Strengthening Pediatric Care Readiness: Expanding Resources and Standards to Save Lives

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Daniel Simon, MD: Hello everyone, this is your Science@UH host Dr. Dan Simon. Today, I'm really excited to be joined by Dr. Charles Macias, Division Chief for Pediatric Emergency Medicine and Chief Quality Officer and Vice Chair of Quality for the University Hospitals Rainbow and Babies Children's System of Care. He is also a tenured Professor of Pediatrics at Case Western Reserve University and is the Co-Director of one of three National Pediatric Centers for Disaster Readiness. Welcome Dr. Macias.

Charles Macias, MD, MPH: Thank you, Dr. Simon. It's quite a pleasure to be here.

Daniel Simon, MD: So Charles, before we get started, you know, I think it's really worth talking a little bit about the difference between an adult and a child and pediatric care and adult care. Tell us a little bit about, in general in the United States, if you have a child and you're taking them to an emergency room, what's the chance that that child is going to be cared for by a pediatric fellowship trained emergency medicine doctor?

Charles Macias, MD, MPH: Excellent question and I’ll start with what we often like to say in pediatrics that children are not just little adults - that goes without saying. The physiology is different. The anatomy is different. The risk looks very different, and in fact, we know from studies around pediatric readiness, the National Pediatric Readiness Survey, and we'll talk a little bit more about that, that over 80% of children with acute medical needs or injuries present to community based hospital emergency departments, not to children's hospitals.

Daniel Simon, MD: So, I think that's really important because that dovetails really beautifully with the next question, which is that, you know, you're a principal investigator for a $48 million grant from HERSA to establish a regional pediatric pandemic network. That will support the planning and preparation of child healthcare facilities to respond to both global health threats and local disasters. Can you tell us a little bit then about how exactly does a nation prepare for disaster readiness in pediatric emergency care? And only 20% of the children even have the access to that kind of a hospital setting.

Charles Macias, MD, MPH: Great question. I think it really starts with everyday readiness. You can't be ready to take care of children in a disaster if you can't take care of them on a random Tuesday. So we think about the enhancements of systems of care from a national readiness perspective for everyday care and we move from that, building that reliability within a system to a more national approach to that work. If you look at the gaps that we know of from the National Pediatric Readiness Project, what I quoted earlier about the over 80% of children that present to one of the nation's 4000 emergency departments that are presenting in community based hospitals, that gap in care from provider to patient with best competencies is exacerbated as well by geographic inequity. So, sparsely populated areas are also going to dictate a lower availability of resources to those areas. Consider, then, that, that when we have specialized care - that's further compounded by the gaps in interstate coordination and systems of care, especially during disasters or global pandemics.

So, let me distill this down to an example. If I considered, for example, the fact that in neonatal intensive care unit, maybe an hour and 45 minutes away from a critically ill infant born precipitously in a community hospital, that may be less important than the fact that, that NICU is across the state line, or financial and regulatory issues may make transferring that patient really challenging. So, having the equipment, the training of the personnel for infant resuscitation, having transfer agreements in place represents that importance of pediatric readiness and the ability to build reliability within healthcare systems. What we do know from scientific data is that research by Stephanie Ames and Craig Newgard have demonstrated that being pediatric ready in those national assessments, so that's top quartile and readiness scores, leads to a 76% lower mortality rate in ill children and a 60% lower mortality rate in injured children, primarily through the dissemination of best practices pediatric evidence based guidelines of care, training, appropriately sized equipment and quality improvement strategies, that inherently address the needs of those children in community based settings.

Daniel Simon, MD: So, Charles, a question, I guess for our listeners, how much of the readiness is transferring to children's hospitals and how much can be accomplished by new technology of telehealth and even televisual health where you can actually, go in and see and help evaluate that patient through video assistance. What's the solution? Is it a combination of both transfer and tele?

