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Changes in Emergency Department Pediatric Readiness, Inpatient Services, and Excess Child Deaths
Craig D Newgard1,2, Amber Lin2, Jeremy D Goldhaber-Fiebert3,4
1Department of Emergency Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco.
Insights
Losing or lacking high pediatric readiness in emergency departments (EDs) and inpatient services is linked to increased child deaths. Improving ED readiness and inpatient services may improve pediatric survival in the US.
Area of Science:
- Pediatric emergency medicine
- Health services research
- Public health
Background:
- Pediatric readiness in emergency departments (EDs) and inpatient services have evolved, but their impact on pediatric outcomes remains unclear.
- Assessing changes in pediatric readiness and services is crucial for understanding their effect on child mortality.
- Previous studies have not fully elucidated the relationship between evolving pediatric care infrastructure and mortality rates.
Purpose of the Study:
- To evaluate pediatric mortality associated with changes in emergency department (ED) pediatric readiness and pediatric inpatient services over a 10-year period.
- To determine the impact of sustained, gained, lost, or never-had high readiness and services on in-hospital mortality.
- To identify specific changes in pediatric care infrastructure linked to excess pediatric deaths.
Main Methods:
- A 10-year cohort study (2012-2021) analyzed data from 759 hospitals across 11 states using National Pediatric Readiness Program assessments from 2013 and 2021.
- Included were over 2.4 million children (0-17 years) admitted through the ED.
- Pediatric readiness was measured by the weighted Pediatric Readiness Score (wPRS), and changes in inpatient services were categorized. Risk-adjusted analyses were performed to assess associations with in-hospital mortality.
Main Results:
- Over 2.4 million children were included, with significant variations in hospital readiness scores and inpatient service availability.
- Hospitals that lost or consistently lacked high ED readiness experienced excess deaths (1727 and 3776, respectively).
- Similarly, hospitals losing or never having inpatient services were associated with excess pediatric mortality (1657 and 3745, respectively).
Conclusions:
- The loss or persistent lack of high emergency department (ED) pediatric readiness and pediatric inpatient services are independently associated with excess child mortality.
- Strategies to increase ED readiness and enhance inpatient services are vital for improving pediatric survival rates.
- These findings underscore the importance of robust pediatric care infrastructure in reducing preventable deaths in children.
Importance:
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.
Objective:
To evaluate pediatric mortality associated with changes to ED pediatric readiness and pediatric inpatient services over a 10-year period.
Design, Setting, And Participants:
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.
Exposure:
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.
Main Outcomes And Measures:
In-hospital mortality, including ED and inpatient deaths.
Results:
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.
Conclusions And Relevance:
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.
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