The level of preparedness of an outside community hospital emergency department (ED) for a pediatric patient, especially a critically ill pediatric patient, is unpredictable – adult providers, adult equipment, rarity of children presenting there, unfamiliarity with pediatric diagnoses like a newborn in cardiogenic shock or pediatric sepsis, lack of focus on developing pediatric skills – the challenges go on. However, does the preparedness matter and how often do critically ill children present to EDs that are not fully equipped to take care of them?
Ames et al, in an upcoming Pediatrics article (10.1542/peds.2019-0568), attempt to answer these questions by performing an in-depth analysis of a cohort of critically ill children seen in the EDs of 5 states – New York, Florida, Iowa, Nebraska, Massachusetts -- who were either admitted to the intensive care unit or succumbed in the ED. They use a linked database created from an administrative database of the Agency of Healthcare Research and Quality (the Healthcare Cost Utilization Project, to capture patients presenting to EDs),and connected to the Centers for Medicare and Medicaid Healthcare Costs Report Information System (to link the hospital admissions), the American Hospital Association Annual Survey (to assess if hospitals had pediatrics-specific ICUs), and the National Pediatric Readiness Project. The pediatric readiness score ranges from 0 to 100, calculated based on a 55-question survey assessing the capacity of a facility to completely care for a child, covering domains of administration, clinical equipment and medications, pediatric-trained staff, and quality improvement, with a 100 being a score of complete readiness. The authors found that over 2/3 of the patients originally presented to an ED with a level of pediatric readiness within the top quartile of the cohort. It is noteworthy that this included pediatric readiness scores ranging from 88 to 99, which is higher than the median of the entire cohort (75). However, even though a majority of the patients presented to EDs that were relatively well-prepared to care for acutely ill children, there was nonetheless a significant difference in the mortality rates of patients presenting to the best performing quartile and those presenting to lower quartiles of pediatric readiness. Interestingly, this association was dose dependent, with a higher readiness score associated with lower mortality.
While much of the burden of pediatric emergencies are handled at well-prepared EDs, this study elucidates how improving pediatric readiness point-by-point can be associated with lesser mortality and better outcomes. This inspires EDs and medical facilities to invest in pediatric preparedness through training, equipment, and personnel to help impact mortality. It would be interesting to note if the authors could present follow up data comparing the lengths of stay based on level of pediatric readiness of the ED site of initial presentation, as a similar association might be found. This study gives plenty of food for thought for larger children’s hospitals as well, who may consider collaborations or ‘adoptions’ with other EDs in their region to improve their pediatric readiness and hence enhance the care the patients get even without coming all the way to the main centers.