Pediatric readiness is essential to the care of children in rural areas. When pediatric specialty care is not immediately accessible, rural clinicians may be required to care for ill or injured children for extended periods of time. Having established programs for pediatric care, including validated quality and safety programs that emphasize pediatric readiness, is an essential component to caring for rural children. Being prepared to care for children in routine situations is vital to being prepared to care for children in a resource-limited disaster situation.
Key points
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Children in rural America have unique health care needs and face unique health care challenges related to increased risk of injury and decreased access to pediatric specialty care.
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Physicians in rural areas need to be prepared to care for children when pediatric specialty centers are not available or accessible.
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Numerous programs and standards exist to guide rural clinicians in developing high-quality pediatric readiness programs.
Case study
During the late evening of Friday, December 10, 2021, a violent, long-tracked EF4 tornado moved across Western Kentucky, causing catastrophic damage to numerous towns, including Mayfield, Princeton, Dawson Springs, and Bremen. There were estimated peak winds of 190 mph and a path length of 128 miles. The tornado was on the ground for 2 hours. Of the 78 fatalities, 12 were children. The affected area was rural, with the closest trauma center a Level IV that had lost both phone and Internet service. Helicopters could not fly. There were 22 injured children who were either triaged and transferred to more distant trauma centers or were treated and released at local hospitals. Of the children who made it to the hospital, all but one patient survived. Thankfully, such tragic disasters are rare. Still, rural pediatricians must be prepared to assist injured patients until they can be stabilized or transferred to higher levels of care. As you read this article, consider the following questions:
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As a pediatrician, are you aware of where the nearest trauma center is and whether it is “pediatric ready” and capable of taking care of an injured child?
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What injury prevention initiatives do you ask about or provide education for in your office?
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What is the role of the pediatrician in preparation and planning for a disaster involving children in their own community?
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Do you know who your community partners are in planning and integration of children into all phases of emergency care where you live?
Introduction
Nearly 12 million children live in the rural United States. Pediatric surgical care in rural environments presents unique challenges due to factors such as limited access to health care resources, long transport times to medical facilities, and disparities in emergency response infrastructure. Common types of pediatric injuries in rural areas include those related to agriculture, recreational activities, motor vehicle accidents, and environmental hazards. Studies indicate that rural children are at 55% higher risk of overall injury, double the risk of motor vehicle crash injury, 49% higher rate of unintentional drowning, and 47% higher suicide than urban children. , Addressing the increased risk of injury to rural children can be done through advocacy and prevention initiatives as these types of injuries all have potentially severe consequences to children’s health and well-being. Preventive measures such as community education, safety training, and implementation of injury prevention programs tailored to the rural context are crucial for mitigating risks and promoting child safety. Prompt access to appropriate medical care and trauma services is essential for reducing morbidity and mortality associated with pediatric injuries in rural settings. By recognizing the unique challenges of rural pediatric surgical care and implementing targeted interventions, health care providers, policymakers, and community stakeholders can work together to improve outcomes and reduce the burden of pediatric injuries in rural environments. This article provides a brief review of pediatric rural injuries, what makes them unique, steps to minimize the frequency, and ways the current health care infrastructure can be improved to achieve better outcomes. Integrating children’s interests into all aspects of preparedness training makes the most sense such that taking care of children creates less apprehension on the part of the clinician.
Understanding the landscape of rural environments
The rural environment is characterized by vast geographic areas with sparse population density, limited access to health care facilities, and diverse socioeconomic backgrounds. These factors contribute to unique challenges in addressing pediatric injuries in rural settings. Limited availability of emergency medical services and trauma centers, coupled with long transport times to reach specialized care, can result in delays in treatment and worsen injury outcomes. The prevalence of agricultural activities, outdoor recreational pursuits, and transportation-related risks in rural areas poses specific injury hazards to children. Environmental factors such as rugged terrain, natural disasters, and exposure to wildlife contribute to the complexity of pediatric injury prevention and management in rural environments. Socioeconomic disparities, including limited access to resources, education, preventive health care services, and primary care physicians, can exacerbate the vulnerability of rural children to injuries. While 20% of American children live in rural communities, only 9% of general pediatricians or nurse practitioners practice in those areas. Child poverty rates are higher in rural areas with nearly 1 in 4 rural children growing up in poverty. These factors contribute to injury rates as much as 55% higher and unintentional injury death rates twice that seen in urban settings for children who live in rural areas. Addressing these challenges requires a multifaceted approach that encompasses community-based interventions, education, policy advocacy, and collaboration among health care providers, policymakers, and community stakeholders to mitigate the impact of pediatric injuries in rural settings.
