Although children account for 20% of all emergency department (ED) visits, the majority of children seek emergency care in hospitals that see fewer than 10 children per day. The National Pediatric ...Readiness Project has defined key system-level standards for all EDs to safely care for ill and injured children. High pediatric readiness is associated with improvement in mortality for critically ill and injured children. However, to improve readiness and sustain system-level changes, hospitals must invest in pediatric champions and empower them to engage in continuous quality improvement. Finally, incorporating pediatric readiness into policy is crucial for its long-term sustainability.
IMPORTANCE: Previous assessments of readiness of emergency departments (EDs) have not been comprehensive and have shown relatively poor pediatric readiness, with a reported weighted pediatric ...readiness score (WPRS) of 55. OBJECTIVES: To assess US EDs for pediatric readiness based on compliance with the 2009 guidelines for care of children in EDs; to evaluate the effect of physician/nurse pediatric emergency care coordinators (PECCs) on pediatric readiness; and to identify gaps for future quality initiatives by a national coalition. DESIGN, SETTING, AND PARTICIPANTS: Web-based assessment of US EDs (excluding specialty hospitals and hospitals without an ED open 24 hours per day, 7 days per week) for pediatric readiness. All 5017 ED nurse managers were sent a 55-question web-based assessment. Assessments were administered from January 1 through August 23, 2013. Data were analyzed from September 12, 2013, through January 11, 2015. MAIN OUTCOMES AND MEASURES: A modified Delphi process generated a WPRS. An adjusted WPRS was calculated excluding the points received for the presence of physician and nurse PECCs. RESULTS: Of the 5017 EDs contacted, 4149 (82.7%) responded, representing 24 million annual pediatric ED visits. Among the EDs entered in the analysis, 69.4% had low or medium pediatric volume and treated less than 14 children per day. The median WPRS was 68.9 (interquartile range IQR 56.1-83.6). The median WPRS increased by pediatric patient volume, from 61.4 (IQR, 49.5-73.6) for low-pediatric-volume EDs compared with 89.8 (IQR, 74.7-97.2) for high-pediatric-volume EDs (P < .001). The median percentage of recommended pediatric equipment available was 91% (IQR, 81%-98%). The presence of physician and nurse PECCs was associated with a higher adjusted median WPRS (82.2 IQR, 69.7-92.5) compared with no PECC (66.5 IQR, 56.0-76.9) across all pediatric volume categories (P < .001). The presence of PECCs increased the likelihood of having all the recommended components, including a pediatric quality improvement process (adjusted relative risk, 4.11 95% CI, 3.37-5.02). Barriers to guideline implementation were reported by 80.8% of responding EDs. CONCLUSIONS AND RELEVANCE: These data demonstrate improvement in pediatric readiness of EDs compared with previous reports. The physician and nurse PECCs play an important role in pediatric readiness of EDs, and their presence is associated with improved compliance with published guidelines. Barriers to implementation of guidelines may be targeted for future initiatives by a national coalition whose goal is to ensure day-to-day pediatric readiness of our nation’s EDs.
We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers.
...ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown.
This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival.
There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present.
ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.
To describe the relationship between statewide pediatric facility recognition (PFR) programs and pediatric readiness in emergency departments (EDs) in the US.
Data were extracted from the 2013 ...National Pediatric Readiness Project assessment (4083 EDs). Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) based on a 100-point scale. Descriptive statistics were used to compare WPRS between recognized and nonrecognized EDs and between states with or without a PFR program. A linear mixed model with WPRS was used to evaluate state PFR programs on pediatric readiness.
Eight states were identified with a PFR program. EDs in states with a PFR program had a higher WPRS compared with states without a PFR program (overall a 9.1-point higher median WPRS; P < .001); EDs recognized in a PFR program had a 21.7-point higher median WPRS compared with nonrecognized EDs (P < .001); and between states with a statewide PFR program, there was high variability of participation within the states. We found state-level PFR programs predicted a higher WPRS compared with states without a PFR program (β = 5.49; 95% CI 2.76-8.23).
Statewide PFR programs are based on national guidelines and identify those EDs that adhere to a standard level of readiness for children. These statewide PFR initiatives are associated with higher pediatric readiness. As scalable strategies are needed to improve emergency care for children, our study suggests that statewide PFR programs may be one way to improve pediatric readiness and underscores the need for further implementation and evaluation.
Pediatric Readiness and Facility Verification Remick, Katherine, MD; Kaji, Amy H., MD, PhD; Olson, Lenora, PhD, MA ...
