Quality of Care of Children in the Emergency Department: Association with Hospital Setting and Physician Training MADAN DHARMAR, MBBS, JAMES P. MARCIN, MD, MPH, PATRICK S. ROMANO, MD, MPH, EMILY R. ANDRADA, MD, FRANK OVERLY, MD, JONATHAN H. VALENTE, MD, DANIELLE J. HARVEY,PHD, STACEY L. COLE, BS, AND NATHAN KUPPERMANN, MD, MPH Objective To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. Study design This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children’s hospitals (RNCHs) and 1 academic urban children’s hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. Results A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference 3.23; 95% confidence interval [CI] 4.48 to 1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the “other” category (difference 3.34, 95% CI 5.40 to 1.27 and 3.12, 95% CI 5.25 to 0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference 2.75; 95% CI 5.40 to 0.05). Older children received better care. Conclusions The quality of care provided to children is associated with age, hospital setting, and physician training. (J Pediatr 2008;153:783-9) S tudies of the infrastructure and quality of pediatric emergency services across US hospitals 1-8 have found that most emergency departments (EDs), particularly in rural areas, 8,9 may not be sufficiently prepared to care for children, 10 and have recommended that facilities be specifically equipped and staffed for pediatric emergency care. 2,6,7 A recent report from the Institute of Medicine documented that only 6% of EDs in the United States are fully equipped for pediatric emergencies. 8,9 The Centers for Disease Control and Prevention reported that only 71% of US EDs have board-certified emergency medicine physicians available round the clock either in-house or on call; furthermore, only 24% of EDs have access to board-certified pediatric emergency med- icine physicians, and 38% of EDs do not have a pediatrician available for consultation at all times. 9 These deficiencies in equipment, staffing, and availability of pediatric expertise can lead to delayed diagnosis, administration of inappropriate therapies and suboptimal medical management in the ED, particularly for critically ill and injured children. 4,11-18 Even though most of the previous studies have investigated differences in the structure of care, little is known about how these differences translate to differences in the processes of care and other measures of quality. Although some instruments have been developed to risk-stratify children in the ED for specific outcomes, including appropri- ateness of admission and return visits within 24 hours of discharge, 19-22 these instruments do not comprehensively evaluate processes of care in the ED. Implicit review, a means of CI Confidence interval ED Emergency department FM Family medicine GEM General emergency medicine ICC Intraclass correlation PEM Pediatric emergency medicine PRISA Pediatric Risk of Admission RNCH Rural non-children’s hospital UCH Urban children’s hospital See editorial, p 738 From the Department of Pediatrics (M.D., J.M., P.R., S.C., N.K.), Center for Health Ser- vices Research in Primary Care (M.D., J.M., P.R., N.K.), Department of Internal Medi- cine (P.R.), Department of Emergency Medicine (E.A., N.K.), and Department of Public Health Sciences (D.H.), University of California Davis, Sacramento, CA, and De- partment of Emergency Medicine, Brown University, Providence, RI (F.O., J.V.). Supported in part by grants from the Agency for Healthcare Research and Qual- ity (AHRQ 1 K08 HS 13179-01), Emer- gency Medical Services for Children (HRSA H34MC04367-01-00), and the California Healthcare Foundation (CHCF 02-2210). The authors declare no conflicts of interest. Submitted for publication Sep 1, 2007; last revision received Apr 15, 2008; accepted May 14, 2008. Reprint requests: Madan Dharmar, MBBS, Department of Pediatrics, University of Cal- ifornia Davis Children’s Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817. E-mail: mdharmar@ucdavis.edu. 0022-3476/$ - see front matter Copyright © 2008 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2008.05.025 783