Trends in Regionalization of Emergency Care for Common Pediatric Conditions

A National Analysis of General Pediatric Inpatient Unit Closures and Openings, 2011-2018

OBJECTIVES

This paper provides an examination of: (1) the frequency and net rates of change for general pediatric inpatient (GPI) unit closures and openings nationally and by state; (2) how often closures or openings are caused by GPI unit changes only or caused by hospital-level changes; and (3) the relationship between hospital financial status and system ownership and GPI unit closures or openings.

METHODS

This study used the Health Systems and Providers Database (2011-2018) plus 3 data sources on hospital closures. We enumerated GPI unit closures and openings to calculate net rates of change. Multinomial logistic regressions analyzed associations between financial distress, system ownership, and the likelihood of closing or opening a GPI unit, adjusting for hospital characteristics.

RESULTS

Across the study period, more GPI units closed th opened for a net closure rate of 2.0% (15.7% [638 of 4069] closures minus 13.7% [558 of 4069] openings). When GPI units closed, 89.0% (568 of 638) did so in a hospital that remained operating. Hospitals with the most financial distress were not more likely to close a GPI unit than those not (odds ratio: 1.01 [95% confidence interval: 0.68-1.50]), but hospitals owned by systems were significantly less likely to close a GPI unit than those not (odds ratio: 0.66 [95% confidence interval: 0.47-0.91]).

CONCLUSIONS

Overall, more GPI units closed than opened, and closures mostly involved hospitals that otherwise remained operational. A hospital's overall financial distress was not associated with GPI unit closures, whereas being owned by a system was associated with fewer closures.

Rural-Urban Disparities in Hospital Services and Outcomes for Children With Medical Complexity

Importance

Limited availability of inpatient pediatric services in rural regions has raised concerns about access, safety, and quality of hospital-based care for children. This may be particularly important for children with medical complexity (CMC).

Objectives

To describe differences in the availability of pediatric services at acute care hospitals where rural- and urban-residing CMC presented for hospitalization; identify rural-urban disparities in health care quality and in-hospital mortality; and determine whether the availability of pediatric services at index hospitals or the experience of interfacility transfer modified rural-urban differences in outcomes.

Design, Setting, and Participants

This retrospective cohort study examined all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 to 2017. Analysis was conducted from May 2023 to July 2024. Participants included CMC younger than 18 years residing in these states and hospitalized during the study period.

Exposures

Rural or urban residence was determined using Rural-Urban Commuting Area codes. Hospitals were categorized as children's hospitals or general hospitals with comprehensive, limited, or no dedicated pediatric services using American Hospital Association survey data. Interfacility transfers between index and definitive care hospitals were identified using health care claims.

Main Outcomes and Measures

In-hospital mortality, all-cause 30-day readmission, medical-surgical safety events, and surgical safety events were operationalized using Agency for Healthcare Research and Quality measure specifications.

Results

Among 36 943 CMC who experienced 79 906 hospitalizations, 16 525 (44.7%) were female, 26 034 (70.5%) were Medicaid-insured, and 34 008 (92.1%) were urban-residing. Rural-residing CMC were 6.55 times more likely to present to hospitals without dedicated pediatric services (rate ratio [RR], 6.55 [95% CI, 5.86-7.33]) and 2.03 times more likely to present to hospitals without pediatric beds (RR, 2.03 [95% CI, 1.88-2.21]) than urban-residing CMC, with no significant differences in interfacility transfer rates. In unadjusted analysis, rural-residing CMC had a 44% increased risk of in-hospital mortality (RR, 1.44 [95% CI, 1.03-2.02]) with no significant differences in other outcomes. Adjusting for clinical characteristics, the difference in in-hospital mortality was no longer significant. Index hospital type was not a significant modifier of observed rural-urban outcomes, but interfacility transfer was a significant modifier of rural-urban differences in surgical safety events.

Conclusions and Relevance

In this cohort study, rural-residing CMC were significantly more likely to present to hospitals without dedicated pediatric services. These findings suggest that efforts are justified to ensure that all hospital types are prepared to care for CMC.

Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness

BACKGROUND

Acute pediatric respiratory illness is one of the most common reasons for emergency department(ED) transfer however few studies have examined predictors of potentially avoidable ED transfer(PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness.

METHODS

Cross-sectional analysis of 8,402,577 visits for patients <17 years from 2018-2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a three-level generalized linear mixed model with adjustment for patient and hospital covariates.

RESULTS

Among 4,409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits(n=472, 42.0%). In the multivariable model, likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09 -3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes(OR 0.48 95% CI 0.26-0.88).

CONCLUSIONS

Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower three quartiles of pediatric volume.

Children's Hospital Resource Utilization During the 2022 Viral Respiratory Surge

OBJECTIVES

Multiple viral respiratory epidemics occurred concurrently in 2022 but their true extent is unclear. To aid future surge planning efforts, we compared epidemiology and resource utilization with prepandemic viral respiratory seasons in 38 US children's hospitals.

METHODS

We performed a serial cross-sectional study from October 2017 to March 2023. We counted daily emergency department (ED), inpatient, and ICU volumes; daily surgeries; viral tests performed; the proportion of ED visits resulting in revisit within 3 days; and proportion of hospitalizations with a 30-day readmission. We evaluated seasonal resource utilization peaks using hierarchical Poisson models.

