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Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023

Date: Dec 11, 2023

Guest Skeptic: Dr. Rachel Hatcliffe is a pediatric emergency medicine attending at Children’s National Hospital in Washington, DC. Her research focuses on prehospital care of children with anaphylaxis. 

Guest Authors: 

Dr. Kate Remick

Dr. Kate Remick is a pediatric emergency medicine physician and Assistant Professor of Pediatrics at Dell Medical School at the University of Texas at Austin. She is an executive lead for the EMS for Children Innovation and Improvement Center. She has held leadership positions with state and national professional organizations to promote high quality emergency care for children.

Dr. Hilary Hewes is a pediatric emergency medicine physician and an Associate Professor of Pediatrics at the University of Utah/Primary Children’s Hospital with interests in prehospital care, pediatric trauma and injury prevention, and disaster medicine and preparedness.  She is the co-Principal Investigator for the EMS for Children Data Center.

Dr. Hilary Hewes

Dr. Marianne Gausche-Hill is a pediatric emergency medicine physician and the interim CEO of the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center. She is also a Professor of Pediatrics and Emergency Medicine at David Geffen School of Medicine at UCLA. She is nationally known for her work as an EMS researcher and educator. 

Case: After your shift in the emergency department (ED) one day, the medical director pulls you aside. She says that they’ve noticed a slight increase in the number of sick pediatric patients coming in recently and the difficulty in finding a hospital to accept the ones who need admission. As a seasoned clinician, she wants your opinion and asks you, “How prepared do you think we are in handling sick children?” and “Do you have any thoughts about how we can improve?”

Dr. Marianne Gausche-Hill

Background: Back in August of 2022, we announced the start of #SGEMPeds for SGEM Season 11. One of the key motivations was the recognition that we needed to get out of the ivory towers of academic pediatric emergency medicine centers as most children are cared for outside of academic centers. We wanted to spread the gospel of evidence-based medicine so that children get the best care, based on the best evidence, regardless of where they receive care. 

But does that always happen? Are general emergency departments ready to care for children? Two previous studies conducted assessing the state of nationwide pediatric readiness were conducted in 2003 and 2013. [1,2] Today we’re covering the third study. Pediatric readiness is important because it is associated with decreased mortality in ill and injured children. [3, 4]

Conflict of Interest Disclosure: Dennis is an Emergency Medical Services for Children (EMSC) fellow in the Knowledge Management domain. 

 

Clinical Question: What was the state of pediatric readiness in emergency departments across the United States during the COVID-19 pandemic?

Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023

  • Population: ED leadership across the United States. It included 3,647 readiness assessments performed, representing 14.1 million annual pediatric ED visits. 
    • Excluded:  EDs that are not open 24 hours a day or 7 days a week. Veterans Affairs and prison hospitals.
  • Intervention: Web-based open assessment questionnaire containing 92 questions. 
  • Comparison: Previous pediatric readiness scores. 
  • Outcome:
    • Primary Outcome: Weighted pediatric readiness score (WPRS, range 0-100); Adjusted WPRS (exclude points for QI plan and Pediatric Emergency Care Coordinator aka PECC)
    • Secondary Outcomes: Changes in WPRS from 2013 to 2021, evaluate factors associated with pediatric readiness.
  • Authors’ Conclusions:“These data demonstrate improvements in key domains of pediatric readiness despite losses in the healthcare workforce, including pediatric emergency care coordinators, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness. This comprehensive assessment found that the presence of PECCs, QI plans for children, and staffing the ED with board-certified EM/PEM physicians were associated with higher pediatric readiness and provides an opportunity for all EDs to initiate organizational changes that can enhance their pediatric capability.”

