Article Figures & Tables
Figures
- Figure 1:
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagrams of articles identified on initial screening, updated in June 2021 and July 2022 and included in the final analysis.
- Figure 2:
Random-effects meta-analysis of the association between in-hospital mortality and weighted pediatric readiness score. Note: CI = confidence interval, IV = inverse variance, SE = standard error.
Tables
Publication, country Study design Study period Type of centre, N Study objective Volume of ED No. of participants Mean age (range), yr Ames et al., (9) 2019, United States Retrospective cohort Data collection: Jan. 1 to Aug. 31, 2013 ED, 426 To determine the proportion of patients presenting to EDs with various levels of pediatric readiness and to evaluate if ED pediatric readiness is associated with mortality No. of ED centres, annual pediatric ED volume
n = 153, Low (< 1800) visits
n = 113, Medium (1800–4999) visits
n = 69, Medium-to-high (5000–9999) visits
n = 91, High (> 10000) visits20 483 Mean = 8 (0–18) Ray et al., (18) 2018, United States Cross-sectional Data collection: Jan. 1 to Aug. 23, 2013 ED, 4090 To determine the geographic accessibility of EDs with high pediatric readiness by assessing the percentage of US children living within a 30-minute drive time of an ED with high pediatric readiness No. of ED centres, ED volume
n = 739, Low (< 4999) visits
n = 490, Medium (5000–9999) visits
n = 2861, High (> 10000) visitsNA Mean = NA (0–17) Newgard et al., (19) 2021, United States Retrospective cohort Data collection: Jan. 1, 2012, to Dec. 31, 2017 ED, 832 To evaluate the association between ED pediatric readiness, in-hospital mortality, and in-hospital complications among injured children presenting to US trauma centres No. of ED centres, annual pediatric ED volume
n = 160, Low (1–4900) visits
n = 86, Medium (4900–8400) visits
n = 105, Medium-to-high (8400–13800) visits
n = 186, High (> 13 800) visits
n = 295, Unknown visits372 004 Mean = NA
Median = 10 (4–15)Lieng et al., (20) 2021a, United States Cross-sectional Data collection: Jan. 1, 2011, to Dec. 31, 2013 ED, 283 To determine the association between potentially avoidable transfers (PATs) and ED pediatric readiness scores and the score’s associated components No. of ED centres, ED volume: median (IQR)
n = 275, 6820 (3148–11042)
n = 269, 6876 (3167–11 046)25 601 Mean = NA (0–18) Lieng et al., (21) 2021b, United States Cross-sectional Data collection: 2011 to 2012 ED, 54 To determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of noninjured children (< 18 yr) presenting to EDs in small rural hospitals in the state of California No. of ED centres, ED volume by WPRS: median (IQR)
n = 44, WPRS (≤ 70): 2194 (1350–4412) visits
n = 10, WPRS (> 70): 2696 (1618–4694) visits135 388 Mean = NA (0–18) Newgard et al., (22) 2022, United States Retrospective cohort Data collection: Jan. 1, 2012, to Dec. 31, 2017, with follow-up to December 2018 ED, 146 To evaluate the association between ED pediatric readiness and 1-year survival among injured children presenting to 146 trauma centres No. of ED centres, annual pediatric ED volume
n = 37, Low (101–5699) visits
n = 36, Medium (5700–12 199) visits
n = 36, Medium-to-high (12200–19999) visits
n = 37, High (> 20000) visits88 071 Mean = NA
Median = 11 (0–17)Newgard et al., (23) 2023, United States Cross-sectional Data collection: Jan. 1, 2012, to Dec. 31, 2019 ED, 2261 To quantify the number of children transported by 911 emergency medical services to high readiness EDs, additional children within 30 min of a high-readiness ED, and the estimated effect on survival No. of ED centres, annual ED volume by WPRS: median (IQR)
n = 583, WPRS (22–57): 11 751 (4399–27 586) visits
n = 559, WPRS (58–70): 18 937 (7537–36 631) visits
n = 570, WPRS (71–85): 21757 (9968–47 400) visits
n = 549, WPRS (86–100): 45 633 (23 818–77 415) visits808 536 Mean = NA
Median = 10 (0–17)Balmaks et al., (24) 2020, Latvia Prospective cohort Data collection: June 1, 2017, to May 31, 2018
Recruitment: Sept. 24, 2017, to Apr. 26, 2018ED, 16 To assess the quality of pediatric acute care and pediatric readiness and determine their association with patient outcomes using a patient registry No. of ED centres, annual ED volume: median (IQR)
n = 5, Low (< 1800) visits: 1238 (809–11916)
n = 6, Medium (1800–4999) visits: 2746 (1965–3000)
n = 4, Medium-to-high (5000–9999) visits: 7703 (5572–7160)
n = 1, High (> 10000) visits: 63905254 Mean = NA
Median = 5 (1–13)Note: ED = emergency department, IQR = interquartile range, NA = not available, WPRS = weighted pediatric readiness score.
