Proposed Approach: We will use a mixed methods study design to identify the components of emergency department (ED) pediatric readiness most predictive of short- and long-term survival among children. This project will help EDs prioritize implementation of ED readiness to save pediatric lives. We will use existing research infrastructure, data science methods, the ability to follow children to one year, novel analytics, and an interdisciplinary team to address this critical public health need. Importance: Injury and acute illness are the leading causes of death in children. We have recently shown that high ED pediatric readiness in US trauma centers and general hospitals is independently associated with improved survival, but the components of ED readiness driving survival are unknown. It is also unclear whether other organizational factors or ED processes of care improve survival among children. Answers to these questions will guide EDs in prioritizing the implementation of ED readiness, especially in smaller hospitals and rural settings with limited resources and budgets. This project is designed to inform the national trauma center verification criteria, the national field triage guidelines, the National Pediatric Readiness Project, and the Emergency Medical Services for Children program. Objectives: There are three specific aims: Specific Aim 1: We will build two multi-state cohorts of children receiving emergency care and use machine learning to identify the components of ED pediatric readiness predictive of short- and long-term survival. Specific Aim 2. Empirically develop a global measure of ED pediatric readiness and compare it to the weighted Pediatric Readiness Score for predicting short- and long-term survival in children. Specific Aim 3: Use a positive deviance approach to identify ED pediatric readiness factors and processes of care associated with improved survival among children receiving emergency care. Study Design & Setting: We will build two cohorts of children using emergency services from 1/1/2018 to 12/31/2022 in 928 EDs in 11 states (ED cohort) and 678 trauma centers in 50 states (Trauma cohort). We will link state vital statistics death records to the cohorts to track outcomes to one year and assess 152 unique components of ED readiness using machine learning methods. We will also conduct 150 interviews in 30 hospitals across the US using positive deviance methods as a complement to the quantitative analyses. Participants: Injured children 0–17 years using emergency services, including 15.6 million children with ED visits, 606,810 hospitalized children, and 264,865 children admitted to US trauma centers. Outcome measures: We will evaluate in-hospital mortality (primary) and 1-year mortality (secondary) at the patient-level. We will also evaluate the observed versus expected mortality at the ED-level to facilitate the positive deviance analysis.

Project Narrative Reducing mortality in children using emergency services is a critical public health priority. We will conduct a mixed methods evaluation of emergency department (ED) pediatric readiness using two multi-state cohorts of children and over 1,500 hospitals to assess which components of ED readiness improve short- and long-term survival, and empirically develop a new global measure of readiness based on these findings. Finally, we will use positive deviance methods and 150 interviews with key informants across 30 hospitals to identify specific processes of care and key aspects of pediatric readiness among EDs with better-than-expected survival.