Critically ill children die at a lower rate if they present to an emergency department (ED) with a higher pediatric readiness score, according to the authors a recent analysis.1

The motivation for conducting the study came from the researchers’ own clinical experience.

“As pediatric intensivists and emergency physicians, we noted a variation in care provided for critically ill children at different emergency departments,” explains Stefanie G. Ames, MD, the study’s lead author and a pediatrician specializing in critical care medicine at UCLA Mattel Children’s Hospital in Los Angeles.

Previous research showed a large variation in EDs, based on the National Pediatric Readiness Survey.2 Therefore, it was already clear EDs varied in how prepared they were for children.

“We wanted to determine how it impacted outcomes for children presenting with a critical illness,” says Ames, an assistant professor in the division of pediatric critical care at University of California, Los Angeles medical school.

Ames and colleagues analyzed data from 20,483 critically ill children presenting to 426 hospitals. They fully expected pediatric readiness to be associated with better care quality and outcomes. Indeed, that was the case.

“We were surprised by the degree to which presentation to a pediatric-ready emergency department was associated with a decreased, risk-adjusted mortality,” Ames reports.

Risk of mortality was four times as likely if the child presented to an ED with low readiness score, compared to an ED with a high score. “These findings support the need for increased pediatric preparedness in some emergency departments,” Ames says.

To mitigate risk, Ames says EDs should, above all, follow appropriate evidence-based guidelines.3 “The guidelines detail the appropriate training, staffing, and equipment needed for quality care of pediatric patients,” Ames notes.

The National Pediatric Readiness Project was developed to support the implementation of these guidelines.4 “This can help hospitals be more prepared to care for pediatric patients as well as meet accreditation goals and decrease liability,” Ames offers.

Notably, about half of all ED visits happen in rural and low-volume EDs.2 “What that means is that the frequency of seeing critically ill children may be few and far between,” says Katherine Remick, MD, FAAP, FACEP, FAEMS, executive lead for the Emergency Medical Services for Children Innovation and Improvement Center.

Statewide pediatric facility recognition programs identify EDs that adhere to a standard level of readiness for children. The programs are linked to higher pediatric readiness, according to the results of a recent study.5

Over the past few years, more hospitals have specialized in stroke, ST-elevation myocardial infarction, and trauma. This kind of specialization is linked to fewer adverse events and lower rates of mortality and morbidity.

“It comes as no surprise that centers that maintain critical pediatric capabilities are going to perform at a higher level,” says Remick, one of the study’s authors. For EDs, the pediatric facility recognition program is a way to differentiate the care they provide to children. “It’s a real nice way for an ED to be recognized, and be able to display signage that speaks to their pediatric capabilities,” Remick says.

If EDs are not seeing critically ill children often, it is more difficult to maintain a constant state of readiness. Placing blame on individual ED providers is not the answer. “There’s been a real shift in focus from the providers to a system perspective,” Remick observes. “Our performance is only as good as what the system was designed to support.”

As individuals, ED providers can only do so much. “Regardless of how good a single nurse or physician is, if you’re in a system that’s broken, it’s really hard to achieve high-quality care,” Remick laments.

REFERENCES

  1. Ames SG, Davis BS, Marin JR, et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics 2020;145:e20200542.
  2. Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr 2015;169:527-534.
  3. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement — Guidelines for care of children in the emergency department. J Emerg Nurs 2013;39:116-131.
  4. Emergency Medical Services for Children Innovation and Improvement Center. National Pediatric Readiness Project Toolkit.
  5. Whitfill TM, Remick KE, Olson LM, et al. Statewide pediatric facility recognition programs and their association with pediatric readiness in emergency departments in the United States. J Pediatr 2020;218:210-216.e2.