More data on how fewer and fewer hospitals are able to provide definitive care for children. Why?

There are 30 million visits a year to America’s emergency departments by children. Most of these are to community hospitals rather than specialized children’s hospitals. A couple of months ago I wrote about what has been a steady trend in pediatric care — community hospitals are transferring an increasingly number of children who come to their emergency departments to other facilities for definitive care of their problems. At first glance one might ask if this could actually be a good thing. After all, isn’t a higher level of capability better for sick children? But it looks to me more as if they just don’t want to provide definitive pediatric care, even for fairly routine things. It seems highly unlikely that sicker and sicker kids are appearing in emergency departments. Now further data is available from a new study from the same research group that confirms this trend and extends its implications.

The first study looked at the past decade across America and identified those facilities that had moved up in their ability to provide definitive inpatient care to children and compared that to the number that had, for whatever reason, downgraded their capacity to care for hospitalized children. This is well shown in this graph:

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The newer study has the advantage of studying three very common conditions that bring children to the emergency department: asthma, croup, and gastroenteritis. Critically ill children were excluded; the authors looked at what are bread-and-butter issues for any emergency department that sees children. They found significant increases in referrals out for all three conditions. Bear and mind these weren’t necessarily children who even needed to be admitted to the hospital. It’s not uncommon at all for them to be sent to another emergency department, evaluated and treated, and then sent home. That’s quite concerning.

For critically ill patients and some specialized conditions, there are clear benefits to transfer, which have informed national recommendations from the American Academy of Pediatrics for implementing regionalized emergency medical services. However, it is uncertain which children with lower-acuity conditions benefit from transfer to pediatric tertiary care hospitals. The majority of pediatric patients transferred between EDs are transferred for common conditions, and as many as one-third of children transferred are discharged from the hospital without requiring further intervention or subspecialty consultation.

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The facilities are ranked from those who see less children (lowest) up to pediatric hospitals. Not surprisingly the rate of referral was highest in the facilities that cared for smaller numbers of children, but there were increases in all of them except for specialized children’s hospitals. What’s going on here? Should we be concerned about it? I’m concerned because, although serious and severe cases should not be cared for in facilities with limited pediatric experience, these three common conditions should be within the expertise of emergency department physicians, pediatricians, and family practitioners, particularly since these days it’s easy for physicians in smaller facilities to call larger ones for advice — I get such calls all the time, as do my pediatric hospitalist colleagues.

Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions. . . . These findings provide further evidence of pediatric care regionalization occurring even for common conditions that do not routinely require specialty care.

This can be very hard on families. Being bounced from one facility to another for a common condition, especially if you are then sent home from the second facility, is traumatic and wasteful. I work in a regional facility and my colleagues in the emergency department not uncommonly see a child sent from a facility on hour or more drive away, only to be sent home. I suspect a major reason for this, as usual, is money. Children typically don’t require all the profit-generating tests and procedures adults do. But they do require that emergency department providers be competent in providing care of children. Clearly more and more facilities have decided it’s not worth the cost to provide this. I also think more than a few hospitals are trying to offload this cost under the guise of securing better care for children.

These articles may be behind paywalls except for the abstracts. If anybody is interested, contact me on the contact form on my homepage and I’ll send you the full articles.