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes. 
  3. Was the cohort recruited in an acceptable way? Yes. 
  4. Was the exposure accurately measured to minimize bias? Unsure
  5. Was the outcome accurately measured to minimize bias? Unsure
  6. Have the authors identified all-important confounding factors? Yes.
  7. Was the follow up of subjects complete enough?  Yes
  8. How precise are the results? Fairly precise
  9. Do you believe the results? Yes. 
  10. Can the results be applied to the local population? Yes. 
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study. No conflicts of interest

Results: There were 3,647 (70.5%) EDs who responded to the survey representing 14.1 million annual pediatric ED visits. Majority (81.4%) of EDs treated fewer than 10 children per day and were mostly located in general hospitals (59.3%) and urban areas (62.9%). Around three-quarters (76.5%) were able to admit children in some capacity. 90.4% reported that there was a physician on site 24/7. Around 37% reported that they had someone in a PECC role. 

Key Results: Pediatric readiness scores decreased during the COVID-19 pandemic BUT there were improvements across many domains except in administration and coordination (PECC).

Median WPRS was 69.5 with an IQR of (59.0-84.0). This increased based on volume of pediatric patients.

Comparing WPRS from 2013 to this most recent study for the hospitals who participated in both years, there was a decrease from 72.7 (60.1-87.8) to 70.5 (61.3-87.4).

Listen to the SGEM podcast to hear Drs. Remick, Hewes, and Gausche-Hill answer our questions. We provide some key points below:

1) Assessment Development: Much of this effort towards pediatric readiness was inspired by guidelines and policy statements from national organizations like the American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), Emergency Nurses Association (ENA), and Emergency Medical Services for Children (EMSC). 

When you were putting together the assessment, how did the expert panel decide how to weigh the assessment items? What were the items that were weighted heavier?

  • The assessment items were given weighted scores using a modified Delphi process with a group of subject matter experts. The weighing process underwent several rounds before final scores were determined. 
  • The National Quality Forum criteria were used: importance for patient outcomes, scientific acceptability, feasibility, and usability. 

2) Assessment Evolution: This was the third assessment of pediatric readiness. The first survey was sent out in 2003 by mail with a 29% response rate. The second survey was sent out in 2013 and web-based with a close to 83% response rate. This second survey had 55-items.

As you have gone through multiple iterations of this assessment survey. This time, the response rate was lower at 70.5%. What have you changed?

This newest version has 92 items. What was added? Did you weigh items differently in each iteration?

  • Several questions were expanded or modified according to the newer version of the Joint Guidelines
  • Of the 88 scored items, 69 were 1:1 comparable and the others had been changed in some ways. 
  • The overall domains of the assessment and the total score for each domain did not change.
  • There was greater emphasis placed on the components of a quality improvement (QI) process rather than simply stating the process alone was in place and pediatric patient assessment (pain, mental status and respiratory monitoring), behavioral health and family-centered care.

3) ED Leadership: The assessment survey was completed by someone designated to be in the ED leadership role. Previous assessments were completed by a medical director (2003) and ED nurse manager (2013). 

For the most recent assessment, do you know who completed the survey? Sometimes there’s a perception that leadership may be removed from the day-to-day operations of the ED.

Do you think the people completing your assessment provided an accurate representation? Or do you think there’s a possibility that there is some disconnect or Hawthorne effect at play?

  • The assessment pre-notice was sent to ED nurse managers and medical directors to try to engage leadership. 
  • Most assessments were filled out by nurses in a nursing leadership position: charge nurse, nurse manager, chief nursing officer, etc. 
  • Some medical directors did fill out the assessment.
  • Study team encouraged nursing and medical leadership work together to review the PDF copy of assessment beforehand to accurately fill out the assessment or do it together.
  • The degree of penetrance (i.e. the degree to which all ED staff are aware of all pediatric readiness components reported) has not been assessed.

4) Resource Allocation: There were a few factors cited that were associated with high readiness scores. Those included the presence of PECCs, pediatric QI plans, and staffing with board-certified EM or pediatric EM physicians. 

In a time where resources are scarce, we’re facing issues with short-staffing, long wait times, boarding. We’re seeing a decrease in pediatric inpatient capabilities.

