aged children, a diaper-changing area, and anything that could possibly be needed to care for children of a wide age range while their parents worked in the hospital.

“CHOC providing these services was heaven-sent,” says Dr. Sonia Morales, a hematology/oncology fellow who enrolled her daughter. “It made a very stressful time less stressful. There is no greater feeling than having your child squeal with excitement when she’s being dropped off.”

The team quickly established a schedule and routine – and support from many other hospital departments was critical.

Older children would get checked-in, their backpacks placed in a cubby and any upcoming Zoom class appointments set as an alarm on a phone. After enjoying breakfast provided by food services, the children could play video games for a bit sometimes – to their delight – broadcast on the center’s large screen. A team of CHOC physical therapists would come by twice daily to lead the kids of all ages through activities and movement exercises.

“We tried our best to support the kids through this difficult time as well,” says Eric Mammen, the child life department’s creative arts supervisor, who helped develop the daycare’s schedule and oversee day-to-day operations. “We also helped with homework when needed and I had to learn how to do elementary math and English again. I admit I had to use Google a few times helping the kids with their homework.”

CHOC's conference center is transformed into an on-campus daycare center
The conference center at CHOC Children’s Hospital converted into a daycare center

A true collaboration

The project was truly a collaboration between many departments across the health system, including environmental services, food services, legal services, patient care services, human resources, information systems, plant operations, regulatory, safety and security, and volunteer services.

And the result was a daycare center that provided wonderful care, structure and fun – not to mention peace of mind for many CHOC working parents who could rest assured their children were safe and happy while they supported patients. 

Little Diego Valencia had never been in daycare before he came to CHOC’s center, says his mother, Jamie, a nurse in the recovery center.

“He will remember all of them forever,” she says. “Without child life’s kind hearts, I would not have been able to work. It was easy to leave Diego in their care because they took such good care of him.”

Being able to check on and nurse her young daughter has been a relief for Dr. Bhavita Patel, a hematology/oncology fellow.

“I cannot say enough about the phenomenal child life staff taking care of our children,” she says. “Bless them for their diligence and flexibility during this time. It takes a village, and they have quickly become a crucial part of mine. My anxiety and overall mental health have improved drastically as a result.”

A child life specialist sits with two children enrolled in CHOC's on-campus daycare for staff.
Special Programs Coordinator Amber Chavez and two young charges

An exercise in agility

Running the center was also an exercise in agility for the child life department, requiring the team to quickly adapt and make changes to meet evolving needs.

The compound’s layout and schedules were adjusted occasionally when needed. Child life specialists made quick dashes to a nearby drug store for nightlights after noticing the windowless conference center was too dark for little ones to nap without fear. Plant operations were called in after realizing an overhead page could thwart a half hour’s work to rock a baby to sleep.

While already a close-knit team, the child life team grew more bonded after the experience.

“It wasn’t easy, but we grew stronger as a department and team,” Amber says. “We lifted each other up when times were tough, and we laughed in times of need.”

Earlier this month, the center’s operations transitioned to a national childcare chain. And though the child life team has transitioned back to their more typical work, the team might be feeling a touch of separation anxiety.

“The child life staff bonded with the children and they looked forward to seeing everyone,” Eric says. “I think it is safe to say that we will all look at the Wade Center a little differently now.”

Learn more about the CHOC Children’s Cherese Mari Laulhere Child Life Department.

How COVID-19 survivors can support others through plasma donation

For Steve Emfinger, donating his blood plasma at CHOC Children’s was fast, painless and a way to give meaning to his battle with COVID-19.

“It was very simple,” he said. “And to know it’s helping kids is very cool.”

Man donates plasma to help COVID-19 patients
Steve with his COVID-19 convalescent plasma donation at CHOC Children’s Blood Bank.

Registered with the U.S. Food and Drug Administration, the CHOC Children’s Blood Bank is available to collect and process blood plasma donations from COVID-19 survivors. These donations are being used to help patients at CHOC and throughout the community.

