Care for the clinically deteriorating child, defined as a pediatric patient (<18 years of age) whose clinical state worsens during hospitalization, leading to an increase in their risk of morbidity (eg, organ dysfunction, protracted hospital stay, disability, or death), often requires increased monitoring, interventions, medications, and nursing care.1 Although more than half of all hospitalizations for children in the United States occur across 3000 community hospitals (general, nonchildren’s hospitals), there are no national guidelines on assessing optimal readiness for children who worsen clinically after admission.2 With many hospitalizations occurring in facilities with a low daily pediatric census,3 community hospitals often face challenges that result from limited exposure to ill pediatric patients, limited access to critical care personnel (eg, fellowship-trained pediatric emergency medicine physicians or pediatric-specific critical care nurses), hospital focus on adult services, limited opportunities for pediatric training, and a lack of continuing competency assessments.4 Additionally, use of pediatric intensivist telemedicine support has been shown to improve patient triage and reduce the need to transfer patients but is not widely available.5,6 Importantly, most inpatient pediatric programs often lose money, further creating challenges to maintaining potential pediatric resources and ancillary services.4 Yet, for hospitals to properly balance the appropriation of financial resources with pediatric services, they need pediatric-specific guidelines and policies, equipment, and staffing to deliver higher-quality care and realize better outcomes. In addition, formalized processes to measure and improve readiness to respond to a clinically deteriorating child are critical to ensure that high-quality, safe, and timely care can be delivered.2
Although no comprehensive national database of community hospitals with pediatric services exists,2,7,8 there is evidence that the responses to handling pediatric acute or emergent care in the inpatient setting of community hospitals are variable.2,9 The Joint Commission and the American Academy of Pediatrics (AAP) provide guidance for the care of pediatric patients in the inpatient setting, but they do not explicitly address the care of the clinically deteriorating child, contributing to the ongoing variability in care and lack of outcomes data.10 Accordingly, with considerable variability in hospital settings regarding volumes and pediatric-specific exposures, a collaborative, national approach is necessary to identify and ensure best practices for the clinically deteriorating child in community hospitals.
Recognizing and Responding to a Clinically Deteriorating Child
The ability to respond to a clinically deteriorating child first requires the timely recognition of a child who is developing a worsening clinical condition followed by initial stabilization and, ultimately, a decision on disposition based on local resources and capabilities. The existing literature suggests several models that may help to identify risk early, but these have been primarily studied in tertiary care children’s hospitals, and the extent to which these practices have been adopted in community hospitals is unknown.11,12 Although the presumption may be that the clinically deteriorating child requires transfer to a higher level of care, many of these children may and should be able to continue to receive optimal care within local institutions with the appropriate infrastructure. To build the necessary tools, processes, and policies to recognize and respond to the clinically deteriorating child, hospitals need guidelines for assessing the child’s status of readiness that include ways to measure competencies in addition to tracking and measuring responses to events. Validated patient-level outcomes described in the literature that could be used to track and measure responses to events in community hospitals include emergency transfers, unrecognized situational awareness failure events, and critical deterioration events.11,13,14 Organized into an assessment tool, data on these outcomes can reveal the value of a system’s readiness to care for the clinically deteriorating child and, over time, explore whether increased readiness is associated with improved outcomes.
Learning From Pediatric Readiness in the Emergency Department
To date, there has been limited work to assess the readiness of community hospitals in the identification and management of the clinically deteriorating child.15 Exploratory studies have revealed several preliminary challenges, including lack of specialized staff availability, lack of institutional prioritization for the hospitalization of children, lack of pediatric-sized equipment or hospital layout not being pediatric specific, and low exposure to critically ill patients.9 This landscape of general inpatient pediatric medicine is similar to that of general emergency medicine given that the majority of children (80%) receive their emergency care in community emergency departments (EDs).15 In 2006, the Institute of Medicine characterized pediatric emergency care in EDs as “uneven,” and national collaborative efforts were subsequently undertaken. A joint policy endorsed by the AAP, American College of Emergency Physicians, and Emergency Nurses Association was developed to define pediatric readiness in the ED, followed by Emergency Medical Services for Children and other national stakeholders developing a quality improvement initiative to help EDs to identify and address gaps in pediatric readiness across 6 domains: administration and coordination of care; health care provider competencies; quality/process improvement; pediatric patient safety; policies, procedures, protocols; equipment/supplies; and medications15 (Table 1). Subsequent research, some of which has required time in addition to integration of multiple data sets, has led to updated guidelines and improvement of pediatric readiness, which has been shown to decrease mortality.16,17
Abbreviated Example of an Inpatient Pediatric Readiness Systems-Level Assessment Tool for the Clinically Deteriorating Child in Community Hospitals
| Domain of Pediatric Readiness . | Potential Measurable Items . |
|---|---|
| Administration and coordination | Guidelines for interfacility transfers |
| Health care provider competencies | System for provider competency in a clinically deteriorating child response evaluation |
| Quality/process improvement | Standardized process for safety event reviews |
| Pediatric patient safety | Appropriate weight-based dosing for pediatric resuscitation drugs at patient bedside |
| Policies, procedures, and protocols | Use of pediatric severity or warning score to identify higher-risk patients |
| Equipment, supplies, and medications | In-room code buttons |
| Domain of Pediatric Readiness . | Potential Measurable Items . |
|---|---|
| Administration and coordination | Guidelines for interfacility transfers |
| Health care provider competencies | System for provider competency in a clinically deteriorating child response evaluation |
| Quality/process improvement | Standardized process for safety event reviews |
| Pediatric patient safety | Appropriate weight-based dosing for pediatric resuscitation drugs at patient bedside |
| Policies, procedures, and protocols | Use of pediatric severity or warning score to identify higher-risk patients |
| Equipment, supplies, and medications | In-room code buttons |
Pediatric readiness has been shown to improve outcomes in the emergency medical services and ED settings, and this work should now be extended to the inpatient unit to complete the continuum of care. We propose a multiphase national project to assess inpatient pediatric readiness and provide the necessary tools, self-assessments, and resources to support national inpatient pediatric readiness. These steps include (1) the formation of an interdisciplinary collaborative to delineate the needed processes and resources for inpatient pediatric preparedness for the clinically deteriorating child, (2) partnering with national organizations to develop consensus-based guidelines and necessary tools for community hospital inpatient pediatric readiness for the clinically deteriorating child, (3) the development of a systems-level assessment tool to measure inpatient readiness for the clinically deteriorating child and provision of resources to improve readiness, (4) a process to encourage hospitals to measure readiness and identify gaps through national surveys, and (5) the development of interventions to close gaps and measure the impact of improved readiness on clinical outcomes (demonstrate value of readiness similar to ED work). Below, we explore the necessary details for steps 1 to 3 to set up a system of pediatric inpatient readiness for measurement and evaluation in steps 4 and 5.
