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. 2023 Jan 3;6(1):e2250941.
doi: 10.1001/jamanetworkopen.2022.50941.

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care

Craig D Newgard  1 , Amber Lin  1 , Susan Malveau  1 , Jennifer N B Cook  1 , McKenna Smith  2 , Nathan Kuppermann  3   4 , Katherine E Remick  5   6 , Marianne Gausche-Hill  7 , Jeremy Goldhaber-Fiebert  8 , Randall S Burd  9 , Hilary A Hewes  2 , Apoorva Salvi  1 , Haichang Xin  1 , Stefanie G Ames  2 , Peter C Jenkins  10 , Jennifer Marin  11   12   13 , Matthew Hansen  1 , Nina E Glass  14 , Avery B Nathens  15 , K John McConnell  1   16 , Mengtao Dai  2 , Brendan Carr  17 , Rachel Ford  18 , Davis Yanez  19   20 , Sean R Babcock  1 , Benjamin Lang  5   6 , N Clay Mann  2 ; Pediatric Readiness Study Group
Collaborators, Affiliations

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care

Craig D Newgard et al. JAMA Netw Open. .

Erratum in

  • Error in Figure 1B.
    [No authors listed] [No authors listed] JAMA Netw Open. 2023 Feb 1;6(2):e231365. doi: 10.1001/jamanetworkopen.2023.1365. JAMA Netw Open. 2023. PMID: 36780168 Free PMC article. No abstract available.

Abstract

Importance: Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown.

Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states.

Design, setting, and participants: This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022.

Exposure: ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment.

Main outcomes and measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states.

Results: There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented.

Conclusions and relevance: These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Newgard reported receiving a grant from the National Institutes of Health (NIH)/National Institute of Child Health and Human Development (NICHD) outside the submitted work. Ms Cook reported receiving grants from the NICHD and the National Heart, Lung, and Blood Institute outside the submitted work. Dr Kuppermann reported receiving grants from the NIH, Health Resources and Services Administration (HRSA), and Patient-Centered Outcomes Research Institute outside the submitted work. Dr Remick reported receiving a grant from HRSA outside the submitted work. Dr Hewes reported receiving a grant from HRSA outside the submitted work. Dr McConnell reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Adjusted Odds Ratios (aORs) for In-Hospital Mortality Among Children With Injuries and Medical Conditions Across Quartiles of Emergency Department (ED) Pediatric Readiness, Including Subgroups
We measured ED pediatric readiness using the weighted Pediatric Readiness Score (wPRS). The reference group for all analyses was the first quartile of ED pediatric readiness (wPRS score of 0-58). The x-axis is in the natural logarithm (ln) scale. Results are shown for the injury cohort (A) and medical cohort (B). The Severity Classification System score ranges from 1 to 5, with scores of 4 or higher representing high clinical severity. AIS indicates Abbreviated Injury Scale; ISS, Injury Severity Score.
Figure 2.
Figure 2.. Adjusted Time to Death for Injured and Medical Children, by Emergency Department (ED) Pediatric Readiness
Graphs show data for the injured cohort (A; 62 588 children) and the medical cohort (483 333 children). The adjusted hazard ratio (aHR) for death to 1 year for quartile 4 (weighted Pediatric Readiness Score [wPRS] 88-100) vs quartile 1 (wPRS 0-58) of ED pediatric readiness was 0.59 (95% CI, 0.42-0.84) for the injury cohort and was 0.34 (95% CI, 0.25-0.45) for the medical cohort. In the medical cohort, comparison of quartile 3 (wPRS 73-87) vs quartile 1 of ED pediatric readiness showed an aHR of 0.68 (95% CI, 0.51-0.92).
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Comment in

References

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