“We’re still learning about COVID-19, but it’s possible that those who have recovered from the disease have produced antibodies to protect them from the infection,” says Dr. Antonio Arrieta, a pediatric infectious disease specialist who is studying the use of convalescent COVID-19 plasma at CHOC. “If so, their blood plasma would contain these antibodies and may be helpful in the treatment of COVID-19 disease in others.”

Since CHOC began collecting and processing blood plasma donations from recovered COVID-19 patients this spring, more than a dozen CHOC patients have benefited.

And as COVID-19 diagnoses continue to mount in Orange County and fall approaches, the need for blood plasma donations will only grow at CHOC, Dr. Arrieta says.

A surprising diagnosis

Typically, an early riser with boundless energy, Steve just felt zapped in late winter. Attributing the lethargy to two back-to-back trips he’d just taken, Steve decided to work from home. 

Though his symptoms – including a slight cough and dizziness – were minor, Steve’s energy shift was so atypical that he ultimately decided to go to a local hospital. There, he was tested for the flu and strep throat and had a chest scan, which all came back negative.

Steve had one more test – for COVID-19. A couple days later, he got word the test was positive.

Steve hunkered down at home, and notified any friends, family and neighbors he’d been in contact within the weeks before his diagnosis. Some days he felt good – able to work remotely and cook meals – and others were much more challenging.

All in all, though, Steve felt fortunate to have mild symptoms, never experiencing a fever, body aches or significant respiratory problems, despite a lifelong mild case of asthma.

“I think I’m blessed to know that I had minor symptoms and was able to get through it and my family didn’t get sick,” he says.

As Steve’s diagnosis came early into the pandemic’s spread in Southern California, he was initially reluctant to share his story with a broader network of friends, family and colleagues. But as he got more comfortable, Steve’s decision to tell others proved fortuitous.

A friend who worked at CHOC told Steve about the COVID-19 convalescent plasma program and how badly donations were needed.

“I had heard that blood plasma was needed, but I didn’t know where to find a donor center,” he said. “I called CHOC the next day to make an appointment.”

The process to donate plasma to support COVID-19 patients
Steve has already donated plasma twice at CHOC Children’s to help support others fighting COVID-19.

Steps to donate

Potential donors must meet some criteria to be eligible:

  1. Donors must show laboratory test proof of their COVID-19 diagnosis either through a diagnostic test (nasopharyngeal swab) at the time they were sick, or a positive serological test for SARS-CoV-2 antibodies after they recovered.
  2. Donors must have been symptom-free for at least 14 days before they donate.
  3. They must meet all other health requirements for blood donors.
  4. Though donors may be male or female, female donors will need to meet some additional requirements that the Blood Bank team will help explain further.

Confirming these requirements takes about a week. Once donors are confirmed and at the Blood Bank, the simple donation process takes about two hours. Donors can return every 28 days to donate again.

Steve is already on his second donation at CHOC and plans to continue in the future – in addition to donating blood and platelets.

“To help someone else makes it all worth it,” he says.

To schedule an appointment or learn more, call the CHOC Children’s Blood Bank at 714-509-8339.

Multisystem Inflammatory Syndrome in children (MIS-C) and COVID-19: What providers should know

Multisystem inflammatory syndrome in children, or MIS-C, is a new syndrome that has been reported worldwide in an increasing number of children who had or were exposed to COVID-19. MIS-C shares many characteristics with Kawasaki disease, an inflammatory disease of childhood that can affect blood vessels.

This Q & A with Dr. Negar Ashouri, a pediatric infectious disease specialist at CHOC Children’s, explores what providers should know about MIS-C, including recently released guidance from the American Academy of Pediatrics.

What is MIS-C?

