1
|
Halgren C, Annich GM, Maratta C. Direct vs. redirected admission of critically ill children to PICU after interfacility transfer: a retrospective cohort study. Front Pediatr 2024; 12:1307565. [PMID: 38434728 PMCID: PMC10904567 DOI: 10.3389/fped.2024.1307565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
Background Critically ill children must often be transported long distances for access to critical care resources in Canada. This study aims to describe and compare characteristics and outcomes in patients presenting in the community and requiring inter-facility transport and admission to a Pediatric Intensive Care Unit (PICU). Methods This is a retrospective cohort study of children admitted to the ICU at the Hospital for Sick Children from 2016 to 2019 after inter-facility transport. Characteristics and outcomes were compared between children admitted to the PICU within 24 h from their initial critical care transport request, and children admitted after initial redirection to a non-ICU care setting, 24-72 h from request. The primary outcome was severity of illness at PICU admission. Secondary outcomes included duration of mechanical ventilation, organ dysfunction, PICU length of stay and mortality. Results A total of 2,730 patients were admitted after inter-facility transport to either the medical/surgical or cardiac ICU within 72 h of initial critical care transport request. Of these children, 2,559 (94%) were admitted within 24 h and 171 (6%) were admitted between 24 and 72 h. Children admitted after initial redirection were younger and residing in more rural centers. Children who were initially redirected had lower severity of illness (PRISM-IV median score 3 vs. 5, p = 0.047) and lower risk of mortality. Interpretation Initial redirection to a non-ICU care setting rather than directly admitting to the PICU did not result in increased severity of illness or mortality. This study highlights the need to better understand which factors influence disposition decision-making at the time of initial transport request. Further research should focus on the impact of transport factors on clinical outcomes after PICU admission.
Collapse
Affiliation(s)
- C. Halgren
- Department of Critical Care, Hospital for Sick Children, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - G. M. Annich
- Department of Critical Care, Hospital for Sick Children, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - C. Maratta
- Department of Critical Care, Hospital for Sick Children, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
2
|
Mitra A, Veerakone R, Li K, Nix T, Hashikawa A, Mahajan P. Telemedicine in paediatric emergency care: A systematic review. J Telemed Telecare 2023; 29:579-590. [PMID: 34590883 DOI: 10.1177/1357633x211010106] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The impact of telemedicine on the access and quality of paediatric emergency care remains largely unexplored because most studies to date are focused on adult emergency care. We performed a systematic review of the literature to determine if telemedicine is effective in improving quality of paediatric emergency care with regards to access, process measures of care, appropriate disposition, patient-centred outcomes and cost-related outcomes. METHODS We developed a systematic review protocol in accordance with PRISMA (Preferred Reporting Items for Systematic Review) guidelines. We included studies that evaluated the impact of synchronous and asynchronous forms of telemedicine on patient outcomes and process measures in the paediatric emergency care setting. Inclusion criteria were study setting, study design, intervention type, age, outcome measures, publication year and language. RESULTS Overall, 1.9% (28/1434) studies met study inclusion and exclusion criteria. These studies revealed that telemedicine increased accuracy of patient assessment in the pre-clinical setting, improved time-to disposition, guided referring emergency department (ED) physicians in performing appropriate life-saving procedures and led to cost savings when compared to regular care. Studies focused on telepsychiatry demonstrated decreased length of stay (LOS), transfer rates and improved patient satisfaction scores. DISCUSSION Our comprehensive review revealed that telemedicine enhances paediatric emergency care, enhances therapeutic decision-making and improves diagnostic accuracy, and reduces costs. Specifically, telemedicine has its most significant impact on LOS, access to specialized care, cost savings and patient satisfaction. However, there was a relative lack of randomized control trials, and more studies are needed to substantiate its impact on morbidity and mortality.
