Pediatric Readiness and Trauma Centers: History, Relevance, and Practical Application

New optimal standards for the care of the injured patient released in 2022 by the American College of Surgeons now include a requirement for trauma centers—adult and pediatric—to assess their own pediatric readiness and take steps to address any gaps. Timely access to high-quality initial resuscitative care for injured children is essential. While the benefit of pediatric trauma centers has been demonstrated, initial post-injury care is often provided at non-pediatric centers due to limited access to this resource. The National Pediatric Readiness Project (NPRP) has outlined a framework for ensuring preparedness for pediatric emergency care in the emergency department, including pediatric trauma care. Pediatric readiness can be quantified by the weighted pediatric readiness score (wPRS). Critically ill and injured children initially treated at emergency departments with higher levels of pediatric readiness have been associated with improved mortality. While pediatric trauma centers have high levels of pediatric readiness, non-pediatric centers have been shown to have significantly lower levels of pediatric readiness—despite a large number of children gaining access to the trauma system. This manuscript is intended as a comprehensive review of the pediatric readiness project: its history, its impact on US trauma center outcomes, and its application via the use of the pediatric readiness assessment and toolkit within an individual trauma center. This review is intended to be a practical guide to ensure that every trauma hospital is ready and able to provide quality triage and initial resuscitation of an injured child in their emergency department.


Introduction
Every year, one in four children has an injury that requires urgent clinical care, and over 30% of all pediatric visits to emergency department (ED) are due to traumatic injuries [1,2].Recognizing the importance of access to high-quality initial resuscitative care for injured children, the American College of Surgeons Committee on Trauma Verification Review Subcommittee has implemented new standards for pediatric readiness at all trauma verified centers-both adult and pediatric [3••].Despite injury remaining the leading cause of death and a major contributor to functional morbidity in children, access to pediatric trauma center care remains limited [4,5].Under ideal conditions, 70% of children reside within 1 h of a pediatric trauma center (PTC) by air, but in reality, greater than 80% of injured children are initially cared for outside of a PTC [6,7].
The provision of high-quality initial care at a receiving hospital is critical, as children are most likely to die in the first hours after their injury [8].PTCs play an important role in trauma systems, having been shown to have superior mortality and solid organ salvage rates for children compared to those treated at adult trauma centers [9,10].While definitive care may be ideal at PTCs, initial resuscitation often occurs locally at adult trauma centers, community hospitals, or critical access hospitals (CAHs).Preparedness for pediatric resuscitation and timely transfer to definitive treatment require addressing all elements of pediatric readiness in the emergency room.The purpose of this review is to summarize the history of the National Pediatric Readiness Project (NPRP), outline the current status of pediatric readiness at United States (US) trauma centers and associated impact on mortality, and provide practical solutions to measure and address gaps in pediatric readiness at the local level.