RESULTS

Peak volumes in the 2022 season were 4% lower (95% confidence interval [CI] -6 to -2) in the ED, not significantly different in the inpatient unit (-1%, 95% CI -4 to 2), and 8% lower in the ICU (95% CI -14 to -3) compared with each hospital's previous peak season. However, for 18 of 38 hospitals, their highest ED and inpatient volumes occurred in 2022. The 2022 season was longer in duration than previous seasons (P < .02). Peak daily surgeries decreased by 15% (95% CI -20 to -9) in 2022 compared with previous peaks. Viral tests increased 75% (95% CI 69-82) in 2022 from previous peaks. Revisits and readmissions were lowest in 2022.

CONCLUSIONS

Peak ED, inpatient, and ICU volumes were not significantly different in the 2022 viral respiratory season compared with earlier seasons, but half of hospitals reached their highest volumes. Research on how surges impact boarding, transfer refusals, and patient outcomes is needed as regionalization reduces pediatric capacity.

Defining Levels of US Hospitals' Pediatric Capabilities

Importance

Classifying hospitals across a wide range of pediatric capabilities, including medical, surgical, and specialty services, would improve understanding of access and outcomes.

Objective

To develop a classification system for hospitals' pediatric capabilities.

Design, Setting, and Participants

This cross-sectional study included data from 2019 on all acute care hospitals with emergency departments in 10 US states that treated at least 1 child per day. Statistical analysis was performed from September 2023 to February 2024.

Exposure

Pediatric hospital capability level, defined using latent class analysis. The latent class model parameters were the presence or absence of 26 functional capabilities, which ranged from performing laceration repairs to performing organ transplants. A simplified approach to categorization was derived and externally validated by comparing each hospital's latent class model classification with its simplified classification using data from 3 additional states.

Main Outcomes and Measures

Health care utilization and structural characteristics, including inpatient beds, pediatric intensive care unit (PICU) beds, and referral rates (proportion of patients transferred among patients unable to be discharged).

Results

Using data from 1061 hospitals (716 metropolitan [67.5%]) with a median of 2934 pediatric ED encounters per year (IQR, 1367-5996), the latent class model revealed 4 pediatric levels, with a median confidence of hospital assignment to level of 100% (IQR, 99%-100%). Of 26 functional capabilities, level 1 hospitals had a median of 24 capabilities (IQR, 21-25), level 2 hospitals had a median of 13 (IQR, 11-15), level 3 hospitals had a median of 8 (IQR, 6-9), and level 4 hospitals had a median of 3 (IQR, 2-3). Pediatric level 1 hospitals had a median of 66 inpatient beds (IQR, 42-86), level 2 hospitals had a median of 16 (IQR, 9-22), level 3 hospitals had a median of 0 (IQR, 0-6), and level 4 hospitals had a median of 0 (IQR, 0-0) (P < .001). Level 1 hospitals had a median of 19 PICU beds (IQR, 10-28), level 2 hospitals had a median of 0 (IQR, 0-5), level 3 hospitals had a median of 0 (IQR, 0-0), and level 4 hospitals had a median of 0 (IQR, 0-0) (P < .001). Level 1 hospitals had a median referral rate of 1% (IQR, 1%-3%), level 2 hospitals had a median of 25% (IQR, 9%-45%), level 3 hospitals had a median of 70% (IQR, 52%-84%), and level 4 hospitals had a median of 100% (IQR, 98%-100%) (P < .001).

Conclusions and Relevance

In this cross-sectional study of hospitals from 10 US states, a system to classify hospitals' pediatric capabilities in 4 levels was developed and was associated with structural and health care utilization characteristics. This system can be used to understand and track national pediatric acute care access and outcomes.

Understanding Pediatric Surge in the United States

The concepts of pediatric surge in the United States continue to evolve from a theoretic framework to practical implementation. As disasters become more frequent, ranging from natural to human-caused, children remain a vulnerable population. The coronavirus disease 2019 pandemic and the 2022 to 2023 tripledemic respiratory surge revealed advances and continued challenges in our ability to care for a large influx of pediatric patients. Understanding pediatric surge through the framework of the 4 S's (space, staff, stuff, and systems/structures) can identify gaps at multiple levels.

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.

"Right now, it's kind of haphazard"-Pediatric emergency care coordinators and quality of emergency care for children: A qualitative study

Objectives

Pediatric readiness varies widely among emergency departments (EDs). The presence of a pediatric emergency care coordinator (PECC) has been associated with improved pediatric readiness and decreased mortality, but adoption of PECCs has been limited. Our objective was to understand factors associated with PECC implementation in general EDs.

Methods

We conducted semistructured qualitative interviews with a purposively sampled set of EDs with and without PECCs. Interviews were completed, transcribed, and coded until thematic saturation was reached. Themes were identified through a consensus process and mapped to the Consolidated Framework for Implementation Research (CFIR).

Results

Twenty-four interviews were conducted and mapped to themes related to innovation, individuals and implementation process, outer setting (health system), and inner setting (hospital/ED). Addressing innovation, individuals, and implementation process, the primary theme was variability in how the PECC role was defined and who was responsible for implementing it. Regarding the outer setting, participants reported that limited system resources affected their ability to implement the PECC role. Key inner setting themes included concerns about limited visit volume, a lack of systems for measuring pediatric quality of care, and significant tension around change.

Conclusions

Implementation of the PECC role appears to be limited by heterogeneous interpretations of the PECC, de-prioritization of pediatrics, and limited system resources. However, many participants described motivation to improve pediatric care and implement the PECC role in context of increasing pediatric visits; they offered strategies for future implementation efforts.

Evaluation of Pediatric Readiness Using Simulation in General Emergency Departments in a Medically Underserved Region

BACKGROUND

Regionalization of pediatric care in the United States was developed to improve care by directing patients to hospitals with optimal pediatric resources and experience, leading to less pediatric-trained providers in medically underserved areas. Children with emergencies, however, continue to present to local general emergency departments (GEDs), where pediatric emergencies are low-frequency, high-risk events.

