In the Journals

Hospital choice could affect pediatric mortality during emergencies

Photo of Jeremy Kahn
Jeremy M. Kahn

Findings published in Pediatrics suggest that a child’s chance of survival in an emergency may depend on the hospital where they receive care.

Researchers assessed the pediatric readiness of EDs in five states and found that hospitals with the highest scores had lower mortality rates.

“For some time, we’ve known that hospitals vary widely with respect to their readiness to care for pediatric emergencies,” Jeremy M. Kahn, MD, MS, professor of critical care medicine and health policy and management at the University of Pittsburgh, told Infectious Diseases in Children. “What’s new about our study is that for the first time, we have empirical data suggesting that these gaps lead to increased mortality risk among certain patients, especially critically ill patients.”

According to Kahn, the presentation of pediatric emergencies may differ from adult emergencies in many ways, including “markedly different” signs and symptoms, and they require different considerations for age and weight-based dosing.

“It’s imperative that drugs and equipment be customized to each child, unlike adult emergencies, which are frequently one-size-fits-all,” he said.

Kahn and colleagues conducted a retrospective cohort study of 20,483 children aged 0 to 18 years who presented to 426 hospitals located in Florida, Iowa, Massachusetts, Nebraska and New York in 2013. The children all presented with a critical illness that required intensive care admission or caused death during treatment in the hospital.

The median weighted readiness score for pediatric emergencies was 74.8 (interquartile range = 59.3-88; range = 29.6-100), according to the researchers. Hospitals with higher readiness scores experienced lower rates of in-hospital pediatric mortality (mortality by lowest to highest readiness quartile = 11.1%, 5.4%, 4.9%, 3.4%; P < .001 for trend).

Only hospitals with readiness scores in the top quartile had decreased odds of pediatric in-hospital mortality after adjusting for age, chronic complex conditions and severity of illness (adjusted OR compared with the lowest quartile = 0.25; 95% CI, 0.18-0.37).

According to Kahn and colleagues, these findings suggest that pediatric outcomes can improve with better hospital readiness. However, the researchers explained that many hospitals do not have pediatric-focused ED policies, pediatric resuscitation equipment or guidelines for transferring patients to hospitals with better pediatric capabilities.

“We don’t yet know the best strategy to improve outcomes for critically ill children,” Kahn said. “The first step may be ensuring that the hospital is appropriately resourced with pediatric-specific equipment and care pathways and that staff are trained to use them. State and regional authorities should consider efforts in the pre-hospital setting, such as having ambulances take the sickest children to hospitals with high pediatric readiness scores when possible.”

Katherine E. Remick, MD, assistant professor of pediatrics at The University of Texas at Austin Dell Medical School, wrote in a related editorial that it has been difficult to measure the impact of hospital readiness on patient outcomes.

“By using previous estimates for the percentage of ED deaths among pediatric patients and by extrapolating from the results described by [Kahn and colleagues], if all EDs adhered to pediatric readiness guidelines, the percentage of pediatric deaths could dramatically decrease,” she wrote. – by Katherine Bortz

References:

Ames SG, et al. Pediatrics. 2019;doi:10.1542/peds.2019-0568.

Remick KE. Pediatrics. 2019;doi:10.1542/peds.2019-1636.

Disclosures: Kahn reports no relevant financial disclosures. Remick reports receiving funding from the Health Resources and Services Administration of HHS.

Photo of Jeremy Kahn
Jeremy M. Kahn

Findings published in Pediatrics suggest that a child’s chance of survival in an emergency may depend on the hospital where they receive care.

Researchers assessed the pediatric readiness of EDs in five states and found that hospitals with the highest scores had lower mortality rates.

“For some time, we’ve known that hospitals vary widely with respect to their readiness to care for pediatric emergencies,” Jeremy M. Kahn, MD, MS, professor of critical care medicine and health policy and management at the University of Pittsburgh, told Infectious Diseases in Children. “What’s new about our study is that for the first time, we have empirical data suggesting that these gaps lead to increased mortality risk among certain patients, especially critically ill patients.”

According to Kahn, the presentation of pediatric emergencies may differ from adult emergencies in many ways, including “markedly different” signs and symptoms, and they require different considerations for age and weight-based dosing.

“It’s imperative that drugs and equipment be customized to each child, unlike adult emergencies, which are frequently one-size-fits-all,” he said.

Kahn and colleagues conducted a retrospective cohort study of 20,483 children aged 0 to 18 years who presented to 426 hospitals located in Florida, Iowa, Massachusetts, Nebraska and New York in 2013. The children all presented with a critical illness that required intensive care admission or caused death during treatment in the hospital.

The median weighted readiness score for pediatric emergencies was 74.8 (interquartile range = 59.3-88; range = 29.6-100), according to the researchers. Hospitals with higher readiness scores experienced lower rates of in-hospital pediatric mortality (mortality by lowest to highest readiness quartile = 11.1%, 5.4%, 4.9%, 3.4%; P < .001 for trend).

Only hospitals with readiness scores in the top quartile had decreased odds of pediatric in-hospital mortality after adjusting for age, chronic complex conditions and severity of illness (adjusted OR compared with the lowest quartile = 0.25; 95% CI, 0.18-0.37).

According to Kahn and colleagues, these findings suggest that pediatric outcomes can improve with better hospital readiness. However, the researchers explained that many hospitals do not have pediatric-focused ED policies, pediatric resuscitation equipment or guidelines for transferring patients to hospitals with better pediatric capabilities.

“We don’t yet know the best strategy to improve outcomes for critically ill children,” Kahn said. “The first step may be ensuring that the hospital is appropriately resourced with pediatric-specific equipment and care pathways and that staff are trained to use them. State and regional authorities should consider efforts in the pre-hospital setting, such as having ambulances take the sickest children to hospitals with high pediatric readiness scores when possible.”

Katherine E. Remick, MD, assistant professor of pediatrics at The University of Texas at Austin Dell Medical School, wrote in a related editorial that it has been difficult to measure the impact of hospital readiness on patient outcomes.

“By using previous estimates for the percentage of ED deaths among pediatric patients and by extrapolating from the results described by [Kahn and colleagues], if all EDs adhered to pediatric readiness guidelines, the percentage of pediatric deaths could dramatically decrease,” she wrote. – by Katherine Bortz

References:

Ames SG, et al. Pediatrics. 2019;doi:10.1542/peds.2019-0568.

Remick KE. Pediatrics. 2019;doi:10.1542/peds.2019-1636.

Disclosures: Kahn reports no relevant financial disclosures. Remick reports receiving funding from the Health Resources and Services Administration of HHS.