Pediatric Readiness in the Emergency Department: History and Components
The NPRP is "a multi-phase quality improvement initiative to ensure that all U.S. emergency departments have the essential guidelines and resources in place to provide effective emergency care to children [11]."This longitudinal project is rooted in multiple components including the joint policy statement "Pediatric Readiness in EDs," which was initially published in 2001 [12].This statement was subsequently revised in 2009 and again updated in 2018 to include a multi-domain ED assessment to be completed by all types of hospitals [13,14].The assessment is paired with a toolkit and a community of practice to improve readiness at every hospital as well as quality improvement (QI) collaboratives supported by the Emergency Services for Children (EMSC) Innovation and Improvement Center.The NPRP has origins that date back nearly three decades, growing out of early initiatives and guideline development intended to improve ED readiness for pediatric patients.A 2003 survey of only 30% of US EDs found that most EDs had poor preparedness for children when evaluated by existing guidelines and standards [15].These gaps were highlighted in a 2006 report detailing the disparate state of readiness among US emergency departments to care for children [16].This initial survey informed the development of the subsequent NPRP national assessments that would later include actionable gap reports.The NPRP is supported by the Health Resources and Services Administration's Emergency Medical Services for Children Program in collaboration and partnership with the American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association.These national stakeholders convened a meeting to address the disparate state of preparedness and concluded: "Pediatric readiness means that an ED, most often the hospital, has the processes, staff, and equipment to treat children, including the ability to recognize when a child may need more specialized care." This stakeholder group also recognized that metrics to measure readiness were needed in order to impact change and to ensure pediatric readiness in the ED.
The first phase of the NPRP national assessment was a web-based self-report survey to be completed by all EDs in the USA as an objective tool to identify gaps and successes in implementing the national stakeholder guidelines.This 55-question web-based assessment was designed to be completed by any hospital that cares for children in the ED-regardless of volume (http:// www.pedsr eady.org).The first NPRP national assessment was administered in 2013 and the analysis and publication was completed in 2015.The survey collected information about the size, staffing, and special verifications of the hospital, as well as subsequent questions specifically related to the domains of pediatric readiness.Most of what is written and published regarding pediatric readiness is based on this 2013 assessment.Updated analyses are expected in the coming year, as a more recent national assessment was administered in 2021 and is currently in the final stages of analysis.There are seven domains of pediatric readiness in the guidelines, but the most actionable six components are addressed in the NPRP assessment and gap reports (Box 1).A modified Delphi approach was used to develop a weighted pediatric readiness score (wPRS), which is based on the six actionable domains and ranges from zero (minimal pediatric readiness) to 100 (optimal pediatric readiness) [17].While the assessment is not trauma-specific, the items included in the assessment are foundational to caring for any critically ill or injured child.
Box 1 Domains of pediatric readiness The 2013 NPRP national assessment was completed by 83% of US EDs and represented a sample of centers that provided care for 24 million pediatric ED visits annually.This 2013 assessment demonstrated improvements in pediatric readiness nationally compared to the initial 2003 survey and allowed for analysis of factors associated with higher pediatric readiness scores.This survey found that almost 70% of responding EDs had low to medium volume, with the majority treating less than fourteen children per day.Higher wPRS was independently associated with higher patient volume and the presence of a pediatric emergency care coordinator (PECC).Unfortunately, over 80% of responding EDs reported barriers to guideline implementation, such as cost of training and lack of educational resources [17].
Significant efforts have been invested in the NPRP, all targeted at improving preparedness to provide emergency care for children.The gaps identified in the 2003 and 2013 surveys led to the development of resources including the development of national quality improvement collaboratives, subsequent communities of practice, a checklist and toolkit, and, more recently, the expansion of pediatric readiness recognition programs.One of the oldest examples is the Emergency Department Approved for Pediatrics (EDAP) program in California, which designated facilities as "Peds Ready" and as having appropriate resources to serve as receiving centers for EMS agencies to triage children.As of 2022, similar statewide efforts to use the pediatric readiness assessment have been implemented in 18 states to recognize EDs with formal "pediatric ready" recognition programs.Quality improvement collaboratives are action and learning networks with infrastructures that support accelerated translation of research to close quality gaps in pediatric care [18].National QI collaboratives have been implemented, such as the National Pediatric Readiness Quality Collaborative (PRQC) and the Pediatric Emergency Care Coordinator (PECC) Workforce Development Collaborative (PWDC), the Facility Recognition Collaborative (FRC), and the National Pediatric Readiness Quality Initiative (NPRQI; www.nprqi.org)-all aiming to improve pediatric readiness and outcomes nationally.The translational impact of pediatric readiness on clinical outcomes has been demonstrated recently, with significant associations between increasing pediatric readiness and lowering in-hospital mortality among critically ill children treated at over 400 hospitals [19].