MIS-C is a rare complication temporally associated with COVID-19. Here is the case definition, per a U.S. Centers for Disease Control Health Advisory:

  • An individual aged <21 years presenting with fever (>38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours); laboratory evidence of inflammation (Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, D-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin.); and evidence of clinically severe illness requiring hospitalization, with multisystem (≥2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurological); AND
  • No alternative plausible diagnoses; AND
  • Positive for current or recent SARS-CoV-2 (COVID-19) infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the four weeks prior to the onset of symptoms.

Is MIS-C dangerous?

MIS-C can be serious, but most children have recovered. MIS-C, like Kawasaki disease, can be a very uncomfortable illness because it causes prolonged fever, irritation and inflammation in many tissues of the body. The main concern with MIS-C and Kawasaki disease is heart and blood vessel involvement.

Conditions that involve inflammation in the heart, such as MIS-C or Kawasaki disease, can affect the heart in different ways. They may cause the heart muscle to be irritated and inflamed, affecting the overall function of the heart.

They may also weaken the wall of one or more of the coronary arteries causing them to bulge or balloon out. Blood clots can form in the ballooned area and possibly block the blood flow through the coronary artery. When this happens, the heart muscle will no longer receive an adequate supply of oxygen-rich blood, and the heart muscle can be damaged.

Dr. Negar Ashouri, pediatric infectious disease specialist, CHOC Children’s

What are the symptoms of MIS-C?

Though clinicians have described differing presentations, sign and symptoms can include an ongoing fever, inflammation detected by blood test, and evidence of organ dysfunction or shock. Here are additional common symptoms:

  • Kawasaki disease-like features including conjunctivitis; red eyes; red or swollen hands and feet; rash; red cracked lips; and swollen glands. Some children have presented with coronary artery enlargement or aneurysms. Some children may present with  more gastrointestinal (abdominal pain or diarrhea) or neurologic (headaches/meningitis) manifestations.
  • Toxic shock syndrome-like features with hemodynamic instability.
  • Cytokine storm/macrophage activation or hyperinflammatory features.
  • Shortness of breath suggestive of congestive heart failure.
  • Respiratory symptoms typically reported in adults with COVID-19 may not be present in pediatric patients with MIS-C.

Patients with the following symptoms ought to seek emergency care:

  • Persistent fevers
  • Trouble breathing
  • Pain or pressure in the chest that does not go away
  • New confusion
  • Inability to wake or stay awake
  • Bluish lips or face
  • Severe abdominal pain

How is MIS-C diagnosed?

Children who present with symptoms may undergo expanded laboratory testing and a cardiac workup that may include:

  • Routine screening labs including CBC with diff, CRP, CMP, and appropriate cultures;
  • If expanded work-up is warranted for hospitalized patients, it may include  troponin, pro-B-type natriuretic peptide, triglycerides, creatine kinase, ,  D-dimer, prothrombin time/partial thromboplastin time, international normalized ratio,  ferritin, lactic acid dehydrogenase,  and fibrinogen, if not already conducted;
  • COVID-19 testing performed with RT-PCR assay and serologic testing in every case;
  • echocardiogram;
  • electrocardiogram;
  • chest X-ray; and
  • abdominal ultrasound.

When should a provider suspect MIS-C?

Per the AAP, any child with suspected MIS-C should also be evaluated for infectious and noninfectious etiologies.

An initial sign may be a persistent fever without a clear clinical source. Providers should be suspicious of any fever accompanied by symptoms concerning in their severity or coincident with recent exposure to COVID-19.

Some children clinically progress rapidly and may develop hemodynamic compromise. These children should be followed and cared for in a hospital with tertiary pediatric/cardiac intensive care units.


How is MIS-C treated?

Kawasaki and MIS-C are best treated in the hospital by a qualified multidisciplinary group of pediatric specialists who will work to reduce inflammation and minimize long-term heart damage.