OBJECTIVE

The goals of this project were to: increase exposure of GEDs in the southeast United States to pediatric emergencies through simulation, assess pediatric emergency clinical care processes with simulation, describe factors associated with readiness including volume of pediatric patients and ED location (urban/rural), and compare these findings to the 2013 National Pediatric Readiness Project.

METHODS

This prospective in situ simulation study evaluated GED readiness using the Emergency Medical Services for Children Pediatric Readiness Score (PRS) and team performance in caring for 4 simulated pediatric emergencies. Comparisons between GED and pediatric ED (PED) performance and PRS, GED performance, and PRS based on pediatric patient volume and hospital location were evaluated. A Composite Quality Score (CQS) was calculated for each ED.

RESULTS

Seventy-five teams from 40 EDs participated (39 GED; 1 PED). The PED had a significantly higher volume of pediatric patients (73,000 vs 4492; P = 0.003). The PRS for GEDs was significantly lower (57% [SD, 17] vs 98%; P = 0.022). The CQSs for all GEDs were significantly lower than the PED (55% vs 87%; P < 0.004). Among GEDs, there was no statistically significant difference in PRS or CQS based on pediatric patient volume, but urban GEDs had significantly higher CQSs versus rural GEDs (59.8% vs 50.6%, P = 0.001).

CONCLUSIONS

This study shows a significant disparity in the performance and readiness of GEDs versus a PED in a medically underserved area. More education and better access to resources is needed in these areas to adequately care for critically ill pediatric patients.

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Importance

Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown.

Objective

To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure.

Design, Setting, and Participants

This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV).

Main Outcomes and Measures

The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success).

Results

Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure.

Conclusions and Relevance

Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

Pediatric Critical Care Referrals for Tertiary Inpatient and Transport Services in Canada's Maritime Provinces: A Retrospective Cohort Study

OBJECTIVE

Accurate triage of children referred for tertiary pediatric critical care services is crucial to ensure optimal disposition and resource conservation. We aimed to explore the characteristics and level of care needs of children referred to tertiary pediatric critical care inpatient and transport services and the characteristics of referring physicians and hospitals to which these children present.

METHODS

We conducted a 1-year retrospective cohort study of children (< 16 years) with documented referral to pediatric critical care and specialized transport services at a tertiary pediatric hospital from regional (24/7 pediatrician on-call coverage) and community (no pediatric specialty services) hospitals in Canada's Maritime provinces.

RESULTS

We identified 205 documented referrals resulting in 183 (89%) transfers; 97 (53%) were admitted to the pediatric intensive care unit (PICU). Of 150 children transferred from centers with 24/7 pediatric specialist coverage, 45 (30%) were admitted to the tertiary hospital pediatric medical unit with no subsequent admission to the PICU. Of 20 children transferred from community hospitals and admitted to the tertiary hospital general pediatric medical unit, 9 (45%) bypassed proximate regional hospitals with specialist pediatric care capacity. The specialized pediatric critical care transport team performed 151 (83%) of 183 interfacility transfers; 83 (55%) were admitted to the PICU.

CONCLUSION

One third of the children accepted for interfacility transfer after pediatric critical care referral were triaged to a similar level of care as could be provided at the sending or nearest regional hospital. Improved utilization of pediatric expertise in regional hospitals may reduce unnecessary pediatric transports and conserve valuable health care resources.

National Characteristics of Emergency Care for Children with Neurologic Complex Chronic Conditions

Introduction

Most pediatric emergency care occurs in general emergency departments (GED), where less pediatric experience and lower pediatric emergency readiness may compromise care. Medically vulnerable pediatric patients, such as those with chronic, severe, neurologic conditions, are likely to be disproportionately affected by suboptimal care in GEDs; however, little is known about characteristics of their care in either the general or pediatric emergency setting. In this study our objective was to compare the frequency, characteristics, and outcomes of ED visits made by children with chronic neurologic diseases between general and pediatric EDs (PED).

Methods

We conducted a retrospective analysis of the 2011-2014 Nationwide Emergency Department Sample (NEDS) for ED visits made by patients 0-21 years with neurologic complex chronic conditions (neuro CCC). We compared patient, hospital, and ED visits characteristics between GEDs and PEDs using descriptive statistics. We assessed outcomes of admission, transfer, critical procedure performance, and mortality using multivariable logistic regression.

Results

There were 387,813 neuro CCC ED visits (0.3% of 0-21-year-old ED visits) in our sample. Care occurred predominantly in GEDs, and visits were associated with a high severity of illness (30.1% highest severity classification score). Compared to GED visits, PED neuro CCC visits were comprised of individuals who were younger, more likely to have comorbid conditions (32.9% vs 21%, P < 0.001), and technology assistance (65.4% vs. 45.9%) but underwent fewer procedures and had lower ED charges ($2,200 vs $1,520, P < 0.001). Visits to PEDs had lower adjusted odds of critical procedures (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI] 0.62-0.87), transfers (aOR 0.14, 95% CI 0.04-0.56), and mortality (aOR 0.38, 95% CI 0.19-0.75) compared to GEDs.

Conclusion

Care for children with neuro CCCs in a pediatric ED is associated with less resource utilization and lower rates of transfer and mortality. Identifying features of PED care for neuro CCCs could lead to lower costs and mortality for this population.

Outcome of interhospital pediatric foreign body transfers

BACKGROUND

Children with foreign bodies are often transferred from general emergency departments (EDs) to children's hospitals for optimal management. Our objective was to describe the outcomes of interhospital pediatric foreign body transfers and examine factors associated with potentially avoidable transfers (PATs) in this cohort.

