Highlight
1. Most emergency departments (EDs) see very few critically ill pediatric patients annually.
2. Nearly one-third of EDs had at least one year without any pediatric critical illness encounters.
3. A minority of critically ill children treated at low-volume EDs were located within a 15-minute drive of a high-volume ED.
4. Direct transport to high-volume centers is unlikely to be a universal strategy to optimize care for critically ill children.
Study Background
Critically ill children requiring emergency care represent a vulnerable population whose outcomes depend on timely and appropriate interventions. Emergency departments vary widely in pediatric patient volume and the frequency with which they manage critical illness. Concentrating care in high-volume centers can potentially improve expertise and outcomes; however, geographic and logistic constraints may limit the feasibility of diverting patients to such centers. Understanding the distribution of pediatric critical illness cases across EDs and the proximity of low-volume centers to high-volume EDs is essential to inform regionalized care strategies and optimize clinical pathways.
Study Design
This retrospective cohort study utilized the Healthcare Cost and Utilization Project (HCUP) State Emergency Department and Inpatient Databases from five states covering 2018 to 2022. Pediatric critical illness was defined by clinically significant endpoints including death, cardiopulmonary resuscitation (CPR), endotracheal intubation in the ED or within hospital days 0 or 1, or billing for ED critical care time, which are robust markers of severe illness. ED volume with respect to pediatric critical illness was calculated annually per ED and categorized into low- or high-volume based on the 75th percentile cutoff for each state and year. Geographic analyses assessed how many critically ill children treated at low-volume EDs were within a 15-minute drive of a high-volume ED, informing potential transport or referral options.
Key Findings
The analysis included 14,313,896 pediatric ED visits across 569 EDs, identifying 40,483 encounters (0.3%) involving pediatric critical illness. The median ED volume of pediatric visits was 1,932 per year (interquartile range [IQR], 680 to 5,068), with a median of 5 critical illness cases per year (IQR 1 to 14), underscoring the rarity with which these cases present to most emergency departments.
Notably, 181 (31.8%) EDs experienced at least one calendar year without any pediatric critical illness cases, indicating substantial variability and infrequency in exposure among many centers. Furthermore, 1,557 (16.8%) of critically ill pediatric patients managed in low-volume EDs were located within a 15-minute driving radius of a high-volume ED. Thus, although a subset of cases might be candidates for direct transport to higher volume centers, the majority were not geographically positioned to facilitate such diversion.
These findings highlight that despite the potential benefits of centralized care for critically ill children, most emergency departments maintain only limited experience due to low case volumes, and only a minority of critical cases treated at low-volume EDs could realistically be redirected given geographic considerations.
Expert Commentary
The study by Joseph et al. addresses an important gap in pediatric emergency care by quantifying the distribution of critical illness cases and the practical feasibility of regionalization strategies based on ED volume and proximity. The heterogeneity in pediatric critical illness exposure among EDs presents a challenge for maintaining provider expertise and quality standards universally.
While concentrating care in high-volume EDs may improve outcomes by leveraging specialized resources and clinical experience, this study underscores that geographic and systemic constraints will limit universal implementation. Transport decisions must balance the urgency of stabilizing critically ill children with the benefits of specialized care, considering transport time, resource availability, and patient stability.
Limitations include the use of administrative data which may under- or overestimate critical illness incidence due to coding variability. Moreover, the 15-minute drive radius, while clinically reasonable, may not capture all practical transport considerations such as traffic or EMS resources. Future research should explore outcomes related to direct transport versus stabilization at lower volume centers and integrate other factors such as telemedicine support and regional resource distribution.
Conclusion
This comprehensive multicenter analysis demonstrates that care for critically ill children is infrequent in most EDs and that only a minority of such encounters at low-volume centers occur close enough to high-volume EDs to facilitate diversion. These findings challenge simplistic models of directing all critically ill pediatric patients to high-volume EDs and suggest that multifaceted regionalized care strategies, including enhancing capabilities of low-volume EDs and optimizing transport protocols, will be necessary to ensure optimal access and quality for pediatric critical illness.
Funding and Clinical Trials
The study by Joseph et al. did not specify funding sources or clinical trial registration information in the abstract. Further details would be accessible via the full publication or through corresponding author disclosures.
References
1. Joseph AM, Michelson KA, Dewan ML, Lipstein EA, Babcock L, Davis BS, Kahn JM. Variation in Emergency Department Experience With Pediatric Critical Illness. Ann Emerg Med. 2026 Jul 2. PMID: 42390397.
2. Kahn JM, et al. Regionalization of Critical Care for Pediatric Patients: Challenges and Opportunities. Crit Care Med. 2014;42(11):2587-2594.
3. Pollack MM, et al. Pediatric critical illness: Epidemiology and outcomes. Pediatr Clin North Am. 2017;64(5):853-866.
