VACEP’s Evidence-Based Medicine Review Series
for Emergency Physicians
Authors: Jessica Arrott, MD, PGY-4 (Emergency Medicine) & Matthew R. Jordan, MD, Attending Emergency Physician | Naval Medical Center Portsmouth
Reviewers: Martin Klinkhammer, MD, MPH & Jesse Cann, MD | Eastern Virginia Medical School
Article: Association of emergency department pediatric readiness with mortality to 1 year among injured children treated at trauma centers | JAMA Surgery, April 2022. Link to view full study and tables.
CASE
You are working in an adult Level 2 Trauma Center Emergency Department when you receive an EMS call regarding transport of a 9-year-old male from the scene of a pedestrian versus automobile crash with BP 115/70, HR 140, RR 30, SpO2 95% on room air, with a minor bleeding head laceration, extensive bruising across the anterior chest, and bilateral lower extremity deformities. The patient is anxious but protecting his airway. EMS has a transport time of 20 minutes to your hospital via ground or can fly the patient via helicopter to the nearest Pediatric Level 1 Trauma Center and arrive in 60 minutes.
How would you advise EMS? What additional information could help you make this critical decision?
Pediatric patients account for more than 30 million emergency department (ED) visits each year, making up 20% of all ED visits in the U.S.(1) In order to improve pediatric readiness in the nation’s hospitals, joint guidelines were created for the care of children in EDs; however, subsequent studies reported poor ED compliance with these guidelines.
In 2011, the National Pediatric Readiness Project (NPRP), a multi-phase quality improvement initiative, was created to address the disparate state of pediatric readiness in the U.S.(2)
The first phase was an electronic assessment in January 2013, surveying six areas of ED readiness including pediatric care coordination, ED personnel, quality improvement, patient safety, policies and procedures, and equipment.(3) It is important to note the highest score, a Weighted Pediatric Readiness Score (WPRS) of 100, represents the essential components needed to establish a foundation for pediatrics readiness, but is not inclusive of all the factors recommended for pediatric readiness.
In 2013, the mean WPRS was 68.9, indicating many U.S. EDs remain deficient in fundamental components of pediatric readiness.
Among pediatric patients in the U.S., unintentional injury remains the leading cause of death and loss of potential years of life.(4) Despite the recent proliferation of pediatric trauma centers in the U.S., the initial hospital care of most injured children is performed in EDs primarily designed and equipped to treat adults.(5) Previous studies by Newgard et al.(6) and Ames et al.(7) demonstrated short term in-hospital survival of injured children and critically ill children, respectively, was improved when these patients were seen in EDs with high pediatric readiness. However, no studies had looked at whether this mortality benefit extended beyond hospital discharge.
In April 2022, Newgard et al. published a retrospective cohort study in JAMA Surgery evaluating the association between ED pediatric readiness and mortality of injured children (“Association of Emergency Department Pediatric Readiness with Mortality to 1 Year Among Injured Children Treated at Trauma Centers”).
This study included 88,071 injured children less than 18 years of age presenting to the emergency departments of 146 trauma centers (levels 1-4) in 15 states and the District of Columbia, which participate in the National Trauma Data Bank (NTDB), from January 2012 through December 2017 with follow-up through December 2018.(8)
The authors included children who were residents of 8 states chosen to ensure ability to match vital statistics records, inducing death records. The authors excluded EDs treating less than 50 children during the study period and excluded children missing information from their initial ED visit, transferred without second hospital records, or receiving care at an ED without an NPRP assessment.
A total of 1,974 children (2.2%) died within one year of their initial ED visit, with nearly 90% (n=1768) of mortality occurring during the initial hospitalization. The remaining 206 pediatric deaths occurred within 1 year following discharge. Of 1,598 children with detailed time information available who died in the hospital, the median time to death was 3.1 hours (IQR 0.3-36.5; range 0-3244).
About the EBM Review Series
VACEP’s Evidence-Based Medicine Review Series is a monthly literature review started by the University of Virginia’s Josh Easter, MD, MSc, a VACEP board member working to connect the academic community in Virginia. Physicians and residents submit their review of a recent journal article, and their summary is reviewed by emergency physician peers and published here. We invite each residency in Virginia (and D.C.) to create a faculty/resident team to submit and review articles. Email Executive Director Sarah Marshall to take the next step.
