Community hospital inpatient pediatric programs face a variety of challenges including financial instability, variable censuses, difficulty maintaining qualified staff, and a lack of focus for the hospital. With the addition of new payment models, such as bundled payments and global budgets, along with a global pandemic, the future of community hospital pediatric inpatient care is uncertain at best. In this article we summarize the challenges, opportunities, and potential solutions to maintaining high-quality care for hospitalized children in community hospitals.

The majority of pediatric hospitalizations in the United States occurs in community hospital settings.1  In response to concerns about quality and safety in the 1980s,2  many community hospitals created robust structures of administration and care delivery that fueled the development of the pediatric hospitalist subspecialty. Throughout the 1990s and early 2000s, many urban and suburban community hospitals developed hospitalist programs to provide 24/7 coverage for pediatric inpatients, newborns, and, occasionally, children in the emergency department.

Over the past few decades, multiple forces have led to a decrease in both overall community hospital volume3  and overall pediatric inpatient volume.4  Coupled with increasing financial pressures for hospitals and relatively low payment for pediatric care, the sustainability of inpatient community hospital care for children is uncertain. Closures of pediatric inpatient units in communities likely would lead to children having to travel extended distances for definitive care. Our objective for this article is to describe the challenges, opportunities, and potential solutions to maintaining high-quality care for hospitalized children in community hospitals.

The trend of overall pediatric admissions is downward. From 1997 to 2016, overall 0- to 17-year-old nonnewborn hospitalizations fell from 6 030 457 to 5 479 699, or 9%.5  As a result, pediatricians have noticed a decrease in pediatric inpatient units. In 2007, Sigrest et al6  surveyed pediatricians who reported that 4% of local hospitals closed their pediatric units and that 22% merged with an adult unit. More recently, Khare and Rauch7  presented data from the American Hospital Association database for medical-surgical beds and noted that, nationally, 3953 pediatric beds closed in small- and medium-sized hospitals between 2002 and 2012, whereas large and children’s hospitals actually increased bed numbers.

The trend toward children’s and regional hospital consolidation has been noted by the lay press; in 2015, the article “Children’s Hospitals Defy Trend for Shrinking Admissions” was published in Modern Healthcare.8  Additional data come from França and McManus9  in Massachusetts, who have demonstrated that from 2004 to 2014 in 66 hospitals, annual pediatric emergency department visits decreased 2.7% (from 379 056 to 368 697) and pediatric admissions decreased 15.0% (from 48 857 to 41 509), but at the same time, the number of pediatric transfers increased 36.2% (from 7190 to 9793). Additionally, Michelson et al10  demonstrated that hospital provision of definitive acute pediatric care decreased significantly from 2008 to 2016, especially in rural areas and hospitals with a low volume of pediatric care. The same group additionally found that the regionalization is not due to complexity of care, noting that the transfer rates of the 3 most common conditions (asthma, croup, and gastroenteritis) increased ∼15% each year from 2008 to 2016.11 

Overall, although general hospitals care for the majority of hospitalized children in the United States,12  the trend toward children’s hospital consolidation and small and medium hospital unit closures is likely only going to increase in the near future. The recent coronavirus disease 2019 (COVID-19) pandemic has put an additional strain on pediatric community hospital use. Volumes of inpatient and pediatric emergency department cases dropped to low levels as schools were canceled and children sheltered at home.13,14 

It could be argued that regionalization of care and fewer community hospitals providing definitive care could improve care. Regionalization and creation of high-volume centers can improve outcomes for neonates and trauma10  and some procedure-dependent diagnoses, such as intussusception,15,16  but there is no evidence that the care of common pediatric conditions is better in regional centers. Additionally, the increase in transfer rates can lead to hospital overcrowding and decreased throughput time in the regional center.10  And although not the most important factor, the inconvenience of having a family travel many miles to a referral center can pose difficulties, especially for low-income families without transportation.17 

In addition to the challenge of overall declining volume noted above, community hospitals face numerous other challenges in providing care to children. The biggest issues community hospitals face include variability in census, hospital focus on adult services, geographical challenges, and financial stability.

General pediatric admissions follow a seasonal pattern, with an increase in volume during respiratory viral seasons and a decrease during the summer. Additionally, with an average length of stay of <2 days per patient, there is substantial daily variation in census. Variability matters because many hospitals set nursing staffing ratios by average daily census. When the census can vary between 1 and 15 inpatients seasonally or daily, it poses staffing challenges. If the average is lower than a significantly higher range, the inability to flex staffing upward in the winter months can lead to an increase in patients transferred out of the hospital. Additionally, because there is not a pool of nurses who just want to work in winter, most community hospital pediatric units employ a nursing staff that does not just care for children. The effects of making pediatric nurses care for adults leads to either a loss of workforce, because the nurses will seek pediatric-only opportunities, or a dilution of skills, because the nurses who stay care for fewer numbers of children. Many community hospitals are challenged to meet the guidelines set by the Society for Pediatric Nursing competencies,18  especially with variable and low censuses.