Common pediatric injuries in rural environments
Common pediatric injuries in rural environments encompass a range of diverse hazards inherent to rural living. Agricultural-related injuries, such as those sustained from farm machinery, livestock interactions, and falls from heights, are prevalent as many children help out on family farms in rural areas. Farm injuries most commonly occur among youth ages from 15 to 19 years and are usually associated with the operation of heavy machinery. Many of these injured adolescents will require hospitalization. The National Ag Safety Database indicates that agriculture is one of the most dangerous occupations in the country where children of any age can be present. Five sobering statistics include (1) a child dies in an agriculture-related incident every 3 days; (2) the number of agriculture-related youth workers is higher than all other industries combined; (3) many agriculture work-related injuries and deaths are associated with children doing work that does not match their developmental level; (4) 60% of child agriculture-related injuries happen to children who are not working; and (5) everyday, about 33 children are injured in an agriculture-related incident. Outdoor recreational pursuits, including all terrain vehicle (ATV) riding, biking, and hunting, also contribute to a notable proportion of pediatric injuries, often resulting from collisions, falls, or accidents involving firearms. , Motor vehicle accidents are a significant concern in rural settings, exacerbated by long stretches of highways, off roads in poor condition, and limited access to emergency medical services. Hung and colleagues cite that vehicle crashes are more likely to be fatal in rural counties due to higher speeds, lower quality road design, and greater distances to hospitals. Emergency medical services may be voluntary and personnel less well trained to take care of injured children. Also, rural communities have lower levels of injury prevention behavior, such as seatbelt use, water safety practices, and use of bike helmets. Environmental factors such as natural disasters, exposure to extreme weather conditions, and encounters with wildlife pose risks to pediatric safety that are higher in rural environments. Overall, the diverse array of hazards present in rural areas underscores the importance of comprehensive injury prevention strategies tailored to address the specific challenges of pediatric safety in these settings. Pediatricians can access prevention tip sheets and information for parents through several organizations including the American Academy of Pediatrics (AAP) (The Injury Prevention Program [TIPP]), SafeKids, and 4-H. Pediatric patient handouts from TIPP help pediatricians implement injury prevention counseling for parents of children newborn through aged 12 years for motor vehicles, firearms, bicycle crashes, drowning, poisoning, choking, burns, falls, and pedestrian hazards. SafeKids provides fact sheets on a number of injuries experienced by all ages of children and advice on prevention strategies for teachers, counselors, and parents. 4-H has more programs geared toward adolescents and promotes mentoring and provides strategies for coping with mental health challenges.
Translating “preparation meets emergency” into everyday care
In 2020, the US census data were updated and many of the statistics that give guidance to rural America are updated more frequently on the Rural Health Information Hub. The US population in 2022 was estimated at 333 million. Rural Americans reside in 72% of the total United States land area but only comprise 14% of the population (46 million).
Nearly a quarter (22.2%) of those living in rural areas as of 2021 are children aged less than 18 years (13.4 million). Overall, 11.6% of families live in poverty and approximately 19 million Americans (6% of the population) still lack access to fixed broadband service at threshold speeds, which has implications for promulgating telehealth as a strategy for patient care. In rural areas, nearly 25% of the population (14.5 million people) lack access to this service. Fig. 1 depicts the current status of rurality by state based on the last census.
Access to trauma care for children who live in rural and underserved areas can be challenging because of access to primary care, emergency care, workforce capable of caring for children, and insurance plans that may dictate referral patterns. Access to care can also be greatly affected by geography, weather, and transportation with the latter 2 situational and codependent on availability of transport over a distance to tertiary care.