Here is the APP guidance for treatment:

  • Some patients with MIS-C have been treated with IVIG, Occasionally,  Patients have also been treated with steroid therapy  and or biologics that may require taper of the medications overtime.
  • Given the need for early intervention and the need to initiate treatment for multiple possible etiologies, many patients have received concurrent antibiotic therapy.
  • A multidisciplinary group is generally involved which may include Infectious disease specialists, cardiologists, intensivists, hospitalists and rheumatologists.

What is the follow-up for patients with MIS-C?

Children who have had serious cases of MIS-C should have close outpatient follow-up care by a group of specialists which may include cardiology, hematology and infectious diseases.

Refer a patient to the infectious disease team at CHOC Children’s.

CHOC hematologist appointed to national COVID-19 therapy evaluation oversight committee

Dr. Diane Nugent has been named co-chair of the Steering Committee for the National Heart, Lung, and Blood Institute (NHLBI) Collaborating Network of Networks for Evaluating COVID-19 and Therapeutic Strategies, or CONNECTS, which will coalesce projects into a national, coordinated effort. She will also serve on the Executive committee for CONNECTS to facilitate the rapid turnaround and implementation of these grants throughout the country.

In addition to her work at CHOC, Dr. Nugent, in this new role, will help fulfill the objectives and ensure compliance for CONNECTS, which will be will be responsible for selection, implementation and analysis of all COVID clinical trials; data streams; biorepository/cohorts; and molecular and phenotypic correlations with the overarching mission to fast track therapies and vaccines that are validated through the hypothesis driven process and proven truly effective.  

“I am honored to help advance the body of knowledge around COVID-19 treatments and contribute meaningfully to work that is so critically needed as we confront this global crisis,” says Dr. Nugent, medical director of hematology at CHOC. “I also wish to stress the importance of research specifically in children and patients with chronic disease to help us understand why certain individuals are at high risk and how this infection impacts health at various ages, and over time. We are beginning to see the late and long-term effects in patients now and need to be prepared for future evolution of disorders in the heart, lung, blood vessels and brain over the next years and decades.”

Dr. Diane Nugent, medical director of hematology at CHOC Children’s

CONNECTS is an integration of major NHLBI clinical networks to collaboratively and efficiently conduct clinical trials while ensuring standardization, shared resources and data, and flexibility to nimbly shift studies as needed based on new knowledge and the changing pandemic clinical landscape. Master protocol-driven adaptive platform trials will be aligned with, or formally part of, National Institutes of Health’s Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) Initiative.

CONNECTS is directed by NHLBI in collaboration with the Biomedical Advanced Research and Development Authority (BARDA), U.S. Department of Health & Human Services’ Operation Warp Speed, and NIH initiatives.

The Executive and Steering committees are charged with overseeing the design, implementation, and analysis of CONNECTS study protocols, including:

  • interpretation, presentation and publication of results;
  • use of common data elements and data standards across CONNECTS study protocols; and
  • sharing of data, biospecimens, images, and other research products developed by CONNECTS.

A prolific author on innovative medicine, Dr. Nugent has coauthored more than 100 journal articles and book chapters. She specializes in all aspects of hematology, bone marrow failure, anemias, immune disorders, bleeding and clotting disorders. Her clinical and research interests include blood disorders, bone marrow failure, bleeding and clotting disorders, and white cell and immune deficiencies.

Refer a patient to a CHOC Children’s hematologist.

Mental health resources to share with patients, families during COVID-19

We know living through a pandemic can compound existing mental health problems or introduce new ones for young patients. And for many providers, the COVID-19 pandemic has prompted a flurry of tough questions from patients and their families: How do I explain this to my children? How do I help my child understand why their birthday party is canceled? How do I maintain normalcy while my child is out of school and stuck at home?

If you’re also fielding these questions from worried caregivers, this compilation of resources from CHOC Children’s — with more to come — can help address these questions and more:

Information, strategies for children, teens with depression, anxiety

Tips for parents of teens

Stress-busting tips

Strategies for kids of all ages

En Español

Self-care tips for parents

Find more information to share with patients and families about COVID-19 at choc.org/coronavirus.