Pediatric Death Higher in EDs With Lower Pediatric Readiness

Nicola M. Parry, DVM

August 23, 2019

Critically ill children who present to emergency departments (EDs) that are poorly prepared to deal with pediatric emergencies are more than three times as likely to die than children who present to child-ready EDs, a study published online today in Pediatrics has shown.

"Primarily, our findings suggest that patient outcomes may be improved by increasing the readiness of hospitals to care for pediatric emergencies," write Stefanie G. Ames, MD, from the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues.

According to the authors, studies have shown variability among some US hospitals in their preparedness to manage critically ill children.

With this in mind, they conducted a retrospective cohort study to investigate whether hospitals' pediatric readiness is associated with greater mortality.

The researchers examined 2013 data from 426 hospitals in five states, including 20,483 critically ill children aged 18 years or younger who presented to an ED.

They also examined National Pediatric Readiness Project (NPRP) assessment data reflecting the pediatric readiness of the hospitals' EDs.

The NPRP assessment provides a weighted pediatric readiness score (WPRS) on the basis of a hospital's performance in the areas of administration and coordination; staffing; quality improvement efforts; child patient safety, policies, or protocols; and equipment, supplies, and medications.

In their analysis, Ames and colleagues grouped the hospitals by quartiles of pediatric readiness.

Among all hospitals included in the study, the median WPRS was 74.8 (interquartile range, 59.3 - 88.0; range, 29.6 - 100).

A child's risk of dying in hospital decreased when presenting to hospitals with higher WPRSs.

The unadjusted in-hospital mortality rates from lowest to highest pediatric readiness quartile were 11.1%, 5.4%, 4.9%, and 3.4% (P < .001 for trend).

This trend remained similar (P < .001) when the researchers adjusted for patient characteristics such as age, chronic complex conditions, and severity of illness.

Hospitals with lower scores were more likely to be smaller hospitals, nonteaching hospitals, and located in smaller communities. These hospitals were also less likely to have a pediatric ED, pediatric inpatient unit, and/or pediatric intensive care unit.

"As detailed in previous work, the most common reasons for low readiness scores are lack of implementation of ED policies dedicated to children, lack of quality improvement efforts, and absence of a dedicated pediatric emergency care coordinator, all of which are plausibly related to patient outcomes," write Ames and colleagues.

The authors emphasize the need for efforts to better prepare EDs that accept pediatric emergencies in order to provide the best care for critically ill children.

In an accompanying editorial, Katherine E. Remick, MD, from Dell Children's Medical Center of Central Texas, Austin, notes that a system-based collaborative approach to assess the effect of pediatric readiness on quality of emergency care delivery or health outcomes is lacking in EDs.

Some of the barriers hindering this assessment at most EDs include insufficient volume of critically ill child patients, a lack of quality improvement activities, and low overall mortality rates in children compared with adults.

Nevertheless,"[b]y using previous estimates for the percentage of ED deaths among pediatric patients and by extrapolating from the results described by Ames et al, if all EDs adhered to pediatric readiness guidelines, the percentage of pediatric deaths in EDs could dramatically decrease," concludes Remick.

This study was supported by the National Institutes of Health, and the Health Resources and Services Administration of the US Department of Health and Human Services. The authors have disclosed no relevant financial relationships. The editorialist reports being funded in part by the Health Resources and Services Administration of the US Department of Health and Human Services.

Pediatrics. Published online August 23, 2019. Abstract, Editorial

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