This retrospective cohort study examined variation in ED-level volume of pediatric critical illness encounters across 569 EDs in 5 U.S. states (2018–2022), and assessed how many low-volume ED encounters occurred within a 15-minute drive of a high-volume ED.
Of 14,313,896 pediatric ED visits, 40,483 (0.3%) were critical. The median ED saw only 5 critically ill children per year (IQR 1–14), and 31.8% of EDs had at least one calendar year with zero pediatric critical illness. Only 1,557 (16.8%) critically ill children at low-volume EDs were within a 15-minute drive of a high-volume ED.
- Data limited to 5 states, which may not represent national patterns. - Critical illness definition relied on billing codes and procedural markers, which may misclassify some cases. - Drive-time proximity does not account for EMS routing protocols, traffic, or clinical stability for transport.
Because most EDs see critically ill children rarely, direct transport to high-volume centers cannot be a universal fix — system-wide readiness training and resource support at low-volume EDs remain essential. Only a small fraction of low-volume encounters are geographically divertible, so regionalization strategies must be paired with broad-based preparedness efforts.