Pediatric Readiness and Trauma Outcomes
While the NPRP focuses globally on emergency care for all children in the ED, it does have a specific impact within the pediatric trauma population.Children treated in EDs with the lowest quartile of pediatric readiness have been shown to have a 1.8-fold higher risk-adjusted mortality compared with children in the highest-readiness EDs [20••].In this study, all trauma centers that responded to the 2011 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) were categorized into quartiles of readiness by their wPRS.The wPRS for high-readiness centers was 93-100 and the wPRS for the lowest quartile of trauma centers was 29-62.Similar to prior general ED studies, this study again demonstrated that hospitals with a high volume of pediatric patients were more likely to have a high wPRS.Center-level risk-adjusted mortality was evaluated over 5 years for children under 18 years of age.The study suggested that 126 children annually could potentially be saved if the children treated in the lowest quartile of readiness were instead cared for in the highest quartile of readiness EDs.This mortality benefit associated with treatment at high-readiness centers was shown to extend to long-term outcomes, for children initially cared for at a high-readiness hospital had a lower risk of death at 1 year as compared to those initially treated at centers in the lowest quartile of wPRS [21].
Unfortunately, US trauma centers have not been shown to have high levels of pediatric readiness universally.While both pediatric trauma centers and adult trauma centers with pediatric readiness recognition-such as the EDAP program-have high wPRS scores, all other trauma centers have scores (median wPRS of 69) similar to those found at community general hospitals [22••] (Fig. 1).These results suggest that adult trauma centers-those low-volume centers that are unfamiliar with resuscitation and stabilization of children-are the centers that may benefit most from targeted efforts to enhance pediatric readiness.Fortunately, pediatric readiness in the ED can be improved with focused efforts and training such as an in-person simulation-based training conducted in community hospitals [23].Simulationbased training and practice can help to uncover deficiencies that can be overcome with resources found in the pediatric readiness toolkit.
Trauma centers may have limited resources to invest in improving pediatric readiness, and as such, it is essential to identify which domains of pediatric readiness have the greatest impact on outcomes.To understand this impact of specific components of pediatric readiness on mortality, a domain-specific examination of all pediatric trauma centers was completed.An unadjusted analysis found that centers were more likely to have a lower than expected mortality if they had "a validated pediatric triage tool, comprehensive quality improvement processes, a pediatric-specific disaster plan, and critical airway and resuscitation equipment."However, on adjusted analysis, this study found that the presence of a PECC was the only factor independently associated with lower than expected mortality when controlling for other trauma center-specific characteristics [24].This amplifies the importance of identifying a PECC in a trauma center as one of the most impactful enablers to facilitating change in all other domains and in improving pediatric readiness locally.It is critical to understand, however, that the PECC must work equally to ensure everyday readiness as well as trauma-specific initiatives.The PECC serves as a link to both medical and trauma priorities.
Pediatric readiness has also been used to evaluate outcomes other than mortality and morbidity, including potentially avoidable transfers.Around 80% of injured children are initially cared for at a non-pediatric trauma center, necessitating a higher level of transfer for those who are critically injured or require higher level care [6].One emphasis of pediatric readiness is triage and timely transfer for kids that need definitive care, counterbalanced by a large number of children that are transferred to pediatric trauma centers and subsequently discharged without inpatient admission.An adjusted analysis of pediatric general medical patients found that a ten-point increase in wPRS was significantly correlated with a reduction in potentially avoidable transfers in injured children.High scores in the QI and PECC domains were significantly associated with lower rates of potentially avoidable transfers [25].Another study found that EDs with a high wPRS (> 70) had a lower odds of transfer compared to those with a lower wPRS [26].While avoiding unnecessary transfers is important, the NPRP is geared towards ensuring all hospitals are properly prepared to complete the initial triage and stabilization of children, but not necessarily prepared to provide definitive care to an injured child.While many centers with extended and high-level capability for definitive care (such as children's hospitals) intrinsically have high levels of pediatric readiness, the converse may not necessarily be true.Centers with high pediatric readiness scores measured on the national assessment should not necessarily be assumed to be prepared to provide definitive inpatient care for children at this time, as the wPRS is specifically an ED-based readiness metric.Prehospital pediatric readiness for EMS systems and hospital-based metrics for

Pediatric Readiness in Critical Access and Rural Hospitals
Critical access hospitals (CAHs) are often the only accessible care that injured children in rural or marginalized communities have readily available.As such these hospitals often have fewer resources and experience in caring for injured children.A study from the Journal of Rural Health examined the wPRS of all CAHs listed by the Center for Medicare and Medicaid services.The vast majority (80%) of these hospitals were low volume with a median wPRS of 59.The remaining CAHs (20%) had a moderate volume and a median wPRS of 67, indicating that nearly all of these hospitals would be in the lowest or second lowest quartile of readiness hospitals.About 60% of these centers had PECCs and interfacility transfer agreements.On an encouraging note, those centers who participated in a pediatric readiness recognition program had a significantly higher wPRS [27].These critical access hospitals-particularly rural trauma centers-should be the focus of interventions to improve care for children in the initial resuscitation phase of their care.Trauma-specific criteria to augment the pediatric readiness assessment (i.e., established protocols for triage, head injury, trauma transfer, and imaging) have demonstrated poor to moderate trauma-specific readiness among adult trauma hospitals and CAHs and may serve as a framework to improve readiness in these hospitals [28].

