Variation in Emergency Department Experience With Pediatric Critical Illness

STUDY OBJECTIVE: We sought to describe variation in emergency department (ED) volume of pediatric critical illness encounters, and to assess the geographic proximity of encounters at low-volume EDs relative to high-volume EDs. METHODS: We conducted a retrospective cohort study of the Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases for 5 states from 2018 to 2022. Critical illness was defined as death, cardiopulmonary resuscitation, or endotracheal intubation in the ED or on hospital day 0 or 1 or ED critical care time billing. We calculated the ED-level incidence of critical illness and dichotomized EDs into low- or high-volume at the 75th percentile of volume for each state and year. We determined how many encounters at low-volume EDs occurred within a 15-minute drive of a high-volume ED. RESULTS: Of 14,313,896 pediatric ED encounters across 569 EDs, 40,483 (0.3%) were critical. The median ED managed 1,932 pediatric visits each year (interquartile range [IQR] 680 to 5,068) and 5 (IQR 1 to 14) with critical illness. We identified 181 (31.8%) EDs with a calendar year with no pediatric critical illness. We found 1,557 (16.8%) critically ill children were managed in low-volume EDs within a 15-minute drive of a high-volume ED. CONCLUSION: Most EDs infrequently care for critically ill children, and a minority of these encounters could be realistically diverted to high-volume EDs. Direct transport to high-volume centers is unlikely to be a universal strategy for ensuring access to high-quality emergency care for critically ill children.