Changes in Emergency Department Pediatric Readiness, Inpatient Services, and Excess Child Deaths

Emergency department (ED) pediatric readiness and pediatric inpatient services have changed over time in many hospitals, but the impact of these changes on pediatric outcomes is unclear.

To evaluate pediatric mortality associated with changes to ED pediatric readiness and pediatric inpatient services over a 10-year period.

This cohort study included data from January 1, 2012, through December 31, 2021, for 759 hospitals in 11 states that completed the 2013 and 2021 National Pediatric Readiness Program assessments. Participants were children aged 0 to 17 years who received care in an ED resulting in hospital admission, interhospital transfer, or death. Data analysis was performed from May 2025 to May 2026.

Changes in ED pediatric readiness and inpatient pediatric services, as measured through national assessments in 2013 and 2021. ED readiness change groups were characterized based on the weighted Pediatric Readiness Score (wPRS, range 0-100) associated with survival (wPRS ≥88 vs wPRS <88): sustained high readiness, gained, lost, or never had. Changes in pediatric inpatient services were defined as sustained, gained, lost, or never had.

In-hospital mortality, including ED and inpatient deaths.

There were 2 416 030 children, including 337 167 who were injured (median [IQR] age, 10 [4-15] years; 4642 deaths [1.38%]) and 2 078 863 who were medically ill (median [IQR] age, 6 [1-14] years; 18 576 deaths [0.89%]). Of the 759 hospitals, the median (IQR) wPRS in 2013 vs 2021 was 71 (58-86) and 72 (62-88), respectively. Ninety-nine EDs (13.0%) had sustained high readiness, 85 (11.2%) gained readiness, 78 (10.3%) lost readiness, and 497 (65.5%) never had high readiness. For inpatient services, 225 hospitals (29.6%) sustained inpatient services, 36 (4.7%) gained services, 120 (15.8%) lost services, and 378 (49.8%) never had services. After risk adjustment, EDs that lost or never had high ED readiness were associated with 1727 (95% CI, 751-2646) and 3776 (95% CI, 2327-5143) excess deaths, respectively. Hospitals that lost or never had inpatient services were associated with 1657 (95% CI, 1214-2067) and 3745 (95% CI, 3127-4328) excess deaths, respectively.

This study found that the loss or persistent lack of high ED pediatric readiness and pediatric inpatient services were independently associated with excess mortality in children. Increasing ED readiness and adding inpatient services may augment pediatric survival in the US health care system.