Emergency Medicine

Pediatric Readiness and the Emergency Care of Children

Pediatric Readiness: National Studies Evaluating Pediatric Emergency Care, Readiness, Quality Outcomes and Value

Improving the value (maximized quality and outcomes for each dollar spent) of emergency care for children is critical for public health and the U.S. healthcare system. To improve the emergency care of children, national and state programs have sought to increase the “pediatric readiness” of emergency services. However, the evidence to inform such programs and characterize a high-value emergency care system for injured children has been sparse.  

Our research shows that improving the emergency department pediatric readiness of a hospital (i.e., the ability to effectively care for children seeking emergency services through a number of measurable and actionable items) improves survival among children who are acutely ill or injured. 

Grant #5R24HD085927

For this project, we will build a 12-state cohort of children, with a particular focus on injured children, to describe deficits in the current emergency care system; test the associations between pediatric readiness, quality, outcomes, and cost; and use decision analysis to identify an optimal system for quality and outcomes in a cost-constrained environment.

Unintentional injury remains the leading cause of death and years of potential life lost in children. The use of emergency services following injury is common, with large variability in the readiness of EDs and hospitals to care for injured children. While several national and state efforts have sought to improve pediatric readiness, it remains unclear whether increased readiness improves quality and health outcomes in children, and at what cost. This project seeks to use population science and big biomedical data to create a 12-state cohort of children and to use this cohort and an interdisciplinary team to rigorously evaluate the emergency care system for children in terms of quality, outcomes, and costs. We will build a dataset of all children seeking emergency care, with a particular focus on injured children. This project will fill key scientific gaps in pediatric trauma care and seeks to identify a re-engineered, high-value emergency care system for injured children that optimizes quality, outcomes, and costs.

Objectives: The proposal has 3 specific aims:

Specific Aim 1. Describe and quantify the emergency care of injured children across 12 states in the context of pediatric readiness, including out-of-hospital care, ED care, inpatient care, and 12-month mortality.  

Specific Aim 2. To evaluate the independent associations between pediatric readiness and quality of care, health outcomes, and costs among injured children, including changes over time.

Specific Aim 3. Use decision analysis to assess the balance of quality, outcomes and costs (“value”) for pediatric readiness in the emergency care of injured children, including whether the value changes over time.    

Funding for this project concluded in June 2023.  Our research team is working to finalize the last 2 manuscripts that will use data we compiled for this project, and expect to have all publications in press by early 2024. 

Grant #H34MC33243

This grant is funded by the Health Resources and Services Administration through the EMS Targeted Issues Grant Program

This project will critically evaluate the impact of national health policy on the emergency care of children over an 8-year period, including ways to further optimize survival and quality, with attention to costs.  We are performing a multi-state evaluation of pediatric readiness, outcomes, quality, and costs based on children seeking emergency care.

We will use three cohorts:

  1. Injured children presenting to 1,504 EDs in 13 states
  2. Children with medical conditions presenting to the same EDs in 13 states
  3. Pediatric trauma patients admitted to 639 trauma centers in 44 states.

We will include children 0–17 receiving ED care from 1/1/2019-12/31/2020 compared to identical cohorts enrolled from 1/12012-12/31/2014. Each of these time periods will be aligned with data from two national pediatric readiness surveys (2012-2013 and 2020) and data from the American Hospital Association national survey. The cohorts will include approximately 13.6 million injured children, 36.4 million children with medical conditions, and 389,565 pediatric trauma patients. Outcomes will include mortality (in-hospital, 30-day, and 1-year), preventable complications (quality measures), and costs (hospital- and patient-level).

Goals and Objectives: The proposal has three objectives:

Objective 1. Quantify ED adoption of the pediatric readiness guidelines over an 8 year period and the resulting association with health outcomes and quality of care among children presenting to 1,504 EDs in 13 states and (separately) 639 U.S. trauma centers.

Objective 2. Estimate the additional gains in health outcomes and quality by shifting the location of emergency care to high-readiness EDs within 30 minutes of home among high-risk children presenting to 1,504 EDs in 13 states and 639 U.S. trauma centers.

Objective 3. Measure the hospital costs of reaching a given level of pediatric readiness (148 EDs in 16 states) and the adjusted patient costs of care among EDs with different levels of readiness (1,504 EDs in 13 states).

