Maximizing Pediatric Readiness in Emergency Departments

HOSPITAL EMERGENCY room (ER) pediatric readiness has received media attention in recent years, most recently with the release in 2024 of a Stanford University-led study that found 75 percent of hospital emergency departments (EDs) are below the top quartile of pediatric readiness. Fortunately, the study also showed that cost-effective improvements could save thousands of lives annually. The data, collected from nearly 750 hospitals in 11 states, representing a variety of community sizes, urban and rural, public and private, concluded that improvements to staffing, training, equipment or some combination could better maximize emergency room pediatric readiness.¹ 

Efforts to improve ER pediatric readiness, defined as the ability to care for acutely ill and injured children, has been on the upswing, says Teale Ryan, PhD, RN, in Salina, Kan. And although pediatric-specific hospitals have the highest level of expertise, despite how the Stanford study results sound, she says pediatric care in regional EDs, big picture, should not be described as inadequate.

However, as hospitals trend away from pediatric-specific facilities, and EDs toward level 4 care that offers minimal pediatrics beyond EDs (level 4 hospitals have seen an increase of 137 percent in the past 20 years), concern for pediatric readiness may be warranted. In fact, pediatric inpatient services are also declining, according to a study conducted at the Oregon Health and Science University and the University of the Utah School of Medicine that looked at ERs across all 50 states and Washington, D.C.² Some cite lower reimbursement rates for pediatric services as a possible cause for the reduction. Others warn pediatric capabilities may worsen under proposed federal funding changes.³ 

Regardless, pediatric readiness is associated with improved survival across the age spectrum, particularly related to traumatic injuries, with younger children deriving the greater benefit, possibly because of their need for specialized personnel and right-sized equipment.⁴ 

Despite 30 million pediatric ER visits in the U.S., half of ER doctors see fewer than 15 pediatric patients per day.⁵ “Even small EDs who see few children need to have equipment and supplies to care for a critically ill or injured child, as they may be the closest ED in an emergency and would need to stabilize the child to the best of their abilities before transferring out to a children’s hospital,” says Theresa A. Walls, MD, MPH, an attending physician in the Emergency Department at Children’s Hospital of Philadelphia (CHOP). “While only 5 to 10 percent of emergency medical services runs are for children, pediatric patients typically make up 20 to 25 percent of all ED visits to community EDs. They are doing a decent job. They want to take good care of kids.” 

Children Are Not Small Adults

Being fully prepared for so few pediatric patients might seem daunting, particularly in a world of cost-reduction strategies. However, addressing the unique needs of children means preparing for the unexpected, providing right-sized equipment and hiring staff who are credentialed and trained to ensure appropriate care for all body sizes. 

Nursing schools often teach to a nurse generalist position, says Dr. Ryan, although some include specific coursework in pediatrics. Generalist training enables nurses to apply learned concepts across the lifespan, but it also means some skills must be acquired at pediatric-specific in-services, continuing education and on-the-job annual training. She cites HALO competencies (high acuity, low occurrence) as critical skills to maintain even though they are less frequently used. As an example, ER nurses will always receive training in pediatric life support, but they might be tempted, in a time-constrained environment, to overlook training to respond to the less common pediatric stroke. 

Medical staff need to be ready to assess and care for all pediatric emergencies. For example, use of the Broselow Tape system to measure a patient’s height with color-coded tape will reasonably estimate the patient’s weight if a true weight cannot be obtained. From this measurement, appropriately sized equipment and pre-calculated medication dosing can be determined in an easy-to-use color-coded system. “Though children are not small adults, the inventories in a pediatric Broselow crash cart are similar,” says Dr. Ryan. “If a child measures in the blue section of the tape, the provider knows to open the blue drawer. If the same child needs to be sedated, the blue drawer contains the dose that should be used.”

