Children experiencing a medical emergency should have access to high-quality care that meets their distinct needs, no matter where they live. Every clinician shares this goal -- emergency physicians, nurses, pediatricians, and surgeons alike.
Despite notable improvements over the last decade, systemic gaps remain in pediatric emergency care, especially for children in rural and underserved areas. Clinicians and advocates have been calling attention to the issue for years and have been working toward a solution: pediatric readiness.
Acutely ill and injured children need a unique, pediatric-specific approach. They are not simply "tiny adults." In fact, research shows that taking steps to prepare for children's unique health needs in emergency departments is associated with 60-70% fewer deaths.
Becoming pediatric ready entails following national recommendations for care, like stocking pediatric-appropriate medications, supplies, and equipment. It includes providing staff with specialized training and establishing pediatric-centered policies and protocols. It also involves appointing at least one, ideally two, clinicians as pediatric emergency care coordinators to monitor, sustain, and improve pediatric readiness as a whole.
Implementing these recommendations takes time and resources.
Research shows becoming pediatric ready is not costly at $4 to $48 per patient. (For comparison, vaccines cost a mean price of $65 per dose through the CDC's Vaccines for Children Program.)
But many emergency departments -- particularly small, community ones -- are already strapped for resources.
Emergency clinicians across the country have navigated a litany of unprecedented strains on capacity in recent years: the opioid crisis, the COVID-19 pandemic, the children's mental health crisis, and last fall's pediatric respiratory surge. Our front-line workers have risen to meet each challenge while being understaffed, overloaded, and quite simply, burnt out. These crises complicate progress toward pediatric readiness.
In addition, pediatric readiness is still an evolving concept. The first set of pediatric readiness recommendations was outlined by the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) in 2001. The recommendations were updated in partnership with the Emergency Nurses Association (ENA) in 2008 and again in 2018. We've advanced significantly over this time period, but we know evidence-based practices can take decades to become incorporated into standard practice in medicine.
Meanwhile, children represent approximately 25% of all emergency department visits.
Health insurance payment models reinforce a focus on adult care, reimbursing it at higher rates than pediatric care. Faced with rising costs, hospitals have shuttered pediatric inpatient units, with a 19% decrease in pediatric units and a 12% decrease in pediatric inpatient beds over the past decade. Rural areas have seen a decrease of 26% in pediatric inpatient beds.
Yet, despite increasing demands and limited resources, many emergency departments have improved care for children.
In the most recent national assessment of pediatric emergency capabilities in 2021, emergency departments improved in all but one category from the last assessment in 2013. The only category showing a decline was the presence of pediatric emergency care coordinators, which is likely tied to widespread workforce shortages exacerbated by the pandemic.
This progress is important given the latest assessment took place during the challenges of COVID-19. But of course, there is still significant work to be done.
The pediatric readiness assessment and resources to address gaps are offered through a partnership between the AAP, ACEP, ENA, and the federal Emergency Medical Services for Children Program. This partnership has recently grown to include the American College of Surgeons and the recently established Pediatric Pandemic Network.
While many of these organizations and the clinicians they represent (including us) have been collaborating on this issue for decades, work remains. The median score for emergency departments in the 2021 national assessment was 69.5 out of 100, nearly 20 points lower than the threshold for significantly reducing deaths.
We have attainable solutions. We must invest more in pediatric readiness improvement efforts and in growing and supporting the healthcare workforce. We must reauthorize the federal Emergency Medical Services for Children Program, which provides grants to states and territories to improve their capacity to respond to pediatric emergencies. We must improve payment rates to fairly compensate pediatric emergency care. We also must ensure consistent standards for pediatric readiness throughout the country and codify standards wherever possible.
Emergency clinicians have been fighting for this for years. It's time for our system at large -- policymakers, regulators, insurers, and beyond -- to join and support them.
Sandy Chung, MD, is a pediatrician and president of the American Academy of Pediatrics. Terry Foster, MSN, RN, is an emergency nurse and president of the Emergency Nurses Association. Aisha Terry, MD, MPH, is an emergency physician and president of the American College of Emergency Physicians.