By Dorothy Brooks
While research has shown high levels of ED pediatric readiness are associated with better survival rates,1 the results of a new, multisite study led by investigators from the Indiana University School of Medicine suggest high levels of readiness also dampen racial and ethnic disparities when looking at in-hospital mortality rates.2
Researchers collected information on 633,536 children who were treated in 586 EDs across 11 states from 2012 to 2017. The patients were divided into two cohorts: those with acute medical emergencies and those with traumatic injuries. Investigators found the mortality rate was higher among Black children than white children across all levels of readiness when looking specifically at children with acute medical emergencies. Higher levels of readiness were associated with lower mortality rates overall, particularly among Black children.
However, among children with traumatic injuries, researchers found no disparities with respect to mortality. Peter Jenkins, MD, MSC, associate professor of surgery at Indiana University School of Medicine and the lead author of the study, says he cannot say for sure what accounts for the difference in disparity levels, but he has some suspicions.
“Our working hypothesis is that treatment protocols are an important part of readiness, and [they are] associated with eliminating biases in care. Trauma care is driven much more by treatment protocols than a lot of medical care,” Jenkins explains. “Our findings support that hypothesis, but it is certainly not definitive.”
When asked how hospitals or EDs might respond to the data showing disparities among patients with medical emergencies, Jenkins again highlights the positive effects of protocol-driven care. “Individual hospitals do have opportunities to look at how they care for their sickest patients and whether the best aspects of their care are standardized,” he says. “If they are not, I would think that hospitals would want to standardize their best practices.”
Further, Jenkins notes even with medical patients, it is helpful to create protocols to identify critically ill kids early. “If you have those systems in place ... then you are going to see improvements across the board,” he says. “I think that also suggests that the absence of those systems is where you have care that is subject to biases and an increased effect of racial disparities.”
The larger message from the study is enhanced pediatric readiness is associated with reduced disparity levels. Even though disparities were not eliminated in the medical emergency cohort of patients, higher levels of ED readiness were associated with reduced disparity levels. “We estimated that if the three quartiles of hospitals that are least [pediatric] ready raised their readiness levels, we would have a threefold reduction in the mortality disparity of our medically ill patients,” Jenkins observes. “Just improving readiness is a step in the right direction.”
Further, Jenkins notes researchers are searching for what components of readiness are most associated with disparities so that pediatric emergency medicine leaders can highlight specific hospital or ED characteristics, with the clear intent of addressing racial and ethnic disparities.
The pediatric readiness movement is an initiative of the National Pediatric Readiness Project (NPRP), which is led by the Emergency Medical Services for Children Program, a part of the Health Resources and Services Administration (HRSA). Pediatric readiness is assessed through periodic surveys of EDs on a range of metrics that pertain to personnel, quality improvement, patient safety, policies and procedures, and equipment/supplies. The latest assessment was completed in 2021.
While EDs are not asked specifically about disparities in these periodic assessments, the NPRP includes an arm called the National Pediatric Readiness Quality Initiative (NPRQI), an open-access, web-based quality improvement platform that captures patient-level clinical data from EDs across the country, explains Kate Remick, MD, FAAP, executive director of the NPRQI.
“[The platform] provides a real-time assessment of pediatric emergency care provided in all types of EDs that allows stakeholders to benchmark care and identify gaps in delivery,” Remick explains. “This allows monitoring of the delivery of pediatric emergency care by assessing changes in quality of pediatric emergency care delivery over time, based on a core set of 28 pediatric-specific quality measures.”
Remick adds the tool provides stakeholders and ED teams with an aggregate assessment of pediatric emergency care delivery to address disparities. “The platform allows users to evaluate their performance by race, gender, age category, payor source, and ethnicity,” she says.
The periodic national assessments of readiness consider structural components that should be present in every ED, regardless of resources, and made available to any and all patients who seek care in that ED. “The question that NPRQI will help answer is to what extent those resources are leveraged for the care of every child. Our goal is to empower frontline ED providers to ensure the highest-quality care is provided to every child even in the most resource-limited ED settings,” Remick explains.
Remick praised the work of Jenkins and colleagues regarding disparities, calling their research “critical to understanding the impact of pediatric readiness on survival across various demographic populations.”
REFERENCES
1. Newgard CD, Lin A, Malveau S, et al. Emergency department pediatric readiness and short-term and long-term mortality among children receiving emergency care. JAMA Netw Open 2023;6 e2250941.
2. Jenkins PC, Lin A, Ames SG, et al. Emergency department pediatric readiness and disparities in mortality based on race and ethnicity. JAMA Netw Open 2023;6:e2332160.
Researchers estimated that if the three quartiles of hospitals that are least pediatric ready raised their readiness levels, there would be a threefold reduction in the mortality disparity of medically ill patients.
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