The paradox of the nested pediatric emergency department

Nested pediatric emergency departments (nPEDs) are defined as dedicated treatment areas operating during peak pediatric hours within general emergency departments (EDs). This study examined three staffing models for nPEDs and their impact on pediatric encounters.

Three models were applied to children younger than 37 months presenting to the ED of an urban community hospital over one year. In the nPED, physicians cared only for nPED patients. In the restricted (rPED) model, physicians cared only for pediatric patients presenting outside nPED hours. In the total ED (tED) model, physicians treated all pediatric patients regardless of time. Full-time equivalent pediatric encounters, potential neonatal lumbar punctures, and illness severity were determined for all models. Statistical analysis was performed by analysis of variance and chi-square test.

For the 3,389 eligible ED visits, the number of annual patient encounters per full-time equivalent was 1,236 for the nPED, 805 for the tED, and 336 for the rPED (p < 0.001). Physicians practicing only in the nPED treated 3.7 times the number of children younger than 37 months than did physicians in the rPED model and 1.5 times the number than did physicians in the tED model. Spending 10% of total practice hours in the nPED would increase pediatric encounters 26% for rPED physicians, while practicing 25% of time in the nPED would increase pediatric encounters 67% and equate to 45% of nPED encounters. An nPED physician could expect to perform 17 neonatal lumbar punctures, compared with ten for a tED physician and four for an rPED physician (p < 0.001). There was no significant difference in severity of illness for the three models.

Physicians practicing in facilities that include an nPED must dedicate some portion of their practice to the nPED to maintain equivalent pediatric encounters.