A survey has been created, using both a paper questionnaire and the link to a database on Google Drive. The data collected have been: age of managed children, presence of triage, presence of Sub-intensive Care Unit and Intensive Care Unit and special questions about Pediatric SSO, availability of training courses for workers, number of ED access in the last 4 years.

National Presidents of Scientific Society were invited to widespread the questionnaire among Directors of Pediatric ED and Pediatric Wards.

Those who did not spontaneously answer, where then directly contacted, via email and/or through a phone call, and invited to fill in the questionnaire and to provide requested information.

In order to reduce potential missed data, by consulting the Ministry of Health list about hospital emergency network (2019 and 2022 editions) and through specific research about hospital pediatric welfare network of each single region, every hospital with ED in each region has been contacted in order to verify the availability of a Pediatric ED and / or a Pediatric Ward [8].

Collected data have been analyzed using Microsoft Excel Pivot and MedCalc statistical software (https://www.medcalc.org/); to best highlight our results, we reported also the data by each single region, to allow Regional President to evaluate the state of the art of pediatric hospital welfare and specifically about SSO.

This survey is still ongoing, without a definite deadline, so we presented the preliminary data, collected at 1st January 2023.

Currently, data collection has been completed in 16 regions (Abruzzo, Basilicata, Calabria, Campania, Emilia-Romagna, Friuli-Venezia-Giulia, Lazio, Liguria, Marche, Molise, Puglia, Sardinia, Tuscany, Umbria, Valle d’Aosta, Veneto), where at 1st January 2022, there were 5,995,349 inhabitants aged under 17 years (equal to 65.16% of the 9,200,287 younger inhabitants surveyed in Italy). Data are still being collected in the other regions (Piedmont, Lombardy, A.P. of Bolzano and Trento, Sicily): in these regions at 1st January 2022, 3,204,938 younger inhabitants were reported (34.84% of the younger surveyed in Italy).

The hospitals have been divided, according to their features, into General Hospitals, first and second level EDs and Pediatric Hospitals.

According to the current legislation [5], General Hospitals could not have a specific Pediatric Ward, whereas they should always be present in first level EDs, which are the Spoke of pediatric hospital emergency network, and in second level ED, which represent the Hub.

Out of the 253 received surveys, there are 180 Pediatric SSOs in activity (71.15% of the Hospitals). There are no active Pediatric SSO in the 33.67% of first level EDs, in the 19.35% of second level EDs, and in the 33.27% of General Hospitals with Pediatric Wards (Table 1).

Active SSO are mainly located (76.11%) within Pediatric Wards (Table 2).

Percentage of active SSO is lower in regions in which national guidelines have not yet been adopted and in regions, such as Lombardy, in which they have been recently adopted (Table 3).

Statistically significant differences have been highlighted among the 16 regions in which the survey collection has been completed, independently from the features of hospital considered (first level EDs, second level EDs, General Hospitals) (Fig. 1):

The regions of Emilia-Romagna, Friuli-Venezia-Giulia, Liguria, Marche, Tuscany, Umbria, Valle d’Aosta, Veneto have adopted guidelines; in these regions, in which altogether live 2.706.425 subjects less than 17 years old, there are 102 Hospital with Pediatric ED and / or Pediatric Wards, and the percentage of active SSOs is 96,08%.

The regions of Abruzzo, Basilicata, Calabria, Campania, Lazio, Molise, Puglia and Sardinia have not yet adopted guidelines: here there are 3,288,924 subjects aged less than 17 years, there are 105 Hospital with Pediatric ED and / or Pediatric Wards and the percentage of active SSOs is 40.00%

Percentage (%) of active pediatric SSOs among all hospitals in the 16 Regions which have completed the survey

In the 8 regions which are following guidelines, SSOs are active in all the second level EDs (compared to 60.87% of the other 8 regions), in the 91.66% of first level EDs (compared to the 33.3%), and in the 97.1% of General Hospitals (compared to 33.3%) (Table 4). Differences, calculated with McNemar test, result statistically significant: p < 0.0001 (Table 5).

The territorial analysis of these 16 regions highlighted significant geographical differences in the percentage of active SSOs in the hospitals of the 3 areas of Italy: North (Emilia-Romagna, Friuli-Venezia-Giulia, Liguria, Valle d’Aosta, Veneto) 93.38%; Center (Lazio, Marche, Umbria, Tuscany) 88.15%; South (Abruzzo, Basilicata, Calabria, Campania, Molise, Puglia, Sardinia) 35.21%. (Fig. 2).

Percentage (%) of active SSOs among the hospitals of the 16 Regions of Italy by geographical areas

Noteworthy, in Molise there are not pediatric SSO, although there are 3 hospitals with a Pediatric Ward, 2 of which are first level ED; moreover, in some regions of Southern Italy, there are some active SSOs although regions have not yet adopted guidelines and do not provide any remuneration. Furthermore, also in regions in which SSO has been adopted, there are first level ED with Pediatric Wards without active SSOs.