When a child needs lifesaving medical care are emergency rooms ready for the task?
Aaron Donoghue, MD, MSCE and Alan Jay Schwartz, MD, MSEd
As we’ve expanded the number of the PAAD’s writers and editors, many of whom I have and will be introducing to you over the next few weeks, I’ve occasionally screwed up and assigned 2 separate teams to cover the same article. In today’s PAAD, Drs. Aaron Donoghue and Alan Jay Schwartz review an article on emergency department readiness for pediatric patients. We posted a review of this article last week by another PAAD team. The topic is so important though, I thought a second bite of the apple would be OK. Myron Yaster MD
Original Article
Newgard CD, Lin A, Goldhaber-Fiebert JD, Remick KE, Gausche-Hill M, Burd RS, Malveau S, Cook JNB, Jenkins PC, Ames SG, Mann NC, Glass NE, Hewes HA, Fallat M, Salvi A, Carr BG, McConnell KJ, Stephens CQ, Ford R, Auerbach MA, Babcock S, Kuppermann N. State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. JAMA Netw Open. 2024 Nov 4;7(11):e2442154. doi: 10.1001/jamanetworkopen.2024.42154. PMID: 39485354; PMCID: PMC11530936.
In 2022, there were 72.5 million children 17 years old and younger living in the US (https://www.childstats.gov/americaschildren/tables/pop1.asp accessed 11/10/2024) This number is projected to grow to 78.2 million by 2050. Emergency department (ED) visits for these pediatric patients is a staggering number. In 2020, of the estimated 23 million ED visits for children 17 years old and younger, there were 31 ED visits per 100 children (https://www.cdc.gov/nchs/data/databriefs/db469-tables.pdf#1 accessed 11/10/2024)
Newgard and colleagues1 noted that of the >660,000 annual at-risk ED visits by children, there were >7,500 deaths given current level of ED readiness of which >2,100 could be saved if all EDs had high pediatric readiness.
Recognizing,
a) the acute need to provide emergency care to the large number of pediatric patients, many of whom require high acuity diagnosis and treatment
b) “A high level of ED pediatric readiness is associated with improved survival compared with low-readiness EDs among critically ill children,2 injured children admitted to trauma centers,3-5 and children with injuries and medical conditions requiring hospitalization.6”
Newgard and colleagues1 investigated the practical questions surrounding the economic impact of assuring that high ED pediatric readiness is available. Newgard et al, as reported by Emily Baumgaertner in the New York Times7 (https://www.nytimes.com/2024/11/01/health/child-deaths-emergency-room.html?searchResultPosition=1 accessed 11/10/2024), concluded that,
“1 in 4 Child Deaths After E.R. Visits Are Preventable…
If every emergency room in the United States were fully prepared to treat children, thousands of lives would be saved, and the cost would be $11.84 or less per child…”
“The annual cost [estimate] for all EDs in the US to reach high ED pediatric readiness from current levels was $207,335,302.”1
Several factors (inadequate numbers of trained personnel and equipment deficiency) are an ever present drag on solving this problem. The current unpopularity of Pediatrics as a future career choice for medical school graduates is striking.8 (We’ve discussed this in several previous PAADs, most recently on July 16, 2024: https://ronlitman.substack.com/p/the-sky-really-is-falling-supply ) Absence of medications and equipment necessary for pediatric acute care in EDs is not a new problem.9
Fortunately, several resources are available to solve this problem. The American College of Emergency Physicians and the American Academy of Pediatrics published guidelines for preparedness.10 Anesthesiologists and in particular, Pediatric Anesthesiologists can and must lend their expertise to EDs to benefit at-risk pediatric patients. Collaborating with ED physicians and allied healthcare providers, Anesthesiologists can provide care for pediatric ED patients or teach others to act as their surrogates. Anesthesiologists can check out the availability of equipment and pharmaceuticals advising the correct size and dose for pediatric patients.
What is the status of high ED pediatric readiness in your institution? When was the last time you discussed this issue with your Pediatric and Emergency Medicine colleagues? When did you last visit your ED and review what is in place for use if and when you or others are called to rescue a high acuity pediatric patient? Send you 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. Ames SG, Davis BS, Marin JR, et al. Emergency Department Pediatric Readiness and Mortality in Critically Ill Children. Pediatrics 2019;144(3) (In eng). DOI: 10.1542/peds.2019-0568.
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, Goldhaber-Fiebert JD, et al. Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers. JAMA surgery 2022;157(4):e217419. (In eng). DOI: 10.1001/jamasurg.2021.7419.
5. Melhado C, Remick K, Miskovic A, et al. The Association between Pediatric Readiness and Mortality for Injured Children Treated at US Trauma Centers. Annals of surgery 2023 (In eng). DOI: 10.1097/sla.0000000000006126.
6. 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.
7. Baumgaertner E. 1 in 4 Child Deaths After E.R. Visits Are Preventable, Study Finds. New York Times2024.
8. Jordan KA, Rao P, Byerley JS. Where Are All the Pediatricians? Jama 2024;332(10):783-784. (In eng). DOI: 10.1001/jama.2024.8485.
9. McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R. Critical pediatric equipment availability in Canadian hospital emergency departments. Annals of emergency medicine 2001;37(4):371-6. (In eng). DOI: 10.1067/mem.2001.112253.
10. American College of Emergency Physicians;, Pediatrics AAo. Care of children in the emergency department: guidelines for preparedness. Annals of emergency medicine 2001;37(4):423-7. (In eng). DOI: 10.1067/mem.2001.114067.