Publication Intervention v. comparator Primary outcome Primary outcome effect estimate Primary outcome results (unadjusted) Variables used to adjust primary outcome Primary outcome results (adjusted) Conclusion Ames et al., (9) 2019 High WPRS v. low WPRS Mortality OR NA Age, chronic complex conditions, and severity of illness WPRS associated with presenting hospital and in-hospital mortality in quartiles, OR (95% CI), p value:
Q1 (WPRS 30–59): 1.00 (ref.)
Q2 (WPRS 59–75): 0.52 (0.30–0.90), p = 0.018
Q3 (WPRS 75–88): 0.36 (0.22–0.58), p < 0.001
Q4 (WPRS 88–100): 0.25 (0.18–0.35), p < 0.001This study showed that critically ill children presenting to hospitals with a high pediatric readiness score is associated with decreased mortality. Efforts to increase ED readiness for pediatric emergencies may improve patient outcomes. Newgard et al., (19) 2021 High WPRS v. low WPRS Mortality OR ED pediatric readiness score association with in-hospital mortality, OR (95% CI), p value:
Non-transfer patients (n = 317005)
Q1 (least ready): ref., p = 0.077
Q2: 1.34 (0.97–1.86)
Q3: 1.01 (0.74–1.36)
Q4 (most ready): 0.69 (0.51–0.92)
Transferred patients (n = 54999)
Q1 (least ready): ref., p = 0.033
Q2: 0.99 (0.65–1.49)
Q3: 0.84 (0.58–1.22)
Q4 (most ready): 0.59 (0.39–0.90)Demographic characteristics (age, sex, race), comorbidities, initial physiology (age-adjusted hypotension), emergent airway intervention, mechanism of injury, ISS, transfer status, blood transfusion, nonorthopedic surgery, orthopedic surgery, and geographic region WPRS associated with in-hospital mortality, OR (95% CI):
Q1 (WPRS 32–69): 1.00 (ref.)
Q2 (WPRS 70–87): 1.16 (0.87–1.54)
Q3 (WPRS 88–94): 0.90 (0.70–1.17)
Q4 (WPRS 95–100): 0.58 (0.45–0.75)In this cohort study, injured children treated in high-readiness EDs had lower mortality compared with similar children in low-readiness EDs, but not fewer complications. These findings support national efforts to increase ED pediatric readiness in US trauma centres that care for children. Newgard et al., (22) 2022 High WPRS v. low WPRS Mortality OR NA Demographic characteristics (age, sex, race), comorbidities, age-adjusted hypotension, emergent airway intervention, blood transfusion, mechanism, ISS, interhospital transfer, and year of visit WPRS associated with in-hospital mortality comparing the highest v. lowest quartiles of ED pediatric readiness, OR (95% CI):
Q1 (WPRS 32–69): 1.00 (ref.)
Q2 (WPRS 70–87): NA
Q3 (WPRS 88–94): NA
Q4 (WPRS 95–100): 0.61 (0.42–0.89)This study showed that children treated in high-readiness trauma centre EDs after injury had a lower risk of death that persisted to 1 year. These findings further support the importance of ED pediatric readiness and the imperative for US trauma centres to meet the high level of ED readiness required to reduce pediatric mortality after injury. Balmaks et al., (24) 2020 High WPRS v. low WPRS Mortality OR NA Nesting of patients in each ED, and patient demographics 1-point increase in WPRS is associated with 6-mo mortality, OR (95% CI), p value:
OR = 0.93 (0.88–0.98), p = 0.011
(re-scaled into OR of 0.93^17 = 0.29 for an increase of 1 interquartile range, which equals 0.87 at the highest quartile)This study nationally assessed that pediatric readiness in EDs, in Latvia was associated with shorter ICU length of stay, shorter hospital length of stay and lower 6-mo mortality. Note: CI = confidence interval, ED = emergency department, ISS = Injury Severity Score, NA = not available, OR = odds ratio, Q = quartile, Ref. = reference, SD = standard deviation, WPRS = weighted pediatric readiness score.