Access to Hospitals with High Pediatric Readiness
Since less than 60% of children live within 30 miles of a pediatric trauma center, ensuring high-quality initial resuscitative care cannot rely on PTCs alone.Leveraging existing adult trauma centers and critical access hospitals to provide access to high-quality initial resuscitative care for children can be improved by focusing on pediatric readiness in all EDs.A study from the Journal of Pediatrics found that while almost 94% of children have access to an ED within 30 min, only 55% have access to an ED with wPRS at or above the 90th percentile (indicating a hospital with greater than expected mortality), and only 70% could travel to an ED with a wPRS ≥ the 75% percentile.Access was lowest in the southeast regions of the country and highest in the mid-Atlantic and northeast [29].
By 2022, eighteen states had established a pediatric readiness recognition (PRR) program, either utilizing their own criteria or those derived from the NPRP.States with a PRR program were significantly more likely to have a greater than 20-point higher wPRS in EDs as compared to states without a PRR [30].Applying these criteria for pediatric readiness recognition to all trauma centers-adult and pediatric-represents a strategy to elevate pediatric readiness across our trauma system nationally and improve access to high-quality initial resuscitative care for injured children.

Optimizing Pediatric Readiness in Individual Trauma Centers
Preparing a specific trauma center to be ready to care for children starts with completing the online NPRP assessment (pedsr eady.org).This can be completed ideally by an ED nurse manager, or alternatively by a trauma program manager.Upon completion, a report of performance and quality gaps is issued which details specific areas for improvement and deficits in preparedness.These deficits apply to both medical and trauma care and should be shared and discussed with the appropriate leadership.
The NPRP has an online toolkit that is free and publicly available to all trauma centers.This toolkit mirrors the domains of the assessment in order to focus on specific areas of improvement as identified by the NPRP assessment.The toolkit is accessible through the EMSC and NPRP website (emscimprovement.centerand www.pedsr eady.org).The first component is an ED Checklist that can be downloaded to ensure that an ED has "the most critical components of the joint policy statement."The list details administration and coordination of the ED, personnel coverage, ED policies, guidelines to quality improvement, disaster preparedness, evidence-based guidelines for treatment and patient safety, and a list of medication and basic equipment that should be available and accessible to all ED staff.The checklist serves as a basic four-page review of the critical components of readiness.The pediatric readiness toolkit serves as an additional resource for examples of guidelines, examples of transfer agreements, roles of personnel, and resources for PECCs.A number of resources-including the pediatric readiness checklist and toolkit-are available to address gaps in pediatric readiness locally and are shown in Table 1.
The NPRP has also established opportunities for engagement, such as the PECC Workforce Development Collaborative and the Pediatric Readiness Recognition Program Community of Practice.These are ongoing learning collaboratives and communities of practice for participants interested in PECC activities to offer support, solutions, and mentoring in improving pediatric readiness.The implementation and utilization of PECCs and PECC resources were studied in a simulation-based quality improvement collaborative based in twelve community EDs in Connecticut.They found that overall wPRS improved over 21 months, specifically by establishing a PECC and improving coordination of patient care, QI activities, and policies and procedure [31].

Conclusion
Access to high-quality initial post-injury resuscitative care for children requires more than pediatric trauma centers.Adult trauma centers are needed as entry nodes into the trauma system for children and must be prepared to resuscitate and stabilize critically injured children prior to transfer to definitive care.The National Pediatric Readiness Project has provided a framework to assess and improve preparedness for pediatric emergency care-a framework that has been associated with improved mortality for injured children.All trauma centers seeking verification with the ACS will now be required to complete the NPRP assessment and develop a plan to address deficiencies in pediatric readiness.Additionally, more and more states are utilizing the PRR programs that will guide triage and treatment of injured children.If available in one's state, pediatric readiness recognition should be sought by all trauma centers of all levels.All hospitals should utilize the comprehensive, free, and open-access resource platform to improve their own readiness though the NPRP website presented in collaboration with and supported by the EMSC Innovation and Improvement Center.

Fig. 1
Fig.1Pediatric readiness at US trauma centers, associations between risk-adjusted mortality and readiness quartiles, and breakdown of median weighted pediatric readiness scores by trauma center type

Table 1
Resources to address gaps in pediatric readiness Domain Available resources to facilitate addressing gaps Administration and coordination for the care of children Pediatric Emergency Care Coordinator (PECC) Workforce Development Collaborative (PWDC) Online resources available at https:// emsci mprov ement.center/ colla borat ives/ pwdc/ and https:// emsci mprov ement.center/ colla borat ives/ pedia tric-readi ness-commu nity-pract