Sick kids left in limbo as hospitals close pediatric units
BROKEN ARROW, OKLA. — It was Lachlan Rutledge’s sixth birthday, but as he mustered a laborious breath and blew out one candle, it was his mother who made a wish: for a pediatric hospital bed in northeast Oklahoma.
The kindergartner has a connective tissue disorder, severe allergies and asthma. Those conditions repeatedly landed him in the pediatric intensive care unit at Ascension St. John Medical Center in Tulsa, with collapsed veins and oxygen levels so low, he was unresponsive to his mother’s voice.
But in April the hospital closed its children’s floor to make room for more adult beds. So on a September morning, after coming down with COVID-19 for the fourth time and with what looked like bilateral pneumonia, Lachlan was struggling to breathe in an overcrowded emergency room at the Children’s Hospital at Saint Francis — the only remaining inpatient pediatric option in Tulsa.
“We’re always preparing for battle. It’s just a question of where we’re going to fight,” said his mother, Aurora Rutledge, looking frightened as she twisted the blond ringlets that poked out from under Lachlan’s Spider-man headphones.
Hospitals around the country, from regional medical centers to smaller local facilities, are closing down pediatric units. The reason is stark economics: Institutions make more money from adult patients.
In April, Henrico Doctors’ Hospital in Richmond, Va., ended its pediatric inpatient services. In July, Tufts Children’s Hospital in Boston followed suit. Shriners Children’s New England said it will close its inpatient unit by the end of the year. Pediatric units in Colorado Springs, Raleigh, N.C., and Doylestown, Penn., have closed as well.
“They’re asking: Should we take care of kids we don’t make any money off of, or use the bed for an adult who needs a bunch of expensive tests?” said Dr. Daniel Rauch, chief of pediatric hospital medicine for Tufts Medicine, who headed its general pediatric unit until it closed over the summer. “If you’re a hospital, that’s a no-brainer.”
Many hospitals have converted children’s beds to adult ICU beds during the pandemic and are reluctant to change them back. Now, staff shortages, inflation — drug costs have increased 37% per patient compared to pre-pandemic levels — low Medicaid reimbursement and dwindling federal subsidies granted during the pandemic have left some health centers operating on negative margins and eager to prioritize the most profitable patients.
Young patients like Lachlan, who has private insurance, occupy beds to recover from infections or asthma attacks but don’t undergo lucrative, billable procedures — like joint or heart surgeries — that are more common among aging patients.
Physician reimbursement through Medicaid, the insurance program for low-income people, is often only about 70% of the amount reimbursed through Medicare, the insurance program for elderly people of all incomes. More than a third of children in the United States are enrolled in Medicaid.
There have been no aggressive legislative efforts to keep hospitals from closing or shrinking their pediatric units. Democratic senators introduced a bill last year to grant funding to specialized children’s hospitals to improve their infrastructure, but it has not moved past the assigned committee.
Health policy experts say an important solution would be to encourage hospitals to care for children by increasing Medicaid reimbursement rates. But even higher Medicaid and private rates wouldn’t come close to what hospitals can charge for remunerative adult procedures, and with many state budgets already strained, experts say the regulatory move is unrealistic.
Hospitals that no longer admit children rely on transferring them to pediatric units at other hospitals. But when even the largest pediatric floors in the country are at capacity, the pileup of critically ill children in ERS can cause patients’ conditions to worsen.
‘Children are not small adults’
The decline of local access to children’s inpatient care began more than a decade ago and accelerated during the pandemic. Between 2008 and 2018 — the most recent national data available — pediatric inpatient units in the United States decreased almost 20%, and nearly a quarter of children found themselves farther from their nearest pediatric unit.
The steepest decline in pediatric inpatient beds was in rural regions, where large health systems acquired community hospitals and consolidated pediatrics to one campus.
Centering pediatric care in specialized centers can erode a local hospital’s ability to care for a critically ill child, doctors say.
“Children are not small adults,” said Dr. Meredith Volle, a pediatrician at Southern Illinois University School of Medicine in Springfield, Ill., who routinely sees patients who travel from two to three hours away.the number of pediatric beds in Illinois has declined, and 48 of its counties now have no pediatrician at all.
Critically ill children are four times as likely to die in hospitals and twice as likely to die in trauma centers that scored low on a “pediatric readiness” test, according to research. Only one-third of children in a national research survey had access to an emergency department deemed highly “pediatric-ready,” and of those, 9 out of 0 lived closer to a less-prepared one.
A parent who is unaware of the wide variability, said Dr. Katherine Remick, the executive director of the National Pediatric Readiness Quality Initiative, “could make a split-second decision that changes their child’s fate.”
Lachlan’s life
On the September morning that Lachlan was in St. Francis struggling to breathe, the ER was so busy that Aurora Rutledge hooked him up to a pulse oximeter herself, quieting the monitor’s settings so it wouldn’t frighten him every time his heart rate spiked.
Lachlan tugged at his collar bone, his chest looking retracted. Five hours later, he still hadn’t been admitted. Rutledge’s hands trembled and tears streamed down her face.
“I know you guys are exhausted at this hospital, and I get it,” she shouted, leaning over Lachlan’s bed to level her eyes with the attending physician on the other side. “But you will not send this child home so he can watch his own vitals drop.”
Lachlan was discharged from the ER after 10 hours with a course of steroids to fight the inflammation in his lungs.
He sleeps in his parents’ bedroom so they can check his oxygen levels and administer nebulizer treatments every few hours throughout the night.