Higher “pediatric-readiness” scores at the emergency department are associated with lower in-hospital mortality in critically ill children, according to a retrospective study.

“Although we’ve known for some time that hospitals vary in the degree to which they are ready for pediatric emergencies, for the first time we have robust data suggesting that this variation influences patient outcome,” Dr. Jeremy M. Kahn of the University of Pittsburgh in Pennsylvania, told Reuters Health by email.

Dr. Kahn and colleagues used data from the State Emergency Department Databases and the State Inpatient Databases from Florida, Iowa, Massachusetts, Nebraska and New York to evaluate the possible association between ED pediatric readiness and mortality in children presenting with critical illnesses, defined as either ICU admission or death during the episode.

Among the 426 hospitals in the final sample, the weighted pediatric readiness score (WPRS) ranged from 29.6 to 100.0 (median, 74.8). Most children (68.6 percent) presented to hospitals in the highest quartile, and only 4.3 percent presented to hospitals in the lowest quartile.

Unadjusted mortality was significantly lower for children presenting to hospitals in the highest quartile of WPRS (3.4 percent) than for those presenting to hospitals in the lowest quartile (11.1 percent), the researchers report in Pediatrics.

In a regression analysis adjusting for patient characteristics, the odds of dying were 64 percent lower for children presenting to hospitals in the second highest WPRS quartile and 75 percent lower for children presenting to hospitals in the highest quartile, compared with children presenting to hospitals in the lowest WPRS quartile.

Results were similar in separate analyses of three prespecified diagnostic conditions (cardiac arrest, sepsis, and traumatic brain injury), although the differences were mostly statistically nonsignificant as a result of small sample sizes.

“Pediatric emergencies are unique—children require specialized equipment, weight-based drug dosing, and other unique measures,” Dr. Kahn said. “Although there is more work to be done to understand the mechanism behind our findings, it’s likely these things that led to differences in outcome.”

“These issues are system-level problems that require system-level solutions,” he said. “But that doesn’t mean physicians don’t play an essential role. It’s our job to advocate for policies that will ensure that the sickest children are seen in well-resourced hospitals.”

“Our work is observational in nature, and causation here is by no means definite,” Dr. Kahn said. “Nonetheless, the data are strong enough that it’s time to act. But while we act, it’s important to study each new policy and quality-improvement initiative so that we learn what works. That way, the evidence underlying the design of our pediatric emergency-care system can get increasingly stronger.”

Dr. Katherine Remick from Dell Medical School at the University of Texas at Austin, who wrote an accompanying editorial, told Reuters Health by email, “No parent will bypass an ‘EMERGENCY’ sign when their child is critically ill or injured. It is, therefore, essential that all EDs maintain high levels of readiness for critically ill children of all ages. The more we triage children away from rural and suburban EDs, the less competent they will become at treating children.”

“Regionalization (transfer of children to pediatric-specialty centers) and/or telemedicine may decrease morbidities and further mortality in children, but would best be utilized only after initial stabilization,” she said. “Regionalization and/or telemedicine may be especially advantageous for high-risk conditions and/or diagnoses requiring intensive care inpatient services.”

“Adherence to specialized systems of care with specific designated resources (e.g., trauma, stroke, ST-elevation myocardial infarction) are associated with decreased morbidity and mortality for the populations impacted and have led to the establishment of national standards of care,” Dr. Remick added. “Children, representing a minority (20 percent) ED population with time-dependent emergencies, deserve, at the very least, a standard level of readiness to ensure all children can be adequately stabilized in the event of an emergency, and, at best, that they have access to high-quality emergency care.”

Dr. Isabel A. Barata of Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and North Shore University Hospital in Manhasset, New York, who has researched various aspects of ED pediatric readiness, told Reuters Health by email, “Even though the better outcomes were associated with hospitals with better emergency department readiness scores, it is possible that this is not simply a reflection of the actual emergency department, but also of the actual preparedness of the entire system within that hospital.”

“Emergency departments need to be prepared to care for children, but also having the regional support from other hospitals would be very helpful,” said Dr. Barata, who was not involved in the study. “Telemedicine may play a very significant role in the future, in terms of patient management, and perhaps in some cases avoiding unnecessary transfers to other facilities.”

“We need to engage smaller emergency departments in understanding the need for this preparation but also the support of larger, teaching institutions to provide the safety net,” she said.