Annals of emergency medicine,
03/2016, Volume:
67, Issue:
3
Journal Article
Peer reviewed
Study objective We perform a needs assessment of pediatric readiness, using a novel scoring system in California emergency departments (EDs), and determine the effect of pediatric verification ...processes on pediatric readiness. Methods ED nurse managers from all 335 acute care hospital EDs in California were sent a 60-question Web-based assessment. A weighted pediatric readiness score (WPRS), using a 100-point scale, and gap analysis were calculated for each participating ED. Results Nurse managers from 90% (300/335) of EDs completed the Web-based assessment, including 51 pediatric verified EDs, 67 designated trauma centers, and 31 EDs assessed for pediatric capabilities. Most pediatric visits (87%) occurred in nonchildren’s hospitals. The overall median WPRS was 69 (interquartile ratio IQR 57.7, 85.9). Pediatric verified EDs had a higher WPRS (89.6; IQR 84.1, 94.1) compared with nonverified EDs (65.5; IQR 55.5, 76.3) and EDs assessed for pediatric capabilities (70.7; IQR 57.4, 88.9). When verification status and ED volume were controlled for, trauma center designation was not predictive of an increase in the WPRS. Forty-three percent of EDs reported the presence of a quality improvement plan that included pediatric elements, and 53% reported a pediatric emergency care coordinator. When coordinator and quality improvement plan were controlled for, the presence of at least 1 pediatric emergency care coordinator was associated with a higher WPRS (85; IQR 75, 93.1) versus EDs without a coordinator (58; IQR 50.1, 66.9), and the presence of a quality improvement plan was associated with a higher WPRS (88; IQR 76.7, 95) compared with that of hospitals without a plan (62; IQR 51.2, 68.7). Of pediatric verified EDs, 92% had a quality improvement plan for pediatric emergency care and 96% had a pediatric emergency care coordinator. Conclusion We report on the first comprehensive statewide assessment of “pediatric readiness” in EDs according to the 2009 “Guidelines for Care of Children in the Emergency Department.” The presence of a pediatric readiness verification process, pediatric emergency care coordinator, and quality improvement plan for pediatric emergency care was associated with higher levels of pediatric readiness.
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.
The National Paediatric Readiness Project applies a systems approach (care coordination, QI, policies and procedures, staff competencies, patient safety and equipment and supplies) to ensuring ...high-quality emergency care for children among diverse EDs.2 Paediatric readiness, as determined by the National Paediatric Readiness Assessment using a weighted 100-point scale, is associated with decreased paediatric mortality among critically ill and injured children.2 4–10 Facilities that incorporate paediatric-specific QI initiatives demonstrate a 26-point increase in their paediatric readiness score.11 Engagement in paediatric readiness efforts is high, yet integration of paediatric QI efforts in EDs is lagging.2 While over 400 paediatric emergency care performance measures have been proposed and prioritised, widespread uptake has been limited.2 12–14 Infrequent paediatric patient encounters make it difficult to assess the cause and effect of care processes. Consensus panel The panel consisted of 41 members who were either identified by their respective national professional society as a content expert or were selected based on the following criteria: expertise in paediatric emergency care applied research, emergency medical services for children, QI, QI data registries, specific areas of clinical practice, clinical practice setting, healthcare system networks, regulatory agencies and federal partners (table 1, online supplemental appendix A).Table 1 Characteristics of consensus panel Characteristic Participants, % (N) N=41 Pediatric Emergency Care Applied Research (EA, EK*, CM, RS, SD*, TC*) 14.6 (6) Emergency Medical Services for Children (CM, CN, EL, HH, MGH) 12.2 (5) Quality Experts from National Professional Societies 26.8 (11) American Academy of Family Physicians (DF) American Academy of Pediatrics (RP, SJ) American College of Emergency Physicians (IB, JA, KG) American College of Surgeons Committee on Trauma (AJ) Emergency Nurses Association (RK, SS) National Association of State Emergency Medical Services Officials (AV) Pediatric Trauma Society (LG) Quality Improvement Data Registries (BM) 2.4 (1) Health System Networks 4.9 (2) US Acute Care Solutions (SI) Hospital Corporation of America (HCA) Healthcare (AY) Regulatory body 2.4 (1) The Joint Commission (TE) Federal partners 4.9 (2) Health Resources and Services Administration (LL) National Highway and Traffic Safety Administration, Office of Emergency Medical Services (EC) Physician specialty 65.9 (27) Paediatric emergency medicine (CM, HH, LA, MG, RP, RS, SI, SJ) Emergency medicine (BM, CN, IB, JA, JL†, KG, KS†) Trauma (AJ) Family medicine (DF) Behavioural health* (BZ, EK, JH, KD, NU, SD, SP, SR, TC, VF) Nursing background 19.5 (8) Emergency medicine (AR†, AY, BW, CR, CT, DG, RK, SS) Trauma (CT, LG, SS) Practice in low-volume ED setting (AR†, AY, CT, DG, JL†, KG, KS†) 17.1 (7) Panellist affiliations are listed in online supplemental appendix A. *Arm 2 panellist, members of the Emergency Medicine Quality Improvement Collaborative for Kids (EMQUICK). All proposed measures were characterised by clinical domain, the six domains of quality, phase of ED care (assessment, interventions, diagnostics, disposition) and measure type (process or outcome).18–20 Structural measures were excluded as they are the focus of the National Paediatric Readiness Assessment.5 Structural measures for behavioural health, proposed by the Emergency Medicine Quality Improvement Collaborative for Kids behavioural health consortium, are included in online supplemental appendix B for future consideration and consensus building; however, they were deemed outside of scope for NPRQI. Phase 2—evaluation of measures The consensus panel was charged with rating each measure based on the National Quality Forum (NQF) Measure Evaluation Criteria: feasible for data collection in a low-volume, low-resourced ED setting, usable to an ED care team, important for patient-centred outcomes and scientifically acceptable.21 The goal was to identify fewer than six measures per clinical domain (assessment, interfacility transfer, clinical reports and behavioural health).