Where do you think we should be directing our efforts and resources?

  • At under $50 average per patient, you can pull any sized hospital into a higher quartile of readiness [5]. 
  • Effort should focus on the system: improving reimbursement rates for pediatric emergency care; asking hospitals and EDs to support pediatric emergency care coordinators, both a nurse and physician, with protected time to do their work.
  • Encourage legislation to ensure pediatric-specific continuing education
  • Strengthen relationships between larger pediatric centers and rural centers to provide support and facilitate efficient transfer when necessary.
  • We have lost >700 pediatric inpatient units over the last decade [6].
  • The median time to death in pediatric emergencies is 3 hours after arrival to the ED. [7]
  • Immediate resuscitation and stabilization via universal pediatric readiness is the short-term solution.
  • Integrate standards related to pediatric readiness into accreditation programs.

5) What’s Next? There’s been some progress in pediatric readiness over the time. In 2003, only 6% of EDs surveyed had all the recommended equipment and supplies in contrast to this study where around 59% of EDs had all the recommended equipment.

In comparing scores from 2013 to today, we saw a decrease in WPRS by around 2 points. How can we interpret this in terms of clinical significance?

  • If you look deeper at the data, we actually improved across 5 of the 6 domains of readiness assessed, and we are making progress over time.  
  • The main reason that scores didn’t increase is that almost 20% of the total score is based on the presence of pediatric emergency care coordinators.
  • There are a number of huge wins related to equipment, policies and patient safety.

When you’re doing this assessment again in 10 years. Where do we go from here? What would you like to see happen? Are there any changes you’re planning to make to the assessment tool?

  • Changes to the tool will be based on updates to the joint guidelines.
  • Goal is to leave the majority of scored items the same to better analyze change over time.
  • Continue the partnership with the American College of Surgeons (ACS) which has started mandating that ACS-verified trauma centers take the assessment and have a plan to address gaps.
  • Work with policy makers to improve reimbursement for pediatric emergency care and support legislation requiring elements of pediatric readiness into ED standards.
  • Sustain the role of PECCs.
  • Address critical gaps related to pediatric continuous quality improvement and the inclusion of children in disaster plans.
  • Demonstrate ability to meet the emergency needs of children’s mental health.

Bonus Question: How does the United States compare to other countries around the world in terms of pediatric readiness?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

SGEM Bottom Line: There are multiple opportunities to improve pediatric readiness in the emergency department. Pediatric readiness is directly associated with better outcomes for children.

Dr. Rachel Hatcliffe

Case Resolution: You tell your medical director that there have been national assessments performed to assess the state of pediatric readiness. These assessments have involved multiple items that include ED personnel, administration, equipment, QI, safety, and policies. You let her know that there is an assessment tool available on www.pedsready.org that is a good starting point to identify gaps and target interventions.

Clinical Application: Pediatric readiness is an important consideration in all emergency departments. An assessment of pediatric readiness can be completed online. Improved pediatric readiness scores are associated with decreased mortality in ill and injured children.

What Do I Tell the Medical Director? 

Tune in to hear the response from the authors!

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics. 2007;120(6):1229-1237.
  2. 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.
  3. Ames SG, Davis BS, Marin JR, et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568.
  4. Newgard CD, Lin A, Malveau S, et al. Emergency department pediatric readiness and short-term and long-term mortality among children receiving emergency care. JAMA Netw Open. 2023;6(1):e2250941.
  5. Gausche-Hill M, Remick KE, et al. Hospital Costs Required to Reach and Maintain High Emergency Department Pediatric Readiness. Poster presented at EMSC All-Grantee Meeting. September 2023. Austin, TX. 
  6. Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of pediatric inpatient services in the united states. Pediatrics. 2021;148(1):e2020041723.
  7. Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. Association of emergency department pediatric readiness with mortality to 1 year among injured children treated at trauma centers. JAMA Surg. 2022;157(4):e217419.