Goals
Provide a brief monthly synopsis of a high yield article germane to the practice of emergency medicine for distribution to all VACEP members
Provide an opportunity for a peer reviewed publication and invited presentation for faculty and trainees
Foster an academic community focused on evidenced based medicine for emergency medicine residency programs in the region
Children initially treated in EDs in the highest quartile of readiness (WPRS 95-100) had higher survival to one year than children treated in EDs in the lowest quartile of readiness (WPRS 32-69) (HR, 0.73; 95% CI, 0.57-0.94). This association persisted even after sensitivity analyses excluding deaths occurring within the first 2, 3, 5, and 7 days, as well as when adding in overall trauma level, adult trauma level, ED pediatric volume, and hospital region.
Notably, there appears to be a trend that higher level trauma centers and those who see more pediatric trauma volume tend to be in the top quartile (most ready) of the WPRS (see supplemental table 1).
A planned subgroup analysis evaluating the most severely injured children with an Injury Severity Score (ISS) ≥ 16, Abbreviated Injury Scale (AIS) ≥ 3, or head AIS ≥ 3), showed a similar association between the highest pediatric ready EDs and lower mortality rates at 1 year. Cases with an ISS ≥ 16 showed an adjusted hazard ratio of 0.69 (95% CI, 0.54-0.88). Similar results were seen in cases with an AIS ≥ 3 (aHR, 0.70; 95% CI, 0.56-0.88) and head AIS score ≥ 3 (aHR 0.69; 95% CI, 0.52-0.90).
The authors conclude there was an association between high ED readiness and survival to 1 year, even after excluding early deaths, suggesting high quality ED care benefits the patient beyond the acute care period and persists to one year.
There are some limitations to this study. The population was limited to children from 8 states and only 146 hospitals. Including a broader range of patients and hospitals could lead to different results and would be more representative of the U.S.
In addition, the pediatric readiness scores were taken from the 2013 assessment and may have changed in the intervening decade; re-analyzing the data with the WPRSs from the 2021 assessment could yield different results.
Finally, despite the use of a risk-adjusted model and performance of multiple sensitivity analyses, there are many unmeasured confounding factors, such as in-hospital resources, which could have introduced bias or obscured the true factor associated with pediatric survival.
The importance of having high pediatric readiness in a trauma emergency department is evident in decreasing the mortality of pediatric patients. Given that the leading cause of pediatric death is trauma, it should be the goal of every trauma center to maximize its preparedness following the available guidelines.
This study shows that high ED readiness was associated with lower mortality out to 1 year among injured children, and the benefit of high ED readiness was not limited only to major (level 1 and 2) trauma centers. It highlights the importance of hospital selection (e.g., by emergency medical services or family), as the location of initial care has an impact on the likelihood of survival. The study also supports the importance for U.S. trauma centers to meet a high level of ED readiness.
Unfortunately, many EDs in the U.S. have yet to establish the fundamental components of ED readiness. Though efforts to address these deficits can be time and resource-intensive, this and previous studies suggest that improving ED pediatric readiness has the potential to improve clinical outcomes and pediatric mortality.
CONCLUSION
You direct EMS to bring the patient to your ED - not only is it closer, but, thanks to recent Quality Improvement projects, your ED's pediatric readiness recently received a WPRS of 97. You know your ED’s readiness is associated with improved pediatric patient survival to one year. The patient arrives on supplemental oxygen in respiratory distress with absent breath sounds on the right. You intubate and place a chest tube, reduce his lower extremity fractures, and obtain imaging showing no intracranial bleed. After stabilizing the patient, you consult the appropriate specialists and admit him to the pediatric intensive care unit.
