Digging deeper into NYTimes story on preventable pediatric deaths

Sometimes the headline of an article is enough to grab your attention and have you sit down and read the article. Such was the case with The New York Times article titled "1 in 4 Child Deaths After E.R. Visits Are Preventable." Is this statement accurate and in what sense?

The article begins with the story of Rebecca, a newborn who died due to a misdiagnosed viral infection after multiple ER visits:

“But during multiple visits to the emergency room, doctors told Ms. Rabinowitz that Rebecca had a common cold and sent them home. At nine days old, Rebecca died; her parents learned from an autopsy that the cause was a viral infection that could have been managed had she been admitted.”

Well that sounds like medical malpractice with the doctors being poorly trained to administer the proper care to a vulnerable newborn. Is this an isolated incident or a more general feature of the medical system that could do more to prevent pediatric deaths?

The New York Times piece highlighted a recent study in the medical journal JAMA that attempted to address this question. The researchers focused on the concept of Emergency Department (ED) pediatric readiness. Loosely speaking it refers to the ability of an ED to handle potentially life-threatening cases of children who come to the emergency room. Annually, 7619 children (1.1%) die during acute care visits (including deaths in EDs and inpatient settings). The hypothesis was that a disproportionate number occur in less pediatric-ready EDs.

ED pediatric readiness was measured based on a questionnaire resulting in a weighted Pediatric Readiness Score (wPRS) between 0 and 100 with. Readiness categories included specialized equipment, training, personnel, protocols, and supplies for pediatric patients. For example, child-specific equipment and training on youth-specific care, such as optimal pediatric vital signs and resuscitation techniques were part of the evaluation. Only 17.4% of EDs (842 out of 4840) had high pediatric readiness (wPRS ≥ 88) with a median wPRS of 69. 

Readiness varied widely from state to state with Arkansas possessing the lowest readiness (2.9% of EDs), whereas Delaware scored the best with 100% of EDs meeting high readiness criteria. One clear trend was the difference between rural and urban EDs. Many rural areas have become “deserts” for specialized pediatric care, with readiness scores decreasing from 2013 to 2021. Pediatric care is increasingly concentrated in large urban hospitals, making access to pediatric-ready ERs difficult for rural families. The ED pictured below (Figure 1) most likely is from a rural area.

Patient data were collected from 2012 to 2022, encompassing EDs across all 50 US states and the District of Columbia and included “children aged 0 to 17 years receiving emergency services and requiring hospitalization, transferred for hospitalization to a different hospital, or who died in the ED (collectively termed at-risk children).” Annually, an estimated 669,019 at-risk children received emergency services in 4840 EDs across the US.

The researchers examined pediatric deaths as a function of pediatric readiness and pediatric volume (number of patients) at each hospital. From these statistics, they could plot the correlation between deaths and readiness. Indeed according to experts, "[c]ritically ill children are four times as likely to die in hospitals and twice as likely to die in trauma centers that score low in “pediatric readiness."

Moreover, the authors investigated how many lives could potentially be saved by raising every ED to high pediatric readiness, i.e. wPRS ≥ 88. They found that of the 7619 pediatric deaths after ED presentation each year, 28.1% (2143 lives) could be prevented with universal high readiness. This is rationale of the statement that "1 in 4 Child Deaths After E.R. Visits Are Preventable."

The cost of bringing all ERs in the U.S. up to this high standard of pediatric readiness was projected to be $207 million annually. It is not a small sum but it amounts to about $100,000 per life saved.

The authors conclude:

"In this cohort study, raising all EDs to high pediatric readiness was estimated to prevent more than one-quarter of deaths among children receiving emergency services, with modest financial investment. State and national policies that raise ED pediatric readiness may save thousands of children’s lives each year."

Figure 1. A presumably low pediatric readiness emergency department (ED) most likely in a rural area (Hiroko Masuike/The New York Times)