Grant # R01HD108017

Background: Unintentional injury remains the leading cause of death and years of potential life lost among children in the US.  Among the many ways children are injured, firearms cause the highest mortality, injury severity, need for major surgery, and cost. Firearm injury prevention research in children is relatively sparse and historically underfunded.  The reasons for firearm injuries, risk factors, risk prediction, and potential interventions to reduce such injuries in children require further investigation.

Summary: Our long-term goal is to reduce the occurrence, morbidity, and mortality of firearm injuries in children. In this grant, we build on a NICHD R24 research resource grant for emergency department (ED) pediatric readiness (#HD085927, PI Newgard; Title: The Value of Pediatric Readiness in the Emergency Care of Children) and HRSA funded grant (#H3433243, PI Newgard, Title: A Multi-State Evaluation of Emergency Department Pediatric Readiness: Guideline Uptake and Association with Quality, Outcomes, and Cost) and an interdisciplinary team to study firearm injuries using three national cohorts of children. We have created research infrastructure to collect detailed emergency care data on children from 1,217 EDs in 8 states (AZ, CA, FL, IA, MD, NJ, NY, NC), 832 trauma centers in 50 states, and 5,461 emergency medical services (EMS) agencies in 28 states. We have also developed data science methods to track children to 1 year after an index ED visit and novel statistical methods to analyze the data. We will leverage this infrastructure and NIH/DHHS investment to study primary (Aim 1), secondary (Aim 2), and tertiary (Aim 3) firearm injury prevention in children through the following specific aims.

Specific Aim 1. Using three national cohorts of children 0 to 17 years requiring emergency services, employ machine learning and geospatial analysis to develop and validate risk prediction models for firearm injury and short-term mortality using individual-, home-, incident-, and county-level factors.

Hypothesis 1: There are specific risk factors readily available at the time of an emergency care visit that can identify children at risk of firearm injury and mortality.

We will study large ED, trauma center, and EMS cohorts with high generalizability. Machine learning and geospatial analysis will provide novel, complementary tools to evaluate predictive factors. Using information readily available from electronic health records (EHRs) and public data sources, we will develop models that could be used to automate risk prediction for primary injury prevention.

Specific Aim 2: Among children discharged alive following a firearm injury, measure injury recidivism, healthcare utilization, and mortality to 1-year and develop risk prediction models to identify children at-risk of adverse outcomes in the year after an index firearm event.

Hypothesis 2: Children surviving an initial firearm injury have high firearm injury recidivism, healthcare utilization, and mortality, which can be predicted at the time of discharge from the index visit.

Using survivors with longitudinal outcomes from two cohorts, we will characterize the natural history following a firearm injury event, including adverse outcomes. We will develop models to identify high-risk children using information available at the time of discharge for secondary injury prevention.

Specific Aim 3: For children presenting to an ED after a firearm injury, identify ED and hospital characteristics independently associated with in-hospital, 30-day, and 1-year survival, and quantify the additional lives saved through feasible shifts in the location of initial emergency care.

Hypothesis 3: The location of initial emergency care is predictive of short- and long-term survival after firearm injuries in children, with additional lives saved through feasible shifts in the site of initial emergency care.

Aim 3 focuses on tertiary injury prevention by identifying the optimal emergency care setting for survival after firearm injury and quantifying preventable mortality. After identifying the types of EDs and hospitals that optimize survival, we will geocode all hospitals within 30 minutes of the injury scene to estimate the number of additional lives saved by improved matching of patients to ideal hospitals. This aim will inform national triage guidelines, trauma center verification, and ED readiness efforts.

Our aims are aligned with NIH notices of special interest for Emergency Medical Services for Children (EMSC) and research in the emergency setting.  Each of the aims addresses multiple consensus-based priority areas identified as critical to advancing the field of pediatric firearm injury prevention. We seek to move the field forward through complementary injury prevention aims, national biomedical data with broad generalizability, novel analytic methods, alignment with national health policy efforts, a study design that will facilitate translation to practice, and assembling an experienced interdisciplinary team.

