How large health care systems can promote pediatric emergency readiness

A recent national cohort study published in JAMA Network Open evaluated the cost and impact of raising all US emergency departments (EDs) to high pediatric readiness, defined by a weighted Pediatric Readiness Score of 88 or greater. Using data from 4,840 EDs across all 50 states and the District of Columbia, investigators estimated that only 17.4% of EDs currently meet this threshold.¹

The authors calculated that an annual national investment of approximately $207 million would be required to bring all EDs to high readiness, with costs ranging from $0 to $11.84 per child by state. Based on current mortality patterns among children who require hospitalization, transfer, or who die in the ED, the study estimated that 2,143 pediatric deaths—more than one-quarter of such deaths each year—may be preventable through universal high ED pediatric readiness.

In this Q&A, Steve Narang, MD, MHCM, president of Inova Fairfax Medical Campus and president of the Pediatric Service Line; and Adam A. Kochman, MD, medical director of the Pediatric Emergency Department at Inova L.J. Murphy Children’s Hospital, discuss the implications of these findings for health systems, hospital leadership, and frontline clinicians. They examine what pediatric readiness means in practical terms, how hospitals can operationalize improvements in emergency care for children, and the role of institutional and policy-level strategies in advancing equitable access to high-quality pediatric emergency services.

Contemporary Pediatrics: Why has pediatric emergency readiness appeared stagnant for more than a decade despite clear evidence it reduces mortality?

A: Pediatric emergency readiness in the United States is at a defining moment. While some national metrics—particularly those related to equipment and supplies—have improved, overall readiness has not advanced at the pace expected, given strong evidence that high pediatric readiness can reduce mortality for critically ill children by up to 76%.

The challenge is not primarily about supplies. More than 80% of children receive emergency care in community hospitals rather than pediatric specialty centers, and the majority of these EDs see fewer than 10 pediatric patients per day. Low pediatric volume perpetuates the belief that comprehensive pediatric training, pathways, and preparation are optional.

Additionally, the continued decline of pediatric inpatient units has shifted system focus and staffing patterns toward adult care, eroding the infrastructure needed for high pediatric readiness. Even when equipment is present, many EDs still lack essential elements such as structured simulation programs, behavioral‑health‑specific protocols, multidisciplinary case review, and pediatric‑focused leadership.

The most important factor explaining slow progress is the lack of widespread investment in Pediatric Emergency Care Coordinators (PECCs). Evidence shows that having a pediatric champion—ideally a physician‑nurse dyad—is the single most impactful driver of higher readiness scores and sustained improvement. Sites that designate PECCs demonstrate measurable and lasting gains; those that do not continue to lag.

In short, access to supplies has improved, but commitment to pediatric leadership has not kept pace. Community EDs can care for children safely and effectively when they invest in PECCs.

Contemporary Pediatrics: What responsibility do large health systems have to ensure consistent pediatric readiness across all emergency departments, not just dedicated pediatric centers?

A: Large, integrated health systems have a fundamental responsibility to ensure that every child receives high‑quality emergency care, regardless of which ED they enter. Children experiencing emergencies go to the nearest ED—not the most specialized one—so readiness must be consistent system‑wide rather than concentrated at flagship pediatric hospitals.

Health systems possess tools that individual EDs do not: the scale to standardize equipment, the infrastructure to align training expectations, and the capacity to implement unified clinical pathways and quality frameworks across multiple sites. Without this coordination, readiness varies by geography, disproportionately affecting rural and under‑resourced communities.

Inova Health System provides a strong example of system‑level investment elevating pediatric readiness. The expansion of the Pediatric Emergency Department at the Inova L.J. Murphy Children’s Hospital—now a 43‑treatment‑space, high‑acuity regional referral ED—combined with the dedicated Pediatric ED at Inova Loudoun Hospital, demonstrates how pediatric expertise can anchor readiness improvements across a system. These centers provide shared pathways, unified equipment standards, and a consistent culture of pediatric safety for patients seen anywhere within the system.

