Emergency and Definitive Care for Children in the United States: The Perfect Storm

In this issue of Pediatrics, Michelson et al¹ quantified what many of us who practice pediatric emergency medicine have suspected: that many hospitals have reduced their pediatric inpatient capability, which has necessitated the need for children to be transferred for definitive care, often outside of their home communities. They further identified that hospitals with emergency departments (EDs) that care for few pediatric patients are least likely to offer inpatient services and that pediatric inpatient care is becoming concentrated in higher-volume urban centers, particularly primary pediatric facilities.¹

In this study, the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database from 2008 to 2016 was used to sample EDs nationally for admission rates and transfers. This sample represented 21.8 million pediatric ED visits in 2008 and 24.1 million visits in 2016. The ED-visit volume was stratified as low volume (<1800 visits), medium volume (1800–4999), medium-high volume (5000–9999), and high volume (≥10 000) on the basis of a similar ED-visit stratification schemata used by the National Pediatric Readiness Project.^2–5 Primary pediatric facilities were further identified as those hospitals for which the ED patient-visit volume was ≥70% patients who were <15 years of age. Measurement of a hospital’s ability to care for pediatric patients was quantified by a Hospital Capability Index (HCI) that ranged from 0 (no inpatient capability, always transfers) to 1 (full inpatient capability, never transfers). The median HCI ranged from zero in low-volume hospitals to 0.88 in primarily pediatric hospitals. Overall, the HCI for hospitals nationwide was reduced by two-thirds over the 8 years of the study, meaning that in 2008, 6% of pediatric patients who could not be discharged from the ED could be admitted to that hospital’s inpatient service, whereas this number reduced to only 2% in 2016. Total ED transfers increased by nearly 28% over the same time period. These results were most significant for low-volume hospitals in rural areas but had an impact on all nonprimary pediatric hospitals.

These results portend a “perfect storm” of events for care of children in the United States health care system. Increasing pediatric ED visits, poor access to EDs ready to care for children, reduced inpatient capability of hospitals, and increased transfers create increased risk for poor outcomes.^1,3,6–8 Pediatric inpatient capacity across most general community hospitals is decreasing, shifting the burden of pediatric inpatient care to regional pediatric centers, often freestanding children’s hospitals with a high Medicaid-insured population of patients. These hospitals, which compose 5% of hospitals yet are responsible for more than one-third of pediatric discharges and are relied on to care for children with complex medical conditions, suffer significant financial losses from pediatric impatient care.^9,10 Although primary pediatric hospitals have the disproportionate share of inpatient care, 83% of all pediatric ED visits occur in community hospitals.³ These EDs are therefore in a situation of managing children who are critically ill and injured until transfer can be arranged.

The American College of Emergency Physicians, the American Academy of Pediatrics, and the Emergency Nurses Association have published national guidelines for pediatric readiness EDs.^11–14 Although national assessments of pediatric readiness of EDs based on these guidelines have revealed modest improvements, much work is left to be done.³ In the latest national assessment in 2013, the median weighted pediatric readiness score (a normalized score from 0 to 100 of compliance with published guidelines) was 69, which had increased from 55 in 2003.^3,15 Efforts nationally have been made by national stakeholders (eg, American College of Emergency Physicians, American Academy of Pediatrics, and Emergency Nurses Association) and the federal Emergency Medical Services for Children program to provide resources to all states and US territories for improvements in pediatric prehospital and emergency care.¹⁶ Despite these efforts, access to pediatric-ready EDs is poor. Ray et al⁷ demonstrated that 94% of children could travel to any ED within 30 minutes, yet only 34% of children could travel within 30 minutes to an ED that met all recommendations in published guidelines. Furthermore, Ames et al⁸ demonstrated that mortality for children with critical illness is reduced in hospitals with high pediatric readiness.

Michelson et al¹ have provided 1 more piece of the puzzle relative to the state of pediatric care within our health care system. The nexus of these data reveals that the capacity of our system to care for the pediatric inpatient is decreasing and becoming centralized in hospitals for which reimbursement is decreasing. Dependence on stabilization of pediatric patients waiting for transfer further stresses the capacity of our health care system to care for children. Outpatient emergency care is provided in hospitals that must transfer children who are critically ill and injured because of lack of inpatient capacity. Although efforts are ongoing to improve pediatric readiness of EDs nationally, gaps in access to pediatric-ready EDs remain. The solution is complex but must involve coordination of regionalized systems of care and innovative reimbursement models that support pediatric emergency and inpatient care.

• Copyright © 2020 by the American Academy of Pediatrics