National standards for 24-hour hospital-based ERs were developed in 2009, updated in 2018 and reaffirmed in 2024 in a joint policy statement by the American Academy of Pediatrics, American College of Emergency Physicians and the Emergency Nurses Association. Covering critical domains of pediatric readiness, the National Pediatric Readiness Project provides a checklist and toolkit based on the joint policy statement that articulates the necessary components of administration and care coordination; policy development; competencies and evaluations; quality and performance improvement plans; procedures and protocols; and all-hazard preparedness that addresses unique needs of pediatric patients. The toolkit is being updated in 2026.⁶ 

Training Today to Be Ready Tomorrow

According to Dr. Walls, one of the most impactful pediatric readiness improvements a hospital ED can make is the appointment of a pediatric emergency care coordinator who is dedicated to pediatric patient care, inclusive of training and equipment, and ensuring pediatric patients are represented in quality improvement plans. “Getting the right equipment is fairly easy and inexpensive, but equally important is making sure all ED staff know where the equipment is and how to use it,” she explains. Dr. Walls encourages hospital EDs to reach out to their local or regional children’s hospital for help and/or contact their state Emergency Medical Services for Children program manager. There are also a wealth of resources available at the Emergency Innovation and Implementation Collaborative.

Dr. Walls participates in CHOP’s Outreach Center for Expertise in Pediatric Emergency Readiness and Training (ExPERT), working with hospitals, EDs, outpatient clinics, EMS departments and schools in the greater Philadelphia area on improving pediatric emergency care. The ExPERT team enables coordinated efforts at skill improvement through simulations that are as realistic as possible. “This allows the nurses, doctors, respiratory techs, pharmacy, all who would care for sick kids, to simulate what to do, to know what equipment they have and what to do in an emergency,” she explains. The training is meant to augment annual training, not replace it. “The size of the hospital might influence what sort of case we do, but even experienced clinicians who see many sick children appreciate the chance to practice skills and ensure their ED is ready.”

Since 2023, CHOP’s ExPERT program has conducted nearly 100 simulation sessions with 39 different organizations (hospital, prehospital, outpatient and community) in the greater Philadelphia area. But, says Dr. Walls, any medical facility can gain instant insight into their own pediatric readiness through the National Pediatric Readiness Project online assessment found at pedsready.org. “This will allow an ED to take the survey and get an immediate score with a gap report to help address the areas most in need of improvement,” she adds. “The site also allows you to print a PDF of the survey to research your answers before submitting online.” In one example, a rural hospital was able to raise its ER pediatric readiness score by 25 points in two years.⁷ 

Cost of Care

Better equipment, better staffing and better training for treating pediatric ER patients saves critical time, improves recovery and health outcomes, and reduces the risk of disability and death (which is rare even in less-than-prepared ERs) by nearly half.¹ 

While it may seem like the cost of upgrading ER policies, procedures and staffing capabilities to maximize outcomes of pediatric patients might be prohibitive for smaller rural hospitals in particular, both the Stanford study and the Oregon and Utah studies confirm just the opposite. 

The Stanford study, which was comprised of data from 7.9 million pediatric ER visits to the nearly 750 ERs, found patients who received treatment for acute or traumatic injuries in ERs that ranked below the readiness threshold fared worse. The study authors estimated a gain of 76,800 years of life expectancy and 69,100 quality-adjusted life years for pediatric patients receiving treatment in well-prepared hospital ERs, and the impact could be greater in situations of disaster, mass casualty and pandemics.² 

The cost of these improvements? Approximately $9,300 per quality-adjusted life year gained or $244,000 per life saved. The study authors found that even improvements costing less than $50,000 per gained quality-adjusted life year were highly cost effective and advantageous. According to the Oregon and Utah university studies, adopting a universal standard of high pediatric readiness could save more than 2,100 pediatric lives, at an annual cost of around $12 or less per child.² 

“The cost of equipment is minimal compared to other hospital spending,” adds Dr. Walls, so it should not be a limiting factor in improving pediatric readiness. Improving readiness takes knowledge of what gaps need to be filled, as well as a commitment of the time, personnel and training resources necessary to connect the dots and ensure pediatric readiness is a priority.

Worth the Effort and Cost

Maximizing pediatric readiness takes a concerted effort across multiple domains. The structure of comprehensive and timely care can mean the difference between a child’s complete recovery or years of illness, disability and even death. If there is one change hospital ERs can make it is the assignment of a pediatric care coordinator to assess the current level of readiness and lead the way for continual improvements. These youngest patients need specialized care, and investment in them is worth the cost.