The loss of pediatric beds and expertise in community hospitals
Myron Yaster MD, Eugenie (Genie) Heitmiller MD, and Jayant (Jay) K. Deshpande MD
I’m sure there are times when you are on-call and it is raining elbow fractures requiring emergency surgery that, in your exhaustion, you are sure that your hospital’s orthopedic surgeons had community give aways for trampolines and bicycles. In reality, the number of children who require emergency surgery may not have changed but the distribution of who and where they are cared for certainly has. In the past, many pediatric patients requiring emergency surgery were treated in community hospitals by non-pediatric surgeons and anesthesiologists. No more. Today’s PAAD reviews articles1-3 that discuss the consequences of reduced pediatric hospital capacity and emergency medicine expertise in dealing with trauma and critically ill children. Myron Yaster MD
Original article: Commentary
Mahant S, Guttmann A. Shifts in the Hospital Care of Children in the US-A Health Equity Challenge. JAMA Netw Open. 2023 Sep 5;6(9):e2331763. doi: 10.1001/jamanetworkopen.2023.31763. PMID: 37656462
Original article
Wall Street Journal
Whyte LE and Evans M: Children Are Dying in Ill-Prepared Emergency Rooms Across America. Hospitals and regulators have done little to ensure E.R.s are ready to treat children in emergencies, while researchers prove taking basic steps can save lives. https://docs.google.com/document/d/1pUQNr4Q45A98Lga4CLGFcwmjlO5c3b1UqOC_1b-ty2s/edit?pli=1
Over the past 2 decades, major reductions (20-25%) have occurred in pediatric hospital capacity in general hospitals, particularly in rural areas.2, 4 “Access to care is compromised, increasing risks for poorer outcomes. Pediatric unit closures may also result in pediatric specialists pulling their outpatient services from a community, further compounding the lack of access to pediatric care. When pediatric patients are transferred outside their local area for hospitalization, the impact on the family and child during this already stressful experience is not inconsequential and may include reduced social and extended family support, time away from paid work, and the indirect costs of being displaced from one’s community. Children with chronic diseases who experience frequent hospitalization may be disproportionately impacted if their local hospital does not admit children or has reduced capability to address their needs.5 Furthermore, inequities based on race and ethnicity overlap with and may intensify inequities based on geography.6 Access to health care is just one of several social determinants of health that challenge the health of those living in rural areas.”1
Why has this happened? As our mentor Dr. Mark Rogers always said: “no matter what they say, it’s always about money”. Almost 5.2 million children are admitted to U.S. hospitals yearly (down from 6.4 million 15 years ago) and although pediatric hospitalization costs have increased substantially over the last decade, reimbursement for these stays represents a small fraction of most hospitals’ total revenue.”2
“Across all hospital types, Medicaid was the predominant payer, covering 43.1% to 52.6% of birth hospitalizations and 54.0% to 61.6% of nonbirth hospitalizations. Rural hospitals had the largest proportion of hospitalizations covered by Medicaid, and more than one-half of rural hospitalizations were experienced by children living in communities with the lowest median incomes. Poverty is a well-established risk factor for pediatric hospitalization; rural-residing children also experience greater unmet health care needs, increased rates of several chronic diseases, and higher child mortality than their urban-residing peers...Thus, low population densities, health professional shortages, substantial hospital fixed costs, and low Medicaid reimbursement rates may contribute to rural hospital closures and loss of dedicated pediatric services at the hospitals that remain open.”2
Which brings us to the article by Whyte and Evans in the Wall Street Journal.3 With loss of pediatric hospital beds and specialists, there is a loss of expertise amongst physicians working in these hospital systems. Why should we be surprised that age-appropriate equipment, medical knowledge and technical expertise will disappear in these institutions? And what happens when children arrive with acute medical and surgical emergencies? Or if they have chronic illnesses and/or technology dependence?
As pediatric anesthesiologists, we can play a part in solving this problem. Consider the suggestion by Mahant and Guttmann1: “Telehealth and technology can be used to support care locally and reduce the need for hospitalization….Other system improvements and innovations that have been suggested include interhospital transfer standards, collaborations between general and children’s hospitals to support high-quality care, and supporting the social and economic needs of displaced children and families around the period of interhospital transfer. However, addressing the financial shortcomings and market forces underlying rural hospital and pediatric unit closures is challenging.”1
We think there is a role for SPA and ASA to help train and maintain expertise in pediatric advanced life support for general anesthesiologists, intensivists, emergency medical doctors, and medical transport teams. As members of a hospital’s medical staff, anesthesiologists can provide expertise and avail transport capabilities to pediatric regional hospitals. We can help transport teams to gain and maintain pediatric skills, similar to what Mayo Clinic, Johns Hopkins, and Dartmouth do for their catchment areas. Unfortunately, there is a short supply of physicians in all of the pediatric subspecialties,7 so in the longer term, we need more pediatric specialists, particularly in rural and community hospitals. Additionally, with the reduction of pediatric coverage in community hospitals, regional pediatric hospitals need increased funding and support to provide transport for higher level of care, real-time consultation, and on-going education for pediatric healthcare. As concerned citizens in our communities, anesthesiologists and our organizations can be strong voices for proper investment in pediatric readiness. Our existing training programs could offer on-site hands-on training and refresher courses for the community physicians, advanced practice providers, and emergency medical technicians.
Should our training programs offer hands-on training and refresher courses? Do you have experience with this in your practice? What do you think? Send your responses to Myron who will post in a Friday Reader response.
References
1. Mahant S, Guttmann A. Shifts in the Hospital Care of Children in the US—A Health Equity Challenge. JAMA network open. 2023;6(9):e2331763-e2331763. doi:10.1001/jamanetworkopen.2023.31763
2. Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA network open. 2023;6(9):e2331807-e2331807. doi:10.1001/jamanetworkopen.2023.31807
3. Whyte LE, Evans ME. Children Are Dying in Ill-Prepared Emergency Rooms Across America October 1, 2023. Accessed 09/01/2023. https://docs.google.com/document/d/1pUQNr4Q45A98Lga4CLGFcwmjlO5c3b1UqOC_1b-ty2s/edit?pli=1
4. Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of Pediatric Inpatient Services in the United States. Pediatrics. Jul 2021;148(1)doi:10.1542/peds.2020-041723
5. Moynihan K, França UL, Casavant DW, Graham RJ, McManus ML. Hospital Access Patterns of Children With Technology Dependence. Pediatrics. Mar 20 2023;151(4)doi:10.1542/peds.2022-059014
6. Richman L, Pearson J, Beasley C, Stanifer J. Addressing health inequalities in diverse, rural communities: An unmet need. SSM Popul Health. Apr 2019;7:100398. doi:10.1016/j.ssmph.2019.100398
7. American Academy of Pediatrics. Pediatric Subspecialty Shortages Fact Sheets. https://www.aap.org/en/advocacy/pediatric-subspecialty-shortages-fact-sheets/