Implementing Pediatric Readiness in a Statewide Trauma System: Texas Trauma Centers Perspectives Following New Trauma Rule Adoption

Pediatric Readiness (PR), a system-based framework to meet the needs of critically ill and injured children in the emergency department (ED), is associated with up to a 76% decreased mortality risk. On September 1, 2025, Texas became the first state to enact new Trauma Designation Rules requiring adoption of PR components including pediatric competencies, quality improvement, pediatric equipment and supplies, imaging guidelines, simulations, and annual participation in the National PR assessment. The proposed Rules, initially published in January 2024, received numerous public comments and concerns about the implementation timeline. This study explores organizational, cultural, and system-level factors influencing the acceptance and implementation of these PR requirements.

This qualitative study used structured interviews with Trauma Medical Directors, Program Managers, and ED leaders. Participants were recruited through a regional trauma system. Interviews followed a standardized script addressing institutional culture, leadership, staffing, data use, and perceived barriers and strengths to PR implementation. Data was analyzed through an inductive coding process and applied to interview transcripts using thematic analysis until saturation was achieved.

Key themes emerged. The strengths of PR implementation included leadership commitment, integration of PR into existing trauma quality structures, and collaboration among ED and trauma teams. Barriers to implementation included low pediatric patient volume, insufficient protected time for PR roles, staff turnover, and resource constraints specifically in lower-level trauma centers. Participants also described variable institutional understanding of PR requirements and inconsistent access to pediatric-specific data to guide quality improvement. Institutional culture and adaptability strongly influenced engagement with these new standards.

Implementation of PR requirements under the new Texas Trauma Rules is shaped by institutional culture, leadership engagement, and workforce capacity. Addressing gaps in infrastructure, staff support, and data collection may enhance statewide PR and inform future trauma system development.