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. 2021 Sep 1;175(9):947-956.
doi: 10.1001/jamapediatrics.2021.1319.

Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers

Craig D Newgard  1 , Amber Lin  1 , Lenora M Olson  2 , Jennifer N B Cook  1 , Marianne Gausche-Hill  3 , Nathan Kuppermann  4 , Jeremy D Goldhaber-Fiebert  5 , Susan Malveau  1 , McKenna Smith  6 , Mengtao Dai  7 , Avery B Nathens  8 , Nina E Glass  9 , Peter C Jenkins  10 , K John McConnell  11 , Katherine E Remick  12 , Hilary Hewes  2 , N Clay Mann  7 ; Pediatric Readiness Study Group
Collaborators, Affiliations

Evaluation of Emergency Department Pediatric Readiness and Outcomes Among US Trauma Centers

Craig D Newgard et al. JAMA Pediatr. .

Abstract

Importance: The National Pediatric Readiness Project is a US initiative to improve emergency department (ED) readiness to care for acutely ill and injured children. However, it is unclear whether high ED pediatric readiness is associated with improved survival in US trauma centers.

Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centers.

Design, setting, and participants: A retrospective cohort study of 832 EDs in US trauma centers in 50 states and the District of Columbia was conducted using data from January 1, 2012, through December 31, 2017. Injured children younger than 18 years who were admitted, transferred, or with injury-related death in a participating trauma center were included in the analysis. Subgroups included children with an Injury Severity Score (ISS) of 16 or above, indicating overall seriously injured (accounting for all injuries); any Abbreviated Injury Scale (AIS) score of 3 or above, indicating at least 1 serious injury; a head AIS score of 3 or above, indicating serious brain injury; and need for early use of critical resources.

Exposures: Emergency department pediatric readiness for the initial ED visit, measured through the weighted Pediatric Readiness Score (range, 0-100) from the 2013 National Pediatric Readiness Project ED pediatric readiness assessment.

Main outcomes and measures: In-hospital mortality, with a secondary composite outcome of in-hospital mortality or complication. For the primary measurement tools used, the possible range of the AIS is 0 to 6, with 3 or higher indicating a serious injury; the possible range of the ISS is 0 to 75, with 16 or higher indicating serious overall injury. The weighted Pediatric Readiness Score examines and scores 6 domains; in this study, the lowest quartile included scores of 29 to 62 and the highest quartile included scores of 93 to 100.

Results: There were 372 004 injured children (239 273 [64.3%] boys; median age, 10 years [interquartile range, 4-15 years]), including 5700 (1.5%) who died in-hospital and 5018 (1.3%) who developed in-hospital complications. Subgroups included 50 440 children (13.6%) with an ISS of 16 or higher, 124 507 (33.5%) with any AIS score of 3 or higher, 57 368 (15.4%) with a head AIS score of 3 or higher, and 32 671 (8.8%) requiring early use of critical resources. Compared with EDs in the lowest weighted Pediatric Readiness Score quartile, children cared for in the highest ED quartile had lower in-hospital mortality (adjusted odds ratio [aOR], 0.58; 95% CI, 0.45-0.75), but not fewer complications (aOR for the composite outcome 0.88; 95% CI, 0.74-1.04). These findings were consistent across subgroups, strata, and multiple sensitivity analyses. If all children cared for in the lowest-readiness quartiles (1-3) were treated in an ED in the highest quartile of readiness, an additional 126 lives (95% CI, 97-154 lives) might be saved each year in these trauma centers.

Conclusions and relevance: In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centers that care for children.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Newgard reported grants from National Institutes of Health, and grants from Health Resources and Services Administration during the conduct of the study. Dr Olson reported grants from HRSA MCHB during the conduct of the study. Dr Kuppermann reported grants from NIH, HRSA This study is federally funded during the conduct of the study; grants from NIH, HRSA I have other research which is federally funded outside the submitted work. Dr Malveau reported grants from NICHD during the conduct of the study. Dr McConnell reported grants from National Institute of Child Health and Human Development during the conduct of the study. Dr Hewes reported grants from HRSA MCHB during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Emergency Department (ED) Pediatric Readiness and Annual ED Pediatric Volume in 832 Trauma Center EDs
Gray bars indicate the number of EDs at each weighted pediatric readiness score (wPRS) and the blue line indicates the median annual ED volume of children at each wPRS.
Figure 2.
Figure 2.. Adjusted In-Hospital Mortality and Composite Outcome (In-Hospital Mortality or Complication) Across Quartiles of Emergency Department (ED) Pediatric Readiness for Injured Children
ED pediatric readiness was measured using the weighted Pediatric Readiness Score (wPRS). The x-axis is in the natural logarithm (ln) scale.
Figure 3.
Figure 3.. Adjusted In-Hospital Mortality for 372 004 Injured Children Across the Spectrum of Emergency Department (ED) Pediatric Readiness Using Best-Fit Fractional Polynomials
The figure was generated using best-fit fractional polynomials to model the association between the weighted Pediatric Readiness Score and in-hospital mortality from the risk-adjustment model using a patient with the following characteristics: male, age 5 to 12 years, White race, no comorbidities, no surgical intervention, mean Injury Severity Score (ISS), motor vehicle crash mechanism, arrival by ambulance, no transfer, hypotension, Glasgow Coma Scale score 9 to 12, intubation, and blood transfusion. Graphs generated using patients with different characteristics were similar in shape, but with higher or lower values for predicted in-hospital mortality.
See this image and copyright information in PMC

References

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    1. The National Pediatric Readiness Project , Emergency Medical Services for Children (EMSC) National Resource Center. Accessed February 19, 2021. http://www.pediatricreadiness.org/

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