Step 1: Form an Interdisciplinary Collaborative to Delineate the Needed Processes, Resources, and Standard Guidelines for Inpatient Pediatric Readiness for the Clinically Deteriorating Child
To ensure that all hospitals can respond to unexpected clinical deterioration, a detailed description of minimum resources, staffing, and equipment is necessary. As a first, step, we propose the formation of a national, interdisciplinary collaborative of key stakeholders across disciplines to determine the essential elements needed by all hospitals that care for children to successfully recognize and stabilize a clinically deteriorating child. This collaborative should include providers from community hospitals and children’s hospitals, community providers, pediatric hospitalists, pediatric intensive care physicians, emergency physicians (general and pediatric emergency trained), nurses, respiratory therapists, pharmacists, administrators, support staff (educational and telemedicine consultants, quality improvement and research staff), and patient families.18,19 The goal of such a collaborative would be to adopt the 6 domains of pediatric readiness that have been proven successful in the ED and to describe the essential inpatient requirements in each domain (Table 1).
Step 2: Partner With National Organizations to Develop Consensus-Based Guidelines and Necessary Tools for Community Hospital Inpatient Pediatric Readiness for the Clinically Deteriorating Child
Through the aforementioned interdisciplinary collaborative, the next step is to partner with relevant academies, societies, and organizations of pediatric inpatient care (eg, AAP, Society of Hospital Medicine, Society of Critical Care Medicine) for national consensus and to iteratively develop a consensus-based guideline, toolkits, and resources to improve community hospital inpatient pediatric readiness for the clinically deteriorating child. Such guidance includes interfacility transfers, rapid response team and code team compositions with response triggers, suggestions for pediatric provider competency checks, and recommendations for frequency of simulation education experiences. Ultimately, a national database of pediatric outcomes in community hospitals should be established to provide benchmarking and outcomes data.
Step 3: Develop a Consensus-Based Guideline That Delineates Inpatient Readiness for the Clinically Deteriorating Child and a Survey to Measure Compliance With That Guideline
Mirroring the framework established through the National Pediatric Readiness Project and the development of the pediatric readiness score and tool kit for the ED setting, the third step would be to translate the findings from the list of essential requirements defined by the interdisciplinary collaborative into a systems-level assessment tool to measure and improve an individual hospital’s inpatient readiness to manage the clinically deteriorating child.15,20 Building upon the established Pediatric Readiness work, the tool would include assessments in the 6 domains listed in Table 1. This would also involve scoring of the domains where a hospital could receive an inpatient pediatric readiness score and a gap analysis report that compare their score with national scores and suggest areas for improvement.
Steps 4: Measure Readiness and Identify Gaps
After a national infrastructure is developed, individual hospitals would be encouraged to measure their inpatient readiness and compare it with national benchmarks in an effort to identify gaps.
Step 5: Develop Interventions to Close the Gaps
With the help of nationally available resources and tools, individual hospitals would develop local interventions to close identified gaps. Subsequent repeat measures could then be collected and linked to patient outcomes.
Supporting High-Quality Care for Children Close to Home
Delivery of optimal care for hospitalized children within local communities requires a systematic, systems-level approach to ensure quality and safety for the clinically deteriorating child. Institutional problem solving is required to inform sustainable solutions and continuous improvement on a national level. An evidence-derived consensus on best practice is required to identify and analyze gaps, and the development of national standards to hold institutions accountable to providing appropriate care for the clinically deteriorating child is imperative. A set of guidelines defining the minimum requirements necessary for the care of the clinically deteriorating child is acutely needed. Beginning this journey in pediatric hospital medicine with a collaborative, national approach would help to ensure that acutely ill children are recognized and receive the care that they deserve no matter where they are.
FUNDING: No external funding.
Drs Qunibi conceptualized, designed, and drafted the initial draft of the manuscript and reviewed and revised the manuscript; Drs Dudas, Abulebda, and Auerbach contributed to the conceptualization of the manuscript and critically reviewed the manuscript for important intellectual content; Dr McDaniel contributed to the conceptualization, design, and initial drafts of the manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
References
Competing Interests
CONFLICTS OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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