More than 80% of families depend on community, rural, and remote emergency departments (EDs) to care for their children who are sick and injured.1 In the great majority of cases, similar to in adult cases, a child’s straightforward illness or injury is easily managed, and the child is discharged from the hospital to his or her family.2 However, unlike adults, when a child presents with a critical illness or injury, most EDs are unprepared to quickly stabilize that child. In this issue of Pediatrics, Ames et al3 evaluate the potential impact of this gap in the study “Emergency Department Pediatric Readiness and Mortality in Critically Ill Children.” On the basis of a national self-assessment of pediatric readiness, EDs commonly lack ≥1 critical elements, including pediatric patient safety and clinical care policies, quality improvement (QI) processes to monitor pediatric emergency care delivery, oversight to ensure that pediatric needs are met and integrated into all aspects of emergency care, and maintenance of pediatric competencies.1,4,6 

The National Pediatric Readiness Project, a national QI collaborative formed jointly by the American Academy of Pediatrics, the American College of Emergency Physicians, the Emergency Nurses Association, and the federal Emergency Medical Services for Children Program, strives to ensure that high-quality pediatric emergency care is available in every ED.7 Staying true to the principles of improvement science, the National Pediatric Readiness Project created self-assessments, resources, tools, and national collaborative activities to support EDs to identify and overcome gaps in pediatric readiness.4,6,8 Yet, despite widespread national engagement, questions regarding the value of pediatric readiness remain. Does pediatric readiness make a difference in patient outcomes?

Over the last few decades, adherence to specialized systems of care with specific designated resources (eg, trauma, stroke, and ST-segment elevation myocardial infarction [STEMI]) has been associated with decreased morbidity and mortality for the populations impacted and has, subsequently, led to the establishment of national standards of care.9,17 More specifically, the development of trauma centers in the United States has resulted in significant reductions in preventable deaths caused by injury.18,19 Similarly, development of stroke and STEMI centers across the United States has decreased morbidity and mortality related to these conditions because of the establishment of standard requirements for resources and processes of care.14,17 Unfortunately, no such national standards exist for pediatric emergency care.

There are several challenges in assessing the impact of pediatric readiness on patient outcomes. Although children account for some 30 million ED visits every year in the United States, most are seen in EDs that evaluate <15 children per day. Most EDs lack sufficient volume of pediatric patients who are critically ill or injured to assess the impact of pediatric readiness on outcomes. Additionally, fewer than half of EDs conduct QI activities to evaluate delivery of emergency care to children. When present, QI processes often take the form of clinical case reviews that are focused more narrowly on case-specific gaps rather than system-based readiness. Finally, overall mortality rates in children are low compared with those of adults. Although the pediatric population accounts for roughly 30% of the total population in the United States and 20% to 25% of all ED visits, <2% (48 000) of all deaths occur in this age range.2,20 Thus, although reductions in mortality due to system changes could be significant, the low rate of occurrences makes childhood mortality a challenging marker to assess. In the absence of a system-based collaborative approach, it is difficult to evaluate the impact of pediatric readiness on quality of emergency care delivery, much less health outcomes.

In their study, Ames et al3 overcome these barriers to demonstrate the potential impact of pediatric readiness on mortality. Previous efforts have revealed an association between the establishment of statewide pediatric readiness recognition programs (ie, pediatric readiness) and decreased trends in pediatric mortality.21,22 Yet, confounding factors limit conclusions that can be drawn from these data. In their study, Ames et al3 link pediatric readiness to health outcomes using data that track individual patients across the entire health care–system encounter, to admission, death, or discharge. While controlling for patient-level confounders (age, chronic conditions, and severity of illness), the authors directly link pediatric readiness to decreased mortality. By using previous estimates for the percentage of ED deaths among pediatric patients and by extrapolating from the results described by Ames et al,3 if all EDs adhered to pediatric readiness guidelines, the percentage of pediatric deaths in EDs could dramatically decrease.20 

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-0568.