Collapse
Affiliation(s)
- Aditi Mitra
- University of Michigan in Ann Arbor, Michigan
| | | | - Kathleen Li
- Department of Public Health, University of Michigan, USA
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, USA
| | - Tyler Nix
- Taubman Health Sciences Library, University of Michigan, USA
| | | | | |
Collapse
|
3
|
Pedrotti CHS, Accorsi TAD, Amicis Lima KD, Filho JRDOS, Morbeck RA, Cordioli E. Cross-sectional study of the ambulance transport between healthcare facilities with medical support via telemedicine: Easy, effective, and safe tool. PLoS One 2021; 16:e0257801. [PMID: 34591876 PMCID: PMC8483335 DOI: 10.1371/journal.pone.0257801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 09/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Feasibility and safety of ambulance transport between healthcare facilities with medical support exclusively via telemedicine are unknown. Methods This was a retrospective study with a single telemedicine center reference for satellite emergency departments of the same hospital. The study population was all critically ill patients admitted to one of the peripheral units from November 2016 to May 2020 and who needed to be transferred to the main building. Telemedicine-assisted transportation was performed by an emergency specialist. The inclusion criteria included patients above the age of 15 and initial stabilization performed at the emergency department. Unstable, intubated, ST-elevation myocardial infarction and acute stroke patients were excluded. There was a double-check of safety conditions by the nurse and the remote doctor before the ambulance departure. The primary endpoint was the number of telemedicine-guided interventions during transport. Results 2840 patients were enrolled. The population was predominantly male (53.2%) with a median age of 60 years. Sepsis was the most prevalent diagnosis in 28% of patients, followed by acute coronary syndromes (8.5%), arrhythmia (6.7%), venous thromboembolism (6.1%), stroke (6.1%), acute abdomen (3.6%), respiratory distress (3.3%), and heart failure (2.5%). Only 22 (0.8%) patients required telemedicine-assisted support during transport. Administration of oxygen therapy and analgesics were the most common recommendations made by telemedicine emergency physicians. There were no communication problems in the telemedicine-assisted group. Conclusions Telemedicine-assisted ambulance transportation between healthcare facilities of stabilized critically ill patients may be an option instead of an onboard physician. The frequency of clinical support requests by telemedicine is minimal, and most evaluations are of low complexity and easily and safely performed by trained nurses.
Collapse
Affiliation(s)
- Carlos H. S. Pedrotti
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- * E-mail:
| | - Tarso A. D. Accorsi
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | | | - Renata A. Morbeck
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| |
Collapse
|
4
|
Telemedicine in Pediatric Intensive Care Units: Perspectives From a Brazilian Experience. CURRENT PEDIATRICS REPORTS 2021; 9:65-71. [PMID: 34277142 PMCID: PMC8274668 DOI: 10.1007/s40124-021-00242-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
Purpose of Review To present the implementation of a telemedicine project (TeleICU) in pediatric intensive care units (ICU) throughout different Brazilian regions. Recent Findings Although telemedicine in pediatric ICUs has shown evidence of benefit in numerous studies with potential to 18 mitigate existing disparities, in Brazil, its use is still under development. Brazil has several opportunities for implementing this resource since, according to the National Registry of Healthcare 20 Establishments (NRHE), there is a discrepancy in the density of pediatric intensive care physicians per patient and the availability 21 of pediatric ICU beds per number of inhabitants. Summary Health technologies are being widely used to fill gaps in the healthcare system. Telemedicine has been an important tool to meet demands in intensive care units, especially the demand for specialized assistance. TeleICU is a Brazilian model of telemedicine that performs multidisciplinary telerounds in remote pediatric ICUs and develops continuing education activities for the healthcare teams. The project aims to systematize and to qualify care, as well as to reduce risks for patients admitted to pediatric ICUs engaged in the project. Preliminary results have demonstrated a positive impact regarding this approach, providing medical care to 6640 inpatients-day in two Brazilian pediatric ICUs, for 616 patients during 946 daily telerounds. Supplementary Information The online version contains supplementary material available at 10.1007/s40124-021-00242-z.