Charles Macias, MD, MPH: I think it's a combination exactly as you point out of both virtual access to the consultant as well as to the patient. So we can have direct to patient, but also direct to consultant support services through telehealth and a lot of the work that we do through the Pediatric Pandemic Network as well as through the Emergency Medical Services Children Innovation and Improvement Center focuses on enhancing telehealth services, but it also recognizes that those telehealth services have inherent barriers within themselves, both during disasters where that care is needed during surges, when we may, for example, as we saw in August of 2022 and the time beyond, a surge in the number of children presenting to emergency departments with acute respiratory needs. But that also has to be coupled with the education components of the work. So, how do we train around stabilization and access to the right equipment that is going to help the telehealth consultant or the telehealth service direct to the patient get to the right pharmacologic interventions and the right facilities.

You know, we face a real challenge in this country. The Pediatric Readiness Surveys tell us that over the last decade we've lost 1,000 hospital beds for children. That's a significant impact in our healthcare system. So that means that whatever resiliency we're building has to be disseminated broadly across all geographies.

Daniel Simon, MD:  You know, it's especially concerning, you know, hearing you talk because it's estimated that about 25% of rural hospitals are under such financial distress that they may close. And you know what you described in that case of a premature NICU baby, born an hour and 45 minutes away to a NICU, is only going to get worse over time.

Let's move for a second, again, and sort of returning to this notion that the federal investment in emergency care structures, processes and even research has a long history. Primarily embedded in the adult population. Can you describe how this and other federal efforts are now supporting pediatric readiness specifically?

Charles Macias, MD, MPH: Absolutely. I think it's important to understand where we've been in the late 60s and the early 70's. The U.S. invested heavily in pre-hospital and hospital emergency care systems, primarily with lessons learned from emergency care at times of war. Those investments really led to improvements in outcomes for both trauma and cardiac care in adults, but the outcomes for children, as you pointed out, lagged behind.

In 1984, the EMS for Children Program was authorized by Congress to leverage the existing U.S. emergency care system, not to create a whole new system, but to leverage what already existed, but targeting pediatric care improvements. So, that program, that's now housed under the Maternal Child Health Bureau within the Health Resources and Services Administration, has a number of assets, including state partnership programs and 57 states and jurisdictions we work with - that particular network of state partnerships, and as well, included in those assets of the EMSC program is the Pediatric Emergency Care Applied Research Network. One of our centers, the MSC Innovation Improvement Center, dually housed in Austin, Texas and here in Cleveland was created in 2016, with the Foundation on Improvement Science. Amongst its goals was to accelerate pediatric readiness across the U.S. healthcare system and we work in partnership with board liaisons at several professional societies to align initiatives for improved pediatric outcomes, including the development of guidelines, policies and educational initiatives. So, that federal investment is also partnered with private investment.

During the COVID-19 pandemic, we saw this surge in pediatric respiratory disease as I mentioned earlier that followed in the fall of 2022. And at that time, there was this recognition that there were fundamentals of disaster and global health threat preparedness and response that were unique to children such as reunification after a disaster. So, through the Special Projects of Regional and National Significance, the SPRANS program, Congress created the Pediatric Pandemic Network where a network of 10 children's hospitals with 27 affiliates, and that investment that initially was $42,000,000 has now grown to over $100 million of federal support.

Daniel Simon, MD: Wow.

Charles Macias, MD, MPH: That network really focuses on everyday readiness and disaster readiness, and as you mentioned earlier. Yes, we leverage telehealth, but we also look at national quality improvement collaborative, educational initiatives and a number of dissemination and implementation science based activities to build everyday readiness and to help prepare the nation to respond to national and global health threats.

Daniel Simon, MD: So, Charles, you know your work obviously in pediatric readiness has been focused, you know as you mentioned on the pediatric disaster readiness and specifically that around COVID-19. There doesn't seem to be a large body of literature supporting the work. How is your research activity driving now the science of pediatric readiness? Do we know what works? What's the best thing to do?

