By John Commins
Critically ill children brought to hospital emergency departments that aren’t prepared to care for pediatric emergencies face more than three times the odds of dying compared to children brought to hospitals well-equipped to care for them.
It’s a problem that will not be solved simply by dumping lots of money into hospitals to upgrade their pediatric emergencies services, says study senior author Jeremy Kahn, MD, because it costs too much money.
“The vast majority of hospitals in the United States care for very small volumes of children, and when you have those low numbers, it’s very hard to be ready for anything that can come your way,” Kahn says.
“It’s not so different from a Caribbean nation being prepared for a snowstorm. It might happen, but it’s going to be incredibly unusual. So, the resource investment required to prepare for every eventuality for every pediatric emergency is ultimately enormous,” he says. “There are reasonable questions about whether that’s a value-based strategy.”
Kahn spoke with HealthLeaders about shortcomings in the nation’s pediatric emergency medicine network and offered suggestions for how that network might be improved. The following is a lightly edited transcript.
HLM: What are the different needs of pediatric and adult ERs?
Kahn: The key difference obviously are the diseases themselves. The things that a child is going to present with the will be vastly different than the things that an adult will present with. Even with the same symptoms, chest pain for example, is a very common presenting symptom in an adult and it has a very serious differential diagnosis, things like heart attacks, obviously, are very concerning. But in a child chest pain has just a very different set of considerations.
There are somethings that are very specific to pediatric emergencies, like weight-based dosing. In the adult emergency world, it’s very often one-size-fits-all. But for children dosage will vary dramatically in their size. And then they use very specific equipment as well.
HLM: Why aren’t all hospital ERs “pediatric ready”?
Kahn: The vast majority of hospitals in the United States care for very small volumes of children, and when you have those low numbers, it’s very hard to be ready for anything that can come your way. It’s not so different from a Caribbean nation being prepared for a snowstorm. It might happen, but it’s going to be incredibly unusual. So, the resource investment required to prepare for every eventuality for every pediatric emergency is enormous.
HLM: In what was are ERs unready for pediatrics?
Kahn: The most common reasons for having low readiness scores was not a lack of ability to do things such as weight-based dosing, or lacking all the equipment, because almost all emergency departments have pediatric-sized equipment. The problem was not having a pediatric-focused quality improvement officer, not having all the policies and procedures in place. Unfortunately, what we found in our study is that those things translate into patient outcomes.
We knew going into our study that there was wide variation in the amount of readiness among hospitals across the country. But now we have empirical data to show that low readiness scores do translate into poor outcomes for at least the sickest patients.
HLM: Are you able to estimate how much improving ED pediatric readiness would cost?
Kahn: I don’t know the answer to that, but I think that’s the issue. It’s just not a value-based strategy to have every hospital in the United States become maximally pediatric ready because, again, there are some hospitals that will just see very low numbers of children.
The key is to take a multipronged approach that customizes for a region or a the state. In some areas where there are no specialized children’s hospitals, it may behoove that area for every hospital to be ready to care for children. But in other areas, maybe there are alternative strategies, such as regionalization, where the sickest children are triaged in the pre-hospital setting to go right to the one or two hospitals in the region that are most ready to care for pediatric emergencies.
Telemedicine is another exciting potential strategy to extend the benefits of pediatric readiness to more hospitals using remote audio-visual equipment. So those are alternative strategies.
HLM: What are some of the key commonalities for pediatric readiness in the high-scoring, pediatric and adult-hospitals?
Kahn: One is volume. We found that obviously having a high volume of children makes you more likely to be pediatric ready. But the highest determinant was having a dedicated physician and nurse who oversee pediatric-focused quality improvement in the hospital.
HLM: How difficult would it be for a hospital to do a pediatric readiness assessment?
Kahn: If there’s any lesson from our study, it’s that hospitals should know what their capabilities are for caring for critically ill children. Those readiness assessments should already be a routine part of that hospital’s policies and procedures.
The question then becomes, how do they respond if they perceive that there are gaps in their readiness? That has to be a very customized approach. There’s not going to be a one-size-fits-all approach.
This is not the responsibility of individual clinicians to fix. This is a systemwide issue, and hospitals and regions within states should get together to strategize about the best ways to deliver emergency care for children.
HLM: What would you like to see done with your study findings?
Kahn: We should not respond to these data with a shrug. We need to do something to increase pediatric readiness among our nation’s hospitals. What we do will be determined by specific hospitals, and specific regions. Different approaches are going to work in different way in different areas.
The only the only mistake would be to do nothing.
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.