Changes in Emergency Department Pediatric Readiness, Inpatient Services, and Excess Child Deaths
Abstract
Importance Emergency department (ED) pediatric readiness and pediatric inpatient services have changed over time in many hospitals, but the impact of these changes on pediatric outcomes is unclear. Objective To evaluate pediatric mortality associated with changes to ED pediatric readiness and pediatric inpatient services over a 10-year period. Design, Setting, and Participants This cohort study included data from January 1, 2012, through December 31, 2021, for 759 hospitals in 11 states that completed the 2013 and 2021 National Pediatric Readiness Program assessments. Participants were children aged 0 to 17 years who received care in an ED resulting in hospital admission, interhospital transfer, or death. Data analysis was performed from May 2025 to May 2026. Exposure Changes in ED pediatric readiness and inpatient pediatric services, as measured through national assessments in 2013 and 2021. ED readiness change groups were characterized based on the weighted Pediatric Readiness Score (wPRS, range 0-100) associated with survival (wPRS ≥88 vs wPRS <88): sustained high readiness, gained, lost, or never had. Changes in pediatric inpatient services were defined as sustained, gained, lost, or never had. Main Outcomes and Measures In-hospital mortality, including ED and inpatient deaths. Results There were 2 416 030 children, including 337 167 who were injured (median [IQR] age, 10 [4-15] years; 4642 deaths [1.38%]) and 2 078 863 who were medically ill (median [IQR] age, 6 [1-14] years; 18 576 deaths [0.89%]). Of the 759 hospitals, the median (IQR) wPRS in 2013 vs 2021 was 71 (58-86) and 72 (62-88), respectively. Ninety-nine EDs (13.0%) had sustained high readiness, 85 (11.2%) gained readiness, 78 (10.3%) lost readiness, and 497 (65.5%) never had high readiness. For inpatient services, 225 hospitals (29.6%) sustained inpatient services, 36 (4.7%) gained services, 120 (15.8%) lost services, and 378 (49.8%) never had services. After risk adjustment, EDs that lost or never had high ED readiness were associated with 1727 (95% CI, 751-2646) and 3776 (95% CI, 2327-5143) excess deaths, respectively. Hospitals that lost or never had inpatient services were associated with 1657 (95% CI, 1214-2067) and 3745 (95% CI, 3127-4328) excess deaths, respectively. Conclusions and Relevance This study found that the loss or persistent lack of high ED pediatric readiness and pediatric inpatient services were independently associated with excess mortality in children. Increasing ED readiness and adding inpatient services may augment pediatric survival in the US health care system.
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Authors: Craig D. Newgard, Amber Lin, Jeremy D. Goldhaber‐Fiebert, Nathan Kuppermann, Katherine Remick, Marianne Gausche-Hill, Ashley A. Foster, Jennifer N. B. Cook, N. Clay Mann, Susan Malveau, Randall S. Burd, Peter C. Jenkins, Andrea M. Lundrigan, Nina E. Glass, Stefanie G. Ames, Mohsen Saidinejad, Aaron R. Jensen, Tabitha Cheng, Steven McGaughey, Apoorva Salvi, Ran Wei, Myra Khushbakht, Hilary A. Hewes
Institutions: University of California, Los Angeles, Oregon Health & Science University, Indiana University School of Medicine, Indiana University – Purdue University Indianapolis, University of Utah, The University of Texas at Austin, Stanford University, Rutgers, The State University of New Jersey, University of California, Riverside, George Washington University Hospital, Children's National, UCSF Benioff Children's Hospital, UCLA Medical Center, Rutgers New Jersey Medical School, San Francisco General Hospital, Center for Policy Analysis, Harbor–UCLA Medical Center