Trends in Capability of Hospitals to Provide Definitive Acute Care for Children: 2008 to 2016

Abstract

BACKGROUND: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care. METHODS: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability. RESULTS: The national median HCI was 0.06 (interquartile range: 0.01-0.17) in 2008 and 0.02 (interquartile range: 0.00-0.09) in 2016 (P , .001). Definitive care became less common regardless of annual pediatric volume, urban or rural designation, or condition frequency. In 2016, 2171 EDs (49.0%) had HCIs ,0.013, which represented the lowest 25% of ED HCIs in 2008. Pediatric visits to EDs categorized in the bottom 2008 capability quartile more than doubled from 2.5 million in 2008 to 5.3 million in 2016. Despite decreasing capability, centers with higher annual pediatric volume and urban centers provided more definitive inpatient care and had fewer inter-ED transfers than lower-volume and rural centers. CONCLUSIONS: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children. WHAT'S KNOWN ON THIS SUBJECT: Definitive care provision has decreased over time in certain states. WHAT THIS STUDY ADDS: Between 2008 and 2016, most hospitals decreasingly provided definitive pediatric acute care and increasingly transferred emergency patients. Low-volume hospitals were least likely to provide definitive care. Pediatric inpatient care is becoming concentrated in fewer centers, decreasing initial access to definitive acute care.

Advanced Pediatric Emergency Airway Management: A Multimodality Curriculum Addressing a Rare but Critical Procedure

“…[1][2][3] Contributing to this challenge are the facts that actual pediatric critical care is uncommon (when compared to the adult population), the distribution of where children seek emergency medical care and who is there to care for them varies, and there are many competing demands on a health care providers' initial and continuing medical education. [4][5][6][7][8][9][10][11] Further compounding these facts is the variation in the rate and quality of procedural skill acquisition amongst each individual learner. This supports the need to utilize varied educational modalities and providing customizable frequencies of practice to meets all learners' needs.…”

Emergency and Definitive Care for Children in the United States: The Perfect Storm

“…In this issue of Pediatrics, Michelson et al 1 quantified what many of us who practice pediatric emergency medicine have suspected: that many hospitals have reduced their pediatric inpatient capability, which has necessitated the need for children to be transferred for definitive care, often outside of their home communities. They further identified that hospitals with emergency departments (EDs) that care for few pediatric patients are least likely to offer inpatient services and that pediatric inpatient care is becoming concentrated in highervolume urban centers, particularly primary pediatric facilities.…”

“…They further identified that hospitals with emergency departments (EDs) that care for few pediatric patients are least likely to offer inpatient services and that pediatric inpatient care is becoming concentrated in highervolume urban centers, particularly primary pediatric facilities. 1 In this study, the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database from 2008 to 2016 was used to sample EDs nationally for admission rates and transfers. This sample represented 21.8 million pediatric ED visits in 2008 and 24.1 million visits in 2016.…”

“…Increasing pediatric ED visits, poor access to EDs ready to care for children, reduced inpatient capability of hospitals, and increased transfers create increased risk for poor outcomes. 1,3,[6][7][8] Pediatric inpatient capacity across most general community hospitals is decreasing, shifting the burden of pediatric inpatient care to regional pediatric centers, often freestanding children's hospitals with a high Medicaid-insured population of patients. These hospitals, which compose 5% of hospitals yet are responsible for more than one-third of pediatric discharges and are relied on to care for children with complex medical conditions, suffer significant financial losses from pediatric impatient care.…”

“…Michelson et al 1 have provided 1 more piece of the puzzle relative to the state of pediatric care within our health care system. The nexus of these data reveals that the capacity of our system to care for the pediatric inpatient is decreasing and becoming centralized in hospitals for which reimbursement is decreasing.…”