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Multicenter Study
. 2024 Jul 1;7(7):e2422107.
doi: 10.1001/jamanetworkopen.2024.22107.

Changes in Emergency Department Pediatric Readiness and Mortality

Craig D Newgard  1 , Shauna Rakshe  2 , Apoorva Salvi  1 , Amber Lin  1 , Jennifer N B Cook  1 , Marianne Gausche-Hill  3 , Nathan Kuppermann  4   5 , Jeremy D Goldhaber-Fiebert  6 , Randall S Burd  7 , Susan Malveau  1 , Peter C Jenkins  8 , Caroline Q Stephens  9 , Nina E Glass  10 , Hilary Hewes  11 , N Clay Mann  11 , Stefanie G Ames  11 , Mary Fallat  12 , Aaron R Jensen  13 , Rachel L Ford  14 , Angela Child  11 , Brendan Carr  15 , Kendrick Lang  1 , Kyle Buchwalder  1 , Katherine E Remick  16   17
Affiliations
Multicenter Study

Changes in Emergency Department Pediatric Readiness and Mortality

Craig D Newgard et al. JAMA Netw Open. .

Abstract

Importance: High emergency department (ED) pediatric readiness is associated with improved survival, but the impact of changes to ED readiness is unknown.

Objective: To evaluate the association of changes in ED pediatric readiness at US trauma centers between 2013 and 2021 with pediatric mortality.

Design, setting, and participants: This retrospective cohort study was performed from January 1, 2012, through December 31, 2021, at EDs of trauma centers in 48 states and the District of Columbia. Participants included injured children younger than 18 years with admission or injury-related death at a participating trauma center, including transfers to other trauma centers. Data analysis was performed from May 2023 to January 2024.

Exposure: Change in ED pediatric readiness, measured using the weighted Pediatric Readiness Score (wPRS, range 0-100, with higher scores denoting greater readiness) from national assessments in 2013 and 2021. Change groups included high-high (wPRS ≥93 on both assessments), low-high (wPRS <93 in 2013 and wPRS ≥93 in 2021), high-low (wPRS ≥93 in 2013 and wPRS <93 in 2021), and low-low (wPRS <93 on both assessments).

Main outcomes and measures: The primary outcome was lives saved vs lost, according to ED and in-hospital mortality. The risk-adjusted association between changes in ED readiness and mortality was evaluated using a hierarchical, mixed-effects logistic regression model based on a standardized risk-adjustment model for trauma, with a random slope-random intercept to account for clustering by the initial ED.

Results: The primary sample included 467 932 children (300 024 boys [64.1%]; median [IQR] age, 10 [4 to 15] years; median [IQR] Injury Severity Score, 4 [4 to 15]) at 417 trauma centers. Observed mortality by ED readiness change group was 3838 deaths of 144 136 children (2.7%) in the low-low ED group, 1804 deaths of 103 767 children (1.7%) in the high-low ED group, 1288 deaths of 64 544 children (2.0%) in the low-high ED group, and 2614 deaths of 155 485 children (1.7%) in the high-high ED group. After risk adjustment, high-readiness EDs (persistent or change to) had 643 additional lives saved (95% CI, -328 to 1599 additional lives saved). Low-readiness EDs (persistent or change to) had 729 additional preventable deaths (95% CI, -373 to 1831 preventable deaths). Secondary analysis suggested that a threshold of wPRS 90 or higher may optimize the number of lives saved. Among 716 trauma centers that took both assessments, the median (IQR) wPRS decreased from 81 (63 to 94) in 2013 to 77 (64 to 93) in 2021 because of reductions in care coordination and quality improvement.

Conclusions and relevance: Although the findings of this study of injured children in US trauma centers were not statistically significant, they suggest that trauma centers should increase their level of ED pediatric readiness to reduce mortality and increase the number of pediatric lives saved after injury.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Newgard reported receiving grants from the National Institute of Child Health and Human Development on emergency department pediatric readiness outside the submitted work. Dr Kuppermann reported receiving grants from the National Institutes of Health, Department of Health and Human Services Health Resources and Services Administration (HRSA), and Patient-Centered Outcomes Research Institute for other research work outside the submitted work. Dr Hewes reported receiving grants from the University of Utah and being the principal investigator for the EMS for Children Data Center, which receives a grant from the HRSA, outside the submitted work. Dr Remick reported receiving grants from HRSA for the EMS for Children Innovation and Improvement Center outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Changes in the Emergency Department (ED) Weighted Pediatric Readiness Score (wPRS) From 2013 to 2021 Among 716 Trauma Centers by Annual ED Pediatric Volume
A, Scatterplot shows change in wPRS from 2013 to 2021 by ED pediatric volume. B, Graph shows changes in each of the 6 domains of ED pediatric readiness from 2013 to 2021 by ED pediatric volume. Y-axis represents the absolute change in wPRS from 2013 to 2021. Boxes represent the IQRs, lines in the boxes represent medians, error bars denote 1.5 times the IQR, and dots are outlier values.
Figure 2.
Figure 2.. Adjusted In-Hospital Mortality Over Time Among Trauma Centers With 4 Patterns of Emergency Department (ED) Pediatric Readiness Over Time (N = 467 932)
The 4 ED readiness change groups included high-high (weighted pediatric readiness score [wPRS], ≥93 during both assessments), low-high (wPRS <93 in 2013 and ≥93 in 2021), high-low (wPRS ≥93 in 2013 and <93 in 2021), and low-low (wPRS <93 during 2013 and 2021). The shaded areas denote 95% CIs.
See this image and copyright information in PMC

References

    1. Emergency Medical Services for Children (EMSC) National Resource Center . The National Pediatric Readiness Project. Accessed April 18, 2022. https://emscimprovement.center/domains/pediatric-readiness-project/
    1. Gausche-Hill M, Ely M, Schmuhl P, et al. . A national assessment of pediatric readiness of emergency departments. JAMA Pediatr. 2015;169(6):527-534. doi:10.1001/jamapediatrics.2015.138 - DOI - PubMed
    1. Remick KE, Hewes HA, Ely M, et al. . National assessment of pediatric readiness of US emergency departments during the COVID-19 pandemic. JAMA Netw Open. 2023;6(7):e2321707. doi:10.1001/jamanetworkopen.2023.21707 - DOI - PMC - PubMed
    1. Ames SG, Davis BS, Marin JR, et al. . Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568. doi:10.1542/peds.2019-0568 - DOI - PMC - PubMed
    1. Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. ; Pediatric Readiness Study Group . Association of emergency department pediatric readiness with mortality to 1 year among injured children treated at trauma centers. JAMA Surg. 2022;157(4):e217419. doi:10.1001/jamasurg.2021.7419 - DOI - PMC - PubMed

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