Association between emergency department pediatric readiness and transfer of noninjured children in small rural hospitals

Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems

OBJECTIVE

To describe the frequency and observed trends for all Indian Health Service (IHS) and tribal emergency department (ED) transfers to a pediatric referral center from January 1, 2017, to December 31, 2020, with a secondary analysis to describe trends in final dispositions, lengths of stay (LOS), and the most common primary ICD-10 diagnoses.

METHODS

We performed a retrospective chart review of IHS and tribal ED transfers to a pediatric referral center from 2017 to 2020 (n = 2433). The data were summarized using frequencies and percentages and we used generalized estimating equations to analyze patient characteristics over time.

RESULTS

IHS and tribal ED transfers accounted for 6.5%-7.1% of all transfers each year between 2017 and 2020 without significant changes over time. Within this group, 60% were admitted and 62% experienced a LOS greater than 24 h. The most common diagnostic code groups for these patients were respiratory conditions, injuries and poisonings, nonspecific abnormal clinical findings and labs, digestive system diseases, and nervous system diseases.

CONCLUSIONS

This study addresses important knowledge gaps regarding transfers from IHS and tribal EDs, highlights potential high-impact areas for pediatric readiness, and emphasizes the need for more granular data to inform resource allocation and educational interventions. Further studies are needed to delineate potentially avoidable transfers seen within this population.

Readiness of emergency departments for pediatric patients and pediatric mortality: a systematic review

BACKGROUND

Most children who need emergency care visit general emergency departments and urgent care centres; the weighted pediatric readiness score (WPRS) is currently used to evaluate emergency departments' readiness for pediatric patients. The aim of this study was to determine whether a higher WPRS was associated with decreased mortality and improved health care outcomes and utilization.

METHODS

We conducted a systematic review of cohort and cross-sectional studies on emergency departments that care for children (age ≤ 21 yr). We searched MEDLINE (Ovid), Embase (Ovid), the Cochrane Library (Wiley), CINAHL (EBSCO), Global Health (Ovid) and Scopus from inception until July 29, 2022. Articles identified were screened for inclusion by 2 independent reviewers. The primary outcome was mortality, and the secondary outcomes were health care outcomes and utilization. We used the Newcastle-Ottawa Scale to assess for quality and bias of the included studies. The I 2 statistic was calculated to quantify study heterogeneity.

RESULTS

We identified 1789 articles. Eight articles were included in the final analysis. Three studies showed an inverse association between highest WPRS quartile and pediatric mortality (pooled odds ratio [OR] 0.45, 95% confidence interval [CI] 0.26 to 0.78; I 2 = 89%, low certainty of evidence) in random-effects meta-analysis. Likewise, 1 study not included in the meta-analysis also reported an inverse association with a 1-point increase in WPRS (OR 0.93, 95% CI 0.88 to 0.98). One study reported that the highest WPRS quartile was associated with shorter length of stay in hospital (β -0.36 days, 95% CI -0.61 to -0.10). Three studies concluded that the highest WPRS quartile was associated with fewer interfacility transfers. The certainty of evidence is low for mortality and moderate for the studied health care outcomes and utilization.

INTERPRETATION

The data suggest a potential inverse association between the WPRS of emergency departments and mortality risk in children. More studies are needed to refute or confirm these findings.

PROTOCOL REGISTRATION

PROSPERO-CRD42020191149.

Prehospital and emergency department pediatric readiness for injured children: A statement from the American College of Surgeons Committee on Trauma Emergency Medical Services Committee

ABSTRACT

Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.

National Assessment of Pediatric Readiness of US Emergency Departments During the COVID-19 Pandemic

Importance

The National Pediatric Readiness Project assessment provides a comprehensive evaluation of the readiness of US emergency departments (EDs) to care for children. Increased pediatric readiness has been shown to improve survival for children with critical illness and injury.

Objectives

To complete a third assessment of pediatric readiness of US EDs during the COVID-19 pandemic, to examine changes in pediatric readiness from 2013 to 2021, and to evaluate factors associated with current pediatric readiness.

Design, Setting, and Participants

In this survey study, a 92-question web-based open assessment of ED leadership in US hospitals (excluding EDs not open 24 h/d and 7 d/wk) was sent via email. Data were collected from May to August 2021.

Main Outcomes and Measures

Weighted pediatric readiness score (WPRS) (range, 0-100, with higher scores indicating higher readiness); adjusted WPRS (ie, normalized to 100 points), calculated excluding points received for presence of a pediatric emergency care coordinator (PECC) and quality improvement (QI) plan.

Results

Of the 5150 assessments sent to ED leadership, 3647 (70.8%) responded, representing 14.1 million annual pediatric ED visits. A total of 3557 responses (97.5%) contained all scored items and were included in the analysis. The majority of EDs (2895 [81.4%]) treated fewer than 10 children per day. The median (IQR) WPRS was 69.5 (59.0-84.0). Comparing common data elements from the 2013 and 2021 NPRP assessments demonstrated a reduction in median WPRS (72.1 vs 70.5), yet improvements across all domains of readiness were noted except in the administration and coordination domain (ie, PECCs), which significantly decreased. The presence of both PECCs was associated with a higher adjusted median (IQR) WPRS (90.5 [81.4-96.4]) compared with no PECC (74.2 [66.2-82.5]) across all pediatric volume categories (P < .001). Other factors associated with higher pediatric readiness included a full pediatric QI plan vs no plan (adjusted median [IQR] WPRS: 89.8 [76.9-96.7] vs 65.1 [57.7-72.8]; P < .001) and staffing with board-certified emergency medicine and/or pediatric emergency medicine physicians vs none (median [IQR] WPRS: 71.5 [61.0-85.1] vs 62.0 [54.3-76.0; P < .001).

Conclusions and Relevance

These data demonstrate improvements in key domains of pediatric readiness despite losses in the health care workforce, including PECCs, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness.

Emergency Department Pediatric Readiness and Potentially Avoidable Transfers

OBJECTIVE

To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components.

STUDY DESIGN

This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates.

RESULTS

After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan.

CONCLUSIONS

Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.