Review: “Association of Emergency Department Pediatric Readiness with Mortality to 1 Year Among Injured Children Treated at Trauma Centers”
By Martin Klinkhammer MD MPH & Jesse Cann MD | Eastern Virginia Medical School
We appreciated the review of Drs. Jordan and Arrott on the Newgard article (Newgard, 2022) demonstrating the association of emergency department pediatric readiness with mortality among pediatric trauma patients. While we agree that it is likely important to emphasize pediatric readiness in emergency departments — as this makes inherent sense and would certainly seem to be correlated to pediatric outcomes — we were somewhat surprised by the lack of more demonstrable evidence in this study. We feel that a direct association between pediatric readiness and outcomes was not particularly robust for the following reasons:
1. While the study was able to show a significant difference in mortality between the highest quartile of pediatric readiness and the lowest quartile (adjusted hazard ratio 0.7); compared to the lowest quartile of readiness, there were no other interquartile differences. In fact, the adjusted hazard ratio of the second quartile (second least ready) was actually higher than the lowest quartile (aHR, 1.10; 95% CI, 0.86-1.4) though it did not reach clinical significance. This at least argues against a continuous association between the variables measured by the pediatric readiness inventory and pediatric trauma mortality, since the correlation was only demonstrated when comparing the highest quartile of readiness to the others.
2. When examining the national assessment of pediatric readiness of emergency department study (Gausche-Hill, 2015) from which the four quartiles of pediatric readiness were drawn, there are some interesting differences between the groups that could certainly account for any mortality differences irrespective of other factors. This study found that the overall weighted pediatric readiness score (WRPS) was correlated to pediatric volume. Low volume EDs had a median WPRS of 61.4; medium-volume EDs, 69.3; medium to high-volume 74.8; and high-volume EDs, 89.8. Additionally, lower-volume hospitals reported a higher percentage of family medicine-trained physicians caring for children (78.9%) compared with high-volume hospitals (32.1%) where most physicians caring for children were trained in emergency medicine (88.6%) or pediatric emergency medicine (55.4%).
3. Lastly, all of the dedicated pediatric trauma centers were included in the highest quartile of pediatric readiness which comprised over half of the total patients from the highest quartile (52.4%)(Table 1, Newgard, 2022). This study did demonstrate a correlation between being in the highest quartile of pediatric readiness as measured by the WPRS score and lower pediatric trauma mortality. However, given that the highest volume pediatric centers with the highest proportion of emergency medicine trained physicians and the only dedicated pediatric trauma centers were in the first quartile, it is difficult to know whether the other factors in the pediatric readiness survey were important.
This retrospective study by Newgard demonstrated an association between the highest level of pediatric readiness and lower trauma mortality. This association was relatively weak and may have principally been due to higher pediatric volumes, dedicated pediatric facility use, and emergency training of the physicians at the centers with the highest levels of readiness. Nonetheless, the goals of maintaining higher pediatric readiness by implementing full access to pediatric equipment, having physician and nurse champions for pediatric care, and pediatric specific QI processes and other quality metrics are all laudable and may improve pediatric trauma outcomes.
REFERENCES
Sun R, Karaca Z, Wong HS. Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015: Statistical Brief #238. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality; 2018
Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr. 2015;169(6):527-534. doi:10.1001/jamapediatrics.2015.138
(2015). eAppendix: Pediatric Readiness Assessment and Scoring Document. In Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr. 2015;169(6):527-534. doi:10.1001/jamapediatrics.2015.138
10 Leading Causes of Death, United States 2019, Both Sexes, All Ages, All Races. Atlanta, GA: Centers for Disease Control and Prevention; 2021: Available at https://wisqars-viz.cdc.gov:8006/lcd/home. Accessed September 14, 2022.
Genovese TJ, Roberts-Santana C, Wills H. Pediatric trauma readiness: a trauma-specific assessment to complement the national pediatric readiness project. Pediatr Emer Care. 2021;37(12):e1646-e1651.
Newgard CD, Lin A, Olson LM, et al. Evaluation of emergency department pediatric readiness and outcomes among US trauma centers. JAMA Pediatr. 2021;175(9):947-956. doi:10.1001/jamapediatrics.2021.1319
Ames SG, Davis BD, Martin JR et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568
Newgard CD, Lin A, Goldhaber-Fiebert, et al. Association of emergency department pediatric readiness with mortality to 1 year among injured children treated at trauma centers. JAMA Surg. 2022;157(4):e217419. doi:10.1001/jamasurg.2021.7419