Grant #R01HD109134

Following a 2006 Institute of Medicine report highlighting major deficiencies in the emergency care of children, the National Pediatric Readiness Project (NPRP) was created to improve emergency department (ED) pediatric readiness, including care coordination, personnel, quality improvement, safety, policies, and equipment. However, a 2013 national assessment showed persistent variability in ED readiness across the US, including trauma centers. We recently demonstrated that a high level of ED pediatric readiness was independently associated with a 42% reduction in the odds of in-hospital mortality among injured children in 832 US trauma centers (756 preventable deaths over 6 years) and that this survival benefit persisted to one year. Our findings were consistent with an earlier study showing that critically ill children cared for in high-readiness EDs had lower mortality. However, the components of ED readiness that drive survival remain unknown. While the weighted Pediatric Readiness Score (wPRS) has been used to show that high ED readiness is associated with lower mortality, the measure was not empirically developed and does not allow identification of the critical aspects of ED readiness. A new national assessment of ED pediatric readiness was completed in 2021, providing an opportunity to identify the essential aspects of ED readiness to guide improvements and save lives, particularly among EDs with constrained budgets and limited resources.

In this project, we will identify the specific components of ED pediatric readiness most closely aligned with survival among children receiving emergency care, quantify these factors in a single metric, and identify readiness practices among EDs with better-than-expected survival. The results will guide targeted improvements in EDs, emergency care systems, and national health policy to optimize survival among children requiring emergency services. We build on an NICHD R24 grant for ED pediatric readiness (#HD085927, PI Newgard), a HRSA grant on ED pediatric readiness (#H34MC33243, PI Newgard), and an established multidisciplinary team to conduct this mixed methods study. We will use 928 EDs in 11 states and 678 trauma centers across the US matched to the 2021 NPRP assessment and novel analytics to take the next important step in improving pediatric emergency care through three specific aims.

Specific Aim 1. We will build two multi-state cohorts of children receiving emergency care and use machine learning to identify the components of ED pediatric readiness predictive of short- and long-term survival.

Identifying specific components of ED readiness associated with survival will allow EDs, trauma centers, and health systems to prioritize finite resources on factors most likely to save pediatric lives. This Aim will provide a data-driven, survival-based roadmap for implementing ED pediatric readiness across the US.

Hypothesis 1: Of the many aspects of ED pediatric readiness, a limited number of components account for most of the survival benefit among children receiving emergency care.

Specific Aim 2: Empirically develop a global measure of ED pediatric readiness and compare it to the weighted Pediatric Readiness Score for predicting short- and long-term survival in children.

Because the wPRS was developed through expert opinion, an empirically developed global measure of ED readiness focused on survival would allow EDs to track their progress toward saving pediatric lives.

Hypothesis 2: An empirically developed global measure of ED pediatric readiness will outperform the wPRS for predicting survival and provide an outcome-focused metric to guide EDs.  

Specific Aim 3: Use a positive deviance approach to identify ED pediatric readiness factors and processes of care associated with improved survival among children receiving emergency care.

We will conduct semi-structured interviews with key informants purposively sampled from EDs at the top, middle, and bottom ranges of observed-to-expected mortality. We will then evaluate components of ED readiness and other modifiable factors from positive outliers relative to other hospitals.   

Rationale 3: Understanding how top-performing hospitals organize emergency care for children will prioritize, guide, and focus ED readiness efforts across the US.

This project will identify the essential aspects of ED pediatric readiness for improving short- and long-term survival among children with injury and acute medical illness using quantitative and qualitative methods. We will generate a survival-based, prioritized roadmap for implementing the various components of ED pediatric readiness, a survival-based global measure of ED readiness for EDs to track their progress and identify unique emergency care processes among high-performing EDs. Our aims align with NICHD’s priorities in Emergency Medical Services for Children (EMSC) and trauma care. Specifically, we will take the next steps in understanding and facilitating ED pediatric readiness to improve the “delivery of EMSC care (quality, processes, safety)” and save pediatric lives. This project will influence pediatric national health policy through the NPRP, EMSC, national and state trauma center verification criteria, and national field trauma triage guidelines, providing direct conduits for translating our results into clinical practice.   

Pediatric Readiness Writing Groups

Currently, research proposals are being accepted only from Investigators that are part of these project teams.  Pediatric Readiness Investigators who are interested in proposing an idea, collaborate or lead a manuscript writing group, may express their interest by following the process outlined below.  

Interested in proposing an idea? 

1. Review: Pediatric Readiness Study Publications Policy

2. Review: Current Dataset(s) and Variables Available to Investigators (5/8/20 - currently in development)

3. Submit your proposal - Manuscript Proposal Form

Writing groups: There are currently 3 proposed manuscript projects in development utilizing the NTDB data.  Writing groups have not yet been formed for any of these papers. As these project develop we will update the Writing Groups & Manuscripts webpage.

Please direct questions, or to express interest in joining a writing group when formed, please contact Jenny Cook