Charles Macias, MD, MPH: I'd really like to be able to elaborate on what you just described, because we can compare the body of literature in pediatric asthma and what we see in pediatric disaster research across all elements of the entirety of that pool, pales in comparison. So we conducted one of the first true scoping reviews of pediatric disaster research and identified only 728 articles that constituted the core of evidence supporting pediatric disaster work. When we categorized it into 5 domains, the four phases of the disaster cycle mitigation, preparedness, response, and recovery, plus a fifth, disaster education, we were able to drive a modified Delphi Process working partnership with an HLDI and the Administration for Strategic Preparedness and Response in Washington, DC, earlier this year.

We've nearly completed the 4th and final stage of that Delphi, and we'll be disseminating the results to line professional societies, federal priorities and internal research agendas of the network, but it takes more than just that test of knowledge, right? We need to be able to implement that. So we're recognizing the need to grow new workforce and pediatric disaster science arena, so we offer career development awards, R-25 one-year researcher training programs, a two-year scholars program for young investigators, $100,000 pilot awards, manuscript and scientific writing groups and an annual pediatric disaster science research annual meeting.

Now with a new set of priorities that we understand will drive the research agenda. We're really attempting to grow the scholarly workforce for pediatric, every day, and disaster readiness.

Daniel Simon, MD: That's really great. So let's just shift gears to our final question. And I mean you're a busy guy, you run our emergency medicine program for pediatrics. You're running a whole national program, but you're also very heavily involved in quality improvement. Can you tell us a little bit about how, you know your research and the hard wiring of pediatric readiness can be applied to other outcome improvement areas such as sepsis? Obviously a big concern in the pediatric population.

Charles Macias, MD, MPH: Well, I think that the work to build higher quality structures, processes, and ultimately outcomes can be leveraged to improve multiple disease processes because the structures and processes that create better diagnostic accuracy through decision, support, education and system integration and coupled with standards and hardwiring of better therapeutic effectiveness with improved communication is applicable to lots of specific disease processes, especially those for which great variation exists in their approaches. It's almost for a formulaic if you're really putting in a structure to disseminate and train for pediatric readiness of bronchiolitis, for example, why not leverage that same structure and process for diseases like sepsis?

So, as an example, as a co-chair of the Improving Pediatric Sepsis Outcomes Quality Improvement Collaborative, we operated in 66 institutions in partnership with the Children's Hospital Association and we saw real gains in our pediatric sepsis work beyond amassing the largest data set of pediatric sepsis or suspected sepsis cases over 375,000 of these, the group standardized a definition for prospective and retrospective data collection and quality improvement…even working with the CDC to create a defining surveillance methodology.

We developed a five element bundle so early recognition that was driven by, one, a screening tool, two, an evidence based order set, and three, a provider and staff group huddle, and then, two treatment elements, a first bolus within 60 minutes and 1st antibiotic within 180 minutes. And so with that five element bundle, we were able to systematically overcome that norm of evidence uptake that would normally take 13 to 17 years to bring it to less than three years from discovery.

So, what we found was that our compliance with the bundle would drop 30 days sepsis attributed mortality from 4.7% to 2.4%. So you think about that, that's a 47.7% drop in the more advanced or severe critical sepsis and for the less severe suspected sepsis. This is detected early, intervened early, the drop in mortality went from 2% to .4%. That's a relative drop of 80.5%. So, if we put that in terms of burden of care the overall national impact was greater than 72,000 hospital days prevented, greater than 35,160 episodes of organ dysfunction prevented, greater than 24,000 ventilator days prevented, greater than 44,000 PICU days prevented, and most importantly, over 570 children's lives saved. Couple that with our ability to really disseminate the knowledge we've now published about eight manuscripts on the various aspects and discoveries of that sepsis related work. And I want to mention these big reductions in mortality did not come from some new pharmacologic intervention or some magic bullet, but from strategically designed quality improvement initiatives that really just demonstrates how aligning best practice, data sharing analytics, quality improvement in education can all drive system improvements all for better outcomes for children.

Daniel Simon, MD: Well, Charles, how inspiring to talk to someone who has saved 570 lives and 70 to 80,000 ICU days and everything else. I mean, it's why I come to work every day to be alongside people like you. So thank you so much for everything that you do.

To learn more about research at University Hospitals, please visit uhhospitals.org/UHresearch. Thank you.