Changes in Emergency Department Pediatric Readiness and Mortality.

Importance: High emergency department (ED) pediatric readiness is associated with improved survival, but the impact of changes to ED readiness is unknown. Objective: To evaluate the association of changes in ED pediatric readiness at US trauma centers between 2013 and 2021 with pediatric mortality. Design, Setting, and Participants: This retrospective cohort study was performed from January 1, 2012, through December 31, 2021, at EDs of trauma centers in 48 states and the District of Columbia. Participants included injured children younger than 18 years with admission or injury-related death at a participating trauma center, including transfers to other trauma centers. Data analysis was performed from May 2023 to January 2024. Exposure: Change in ED pediatric readiness, measured using the weighted Pediatric Readiness Score (wPRS, range 0-100, with higher scores denoting greater readiness) from national assessments in 2013 and 2021. Change groups included high-high (wPRS ≥93 on both assessments), low-high (wPRS <93 in 2013 and wPRS ≥93 in 2021), high-low (wPRS ≥93 in 2013 and wPRS <93 in 2021), and low-low (wPRS <93 on both assessments). Main Outcomes and Measures: The primary outcome was lives saved vs lost, according to ED and in-hospital mortality. The risk-adjusted association between changes in ED readiness and mortality was evaluated using a hierarchical, mixed-effects logistic regression model based on a standardized risk-adjustment model for trauma, with a random slope-random intercept to account for clustering by the initial ED. Results: The primary sample included 467 932 children (300 024 boys [64.1%]; median [IQR] age, 10 [4 to 15] years; median [IQR] Injury Severity Score, 4 [4 to 15]) at 417 trauma centers. Observed mortality by ED readiness change group was 3838 deaths of 144 136 children (2.7%) in the low-low ED group, 1804 deaths of 103 767 children (1.7%) in the high-low ED group, 1288 deaths of 64 544 children (2.0%) in the low-high ED group, and 2614 deaths of 155 485 children (1.7%) in the high-high ED group. After risk adjustment, high-readiness EDs (persistent or change to) had 643 additional lives saved (95% CI, -328 to 1599 additional lives saved). Low-readiness EDs (persistent or change to) had 729 additional preventable deaths (95% CI, -373 to 1831 preventable deaths). Secondary analysis suggested that a threshold of wPRS 90 or higher may optimize the number of lives saved. Among 716 trauma centers that took both assessments, the median (IQR) wPRS decreased from 81 (63 to 94) in 2013 to 77 (64 to 93) in 2021 because of reductions in care coordination and quality improvement. Conclusions and Relevance: Although the findings of this study of injured children in US trauma centers were not statistically significant, they suggest that trauma centers should increase their level of ED pediatric readiness to reduce mortality and increase the number of pediatric lives saved after injury.

A Geospatial Evaluation of 9-1-1 Ambulance Transports for Children and Emergency Department Pediatric Readiness.

OBJECTIVE: Whether ambulance transport patterns are optimized to match children to high-readiness emergency departments (EDs) and the resulting effect on survival are unknown. We quantified the number of children transported by 9-1-1 emergency medical services (EMS) to high-readiness EDs, additional children within 30 minutes of a high-readiness ED, and the estimated effect on survival. METHODS: This was a cross-sectional study using data from the National EMS Information System for 5,461 EMS agencies in 28 states from 1/1/2012 through 12/31/2019, matched to the 2013 National Pediatric Readiness Project assessment of ED pediatric readiness. We performed a geospatial analysis of children 0 to 17 years requiring 9-1-1 EMS transport to acute care hospitals, including day-, time-, and traffic-adjusted estimates for driving times to all EDs within 30 minutes of the scene. We categorized receiving hospitals by quartile of ED pediatric readiness using the weighted Pediatric Readiness Score (wPRS, range 0-100) and defined a high-risk subgroup of children as a proxy for admission. We used published estimates for the survival benefit of high readiness EDs to estimate the number of lives saved. RESULTS: There were 808,536 children transported by EMS, of whom 253,541 (31.4%) were high-risk. Among the 2,261 receiving hospitals, the median wPRS was 70 (IQR 57-85, range 26-100) and the median number of receiving hospitals within 30 minutes was 4 per child (IQR 2-11, range 1 to 53). Among all children, 411,685 (50.9%) were taken to EDs in the highest quartile of pediatric readiness, and 180,547 (22.3%) children transported to lower readiness EDs were within 30 minutes of a high readiness ED. Findings were similar among high-risk children. Based on high-risk children, we estimated that 3,050 pediatric lives were saved by transport to high-readiness EDs and an additional 1,719 lives could have been saved by shifting transports to high readiness EDs within 30 minutes. CONCLUSIONS: Approximately half of children transported by EMS were taken to high-readiness EDs and an additional one quarter could have been transported to such an ED, with measurable effect on survival.

Intermittent complete heart block with ventricular standstill after Pfizer COVID-19 booster vaccination: A case report.

As the COVID-19 pandemic continues around the globe, vaccines are undoubtedly central to the fight to control the spread of the virus. However, as with any therapy, these vaccines are not without side effects. Documented cardiac complications of COVID-19 vaccination include myocarditis, pericarditis, and cardiac conduction abnormalities. Here, we report a novel case of intermittent complete heart block with ventricular standstill occurring within 24 hours of administration of a Pfizer-BioNTech COVID-19 booster vaccine. The patient presented to the emergency department (ED) via ambulance for evaluation of syncope. On arrival, the patient lost pulses as a result of intermittent complete heart block with ventricular standstill. He required cardiopulmonary resuscitation (CPR) with intubation, transcutaneous pacing, and subsequent transvenous pacing in the ED. After stabilization and extensive workup, the patient was diagnosed with lymphocytic myocarditis and complete heart block that is suspected to be secondary to COVID-19 booster vaccination. Ultimately, the patient's complete heart block resolved spontaneously, and he was discharged home with ambulatory rhythm monitoring.