on diversion and 22 percent having patients boarded, awaiting transfer to an inpatient bed (Schneider et al., 2003). However, because most communities and states do not systematically monitor rates of ambulance diversion and the boarding of inpatients in hospital EDs, the extent of these problems and the magnitude of their impact on access to care are largely unknown.

Most studies of boarding and diversion do not specifically address pediatric patients, so the extent to which these problems affect such patients is also unknown. However, a Government Accountability Office (GAO) study found that ED staff have less difficulty transferring patients to pediatric beds than to adult critical care or other adult inpatient beds (GAO, 2003). Some children’s hospitals report that they do not go on diversion because there is no alternative source of care for critically injured or ill pediatric patients. However, ED crowding is at least anecdotally an important problem for many children’s hospitals. And in hospitals where adults and children are treated in the same ED, the hospital’s diversion status will affect pediatric and adult patients equally.

Another challenge to the system is that hospitals are finding it increasingly difficult to identify key specialists, such as neurosurgeons and orthopedists, who are able and willing to take call to treat emergency cases. Surgical specialists typically do not work in the ED full time, but serve in an on-call capacity in case they are needed. Surveys confirm that the availability of on-call specialists, including pediatric specialists, in many areas is rapidly eroding or is already inadequate to meet patients’ needs (AAP, 2003; ACEP, 2004; Vanlandingham et al., 2005), and that the problem is worsening (Green et al., 2005; O’Malley et al., 2005).

The role of the emergency care system as a safety net provider also takes a toll. Emergency care providers are the providers of last resort for millions of patients who are uninsured or lack adequate access to care from community providers. Hospitals on the front lines of safety net care encounter patients with intractable social problems, complications resulting from substance abuse or mental illness, and exacerbations of chronic diseases because of inadequate primary care and lack of adherence to medical instructions. Much of the service provided to these difficult patients is compensated poorly or not at all. This care places tremendous financial pressure on safety net hospitals, many of which have closed or are in danger of doing so as a result.

It is within this difficult environment that the emergency care system struggles to meet the unique needs of pediatric patients.

Pediatric Emergency Care and the Six Quality Aims

One way to assess how the current emergency care system is meeting the needs of children is to consider each of the six quality aims for care

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