The Changing Landscape of Pediatric Emergency Care

Naomi Hughes, MD, and Cynthia Jacobstein, MD, MSCE

The needs of pediatric patients in emergency care have been recognized since the 1980s when fellowship programs were developed to focus on care of the acutely injured and critically ill child. In 1991, the American Boards of Pediatrics and Emergency Medicine formally recognized pediatric emergency medicine as a subspecialty. The idea of specialized care for children started much earlier, with Hôpital Necker-Enfants Malades in Paris, France, founded in 1801. This hospital was focused on the study of pediatric disease, development, and nutrition with many firsts, including the invention of the stethoscope by 1816 by Laennec. In 1852, England followed with the Great Ormond Street Hospital for Children, and in 1855, Drs Francis West Lewis, Thomas Hewson Bache, and R.A.F Penrose opened Children’s Hospital of Philadelphia—our nation’s first pediatric hospital.

Today, there are more than 220 children’s hospitals in 9 countries that are part of the Children’s Hospital Association, which ensures that they meet the specific health needs of children, including appropriate equipment sizes and medication dosing, healthcare teams that are specialized in providing child-centered care with child life specialists, physical therapists, radiology technicians, and more.

Only 17% of children go to pediatric EDs

Still, 83% of children seeking emergency care in the United States are treated in community hospitals, which vary in their readiness to care for pediatric patients. The 2006 Institute of Medicine Report, “Emergency Care for Children: Growing Pains,” described the quality of care provided for pediatric patients in general EDs compared with pediatric EDs as uneven. Federal funding and advocacy for improving pediatric care in all emergency departments has resulted in improvements in pediatric readiness in general emergency departments, from a readiness score of 55 to 69 between 2003 and 2013. Pediatric readiness relates to having appropriate equipment, oversight, medications, and bare necessities to care for a pediatric emergency. Although quality of care provided to children in general emergency departments has been improving over the last several decades, there is still work to be done.

Urgent care centers are also an option for families seeking acute medical care for their children. They often provide a more efficient model of care with a lower copay. Urgent care centers can evaluate a patient and most often treat and discharge, but they can also triage the patient to identify when a more extensive workup or management is required in an Emergency Department. However, urgent care centers also vary in the level of pediatric expertise and supplies available as well as the degree of child-centric care provided.

As advocates for improved emergency care for children everywhere, Children’s Hospital of Philadelphia has ongoing relationships with the many community hospitals in the tri-state area that refer patients to our system for care. We are educating emergency medicine residents from many of the region’s training programs and providing updates and follow-up to emergency providers who refer patients for care in our system. CHOP also has a well-established pediatric emergency department at Virtua Voorhees, where our board-certified Pediatric Emergency Medicine physicians provide high-quality pediatric emergency care in a general community hospital with an adjacent adult emergency department.

CHOP’s newest venture is the Middleman Family Pavilion at Children’s Hospital of Philadelphia, King of Prussia, our second hospital, which opened in January 2022. This is a model that has been established in a few other areas of the country, where a major academic children’s hospital creates an associated smaller pediatric hospital that provides pediatric-centered care in a smaller setting, creating convenient access to pediatric care to families in a broader geographic area. The Madlyn K. Abramson ED in King of Prussia, with 20 beds and 2 resuscitation bays, is located adjacent to CHOP’s After-hours Urgent Care in the same building. The Middleman Family Pavilion, with its 80 single inpatient rooms, also has critical care and surgical services, so many patients will be able to get definitive care there. When more complex, specialized care is required, CHOP will provide an easy transition to our larger tertiary care site on the Philadelphia Campus via our skilled emergency transport team.

This new model of providing pediatric emergency care in a smaller children’s hospital is another step toward providing more access to child-centered, high-quality healthcare to the children who need it.

References and suggested readings

Chamberlain JM, Krug S, Shaw KN. Emergency care for children in the United States. Health Aff (Millwood). 2013;32(12):2109-2115.

Casimir G. Why children’s hospitals are unique and so essential. Front Pediatr. 2019;7:305.

Bell M. Images of America: The Children’s Hospital of Philadelphia. Charleston, South Carolina: Arcadia Publishing. 2015.

About Children’s Hospitals. Children’s Hospital Association website. https://www.childrenshospitals.org/About-Us/About-Childrens- Hospitals. Accessed December 7, 2021.

Gausche-Hill M. Emergency and definitive care for children in the United States: the perfect storm. Pediatrics. 2020;145(1):e20193372.

Institute of Medicine of the National Academies. Emergency care for children: growing pains. Washington DC: National Academy Press; 2006.

Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments [published correction appears in JAMA Pediatr. 2015 Aug;169(8):791]. JAMA Pediatr. 2015;169(6):527-534.