All community hospitals with pediatric inpatient services (and even many children’s hospitals within a hospital) are small parts of a larger health care operation. Often seen as a “loss leader” or “mission area,” the vast majority of pediatric departments in community settings do not provide a profit margin for the institution. As such, the ability to garner the necessary resources to provide the full scope of pediatric care is nearly impossible. Ancillary services, such as laboratory, radiology, respiratory therapy, and rehab (physical, occupational, and speech therapy), are most often affected by the distribution of resources. It is not possible to hire a pediatric radiologist who is competent doing air enemas for intussusception if that event only happens twice a year and usually on weekends or at night. Other therapists cannot specialize in children if the volume does not support it, which might be ok most of the time, but not when the service is most needed, such as when a child is becoming critically ill, or seasonally, such as during the winter respiratory virus surge. Other important services, such as social work, child protection, and child life, are also difficult to maintain for low total volume despite the impact each can have on any individual case.

To keep in-house pediatricians busy, many community pediatric hospitalist programs rely on coverage of multiple areas in the hospital. Unfortunately, in a typical community hospital set up, the 3 areas a pediatric hospitalist often cover (the inpatient unit, nursery, and emergency department) are rarely near each other. The challenge of responding to a delivery while a sick infant with bronchiolitis is on the inpatient unit and the emergency department is calling for a consultation on a child who is septic is substantial and a potential patient safety risk.

Pediatric hospitalist programs, especially in community settings, are inherently financially unstable. To provide 24/7 inpatient pediatrician coverage, the smallest programs will employ or contract for a minimum of 3 attending pediatricians. For in-house coverage, the number increases to 5. Couple the personnel costs with a per case part B average payment of ∼$300,19  it is not a surprise that in the 2016 Society of Hospital Medicine Productivity and Compensation Survey, 93% of pediatric hospitalist programs reported receiving financial support, with an average amount of $151 936 per full time equivalent position. Being a financial drain on an institution places the department in a precarious position every budget year when the hospital looks at cost-cutting measures.

Over the past decade, community pediatric hospitalist programs have employed a number of strategies to survive and thrive in the challenging environment. The first is to maximize volume by covering multiple services. Most commonly, the pediatric hospitalist will cover the newborn nursery and deliveries in addition to the children on the inpatient unit. Even adding in consultations in the emergency department may be inadequate to provide sufficient payment to cover the personnel costs. Programs from across the country have added a variety of add-on services to the traditional hospitalist model (Table 1) to enhance profitability and the likelihood of survival.

TABLE 1

Nontraditional Pediatric Hospitalist Services

Care for patients in the emergency department or hospital-based urgent care 
Infusion center or infusions on inpatient unit 
NICU stepdown or level 2 coverage 
Outpatient newborn follow-up examinations in the hospital 
Postdischarge follow-up examinations in the hospital 
Night coverage for NICU, PICU, or primary care practices 
Sedation services for radiology and/or procedures 
Circumcision clinic (if not already doing in the nursery) 
Care for patients in the emergency department or hospital-based urgent care 
Infusion center or infusions on inpatient unit 
NICU stepdown or level 2 coverage 
Outpatient newborn follow-up examinations in the hospital 
Postdischarge follow-up examinations in the hospital 
Night coverage for NICU, PICU, or primary care practices 
Sedation services for radiology and/or procedures 
Circumcision clinic (if not already doing in the nursery) 

A second approach to community hospital care delivery is to maximize geography by colocating services such as a pediatric emergency department and inpatient unit or the nursery and inpatient unit; the pediatric hospitalist can more successfully manage 2 groups of patients simultaneously. The hybrid pediatric emergency department and inpatient unit has been widely employed in the mid-Atlantic region and has revealed improved financial and quality outcomes.19,20 

Recently, many community hospitals have partnered with regional children’s hospitals to provide staffing for the community site. Potential advantages for the community hospital include a more secure manpower pipeline, enhanced support for subspecialty patients, and marketing to their local community.21  Additionally, community-oriented academic pediatric hospitalists may be more likely to join a group that covers both the community and children’s hospital sites. However, some potential pitfalls exist, including a loss of identity and the potential for a loss of volume if more sick children are transferred out. More importantly, coverage of a community site really should take on a multidisciplinary approach. Nursing and ancillary services have to be built or maintained to provide quality care in the community setting, and just adding a competent medical staff to a community hospital might not solve the underlying challenge. The ability to develop and maintain competent pediatric nurses in the setting of a low volume of patients remains challenging.

