Pediatric Readiness of U.S. Emergency Departments
Myron Yaster MD, Lynne G. Maxwell MD, and Jayant K. Deshpande MD
“There can be no keener revelation of a society’s soul than the way in which it treats its children.” Nelson Mandela
The sad truth is that many U.S. hospitals are woefully underprepared for pediatric emergencies, that is, they lack “care coordination, personnel, quality improvement, safety, policies and procedures, and equipment to care for acutely ill and injured children.”1 The National Pediatric Readiness Project (NPRP), is a quality improvement initiative that was created more than a decade ago to improve survival among critically ill children.1-4 Despite the NPRP, pediatric readiness across U.S. emergency departments and trauma centers has not improved and may have actually worsened. In today’s PAAD and its accompanying editorial,2 the consequences on mortality and what it would cost to fix systemic problems are explored. Myron Yaster MD
Original article
Newgard CD, Rakshe S, Salvi A, Lin A, Cook JNB, Gausche-Hill M, Kuppermann N, Goldhaber-Fiebert JD, Burd RS, Malveau S, Jenkins PC, Stephens CQ, Glass NE, Hewes H, Mann NC, Ames SG, Fallat M, Jensen AR, Ford RL, Child A, Carr B, Lang K, Buchwalder K, Remick KE. Changes in Emergency Department Pediatric Readiness and Mortality. JAMA Netw Open. 2024 Jul 1;7(7):e2422107. doi: 10.1001/jamanetworkopen.2024.22107. PMID: 39037816; PMCID: PMC11265139.
Invited editorial
Burke LG, Beaute JI, Michelson KA. Saving Children’s Lives Through Universal Pediatric Readiness Is a Wise Investment. JAMA Netw Open. 2024;7(11):e2442139. doi:10.1001/jamanetworkopen.2024.42139
New York Times
Baumgaertner E. 1 in 4 Child Deaths After E.R. Visits Are Preventable, Study Finds. New York Times 10/01/2024. https://www.nytimes.com/2024/11/01/health/child-deaths-emergency-room.html
In today’s featured PAAD, the authors performed a retrospective cohort study and “examined changes in ED pediatric readiness among US trauma centers, as measured in 2013 and 2021, and the association with pediatric mortality (ED and in-hospital). The authors quantified the mortality associated with changes in ED pediatric readiness using the number of pediatric lives saved vs lives lost among trauma centers over a 10-year period.”1
“There were 467 932 children (300 024 boys [64.1%]; median [IQR] age, 10 [4-15] years; median [IQR] ISS, 4 [4-15]) at 417 trauma centers in the primary analysis, of whom 9544 (2.0%) died (4301 [45.1%] deaths occurred in the ED and 5243 deaths [54.9%] occurred while inpatient).”1 In addition, the authors reviewed 705,974 children in th medical cohort, of whom 7688 (1.1%) died. “Change in ED pediatric readiness, measured using the weighted Pediatric Readiness Score (wPRS, range 0-100, with higher scores denoting greater readiness) from national assessments in 2013 and 2021. Change groups included high-high (wPRS ≥93 on both assessments), low-high (wPRS <93 in 2013 and wPRS ≥93 in 2021), high-low (wPRS ≥93 in 2013 and wPRS <93 in 2021), and low-low (wPRS <93 on both assessments).”1
Perhaps not surprisingly, or at least not surprising to us, Newgard et al. found that “ED pediatric readiness decreased in US trauma centers between 2013 and 2021, particularly owing to the loss of pediatric emergency care coordinators (PECCs) and reduction in quality improvement. Observed mortality was highest in EDs with persistently low pediatric readiness, but fluctuated among other readiness change groups. Our risk-adjusted findings suggested that high ED pediatric readiness at trauma centers (persistent or change to) was associated with pediatric lives saved after injury. Conversely, low ED readiness at trauma centers was associated with lives lost.”1 Simply, if the center was not prepared for pediatric emergencies, mortality from trauma or medical illness increased. Finally, the authors, using of economic modeling, found that cost of upgrading pediatric readiness was relatively low. They estimated the cost of bringing all US EDs to high pediatric readiness at $207 million, which is less than 0.005% of the $4.5 trillion in US health care spending in 2022. Costs varied substantially between states, ranging from no cost in Delaware (which has already attained universal readiness) to $18 million in Texas. The estimated annual cost per child was highest in North Dakota at a modest $11.84 per child per year. Based on data from Newgard et al,5 we calculated that US costs per life saved were $96 750 and ranged in states from $53 157 to $216 325. Given the number of years most children will live, in all states this investment would achieve any cost-effectiveness threshold.”2
The authors note that “the NPRP assessment was repeated in 2021, but these data and the accompanying patient-level ED and inpatient data area not yet available.” They state “an additional study is under way to evaluate changes in ED pediatric readiness from 2013 to 2021 and the impact on pediatric mortality.” In addition, they state that “the American College of Surgeons has already introduced a requirement to assess ED pediatric readiness as part of the 2022 trauma center verifications guidelines.6 It should be noted that the American College of Surgeons Children's Surgery Verification Quality Improvement Program7 includes standards for personnel, staffing and equipment for adequate ED care of children as part of quality surgical care beyond trauma care, but this program applies only to children’s hospitals, not to the broad range of hospitals studied by the authors of today’s PAAD.
The editorial suggests that hospitals could be incentivized to meet the NPRP requirements by tying “ED pediatric readiness to reimbursement for care. In addition, this level of ED pediatric readiness could be made publicly available, allowing emergency medical services, physicians, and families to select high-readiness EDs. However, this option may have unintended consequences, such as worsened care in low-readiness EDs (based on further reductions in volume, clinician skill erosion, and greater quality divides), delays in care to avoid low-readiness EDs, and further competition among hospitals. Because 30% of children live more than 30 minutes from a high-readiness ED and 27% of children transported by ambulance do not have a high-readiness ED available, the optimal solution is to promote policies and incentives to increase ED pediatric readiness among all US hospitals, including rural and frontier regions.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Newgard CD, Rakshe S, Salvi A, et al. Changes in Emergency Department Pediatric Readiness and Mortality. JAMA network open 2024;7(7):e2422107. (In eng). DOI: 10.1001/jamanetworkopen.2024.22107.
2. Burke LG, Beaute JI, Michelson KA. Saving Children’s Lives Through Universal Pediatric Readiness Is a Wise Investment. JAMA network open 2024;7(11):e2442139-e2442139. DOI: 10.1001/jamanetworkopen.2024.42139.
3. Newgard CD, Lin A, Olson LM, et al. Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers. JAMA pediatrics 2021;175(9):947-956. (In eng). DOI: 10.1001/jamapediatrics.2021.1319.
4. Newgard CD, Lin A, Malveau S, et al. Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care. JAMA network open 2023;6(1):e2250941. (In eng). DOI: 10.1001/jamanetworkopen.2022.50941.
5. Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. JAMA network open 2024;7(11):e2442154. (In eng). DOI: 10.1001/jamanetworkopen.2024.42154.