METHODS

We conducted a retrospective cohort study of children aged <18 years transferred to our hospital for the primary complaint of foreign body from January 1, 2020, to September 30, 2022. Data collected included demographics, diagnostic studies and interventions performed, and disposition. A transfer was considered a PAT if the patient was either discharged from the pediatric emergency department (PED), or from inpatient care within 24 h, did not require procedural sedation and any procedural intervention by a pediatric sub-specialist (other than a pediatric ED physician). Logistic regression analysis was performed to evaluate factors associated with PATs.

RESULTS

A total of 213 patients were analyzed based on eligibility criteria. The majority of patients were male (51.2%), pre-school age (59.2%), symptomatic (55.8%), and transferred from academic EDs (61%). Coins were the most common foreign bodies (30%), with the gastrointestinal tract (63.8%) being the most common location. Half of the non-respiratory and non-gastrointestinal foreign bodies were successfully removed in the PED. Over half (57.3%) of the patients were discharged from PED. Operative intervention was required in 82 (38.5%) patients, most commonly for coins (50%). 41.8% of transfers were deemed PATs. Presence of foreign body in the esophagus or respiratory tract (OR: 0.071, 95% CI: 0.025-0.200), symptoms at presentation (OR: 0.265, 95% CI: 0.130-0.542), magnet ingestions (OR: 0.208, 95% CI: 0.049-0.886) and transfers from community EDs (OR: 0.415, 95% CI: 0.194-0.885) were less likely associated with PATs. Button battery-related transfers were more likely associated with an avoidable transfer (OR: 6.681, 95% CI: 1.15-39.91).

CONCLUSIONS

PATs are relatively common among children transferred to a children's hospital for foreign bodies. Factors associated with PATs have been identified and may represent targets for interventions to avoid low value pediatric foreign body transfers.

Pediatric Patient Insurance Status and Regionalization of Admissions

BACKGROUND

Pediatric hospital care is becoming increasingly regionalized, and previous data have suggested that insurance may be associated with transfer. The aims of the study are to describe regionalization of pediatric care and density of the interhospital transfer network and to determine whether these varied by insurance status.

METHODS

Using the New York State ED Database and State Inpatient Database from 2016, we identified all pediatric patients and calculated regionalization indices (RI) and network density, overall and stratified by insurance. Regionalization indices are based on the likelihood of a patient completing care at the initial hospital. Network density is the proportion of actual transfers compared with the number of potential hospital transfer connections. Both were calculated using the standard State ED Database/State Inpatient Database transfer definition and in a sensitivity analysis, excluding the disposition code requirement.

RESULTS

We identified 1,595,566 pediatric visits (emergency department [ED] or inpatient) in New York in 2016; 7548 (0.5%) were transferred and 7374 transferred visits had eligible insurance status (Medicaid, private, uninsured). Of the transfers, 24% were from ED to ED with discharge, 28% from ED to ED with admission, 31% from ED to inpatient, 16% from inpatient to inpatient, and 1.2% from inpatient to ED. The overall RI was 0.25 (95% confidence interval [95% CI], 0.20-0.31). The overall weighted RI was 0.09 (95% CI, 0.06-0.12) and was 0.09 (95% CI, 0.06-0.13) for Medicaid-insured patients, 0.08 (95% CI, 0.05-0.11) for privately insured patients, and 0.08 (95% CI, 0.05-0.11) for patients without insurance. The overall network density was 0.018 (95% CI, 0.017-0.020). Network density was higher, and transfer rates were lower, for patients with Medicaid insurance as compared with private insurance.

CONCLUSIONS

We found significant regionalization of pediatric emergency care. Although there was not material variation by insurance in regionalization, there was variation in network density and transfer rates. Additional work is needed to understand factors affecting transfer decisions and how these patterns might vary by state.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States: 2019 update

BACKGROUND

General hospitals (GH) provide inpatient care for the majority of hospitalized children in the United States, yet the majority of hospital pediatrics research is conducted at freestanding children's hospitals.

OBJECTIVE

Updating a prior 2012 analysis, this study used 2019 data to describe characteristics of pediatric hospitalizations at general and freestanding hospitals in the United States and identify the most common and costly reasons for hospitalization in these settings.

DESIGNS, SETTING, AND PARTICIPANTS

This study examined hospitalizations in children <18 years using the Healthcare Cost and Utilization Project's 2019 Kids' Inpatient Database, stratifying neonatal and nonneonatal hospital stays.

INTERVENTION

Not applicable.

MAIN OUTCOME AND MEASURES

Sociodemographic and clinical differences between hospitalizations at general and freestanding children's hospitals were examined, applying survey weights to generate national estimates.

RESULTS

There were an estimated 5,263,218 pediatric hospitalizations in 2019, including 3,757,601 neonatal and 1,505,617 nonneonatal hospital stays. Overall, 88.6% (n = 4,661,288) of hospitalizations occurred at GH, including 97.6% of neonatal hospitalizations and 65.9% of nonneonatal hospitalizations. 11.4% (n = 601,930) of hospitalizations occurred at freestanding children's hospitals, including 2.4% (n = 88,313) of neonatal hospitalizations and 34.1% (n = 513,616) of nonneonatal hospitalizations. In total, 98.9% of complicated birth hospitalizations and 66.0% of neonatal nonbirth hospitalizations occurred at GH. Among nonneonatal stays, 85.2% of mental health hospitalizations, 63.5% of medical hospitalizations, and 61.3% of surgical hospitalizations occurred at GH.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019

Importance

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood.