In 2022, according to the American Hospital Association (AHA) Annual Survey database, there were 6093 US hospitals, of which 5139 were considered community hospitals and 1796 of these were considered rural community hospitals. At the same time, there were approximately 279 children’s hospitals. An article published in 2020 intentionally tried to discriminate children’s hospitals from non-children’s hospitals using an American Hospital Association Healthcare Institute Claims database from 2015. There were 4464 hospitals in the database and they were tiered according to pediatric services. There were 5 tiers with Tier A being freestanding children’s hospitals (51), B having key pediatric services and characterized by children’s hospitals within a larger hospital or system (228), C having limited pediatric services (1721), D having no pediatric services (1728), and E unclassified (738). According to claims data, the percentage of admissions that were pediatric was highest in tier A (88.9%), followed by tiers B (10.9%), C (3.9%), and D (3.9%). Of interest, 28.06% of admissions at unclassified hospitals were pediatric, although the services provided were not robust. Pertinent is the number of states in the northern plains and midwest where the number of children’s hospitals is far fewer. In 2020, Fallat and colleagues studied pediatric trauma system development and integration across the country. Each state was assigned a score based on 6 domains of planning and development that affect children’s care: disaster, legislation, and funding; access to care; injury prevention and recognition; quality improvement and trauma registry; and pediatric readiness. The entire report is available as a PDF download and is accessible on the Emergency Medical Services for Children (EMSC) Innovation and Improvement Center (EIIC) Web site. The maximum score was 100, but the study showed that many states lack a number of essential resources for children. A blueprint for helping states improve their resources for children has recently been published.
Strategies for intervention: pediatric readiness comes of age for trauma centers
Being “ready,” willing or capable of performing a task has taken on new meaning since the stresses to the health care system associated with the corona virus disease of 2019 (COVID-19) pandemic. “Readiness” as defined as “being fully prepared for something” is now much more about being ready everyday for the mass casualty event that might take place tomorrow. It used to be easier for a trauma or acute care surgery team to say, “we do not take care of kids here” and to send the children to a center that specializes in pediatric care. As we consider the consequences and increasing frequency of mass shootings and of climate change and natural disasters (tornados, hurricanes, floods, mudslides, fires, and the threat of earthquakes), there will be circumstances where children must be managed in a rural or underserved environment at least temporarily and possibly for days until a tertiary or quaternary center can accept them in transfer. High-level pediatric trauma centers are also at risk to be damaged or inaccessible during a disaster.
The American College of Surgeons Committee on Trauma has partnered with the programs in the Health Resources and Services Administration (HRSA) including the EMSC and the EIIC to promote the importance of “pediatric readiness” in the emergency departments of trauma centers and Emergency Medical Services (EMS) Services. , There are several other key stakeholders in pediatric readiness, including the AAP, the American College of Emergency Physicians, and the Society for Trauma Nurses. Two recent publications highlighted the survival benefits of a pediatric-ready emergency department for ill and injured children, , but it also makes sense that injured patients of any age should be taken to a higher level pediatric trauma center preferentially. There are many areas of the country, particularly in the northern plains and western parts of the United States where pediatric trauma centers are hours away from injured children and children need to be triaged to and stabilized at adult-centered hospitals, some of which see few children in their emergency departments daily. The pediatric readiness project enables the emergency department team to better prepare for medical and surgical emergencies that involve children. A standardized checklist helps the emergency department (ED) team understand the gaps in equipment, supplies, medications and dosing, education, training, protocols, and transfer agreements needed to optimize care. The program also champions designation of a key person or pediatric emergency care coordinator (PECC) to be the program manager in charge of pediatric readiness. Optimally, there will be a physician and nurse dyad who can oversee quality improvement and make sure there are quality and safety programs in place.
Beginning in August 2023 when the new resources for optimal care of the injured patient (“The Gray Book”) went into effect, the American College of Surgeons trauma center verification program now has a pediatric readiness standard in place for all levels of trauma center verified by the American College of Surgeons (ACS) ( Table 1 ). The best way to approach the standard is to work with a hospital’s emergency department team, who will oversee making sure your local trauma center or hospital is pediatric ready ( Box 1 ). Responsibilities for trauma centers will include understanding gaps in care for children and having a plan in place to address the gaps, but this should be the goal for all hospitals.
