TOPLINE

A retrospective cohort study found that most emergency departments (EDs) managed a median of just five critically ill children per year, and only 16.8% of critical illness encounters at low-volume centers were potentially divertible to nearby high-volume pediatric facilities.

METHODOLOGY

• Researchers conducted a retrospective cohort study using data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from five US states between 2018 and 2022.
• Among 14,313,896 pediatric ED encounters across 569 EDs, researchers identified those involving critical illness (defined by the occurrence of death, cardiopulmonary resuscitation, endotracheal intubation in the ED or on hospital day 0 or 1, or ED critical care billing).
• EDs were classified as low volume if they were not in the top quartile of pediatric critical illness volume for a given state and year.
• The outcomes were ED experience managing pediatric critical illness, measured by the annual volume of pediatric critical illness encounters, and encounters that were potentially divertible to high-volume EDs.
• Drive times were estimated, and encounters were classified as potentially divertible if a high-volume ED was within a 15-minute drive from the patient's home or the index ED.

TAKEAWAY

• A total of 0.3% of ED encounters (40,483 children; median age, 6 years; 44.4% girls) involved critical illness. Each ED treated a median of 1932 pediatric patients annually, of whom five met the criteria for critical illness.
• Among the EDs, 31.8% did not treat critically ill children in at least 1 year, and 71.4% treated fewer than 12 critically ill children annually.
• Of the 9281 critical illness encounters at low-volume EDs, only 16.8% had at least one high-volume ED within a 15-minute drive from the patient's home or the index ED and were, therefore, potentially divertible. Pediatric critical illness rates were 0.2%-0.5% across states, but ED-level volume and diversion potential varied widely — from a median of one critically ill child per year in Nebraska to eight in Florida and from 7.5% of encounters in Iowa to 29.5% of encounters in Maryland that were divertible to a nearby high-volume ED.
• High-volume EDs were more likely to have pediatric ICUs (21.1% vs 4.5%; P < .001), neonatal ICUs (44.7% vs 8.9%; P < .001), and pediatric inpatient wards (63.1% vs 37.6%; P < .001) than EDs that never met high-volume criteria.

IN PRACTICE

"We found that critical illness is rare among pediatric ED encounters and that most EDs rarely treat critically ill children. However, most of these encounters in low-volume EDs are unlikely to be good candidates for out-of-hospital diversion to high-volume centers. Thus, improving outcomes for critically ill children in the emergency setting likely requires renewed investment in developing new training and support systems for EDs," the authors wrote.

SOURCE

The study was led by Allan M. Joseph, MD, MPH, University of Cincinnati College of Medicine, Cincinnati. It was published online on July 2, 2026, in the Annals of Emergency Medicine.

LIMITATIONS

The study was limited by the use of ED volume as a proxy for capability, reliance on administrative billing and procedural codes to identify critical illness, the lack of prehospital data, the potential overestimation of diversion feasibility, limited geographic coverage, and uncertain generalizability beyond the five participating states.

DISCLOSURES

One author reported receiving support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors reported having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.