Objective

To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity.

Design, Setting, and Participants

This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023.

Exposures

Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals.

Main Outcomes and Measures

The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009.

Results

The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year.

Conclusions and Relevance

Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Neighborhood Poverty and Distance to Pediatric Hospital Care

OBJECTIVE

To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care.

METHODS

This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity.

RESULTS

Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001).

CONCLUSIONS

Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.

Development of an Approach to Assessing Pediatric Fellows' Transport Medical Control Skills

BACKGROUND AND OBJECTIVE

Pediatric interfacility transport teams facilitate access to subspecialty care, and physicians often guide management remotely as transport medical control (TMC). Pediatric subspecialty fellows frequently perform TMC duties, but tools assessing competency are lacking. Our objective was to develop content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

METHODS

We conducted a modified Delphi process among transport and fellow education experts in pediatric critical care medicine, pediatric emergency medicine, neonatal-perinatal medicine, and pediatric hospital medicine. The study team generated an initial list of items on the basis of a literature review and personal experience. A modified Delphi panel of transport experts was recruited to participate in 3 rounds of anonymous, online voting on the importance of the items using a 3-point Likert scale (marginal, important, essential). We defined consensus for inclusion as ≥80% agreement that an item was important/essential and consensus for exclusion as ≥80% agreement that an item was marginal.

RESULTS

The study team of 20 faculty drafted an initial list of items. Ten additional experts in each subspecialty served on the modified Delphi panel. Thirty-six items met the criteria for inclusion, with widespread agreement across subspecialties. Only 1 item, "discussed bed availability," met the criteria for inclusion among some subspecialties but not others. The study team consolidated the final list into 26 items for ease of use.

CONCLUSIONS

Through a consensus-based process among transport experts, we generated content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

Urban-rural disparities in interfacility transfers for children during COVID-19

PURPOSE

We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling.

FINDINGS

Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168.

CONCLUSIONS

Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.

Implementing modified family integrated care in a U.S. neonatal intensive care unit: nursing perspectives and effects on parents

OBJECTIVES

(1) Assess effects of a modified Family Integrated Care (FICare) model on U.S. Neonatal Intensive Care Unit (NICU) parents; (2) Evaluate NICU nurses' perspectives.

DESIGN

Case -control design with parental stress assessed before and after NICU-wide FICare implementation using Parent Stressor Scale: NICU (PSS:NICU) questionnaire. In addition, stratification by degree of participation evaluated associations with parental stress, parental-staff communication and discharge readiness. Questionnaires captured nursing perspectives on FICare.

RESULTS

79 parents (88%) participated prior to FICare; 90 (90%) after. Parent stress was lower (p < 0.001) with FICare. Parents learning 5-15 infant-care skills had lower stress compared to those learning <5 (p = 0.008). Parent utilization of an educational app was associated with improved communication frequency (p = 0.007) and quality (p = 0.012). Bedside NICU nurses reported multiple positive associations of FICare for parents and staff.

CONCLUSIONS

Any degree of FICare participation decreases parental stress; increased participation has multiple positive associations.

Characteristics of Pediatric Patient Transfers From General Emergency Departments in California From 2005 to 2018

OBJECTIVE

Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time.

METHODS

This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005-2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission.

RESULTS

Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87-16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46-3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90-63.20), poisoning (OR, 11.78; 95% CI, 11.30-12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84-6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46-4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45-3.79) had increased odds of transfer.

CONCLUSION

Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.

Using human-centered design to develop a nurse-to-family telehealth intervention for pediatric transfers

Objective

To develop a nurse-to-family telehealth intervention for pediatric inter-facility transfers using the human-centered design approach.

Methods

We conducted the inspiration and ideation phases of a human-centered design process from July 2022 to December 2022. For the inspiration phase, we conducted a qualitative cross-sectional case study design over 3 months. We used thematic analysis with the framework approach of parent and provider interviews. Five team members individually coded transcripts and then met to discuss memos, update a construct summary sheet, and identify emerging themes. The team adapted themes into "How Might We" statements. For the ideation phase, multidisciplinary stakeholders brainstormed solutions to the "How Might We" statements in a design workshop. Workshop findings informed the design of a nurse-to-family telehealth intervention, which was iteratively revised over 2 months based on stakeholder feedback sessions.

Results

We conducted interviews with nine parents, 11 nurses, and 13 physicians. Four themes emerged supporting the promise of a nurse-to-family telehealth intervention, the need to effectively communicate the intervention purpose, the value of a user-friendly workflow, and the essentiality of ensuring that diverse populations equitably benefit from the intervention. "How Might We" statements were discussed among 22 total workshop participants. Iterative adaptations were made to the intervention until feedback from workshop participants and 67 other stakeholders supported no further improvements were needed.

Conclusion

Human-centered design phases facilitated stakeholder engagement in developing a nurse-to-family telehealth intervention. This intervention will be tested in an implementation phase as a feasibility and pilot trial.

Systematic Improvement in the Patient Transfer Process to a Tertiary Care Children's Hospital

OBJECTIVE

Interfacility transfer of pediatric patients to a children's hospital is a complex process that can be time consuming and dissatisfying for referring providers. We aimed to improve the efficiency of communication and acceptance for interfacility transfers to our hospital.

METHODS

We implemented iterative improvements to the process in 2 phases from 2013 to 2016 (pediatric medicine) and 2019 to 2022 (pediatric critical care and surgery). Key interventions included creation of a hospitalist position to manage transfers with broad ability to accept patients and transition to direct phone access for transfer requests to streamline connection. Effective initiatives from Phase 1 were adapted and spread to the other services in Phase 2. Data were manually extracted monthly from call transcripts and monitored by using statistical process control (SPC) charts. Primary outcome measures were time from call to connection to a provider and number of providers added to the call before making a disposition decision.

