Michigan hospitals have coordinated pediatric transfers informally for years, through a shared dashboard and a standing weekly call. The Pediatric Safety Net turns those habits into a documented, governed system that holds when a season turns bad. Hospitals, EMS, public health, and state partners are building it together.
The content provided reflects the authors' viewpoints and perspectives. It does not represent the official views or endorsements of the Administration for Strategic Preparedness and Response (ASPR), the Department of Health and Human Services (HHS), or the United States Government. Region V for Kids Pediatric Disaster Center of Excellence is funded by a grant from the Administration for Strategic Preparedness and Response (ASPR) within the U.S. Department of Health and Human Services (#U3REP190615-10-13). The authors are supported by this grant. For more information, visit ASPR.gov.
A severe RSV season pushed Michigan's informal coordination past its limits. Leaders were meeting twice a week, working the dashboard, and still sending children to Ohio and calling hospitals in Illinois. Four conditions made that outcome likely, and each one shapes what the model has to solve.
Pediatric ICUs cluster in a handful of urban centers, and many rural communities have no PICU within 60 to 90 minutes. The Upper Peninsula depends heavily on Wisconsin for winter transport. When a storm degrades roads and grounds air crews, the closest reachable bed matters more than the usual referral relationship.
One hospital never boards because it can flex inpatient space. Another boards routinely and cannot expand. Some count a bed as staffed the moment the room exists, because they will find a way to staff it, and others do not. A shared system that caps at one hundred percent also makes a stressed hospital look better the moment it opens beds and its occupancy falls.
Physical space is rarely the constraint. Beds sit closed for lack of staff, and a surge can come down to one committed critical care transport crew with air out of service. Transport runs every day and fails first in bad weather. It is not currently a standing item on the coordination calls.
When things get tight, each hospital guards its own beds and its own community first. The instinct makes sense inside a single hospital. It is also the reason a child in one part of the state can wait while capacity sits open in another. The model exists to move the group past it at the moments when it matters most.
When a hospital has called three centers and still has nowhere to send a child, the system is already in trouble, whatever the bed numbers show.
A finding the group returned to throughout this workWatch borrows the intuition of a tornado watch: something is developing, everyone is paying attention, no one is acting yet. Active coordination is the state where hospitals are actively helping one another move patients and resources. Crisis is the state where the system needs coordinated participation to keep children safe. Working teams have read live data sheets and arrived at the same levels independently. That was the test the scale was built to pass.
Volume is climbing and a hospital or two reports local strain, but every facility still has internal strategies to manage its own census.
Placement is getting hard, declines are becoming common, and hospitals need each other to move patients and resources.
Children cannot be placed, scarce resources such as ECMO circuits are committed, and the system needs coordinated participation to keep children safe.
A community hospital working seven or eight calls down a referral list, spending hours and being told to check back if it gets bad enough, is a clearer signal than any occupancy percentage. That pattern happens every respiratory season, and it is what prompts the larger centers to start changing what they do. The model treats it as an access failure and reads it as a trigger.
The shared system can display beds, equipment, and transfer status on its own. How a hospital is actually doing, and what it can still flex, tends to surface only on the call. Sorting the two sets what the group automates and what each organization is expected to say out loud.
Current, ideally automated, and the same for everyone looking at it. This is the layer where standard definitions matter most, because the number has to mean the same thing at every hospital.
How a hospital is really doing, what it can still flex, and what it needs. None of this appears in a bed count, and teams asked for it before committing to a level.
It can convene hospitals and align them around a shared read of the situation. It cannot compel a hospital to open a bed, staff a unit, or accept a patient. Its influence rests on organizations choosing to accept the process, so the commitment has to scale with the level and be settled well before a crisis makes it urgent.
Hospitals share what they are seeing and keep the standing call. Participation is voluntary at this level.
The coordinating body actively helps hospitals move patients and resources, guides sending facilities to where capacity actually sits, and gives the call real structure through named liaisons and clear report-out roles.
Participation is backed by agreements organizations signed in advance. A formal memorandum of understanding is reserved for the crisis level. Settling this ladder is the step the rest of the work depends on.
Today the first call goes to whoever a site always calls, and the caller often works down a list of transfer centers on hold. Regional and community hospitals have described wanting one place to start. What that becomes, and who staffs it, is still being worked through with the organizations that would carry it. In the near term, much of it can run on the bed placement teams and the tools already in daily use.
Every hospital in the state has a role in the pediatric continuum, whether or not it has a PICU bed. The model is built so that stabilizing, holding, and receiving all count.
A shared way to say where the system is, so a room of busy people can agree on the level and what follows from it.
Standard definitions so the same number means the same thing at every hospital reporting it.
A structured coordination call with a named liaison, a standing agenda, and transport reported alongside beds.
A known path for a hospital that cannot place a child, including who to call and what happens next.
Several parts of the model are deliberately unfinished. Naming them is more useful than papering over them, because each one changes how the model behaves when it is needed.
If pediatric ICU capacity becomes the trigger, the group has to state plainly whether that percentage is measured against licensed beds or against real time staffed beds on a given morning.
De-escalation from crisis and surge to routine operations is the least defined decision in the whole model, and the group has named it as the most critical one to settle.
One thread favors a composite acuity or surge score drawn from the record. Clinical leaders note that acuity is statistically stable across pediatric centers unless something truly abnormal is happening, and argue for an objective, documentable trigger. Both have merit and need reconciling into one.
Scarce resource allocation rules and crisis standards of care do not exist yet. In practice people do the right thing in the moment and sort out reimbursement afterward, which gets complicated across systems and across state lines.
A sudden bolus of pediatric patients from a single event came up repeatedly. Whether the current approach handles it or needs its own method should be resolved deliberately rather than assumed.
Much of the early warning and much of the strain lives with these hospitals. They are also the least connected to the dashboard and the coordination structure. They need a way in that they will actually use during a season.
Children's hospitals, community and rural hospitals, EMS and transport, public health, the hospital association, and state partners work the same problem at the same table. Similar conversations are happening at large centers around the country. Few are running at the state level with this range of partners in one room.
A named champion at each participating organization who carries the work locally and keeps it moving between sessions.
Rural and community health leadership at the table, so the parts of the state with the least access shape the model directly.
The family and community perspective, which the provider side of the framework does not yet capture, gathered through a family focus group and folded back into the model.
TranscendX thanks Corewell Health Children's for sponsoring this work and for the opportunity to take part in it, carried out under the umbrella of Region V for Kids, the Pediatric Disaster Center of Excellence.
Everything on this page comes from work the group did together and documented in full. The reports include the complete data elements, trigger criteria, governance discussion, recommendations, and the open questions, along with the reasoning behind each.
The foundational report. Three working groups built the pediatric data set and dashboard requirements, the trigger based activation framework, and the redesigned critical care distribution model, including the coordination hub concept and early governance thinking.
The framework tested in live decision making. Teams read hospital data sheets, diagnosed the level themselves, and worked escalating scenarios. This report covers how the group reads the situation, what constrains the response, where authority and crisis governance still need to be built, and the data the calls need to carry.
These reports document work in progress. Where the group has not reached agreement, the reports say so rather than resolving it on paper.