Payment for hospital services in the United States is undergoing a rapid transformation to value-based care. Value payments come in a variety of forms, from bundling by diagnosis-related group, to per diem rates, to global capitation. Hospitals are becoming incentivized to manage populations and costs rather than increase volume and not worry about length of stay. Although these pressures are more likely to impact high-cost adult conditions first, pediatric care will also be affected. Population health efforts are likely to focus on high users and children at risk for readmissions, which will impact children with special health care needs or complex care as well as children with chronic medical conditions, such as asthma, sickle cell disease, inflammatory bowel disease, and cystic fibrosis. These efforts are likely to further reduce the need for inpatient pediatric beds and highlight the importance of transitions of care.

Another external force that will impact inpatient pediatric care is the increasing trend of health system consolidations. A record number of hospital consolidations occurred in 2017,22  and that trend is likely to continue into the near future because stand-alone hospitals increasingly have difficulty creating enough profit for capital improvements on their own. Consolidation may lead to a closure of hospitals and/or services. As noted above, rural and smaller hospitals are much more likely to close pediatric beds. A newly formed system may decide it does not need multiple hospitals providing the same service and consolidate care at a single regional site or children’s hospital. Additionally, some systems may decide to stop offering pediatric services completely if there are other systems in the region already doing so.23 

The Affordable Care Act helped hospital finances by reducing uninsured care but also stressed finances by reducing payments for hospitalizations so that care of routine or simple pediatric diagnoses in Medicaid-insured patients produced even less revenue.24  The hospitals providing that type of care, and not higher-reimbursed tertiary or quaternary care, came under pressure to change those beds from pediatrics to a higher-reimbursed service.

Most recently, the COVID-19 pandemic has put unprecedented stress on pediatric units. Although data on hospital and unit closures are not available, what is known is that acute pediatric illnesses fell dramatically once children left school and families started maintaining physical distancing. A report from the Children’s Hospital of Philadelphia revealed a marked drop of volume from an average of 286 daily visits in the 3 previous years to 95 daily visits after the COVID-19 stay-at-home order in Pennsylvania.13  Anecdotally, this has translated into major drops in pediatric census for all pediatric hospitals, especially community pediatric sites, which rely on healthy children with episodic illnesses to maintain volumes. The financial consequence of COVID-19 on hospitals in general, and pediatric units specifically, will likely speed up closing small units in community hospitals.

Community hospital inpatient pediatric care faces an inflection point. The economic pressures facing hospitals to maintain inpatient pediatric care as a loss leader will be enormous and likely unsustainable. Unless the economic model of how the country pays for pediatric care significantly changes and a coordinated and regionalized approach is taken to properly distribute pediatric beds and resources, we are likely going to see further closures of community hospital pediatric units and increased regionalization.

Decades-long trends of decreased pediatric hospitalizations, coupled with centralization or regionalization of tertiary and quaternary care at larger hospitals and freestanding children’s that are stretched beyond their capacity will likely lead to even more consolidation of pediatric care and closure of small units. The current economic model for financial reimbursement of care makes lower-volume units operate at a loss, and most community hospitals in general already have a low profit margin or lose money. COVID-19 has further stressed the financial stability of many community hospitals, and potential shortfalls in city, county, and state finances will exacerbate the need for community hospitals to find every possible cost savings.

The other possibility is that by joining networks and using technology, there may be a resurgence of pediatric care in community centers, partially fostered by pediatric hospitalists. Tertiary care centers have long recognized that routine inpatient pediatric care does not need to be done at a children’s hospital.25  Partnering with academic centers can provide a source of patients and additional resources to the community.21  Some of the concern about maintaining the skill level needed to care for inpatients is addressed by the emergence of pediatric hospitalists rather than the pool of outpatient pediatricians or family practice doctors who individually rarely provide inpatient care. Telemedicine can increase the availability of specialty consultations, reducing the need for transfers and maintaining care near the family’s home. Advanced simulation can help maintain skills. COVID-19 has revealed the value of telehealth, and it remains to be seen how that will impact care delivery in the future.

We believe there is value in keeping children as close to home as possible and that technology will allow a farther reach of specialty care, particularly with the aid of bedside providers skilled in higher levels of inpatient care. It will be up to hospital systems to invest in the technology needed to support such care and a change in health care finance to make such investments achievable and sustainable.

We thank Dr JoAnna Leyenaar and Dr Christopher Maloney for their participation in the Pediatric Academic Societies Plenary Session, which sparked the idea for this article.

All authors conceptualized and designed the concept for the manuscript, drafted the initial manuscript, and approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.