     
  • ED

    emergency department

  •  
  • QI

    quality improvement

  •  
  • STEMI

    ST-segment elevation myocardial infarction

1
Gausche-Hill
M
,
Ely
M
,
Schmuhl
P
, et al
.
A national assessment of pediatric readiness of emergency departments.
JAMA Pediatr
.
2015
;
169
(
6
):
527
534
[PubMed]
2
McDermott
KW
,
Stocks
C
,
Freeman
WJ
.
Overview of Pediatric Emergency Department Visits, 2015
.
Rockville, MD
:
Agency for Healthcare Research and Quality
;
2018
3
Ames
S
,
Davis
B
,
Marin
J
, et al
.
Emergency department pediatric readiness and mortality in critically ill children.
Pediatrics
.
2019
;
144
(
2
):
e20190568
4
Remick
K
,
Gausche-Hill
M
,
Joseph
MM
,
Brown
K
,
Snow
SK
,
Wright
JL
;
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Section on Surgery
;
American College of Emergency Physicians, Pediatric Emergency Medicine Committee
;
Emergency Nurses Association, Pediatric Committee
.
Pediatric readiness in the emergency department.
Ann Emerg Med
.
2018
;
72
(
6
):
e123
e136
[PubMed]
5
Remick
K
,
Gausche-Hill
M
,
Joseph
MM
,
Brown
K
,
Snow
SK
,
Wright
JL
;
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Section on Surgery
;
American College of Emergency Physicians, Pediatric Emergency Medicine Committee
;
Emergency Nurses Association, Pediatric Committee
.
Pediatric readiness in the emergency department [published correction appears in J Emerg Nurs. 2019;45(1):3].
J Emerg Nurs
.
2019
;
45
(
1
):
e3
e18
[PubMed]
6
Remick
K
,
Gausche-Hill
M
,
Joseph
MM
,
Brown
K
,
Snow
SK
,
Wright
JL
;
American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Surgery
;
American College of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Committee
.
Pediatric readiness in the emergency department [published correction appears in Pediatrics. 2019;143(3):e20183894].
Pediatrics
.
2018
;
142
(
5
):
e20182459
[PubMed]
7
Auerbach
M
,
Gausche-Hill
M
,
Newgard
CD
.
National Pediatric Readiness Project: making a difference through collaboration, simulation, and measurement of the quality of pediatric emergency care.
Clin Pediatr Emerg Med
.
2018
;
19
(
3
):
233
242
8
Emergency Medical Services for Children Innovation and Improvement Center
. National Pediatric Readiness Project. Available at: https://emscimprovement.center/domains/hospital-based-care/pediatric-readiness-project/. Accessed May 15, 2019
9
MacKenzie
EJ
,
Rivara
FP
,
Jurkovich
GJ
, et al
.
A national evaluation of the effect of trauma-center care on mortality.
N Engl J Med
.
2006
;
354
(
4
):
366
378
[PubMed]
10
Celso
B
,
Tepas
J
,
Langland-Orban
B
, et al
.
A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems.
J Trauma
.
2006
;
60
(
2
):
371
378; discussion 378
[PubMed]
11
Demetriades
D
,
Martin
M
,
Salim
A
,
Rhee
P
,
Brown
C
,
Chan
L
.
The effect of trauma center designation and trauma volume on outcome in specific severe injuries.
Ann Surg
.
2005
;
242
(
4
):
512
517; discussion 517–519
[PubMed]
12
Hesdorffer
DC
,
Ghajar
J
.
Marked improvement in adherence to traumatic brain injury guidelines in United States trauma centers.
J Trauma
.
2007
;
63
(
4
):
841
847; discussion 847–848
[PubMed]
13
Nirula
R
,
Brasel
K
.
Do trauma centers improve functional outcomes: a national trauma databank analysis?
J Trauma
.
2006
;
61
(
2
):
268
271
[PubMed]
14
Heidenreich
PA
,
Zhao
X
,
Hernandez
AF
, et al
.
Impact of an expanded hospital recognition program for heart failure quality of care.
J Am Heart Assoc
.
2014
;
3
(
5
):
e000950
[PubMed]
15
American Heart Association
. Mission: lifeline hospital STEMI and NSTEMI recognition. 2018. Available at: https://www.heart.org/en/professional/quality-improvement/mission-lifeline/mission-lifeline-hospital-stemi-and-nstemi-recognition. Accessed May 14, 2019
16
Heidenreich
PA
,
Zhao
X
,
Hernandez
AF
, et al
.
Impact of an expanded hospital recognition program for stroke quality of care.
J Am Heart Assoc
.
2017
;
6
(
1
):
e004278
[PubMed]
17
Friese
CR
,
Xia
R
,
Ghaferi
A
,
Birkmeyer
JD
,
Banerjee
M
.
Hospitals in ‘magnet’ program show better patient outcomes on mortality measures compared to Non-‘Magnet’ hospitals.
Health Aff (Millwood)
.
2015
;
34
(
6
):
986
992
[PubMed]
18
Notrica
DM
,
Weiss
J
,
Garcia-Filion
P
, et al
.
Pediatric trauma centers: correlation of ACS-verified trauma centers with CDC statewide pediatric mortality rates.
J Trauma Acute Care Surg
.
2012
;
73
(
3
):
566
570; discussion 570–572
[PubMed]
19
Potoka
DA
,
Schall
LC
,
Gardner
MJ
,
Stafford
PW
,
Peitzman
AB
,
Ford
HR
.
Impact of pediatric trauma centers on mortality in a statewide system.
J Trauma
.
2000
;
49
(
2
):
237
245
[PubMed]
20
O’Malley
P
,
Barata
I
,
Snow
S
;
American Academy of Pediatrics Committee on Pediatric Emergency Medicine
;
American College of Emergency Physicians Pediatric Emergency Medicine Committee
;
Emergency Nurses Association Pediatric Committee
.
Death of a child in the emergency department.
Pediatrics
.
2014
;
134
(
1
). Available at: www.pediatrics.org/cgi/content/full/134/1/e313
[PubMed]
21
Rice
A
,
Dudek
J
,
Gross
T
,
St Mars
T
,
Woolridge
D
.
The impact of a pediatric emergency department facility verification system on pediatric mortality rates in Arizona.
J Emerg Med
.
2017
;
52
(
6
):
894
901
[PubMed]
22
Ball
JW
,
Sanddal
ND
,
Mann
NC
, et al
.
Emergency department recognition program for pediatric services: does it make a difference?
Pediatr Emerg Care
.
2014
;
30
(
9
):
608
612
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Remick is funded in part by the Health Resources and Services Administration of the US Department of Health and Human Services under grant U07MC29829 (Emergency Medical Services for Children Innovation and Improvement Center Cooperative Agreement). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by, the Health Resources and Services Administration, the US Department of Health and Human Services, or the US Government.