RESULTS

Average time from call initiation to provider connection for pediatric medicine calls decreased from 11 minutes to 5 minutes. The average number of internal physicians on each call before acceptance decreased from 2.1 to 1.3. In Phase 2, time to provider connection decreased from 11 to 4 minutes for pediatric critical care calls and 16 to 5 minutes for pediatric surgery calls.

CONCLUSIONS

We streamlined the process of accepting incoming transfer requests throughout our children's hospital. Prioritizing direct communication led to efficient disposition decisions and progression toward transfer and was effective for multiple service lines.

Pediatric Transport-Specific Illness Severity Scores Predict Clinical Deterioration of Transported Patients

OBJECTIVE

The Transport Risk Assessment in Pediatrics (TRAP) and Transport Pediatric Early Warning Scores (T-PEWS) are transport-specific pediatric illness severity scores that are adjunct assessment tools for determining disposition of transported patients. We hypothesized that these scores would predict the risk of clinical deterioration in transported patients admitted to general pediatric wards.

METHODS

Activation of a rapid response team (RRT) in the first 24 hours of admission was used as a marker of deterioration. All pediatric transports between March 2017 and February 2020 admitted via critical care transport were included. Transports to the emergency department (ED) were excluded. This retrospective chart review evaluated TRAP and T-PEWS scores at 3 points: (1) arrival of transport team at referring hospital, (2) admission to the children's hospital, and (3) RRT activation, if occurring within 24 hours of admission.

RESULTS

There were 1137 team transports during this period. Three hundred ninety-nine patients transported to the ED were excluded, leaving 738 included patients; 405 (55%) admitted to the general wards and 333 (45%) admitted to the pediatric intensive care unit. Twenty-five patients admitted to the wards (6%) had an RRT activation within 24 hours of admission. Statistical analysis used 2-sample t tests. There was a statistically significant difference in scores for ward admissions between those who had RRT activation and those who did not.

CONCLUSIONS

Both TRAP and T-PEWS can be used to predict the risk of clinical deterioration in transported patients admitted to general wards. These scores may assist in assessing which patients admitted to the wards need closer observation.

Characteristics of Children Who Deteriorate After Transport and Associated Preadmission Factors

OBJECTIVE

The incidence of deterioration and associated characteristics are largely unknown for children transported for admission from referring emergency departments (EDs) to general inpatient units. This study describes this population and identifies associated preadmission characteristics.

METHODS

This single-center cohort study included children ≤ 18 years old transferred from an ED and directly admitted to general inpatient units from 2016 to 2019. Deterioration was defined as 1 or more of the following occurring within 24 hours of admission: rapid response team activation, transfer to the intensive care unit (ICU), or cardiac or respiratory arrest. ICU transfer was the secondary outcome. Logistic regression was performed.

RESULTS

One thousand nine hundred eighty-eight patients were included; the median age was 4.2 years, 53.9% were male, and 44.1% had respiratory diagnoses. Deterioration occurred in 135 (6.8%) children overall and in 10.1% of children with respiratory complaints. Deterioration was associated with ≥ 2 complex chronic conditions (adjusted odds ratio [aOR] = 2.09; 95% confidence interval [CI], 1.04-4.19) and a longer stabilization time (per 10 minutes) (aOR = 1.17; 95% CI, 1.01-1.36). ICU transfer was associated with ≥ 2 complex chronic conditions (aOR = 2.33; 95% CI, 1.13-4.80), supplemental oxygen via nasal cannula (aOR = 2.13; 95% CI, 1.18-3.85), and nebulizer treatment (aOR = 2.77; 95% CI, 1.21-6.35).

CONCLUSION

Deterioration was experienced by 7% of children admitted to a general unit, with the majority having respiratory complaints. Transport teams should consider the potential for increased risk of deterioration among children with respiratory disease, multiple complex chronic conditions, and a nasal cannula or nebulizer therapy. The clinical significance of marginally longer stabilization times is unclear and warrants further investigation.

Closure of Licensed Pediatric Beds in Health Care Markets Within Illinois

OBJECTIVE

Our objective was to understand the market characteristics related to closures of licensed pediatric hospital beds that may be related to increasing regionalization of pediatric hospital care.

METHODS

We performed a retrospective descriptive analysis of 110 hospitals with licensed pediatric hospital beds from a statewide survey of health care facilities (2012-2017) and administrative data of hospital admissions (2013-2018) in Illinois. We quantified closures of licensed pediatric hospital beds and categorized hospital bed closures by hospital and market characteristics.

RESULTS

From 2012 through 2017, the number of licensed pediatric beds declined from 1706 to 1254 (-26.5%). Over the same time period, annual pediatric inpatient days minimally changed (+1.1%), while annual pediatric inpatient days at hospitals affiliated with the Children's Hospital Association increased (+30.5%). After accounting for re-openings, the 33 hospitals that closed all licensed pediatric beds fit 4 distinct typologies: 1) Hospitals with minimal pediatric volume throughout the study (n = 19); 2) Hospitals that sustained at least 50% of their pediatric volume after closure of licensed pediatric beds (n = 8); 3) Hospitals with low market share in metropolitan areas (n = 5); and 4) Hospital with a decline in pediatric market share, while a nearby hospital saw a corresponding rise in pediatric market share (n = 1).

