One of us recently cared for a sick toddler and was concerned that the child could have leukemia. This was in a community emergency department just 10 miles from Boston Common — practically a stone’s throw from some of the world’s leading pediatric care centers.
Not one of those centers would accept the patient.
Emergency physicians like us are comfortable with the initial stabilization and diagnosis of seriously ill or injured children. We do it all year long. But eventually we need to transfer the care of these children to pediatric specialists.
There are still some community hospitals with strong pediatric care units; South Shore Hospital in Weymouth and St. Luke’s Hospital in New Bedford come to mind. But these are the exceptions. The rule is that when it comes to caring for sick children, the resources, funding, and expertise are concentrated at academic pediatric centers.
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Yet all too often now, those centers don’t open the door when the community doctor calls.
When the academic center hears about a sick kid and then says “No, sorry,” hours of tense phone negotiations ensue. Frightened parents and their child are left in limbo while community physicians plead in turn with each of the state’s five academic pediatric centers — Children’s Hospital of Boston, Mass General for Children, Boston Medical Center, UMass Children’s in Worcester, and Baystate Children’s in Springfield. When that fails, they look even farther afield, for a pediatric center in Connecticut, Rhode Island, or New Hampshire.
Earlier this month, colleagues at southern Massachusetts emergency departments repeatedly had to helicopter sick children to Maine — flying over multiple Boston pediatric hospitals. In the case of the toddler with possible leukemia, after many hours of phone calls, he was accepted on a second try to Hasbro Children’s in Providence. He is a Boston-area kid, but he had to be transported to another state because Boston’s academic hospitals declined to see him that day.
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This ongoing crisis of critical pediatric care has stressed Massachusetts for months. We are moved to comment on it in part because we dread that it is about to get worse. This winter, even as infections including respiratory syncytial virus, influenza, and COVID-19 bring more sick children to hospitals, there will be fewer pediatric beds.
Tufts Children’s Hospital closed its 41-bed operation in July, with ramifications for Boston and the state that we all have yet to come to terms with. Massachusetts also stands poised to lose a 20-bed inpatient unit in Springfield, which Shriners Hospitals for Children has announced it will close. This follows a national trend: Hospitals across America over the past decade have shut down about 20 percent of all pediatric beds.
Why is this happening?
In part because kids are not lucrative.
Tufts Children’s was a smaller player, one-tenth the size of Children’s Hospital of Boston, which has 415 beds. But it was still precious pediatric care space. Tufts converted it to adult use — part of a national trend just covered in The New York Times — because adults have more surgeries and invasive procedures, which generate higher payments from insurance companies. So adult beds make more money.
Today we are seeing what happens when that market-driven trend of quietly shedding pediatric beds collides with an acute, industry-wide staffing crisis.
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Hospitals across the nation — including pediatric centers — report that they cannot hire enough staff. What they actually mean is that even as they continue to spend generously on things like marketing campaigns, real estate upgrades, and administration, hospitals are reluctant to raise baseline nursing wages — at a time when many nurses (and doctors) have left hospital-based medicine for less stressful and better-paying arrangements. As a Band-Aid fix, hospitals everywhere have brought in a handful of expensive “traveler” nurses — but always on short-term contracts. There are no real long-term reinforcements on the immediate horizon.
Under such stresses, is it any wonder that pediatric academic center medical staff feel overwhelmed, to the point that they now often decline transfers of cases — of sick children — that they once would have accepted in a heartbeat?
It’s even more dysfunctional than this suggests. Consider again the toddler with possible leukemia: Each of Boston’s three pediatric academic centers declined to accept him in transfer. What if his parents had checked him out of the community emergency department and driven him just a few miles to any one of those hospitals? Frustrated parents — particularly once they are told our only option is to transport their child to a different state — occasionally ask us if they should do that. We tell them no. A sick child should be transported in an ambulance, with paramedics who can monitor the child, continue any intravenous treatments already begun, and communicate diagnostic findings to the receiving hospital team.
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But the parents who ask this also recognize, correctly, that if they did drive to the pediatric center of their choice, they would eventually be seen. That’s because under EMTALA, the federal Emergency Medical Treatment and Labor Act of 1986, no emergency department can ever refuse to see and care for a patient who shows up.
EMTALA guarantees to all patients, regardless of their ability to pay, an emergency medical evaluation and stabilizing treatments. According to the federal government, EMTALA also means that academic hospitals “shall not refuse to accept an appropriate transfer” of a patient who needs their special expertise “if the hospital has the capacity to treat the individual.”
It’s that last part — “if the hospital has the capacity” — that academic centers implicitly cite as a reason to pass on a sick kid. Often, however, the state’s top pediatric hospitals have more capacity than they realize. Their emergency departments may be busy — join the club — but they are not on Code Black crisis status, which calls for diverting or deferring patients. All day long, these hospitals are receiving the community’s walk-ins, as well as its 911 ambulance traffic, which by law can’t be refused.
However, once they get called with a transfer request, the staff of these hospitals often worry that “beds are tight” and so any seriously ill child they accept in transfer will just become one more “boarder” — the term for admitted patients who remain physically stuck in an emergency department, waiting hours for a bed to become free upstairs.
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Rather than accept a transfer, these academic centers often suggest that we board a child in our own community emergency departments — for hours or even days — until space becomes available. The idea seems to be, “They will board here or board there, so what’s the difference?”
The difference is huge. Kids who are “boarders” in the emergency department of a pediatric academic center still have access to specialist consultants, diagnostics, and therapeutics. A kid with leukemia who boards at such a center will be cared for by a pediatric-trained nurse and, if indicated, could get a bone marrow biopsy and even start chemotherapy. That same patient boarding in a community emergency department can’t have any of those things.
A fix is desperately needed. As a stopgap, that probably involves immediate better compensation by insurance payers for pediatric care, and recognition by the leadership of the pediatric centers that they need to open more beds, hire more staff, and — easy for us to say out here in the community — accept more transfer cases, even when it’s so busy that it feels uncomfortable.
More proactive community pediatric practices could also help decompress all of the emergency departments this winter. It is striking how many parents in the past two years have told us they just wanted their febrile child’s ears and throat checked and doubted it was appropriate to come to the emergency department for this — but were referred in anyway by their doctor’s office reception.
For now, though, if a sick child is brought to a community hospital and it turns out they need a tertiary level of care, there is no guarantee it will be available in Boston, in Massachusetts, or anywhere in New England. That’s shocking, considering we are home to some of the best pediatric hospitals in the world.
It’s also just the latest condemnation of a medical system in which there’s always money for a new building or an ad campaign but never enough for basic patient care — a system that injures the kids, their parents, and their nurses and physicians, who are all trapped together inside it.
Dr. Jon Roberts and Dr. Matt Bivens are emergency medicine physicians at community and academic hospitals in Massachusetts.