The morning after Phyllis Rabinowitz brought her newborn daughter home from the hospital, she knew something was terribly wrong. The baby, Rebecca, had thick mucus, trouble breathing and lethargy unlike anything Ms. Rabinowitz had seen in her first child.
But during multiple visits to the emergency room, doctors told Ms. Rabinowitz that Rebecca had a common cold and sent them home. At nine days old, Rebecca died; her parents learned from an autopsy that the cause was a viral infection that could have been managed had she been admitted.
More than 80 percent of emergency departments in United States hospitals are not fully prepared for pediatric cases, a new study finds, despite the fact that children make up about 20 percent of visits each year.
The new analysis, published Friday in the journal JAMA Network Open, estimated that if every emergency department in the United States had the core features of “pediatric readiness,” more than a quarter of the child deaths that follow E.R. visits could be prevented, a figure that equates to thousands of young lives each year.
Even in the most ill-prepared states, the cost to ready every emergency room would be less than $12 per child living there, the researchers found.
“You can now find your state and see: How many children who would otherwise die could we expect to save if we implemented universal pediatric readiness at a high level?” said Dr. Craig Newgard, who was the lead author on the paper, and is the director of the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University.
“The numbers are nontrivial, and I think they’re pretty compelling at a state-by-state level — enough to motivate people to want to raise readiness,” he said.
The Cost of Status Quo
The checklist for so-called readiness, established by the National Pediatric Readiness Project, includes stocking child-size equipment and supplies and establishing protocols and trainings for youth-specific care, such as optimal vital signs for children and resuscitation techniques. From a public health perspective, those preparations are considered extremely cost-effective — even more so than several routine childhood vaccines.
Clinicians who study the effects of hospital readiness say the checklist is achievable regardless of the hospital’s size or financial resources: Most general emergency departments stock more than 90 percent of the supplies that are that needed to properly care for children, and an on-staff nurse or doctor can undergo training and double as a specialized pediatric care coordinator, for example.
“Even a tiny, little five-bed emergency department in a rural or frontier setting can reach the same level of readiness as a large tertiary care hospital in an urban setting,” Dr. Newgard said. “If they saw this paper and decided, ‘Hey, this is something we should really do,’ there are resources to walk them through and figure out where best to start.”
Still, those preparations can be low on the priority list of struggling health centers, and large, mostly rural swaths of the country have become deserts for specialized pediatric emergency care. In a national assessment, overall “pediatric readiness” scores for emergency rooms decreased slightly between 2013 and 2021, and an ongoing consolidation of pediatric care to large urban tertiary care centers has forced families to travel even farther for treatment.
Only a third of children live near an emergency department that is considered highly “pediatric-ready,” and among them, nine out of 10 live closer to a less-prepared one. Data shows that those families pay a harsh price: Critically ill children are four times as likely to die in hospitals and twice as likely to die in trauma centers that score low in “pediatric readiness.”
Hope in the Data
The goal of the researchers in the new study was to estimate the annual cost of making emergency rooms ready for children — and the number of children’s lives that could be saved each year if the effort were successful.
Using data from 4,840 emergency departments in all 50 states and in the District of Columbia from 2012 to 2022, they estimated that about 669,000 children were acutely ill or injured when they sought care, meaning that they were admitted to a hospital, transferred to another or died in the unit.
Researchers found that 842 of the 4,840 emergency rooms — less than one-fifth — were considered well-prepared for pediatric emergencies. The level of preparedness at a statewide level ranged from 100 percent of hospitals in Delaware to just 2.9 percent in Arkansas.
They used predictive models to examine how mortality rates would be affected if every emergency department earned a pediatric readiness score of at least 88 out of 100. Of about 7,619 deaths that occur among children who show up at emergency rooms, the researchers concluded that 2,143 could be saved — more than a 25 percent reduction in mortality. In most states, that would be dozens of children saved per year.
The model predicted that the annual cost for all emergency departments in the country to achieve that status would be more than $207 million. The cost per state ranges from $0 in Delaware to more than $18 million in Texas, equating to up to $11.84 per child resident depending on the state.
A Road Map
Authors of the paper highlighted several ways to incentivize hospitals to become better prepared for pediatric emergencies, such as by adding a readiness score threshold to hospital accreditation requirements or by using performance-based reimbursement models.
But hospitals can make the investment themselves, and the four-bed emergency room at South Lincoln Hospital District in Wyoming is a prime example: After a 2021 assessment ranked its preparedness at a 44 out of 100, “we decided, no, we’re going to take this very seriously, and we’re going to do what it takes,” said Andrew Appleby, a nurse who serves as pediatric coordinator there.
The emergency room at South Lincoln, the only health care facility in a 50-mile radius, raised its score by 25 points in two years, and thanks to new pediatric protocols and training simulations, Mr. Appleby said, he recently gave lifesaving epinephrine to a child in anaphylaxis before the sole physician on duty could arrive.
Ms. Rabinowitz, who now runs a foundation advocating pediatric readiness in emergency rooms, believes that kind of vigilance among the staff could have saved her baby Rebecca’s life. When she learned of the new data set that quantifies the potential for preventing similar tragedies, she wept.
“I actually feel optimistic for the first time,” she said through tears. “If these changes can be mandated in the whole emergency system — if they can be ready for children — my charity can go out of business. That would be the best-case scenario.”