The National Pediatric Readiness Project assessment provides a comprehensive evaluation of the readiness of US emergency departments (EDs) to care for children. Increased pediatric readiness has been ...shown to improve survival for children with critical illness and injury.
To complete a third assessment of pediatric readiness of US EDs during the COVID-19 pandemic, to examine changes in pediatric readiness from 2013 to 2021, and to evaluate factors associated with current pediatric readiness.
In this survey study, a 92-question web-based open assessment of ED leadership in US hospitals (excluding EDs not open 24 h/d and 7 d/wk) was sent via email. Data were collected from May to August 2021.
Weighted pediatric readiness score (WPRS) (range, 0-100, with higher scores indicating higher readiness); adjusted WPRS (ie, normalized to 100 points), calculated excluding points received for presence of a pediatric emergency care coordinator (PECC) and quality improvement (QI) plan.
Of the 5150 assessments sent to ED leadership, 3647 (70.8%) responded, representing 14.1 million annual pediatric ED visits. A total of 3557 responses (97.5%) contained all scored items and were included in the analysis. The majority of EDs (2895 81.4%) treated fewer than 10 children per day. The median (IQR) WPRS was 69.5 (59.0-84.0). Comparing common data elements from the 2013 and 2021 NPRP assessments demonstrated a reduction in median WPRS (72.1 vs 70.5), yet improvements across all domains of readiness were noted except in the administration and coordination domain (ie, PECCs), which significantly decreased. The presence of both PECCs was associated with a higher adjusted median (IQR) WPRS (90.5 81.4-96.4) compared with no PECC (74.2 66.2-82.5) across all pediatric volume categories (P < .001). Other factors associated with higher pediatric readiness included a full pediatric QI plan vs no plan (adjusted median IQR WPRS: 89.8 76.9-96.7 vs 65.1 57.7-72.8; P < .001) and staffing with board-certified emergency medicine and/or pediatric emergency medicine physicians vs none (median IQR WPRS: 71.5 61.0-85.1 vs 62.0 54.3-76.0; P < .001).
These data demonstrate improvements in key domains of pediatric readiness despite losses in the health care workforce, including PECCs, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness.
Objective
We estimate annual hospital expenditures to achieve high emergency department (ED) pediatric readiness (HPR), that is, weighted Pediatric Readiness Score (wPRS) ≥ 88 (0–100 scale) across ...EDs with different pediatric volumes of children, overall and after accounting for current levels of readiness.
Methods
We calculated the annual hospital costs of HPR based on two components: (1) ED pediatric equipment and supplies and (2) labor costs required for a Pediatric Emergency Care Coordinator (PECC) to perform pediatric readiness tasks. Data sources to generate labor cost estimates included: 2021 national salary information from U.S. Bureau of Labor Statistics, detailed patient and readiness data from 983 EDs in 11 states, the 2021 National Pediatric Readiness Project assessment; a national PECC survey; and a regional PECC survey. Data sources for equipment and supply costs included: purchasing costs from seven healthcare organizations and equipment usage per ED pediatric volume. We excluded costs of day‐to‐day ED operations (ie, direct clinical care and routine ED supplies).
Results
The total annual hospital costs for HPR ranged from $77,712 (95% CI 54,719–100,694) for low volume EDs to $279,134 (95% CI 196,487–362,179) for very high volume EDs; equipment costs accounted for 0.9–5.0% of expenses. The total annual cost‐per‐patient ranged from $3/child (95% CI 2–4/child) to $222/child (95% CI 156–288/child). After accounting for current readiness levels, the cost to reach HPR ranged from $23,775 among low volume EDs to $145,521 among high volume EDs, with costs per patient of $4/child to $48/child.
Conclusions
Annual hospital costs for HPR are modest, particularly when considered per child.
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