CONCLUSIONS

In Illinois, licensed pediatric hospital beds declined while pediatrics inpatient days stayed the same over a recent 6-year period. Typologies of closures describe the nuanced dynamics leading to decline of pediatric hospital beds. Understanding these patterns is critical to ensure that children receive quality pediatric-tailored care.

Resources for Improving Pediatric Readiness and Quality of Care in Rural Communities and Emergency Departments

OBJECTIVES

To share the process and products of an 8-year, federally funded grant from the Health Resources and Services Administration Emergency Medical Services for Children program to increase pediatric emergency readiness and quality of care provided in rural communities located within 2 underserved local emergency medical services agencies (LEMSAs) in Northern California.

METHODS

In 2 multicounty LEMSAs with 24 receiving hospital emergency departments, we conducted focus groups and interviews with patients and parents, first responders, receiving hospital personnel, and other community stakeholders. From this, we (a regional, urban children's hospital) provided a variety of resources for improving the regionalization and quality of pediatric emergency care provided by prehospital providers and healthcare staff at receiving hospitals in these rural LEMSAs.

RESULTS

From this project, we provided resources that included regularly scheduled pediatric-specific training and education programs, pediatric-specific quality improvement initiatives, expansion of telemedicine services, and cultural competency training. We also enhanced community engagement and investment in pediatric readiness.

CONCLUSIONS

The resources we provided from our regional, urban children's hospital to 2 rural LEMSAs facilitated improvements in a regionalized system of care for critically ill and injured children. Our shared resources framework can be adapted by other regional children's hospitals to increase readiness and quality of pediatric emergency care in rural and underserved communities and LEMSAs.

Transport Medical Control Education for Pediatric Critical Care Fellows: A National Needs Assessment Study

OBJECTIVES

Characterize transport medical control education in Pediatric Critical Care Medicine fellowship.

DESIGN

Cross-sectional survey study.

SETTING

Pediatric Critical Care Medicine fellowship programs in the United States.

SUBJECTS

Pediatric Critical Care Medicine fellowship program directors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We achieved a 74% (53/72) response rate. A majority of programs (85%) require fellows to serve as transport medical control, usually while carrying out other clinical responsibilities and sometimes without supervision. Fellows at most programs (80%) also accompany the transport team on patient retrievals. Most respondents (72%) reported formalized transport medical control teaching, primarily in a didactic format (76%). Few programs (25%) use a standardized assessment tool. Transport medical control was identified as requiring all six Accreditation Council for Graduate Medical Education competencies, with emphasis on professionalism and interpersonal and communication skills.

CONCLUSIONS

Transport medical control responsibilities are common for Pediatric Critical Care Medicine fellows, but training is inconsistent, assessment is not standardized, and supervision may be lacking. Fellow performance in transport medical control may help inform assessment in multiple domains of competencies. Further study is needed to identify effective methods for transport medical control education.

Regionalization of congenital cardiac surgical care: what it will take

PURPOSE OF REVIEW

Decentralized, inconsistent healthcare delivery results in variable outcomes and wastes nearly one trillion dollars annually in the United States (US). Congenital heart surgery (CHS) is not immune due to high, variable costs and inconsistent outcomes across hospitals. Many European countries and Canada have addressed these issues by regionalizing CHS. Centralizing resources lowers costs, reduces in-hospital mortality and improves long-term survival. Although the impact on travel distance for patients is limited, the effect on healthcare disparities requires study. This review summarizes current data and integrates these into paths to regionalization through health policy, research, and academic collaboration.

RECENT FINDINGS

There are too many CHS programs in the US with unnecessarily high densities of centers in certain regions. This distribution lowers center and surgeon case volumes, creates redundancy, and increases variation in costs and outcomes. Simultaneously, adhering to suboptimal allocation impedes the understanding of optimal regionalization models to optimize congenital cardiac care delivery.

SUMMARY

CHS regionalization models developed for the US increase surgeon and center volume, decrease healthcare spending, and improve patient outcomes without substantially increasing travel distance. Regionalization in countries with few or no existing CHS programs is yet to be explored, but may be associated with more efficient spending and procedural complexity expansion.

Association of Socioeconomic Characteristics With Where Children Receive Emergency Care

OBJECTIVE

Outcomes of emergency care delivered to children vary by patient-level socioeconomic factors and by emergency department (ED) characteristics, including pediatric volume. How these factors intersect in emergency care-seeking patterns among children is not well understood. The objective of this study was to characterize national associations of neighborhood income and insurance type of children with the characteristics of the EDs from which they receive care.

METHODS

We conducted a cross-sectional study of ED visits by children from 2014 to 2017 using the Nationwide Emergency Department Sample. We determined the associations of neighborhood income and patient insurance type with the proportions of visits to EDs by pediatric volume category, both unadjusted and adjusted for patient-level factors including urban-rural status of residence.

RESULTS

Of 107.6 million ED visits by children nationally from 2014 to 2017, children outside of the wealthiest neighborhood income quartile had lower proportions of visits to high-volume pediatric EDs (57.1% poorest quartile, 51.5% second, 56.6% third, 63.5% wealthiest) and greater proportions of visits to low-volume pediatric EDs (4.4% poorest, 6.4% second, 4.6% third, 2.3% wealthiest) than children in the wealthiest quartile. Adjustment for patient-level factors, particularly urban-rural status, inverted this association, revealing that lower neighborhood income was independently associated with visiting higher-volume pediatric EDs. Publicly insured children were modestly more likely to visit higher-volume pediatric EDs than privately insured and uninsured children in both unadjusted and adjusted analyses.

CONCLUSIONS

Nationally, children in lower-income neighborhoods tended to receive care in pediatric EDs with lower volume, an association that appears principally driven by urban-rural differences in access to emergency care.