Publication Intervention v. comparator Secondary outcome Secondary outcome effect estimate Secondary outcome results (unadjusted) Variables used to adjust secondary outcome Secondary outcome results (adjusted) Conclusion Ray et al., (18) 2018 High WPRS v. no WPRS Access to EDs within a 30-min drive Percentage NA ED characteristics (pediatric ED, trauma centre level, total volume, triage system)
Hospital characteristics (bed size, inpatient pediatric ward, pediatric ICU, neonatal ICU, pediatric cardiology, CT scanner, MRI)
Accreditations (The Joint Commission, Accreditation Council for Graduate Medical Education)
Geographic characteristics (rural/urban status, state)National proportion of pediatric population (%) within 30-min drive to ED with: WPRS ≥ 83.6 (at 75th percentile) = 70.20
WPRS ≥ 94.3 (at 90th percentile) = 55.30
WPRS 100 = 33.70 No WPRS specified threshold = 93.70This study nationally quantified geographic access to EDs, in the US, with high pediatric readiness for children, and indicated major gaps in access are due to the lack of an ED with high pediatric readiness. One in 3 children can reach an ED with a max WPRS score. 90.9% of children lived closer to at least 1 alternative ED with a WPRS below the maximum. Lieng et al., (20) 2021a High WPRS v. low WPRS Potentially avoidable transfers (PATs) OR 10-point increase in WPRS associated with PATs, OR (95% CI):
Injured children PATs: OR 0.93 (0.90–0.96)
Noninjured children PATs: OR 0.90 (0.88–0.93)Patient demographics, injury/illness severity, complex chronic condition, pediatric volume, trauma centre designation, pediatric admitting capability 10-point increase in WPRS associated with PATs, OR (95% CI):
Injured children PATs: OR 0.92 (0.86–0.98)
Noninjured children PATs: OR 0.94 (0.88–1.00)Hospital ED pediatric readiness is associated with lower odds of a PAT. Having a nurse pediatric emergency care coordinator and a quality improvement plan are modifiable risk factors that EDs may target to reduce PATs. Lieng et al., (21) 2021b High WPRS v. low WPRS Interfacility transfer OR High pediatric readiness score > 70 associated with inter-facility transfers, OR (95% CI), p value: OR 0.64 (0.55 to 0.74), p < 0.01 Patient demographics, insurance, severity of illness, complex chronic condition, pediatric inpatient capabilities, pediatric volume, proportion Medicaid, index hospital-level High pediatric readiness score > 70 associated with interfacility transfers, OR (95% CI), p value: OR 0.55 (0.33–0.93), p < 0.05 Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Newgard et al., (23) 2023 High WPRS v. low WPRS Proportion of high-risk children transported by ambulances to EDs within a 30-min drive Percentage NA Day, time, and traffic High-risk children transported to EDs, n (%), by WPRS:
Q1 (WPRS 22–57): 26 757 (10.55)
Q2 (WPRS 58–70): 39 908 (15.74)
Q3 (WPRS 71–85): 50 336 (19.85)
Q4 (WPRS 86–100): 136 540 (53.85)
High-risk children transported to lower WPRS EDs but within 30-min to high WPRS EDs, n (%): 58 981 (23.26)Approximately half of children transported by emergency medical services were taken to high-readiness EDs and an additional one quarter could have been transported to such an ED, with a measurable effect on survival. Balmaks et al., (24) 2020 High WPRS v. Low WPRS Patient length of stay Regression (β) coefficient WPRS associated with PICU length of stay and hospital length of stay, β (95% CI), p value:
PICU length of stay (d): β −0.01 (−0.02 to 0.01), p = 0.41
Hospital length of stay (d): β −0.03 (−0.15 to 0.09), p = 0.61Nesting of patients in each ED, and patient demographics WPRS associated with PICU length of stay, hospital length of stay, β (95% CI), p value:
PICU length of stay (days): β −0.06 (−0.10 to −0.01), p = 0.02
Hospital length of stay (days): β −0.36 (−0.61 to −0.10), p = 0.01This study nationally assessed that pediatric readiness in the ED was associated with shorter ICU length of stay, shorter hospital length of stay, and lower 6-mo mortality. Note: CI = confidence interval, CT = computed tomography, ED = emergency department, ICU = intensive care unit, MRI = magnetic resonance imaging, NA = not available, OR = odds ratio, PAT = potentially avoidable transfers, PICU = pediatric intensive care unit, Q = quartile, SD = standard deviation, WPRS = weighted pediatric readiness score.
Patient or population: Mortality
Setting: Emergency departments
Intervention: High WPRS
Comparison: Low WPRSOutcome Anticipated absolute effect* (95% CI) Relative effect (95% CI) No. of participants Certainty of the evidence (GRADE)† Risk with low WPRS Risk with high WPRS Mortality 1000 per 1000 450 per 1000 (260–780) RR 0.45 (0.26–0.78) 480 558 ⊕⊕øø‡
Low§,¶,**,††Note: CI = confidence interval; GRADE = Grading of Recommendations Assessment, Development and Evaluation; RR = risk ratio; WPRS = weighted pediatric readiness score.