The sites that consistently improve are those that treat pediatric readiness not as compliance, but as a quality‑of‑care imperative—and large health systems are uniquely positioned to lead this work.

Contemporary Pediatrics: How do you make the case that investing in pediatric emergency care is both a clinical imperative and a sound operational decision?

A: Clinically, the argument is decisive: if all EDs operated at high readiness, more than 2,100 children could be saved annually. Strong pediatric readiness improves time‑to‑diagnosis and time‑to‑treatment for asthma, sepsis, trauma, and behavioral‑health emergencies, while reducing unnecessary transfers and enhancing family trust.

Operationally, the investment is modest, estimated at $4 to $48 per pediatric visit, depending on ED volume and local needs. The greatest operational return comes from investing in PECCs, not from equipment alone. PECCs lead training, ensure pathway adoption, coordinate quality review, and sustain improvements over time.

Health systems that invest in pediatric capability often see spillover benefits: strengthened maternal‑child service lines, better regional alignment, and enhanced community reputation. In Inova’s case, readiness investments have reduced avoidable transfers, improved regional capability, and solidified the Fairfax and Loudoun pediatric EDs as trusted destinations for safe, high‑quality care.

Contemporary Pediatrics: Which elements of the updated national recommendations are most critical for moving from minimal compliance to true readiness?

A: Several components are essential to achieving true, sustainable readiness:

• Pediatric Emergency Care Coordinators (PECCs)

The cornerstone of readiness. PECCs provide leadership for training, equipment alignment, pathway integration, and continuous quality improvement.

• Standardized clinical pathways

Especially for asthma, sepsis, trauma, and behavioral‑health presentations. These should include weight‑based medication tools and evidence‑based decision support, particularly important in low‑volume EDs.

• Pediatric behavioral‑health preparedness

Including safe spaces, validated screening tools, and de‑escalation training—now indispensable as behavioral‑health ED visits rise.

• Regular simulation and structured case reviews

Simulation builds muscle memory for low‑frequency, high‑acuity events, increasing team confidence and performance. Video‑assisted debriefing can amplify learning where available.

These elements move readiness from a checklist to a durable system of pediatric capability.

Contemporary Pediatrics: With the next National Pediatric Readiness Project (NPRP) assessment launching in March, what practical advice would you give health care leaders who want to improve their scores and ensure true readiness?

A: The March 2026 NPRP assessment offers health systems an ideal opportunity to accelerate readiness work. Practical steps include:

• Begin with a structured readiness audit.

Assess gaps in staffing, pathways, simulation, behavioral‑health readiness, equipment, and safety processes.

• Designate PECCs early—and ideally as physician‑nurse dyads.

This single step provides accountability, momentum, and the greatest measurable impact on readiness scores.

• Prioritize high‑impact, low‑cost investments.

Weight‑based medication systems, pediatric resuscitation tools, and standardized pathways for high‑risk conditions provide outsized returns.

• Implement regular simulation and transparent case review.

These are essential for both performance and culture building.

• Leverage system scale.

Spread best practices from strong pediatric EDs—such as those at Inova Fairfax and Inova Loudoun—into all mixed‑age EDs.

• Partner with aligned organizations.

Groups such as US Acute Care Solutions (USACS) that invest in pediatric champions and readiness infrastructure can accelerate system‑wide improvement.

Ultimately, pediatric readiness is more than a score. It reflects a health system’s commitment to safety, equity, and uncompromising clinical excellence for every child, in every ED, every day.

Reference

Newgard CD, Lin A, Goldhaber-Fiebert JD, et al. State and National Estimates of the Cost of Emergency Department Pediatric Readiness and Lives Saved. JAMA Network Open. 2024;7(11):e2442154-e2442154. doi:https://doi.org/10.1001/jamanetworkopen.2024.42154