Injured children treated in high-readiness EDs recorded lower mortality rates vs. similar children in low-readiness EDs.1

The National Pediatric Readiness Project is a longstanding initiative to improve pediatric emergency care. “But there has only been one study suggesting a link between ED readiness and improved outcomes,” says Craig Newgard, MD, MPH, professor of emergency medicine at Oregon Health & Science University.2 Newgard and colleagues wanted to examine the relationship between ED readiness and outcomes on a broad scale in U.S. trauma centers. “Because trauma centers are the most developed form of regionalized healthcare in the world, this seemed a perfect setting to evaluate the potential impact of ED readiness,” says Newgard.

Researchers analyzed data on 372,004 injured children seen at 832 EDs in U.S. trauma centers from 2012-2017. They expected to find better-prepared EDs recorded higher survival rates. “But we did not know ‘how ready’ an ED had to be to start improving survival,” Newgard reports.

In fact, Newgard and colleagues found survival only increases among trauma centers in the highest quartile of readiness. Also, there was no association between high ED readiness and fewer in-hospital complications. “This probably reflects these events occurring well after the ED visit, later in a hospital stay,” Newgard says.

Newgard is unaware of any specific examples of ED pediatric readiness that were used in medical malpractice claims. “However, the measurement of ED readiness is based on national guidelines for ED pediatric care,” he notes.

Poor readiness means EDs are noncompliant with established guidelines. “It would seem prudent from a risk management perspective to run an ED that is fully compliant with national guidelines and, therefore, fully ready to care for children and maximize their survival after injury,” Newgard offers.

A joint policy statement from the American Academy of Pediatrics/American College of Emergency Physicians/Emergency Nurses Association on pediatric readiness in the ED recommends resources and training to provide optimal emergency care for children.3 “A plaintiff’s attorney will try to show the recommendations in the policy statement were not followed,” says Jonathan M. Fanaroff, MD, JD, FAAP, professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland.

Fanaroff says resuscitation equipment and supplies should be in the ED. Also, medications should be checked daily for expiration. “If expired medications are used, [plaintiff attorneys] will argue that substandard care was provided,” he cautions.

Administrators also should designate a pediatric emergency care coordinator (PECC) to help coordinate high-quality pediatric care. “If a poor outcome occurs and the ED does not have a PECC, the plaintiff’s lawyer may argue that the hospital was systematically unprepared to care for children,” Fanaroff says.

The vast majority of ill and injured pediatric patients aren’t seen at large specialized children’s hospitals.3 “The reality is most kids get treated in community EDs that don’t have pediatric ED staff,” says Brigitta U. Mueller, MD, MHCM, MSJ, CPPS, CPHQ, FISQua, FAAP, executive director of patient safety, risk & quality at ECRI.

An EP in a small community ED generally would not be held to the same standard as an EP in a high-volume pediatric ED. “Consider a traumatic brain injury, where there are vastly different capabilities due to access to a pediatric neurosurgeon,” says Andrew Furman, MD, MMM, FACEP, executive director of clinical excellence at ECRI.

If a small community ED cannot meet the child’s needs, transfer delays could become an issue in subsequent litigation. Regardless, whether the plaintiff can successfully argue the ED was negligent for delayed transfer depends on the circumstances. If a blizzard caused the delay, there should not be liability for the ED. “But if the failure was to recognize and initiate timely transfer of a surgical emergency, such as appendicitis, there may very well be liability,” Fanaroff says.

Transfer decisions require both the sending and receiving hospitals to play roles. “These roles are best to establish proactively,” Furman says. Some large pediatric centers dispatch their own personnel to the sending ED to provide diagnostic and/or treatment guidance to the onsite EP while awaiting transport. “It is important as a physician to know when action is immediately required and when there is time to consult with other experts,” Furman observes.

Katherine Remick, MD, FAAP, FACEP, FAEMS, executive lead for the EMS for Children Innovation and Improvement Center, says plaintiffs can try to prove an ED was unprepared for pediatric patients by checking for a resuscitation cart, availability of resuscitation equipment, policies on abnormal vital signs in children, and clinical decision support tools for specific complaints. “Ideally, all emergency departments follow evidence-based guidelines. But uptake may be slower in certain areas,” Remick reports.


  1. Newgard CD, Lin A, Olson LM, et al. Evaluation of emergency department pediatric readiness and outcomes among US trauma centers. JAMA Pediatr 2021 Jun 7;e211319. doi: 10.1001/jamapediatrics.2021.1319. [Online ahead of print].
  2. Ames SG, Davis BS, Marin JR, et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics 2019;144:e20190568.
  3. Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric readiness in the emergency department. Pediatrics 2018;142:e20182459.