↵* The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
↵† GRADE Working Group grades of evidence. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
↵‡ Commonly used symbols to describe certainty in evidence in evidence profiles: high certainty ⊕⊕⊕⊕, moderate certainty ⊕⊕⊕ø, low certainty ⊕⊕øø and very low certainty ⊕øøø.
↵§ We downgraded by 1 level for risk of bias. The contributing studies were all high.
↵¶ We downgraded by 1 level for inconsistency. There was considerable heterogeneity (I2 = 89%) and variation in point estimates.
↵** We upgraded by 1 level for large effect. The pooled odds ratio was less than 0.5.
↵†† We upgraded by 1 level for dose response gradient. We observed a change in odds ratio for every increase in WPRS.
- Table 5:
Summary of findings, high WPRS compared with low WPRS in health care outcomes and utilization
Patient or population: Health care outcomes and utilization
Setting: Emergency departments
Intervention: High WPRS
Comparison: Low WPRSOutcome Impact No. of participants Certainty of the evidence (GRADE)* Length of stay assessed with: days Pediatric readiness in the ED was associated with shorter ICU length of stay, shorter hospital length of stay, and lower 6-month mortality. 254 ⊕⊕øø†
Low‡,§,¶Access to an ED within a 30-min drive 1 in 3 children can reach an ED with a WPRS score of 100. 90.9% of children lived closer to at least 1 alternative ED with a WPRS below the maximum. NA ⊕⊕øø†
Low‡,§,¶Proportion of high-risk children transported by ambulances to EDs within a 30-min drive Approximately 50% of children transported by emergency medical services were taken to high WPRS EDs and an additional 25% could have been transported to such an ED, with a measurable effect on survival. 808 536 ⊕⊕øø†
Low‡,§,¶Interfacility transfer Pediatric patients presenting to EDs at small rural hospitals with high WPRS may be less likely to be transferred. 135 388 ⊕⊕øø†
Low‡,§,¶Potentially avoidable transfers High WPRS of EDs is associated with lower odds of a potentially avoidable transfers. 25 601 ⊕⊕øø†
Low‡,§,¶Note: ED = emergency department; GRADE = Grading of Recommendations Assessment, Development and Evaluation; ICU = intensive care unit; NA = not applicable.
↵* GRADE Working Group grades of evidence. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
↵† Commonly used symbols to describe certainty in evidence in evidence profiles: high certainty ⊕⊕⊕⊕, moderate certainty ⊕⊕⊕ø, low certainty ⊕⊕øø and very low certainty ⊕øøø.
↵‡ We downgraded by 1 level for risk of bias. The contributing study was high.
↵§ We upgraded by 1 level for plausible confounding. There are residual confounders in the estimate.
↵¶ We upgraded by 1 level for dose response gradient. We observed a change in the point estimate for every increase in WPRS.
Publication Study design Selection* Comparability† Assessment‡ Follow-up§ Statistical¶ 1 2 3 4 5 6 7 8 9 Ames et al., (9) 2019 Retrospective cohort Low risk Low risk Low risk High risk Low risk Low risk Low risk Low risk NA Ray et al., (18) 2018 Cross-sectional Low risk Low risk Low risk High risk Low risk Low risk NA NA Low risk Newgard et al., (19) 2021 Retrospective cohort Low risk Low risk Low risk High risk Low risk Low risk Low risk Low risk NA Lieng et al., (20) 2021a Cross-sectional Low risk Low risk Low risk High risk Low risk Low risk NA NA Low risk Lieng et al., 2021b (21) Cross-sectional Low risk Low risk Low risk High risk Low risk Low risk NA NA Low risk Newgard et al., (22) 2022a Retrospective cohort Low risk Low risk Low risk High risk Low risk Low risk Low risk Low risk NA Newgard et al., (23) 2023 Cross-sectional Low risk Low risk Low risk High risk Low risk Low risk NA NA Low risk Balmaks et al., (24) 2020 Prospective cohort Low risk Low risk Low risk High risk Low risk Low risk Low risk Low risk NA Note: NA = not applicable.
↵* Selection: 1. Representativeness of the exposed sample (selection bias); 2. Selection of the non-exposed sample (selection bias); 3. Ascertainment of exposure (selection bias); 4. Demonstration that outcome of interest was not present at start of study (selection bias).
↵† Comparability: 5. Comparability of samples on the basis of the design or analysis (comparability bias).
↵‡ Assessment: 6. Assessment of outcome (assessment bias).
↵§ Follow-up: 7. Was follow-up long enough for outcomes to occur (follow-up bias); 8. Adequacy of follow-up of cohorts (follow-up bias).
↵¶ Statistical: 9. Statistical test (statistical bias).
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