Outcome Differences Between Direct Admissions to the PICU From ED and Escalations From Floor

OBJECTIVES

To compare the outcomes (mortality and ICU length of stay) of patients with direct admissions to the PICU from the emergency department [ED]) versus as an escalation of care from the floor.

METHODS

A retrospective cohort study with a secondary analysis of registry data. Patient demographics and outcome variables collected from January 1, 2015, to December 31, 2019, were obtained from the Virtual Pediatric Systems database. Patients with a source of admission other than the hospital's ED or pediatric floor were excluded. Multivariable regression analysis controlling for age groups, sex, race, diagnostic categories, and severity of illness (Pediatric Index of Mortality III), with clustering for sites, was performed.

RESULTS

A total of 209 695 patients from 121 sites were included in the analysis. A total of 154 716 (73.7%) were admitted directly from the ED, and 54 979 were admitted (26.2%) as an escalation of care from the floor. Two groups differed in age and race distribution, medical complexity, diagnostic categories, and severity of illness. After controlling for measured confounders, patients with floor escalations had higher mortality (2.78% vs 1.95%; P < .001), with an odds ratio of 1.71 (95% CI 1.5 to 1.9) and longer PICU length of stay (4.9 vs 3.6 days; P < .001). The rates of most of the common ICU procedures and their durations were also significantly higher in patients with an escalation of care.

CONCLUSIONS

Compared with direct admissions to the PICU from the ED, patients who were initially triaged to the pediatric floor and then require escalation to the PICU have worse outcomes. Further research is needed to explore the potential causes of this difference.

Availability of Pediatric Inpatient Services in the United States

OBJECTIVES

We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States.

METHODS

We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model.

RESULTS

Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing.

CONCLUSIONS

Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.

Pandemic-Related Shifts in New Patients Admitted to Children's Hospitals

OBJECTIVES

During the coronavirus disease 2019 pandemic, professional organizations recommended preferential transfer of pediatric patients from general hospitals to children's hospitals. Patients previously receiving all care at other facilities would be new to children's hospitals. As a proxy for care consolidation, we sought to describe changes in new patient encounters at children's hospitals and test associations between local severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) incidences and new patient encounters.

METHODS

This retrospective cohort study included patients aged 6 months to 18 years admitted to children's hospitals from March 15, 2019, to June 30, 2019 (control) and 2020 (pandemic period). Primary outcome was odds ratio of being a new versus established patient by study period. Generalized linear models estimated odds of being a new patient with adjustment for diagnosis. Analyses were also stratified by local SARS-CoV-2 transmission.

RESULTS

There were 205 283 encounters (45.3% new patients). New patients were more common in the pandemic period than in the control (46.4 vs 44.7%, OR 1.07, 95% confidence interval [CI]: 1.05 to 1.09). After adjusting for diagnosis, pandemic new patients were no more common than control new patients (adjusted odds ratio 1.00, 95% CI: 0.98 to 1.02). Compared with hospitals experiencing low local SARS-CoV-2 transmission, admission encounters at both medium and high transmission hospitals were more likely to be new (adjusted odds ratio 1.08, 95% CI: 1.03 to 1.14 and 1.09, 95% CI: 1.03 to 1.15, respectively).

CONCLUSIONS

During the early coronavirus disease 2019 pandemic, proportional increases in new patients to children's hospitals appeared to be due to changes in diagnoses but were also associated with local SARS-CoV-2 transmission. Pediatric care consolidation may have occurred; how this may have impacted outcomes for hospitalized children is unclear.

The Future of Inpatient Community Hospital Care: Is There One?

Community hospital inpatient pediatric programs face a variety of challenges including financial instability, variable censuses, difficulty maintaining qualified staff, and a lack of focus for the hospital. With the addition of new payment models, such as bundled payments and global budgets, along with a global pandemic, the future of community hospital pediatric inpatient care is uncertain at best. In this article we summarize the challenges, opportunities, and potential solutions to maintaining high-quality care for hospitalized children in community hospitals.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

OBJECTIVE

To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer.

STUDY DESIGN

Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ² statistics.

RESULTS

Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions.

CONCLUSIONS

Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.

Age Cutoffs for Hospitalization at Hospitals Without Pediatric Inpatient Capability

OBJECTIVES

To determine age cutoffs that hospitals without pediatric inpatient beds apply when hospitalizing children.

METHODS

We conducted a cross-sectional study of patients <25 years old visiting emergency departments in 5 states in 2016 using the Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases. Hospitals were classified as adult (no pediatric inpatient beds) or pediatric capable (>0 pediatric beds). Referral rates were calculated for each year of life as transfers divided by transfers plus hospitalizations. Two age cutoffs were determined for defining pediatric patients: a specific cutoff (the age at which referral rates were significantly lower than those for younger patients) and an inclusive cutoff (the age at which referral rates differed most from those for younger patients).

RESULTS

Among 389 581 transfers and hospitalizations, 91 967 (23.6%) occurred in adult hospitals. Referral rates at adult hospitals were 86.0% at age 15, 80.6% at age 16, 72.0% at age 17, and 30.5% at age 18. The specific age cutoff was 16 because referral rates were lower than those for ages 0 to 15 (P < .001). The inclusive age cutoff was 18 because the odds ratio for referral was lowest when comparing age 18 to ages 0 to 17.

CONCLUSIONS

Children aged <16 years specifically define a population of pediatric patients, as defined by whether an adult hospital would hospitalize instead of transfer from an emergency department. Children aged <18 years inclusively define a population of pediatric patients. These age cutoffs may be used when studying patterns of national acute care for children.