Collapse
|
5
|
Vinadé Chagas ME, Rodrigues Moleda Constant HM, Cristina Jacovas V, Castro da Rocha J, Galves Crivella Steimetz C, Cotta Matte MC, de Campos Moreira T, Cezar Cabral F. The use of telemedicine in the PICU: A systematic review and meta-analysis. PLoS One 2021; 16:e0252409. [PMID: 34048494 PMCID: PMC8162650 DOI: 10.1371/journal.pone.0252409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/14/2021] [Indexed: 11/22/2022] Open
Abstract
The use of telemedicine in ICUs has grown and is becoming increasingly recognized. However, its impact on PICUs remains unclear. This systematic review and meta-analysis aimed to evaluate whether telemedicine in the PICU has the potential to improve clinical and non-clinical outcomes. PubMed, Scopus, LILACS, and CINAHL electronic databases were searched to identify studies that assessed the impact of telemedicine on clinical outcomes, with no publication date restrictions. The reference lists of the selected articles were hand-searched for additional studies that had not been identified by the initial electronic search. Studies were included if they had a cohort design, used telemedicine, were conducted in PICUs or specialized PICUs, and were published in Portuguese, English, or Spanish. Two groups of reviewers independently screened titles and abstracts for inclusion. The same group of reviewers independently assessed the full-text articles for eligibility and extracted the following information: telecommunication method, intervention characteristics, patient characteristics, sample size, and main results. Studies were meta-analyzed using a random-effects model to estimate the pooled prevalence of PICU mortality and length of PICU stay. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 2703 studies initially identified, 2226 had their titles and abstracts screened. Of these, 53 were selected for full-text reading, of which 10 were included and analyzed. The main results of interest were length of PICU stay, number of deaths or mortality rate, and satisfaction of health professionals and family members. The results of meta-analysis show that the mortality rate reduced by 34% with an increase of the length of PICU stay in the PICUs with the use of telemedicine. Family members and health professionals were satisfied with the use of telemedicine. Telemedicine has the potential to improve PICU outcomes, such as mortality rate and family and staff satisfaction. However, it extended length of PICU stay in the studies included in this systematic review.
Collapse
Affiliation(s)
- Maria Eulália Vinadé Chagas
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
- * E-mail:
| | | | - Vanessa Cristina Jacovas
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Jacqueline Castro da Rocha
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Carina Galves Crivella Steimetz
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Maria Cristina Cotta Matte
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Taís de Campos Moreira
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| | - Felipe Cezar Cabral
- Brazilian Unified Health System Institutional Development Program (PROADI-SUS), Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil
| |
Collapse
|
6
|
Sauers‐Ford HS, Hamline MY, Gosdin MM, Kair LR, Weinberg GM, Marcin JP, Rosenthal JL. Acceptability, Usability, and Effectiveness: A Qualitative Study Evaluating a Pediatric Telemedicine Program. Acad Emerg Med 2019; 26:1022-1033. [PMID: 30974004 DOI: 10.1111/acem.13763] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/04/2019] [Accepted: 04/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric emergency telemedicine consultations have been shown to provide support to community emergency departments treating critically ill pediatric patients. However, despite the recognized value of telemedicine, adoption has been slow. To determine why clinicians frequently do not use telemedicine when it is available for pediatric patients, as well as to learn how to improve telemedicine programs, we conducted a qualitative study using stakeholder interviews. METHODS We conducted a qualitative study using grounded theory methodology, with in-depth interviews of referring and accepting physicians and referring, transport, and transfer center nurses. We analyzed data iteratively and adapted the interview guide based on early interviews. We solicited feedback from the participants on the conceptual model. RESULTS Sixteen interviews were conducted; all respondents had been involved in a telemedicine consultation at least five times, with some having used telemedicine more than 30 times. Analysis resulted in three themes: 1) recognizing and addressing telemedicine biases are central to gaining buy-in; 2) as technology advances, telemedicine processes need to adapt accordingly; and 3) telemedicine increases collaboration among health care providers and patients/families in the patient care process. CONCLUSIONS To improve patient care through increased use of telemedicine for pediatric emergency consultations, processes need to be modified to address provider biases and end-user concerns. Processes should be adapted to allow users to utilize a variety of technologies (including smartphones) and to enable more users, such as nurses, to participate. Finally, telemedicine can be used to improve the patient and family experience by including them in consultations.
Collapse
Affiliation(s)
| | | | - Melissa M. Gosdin
- Center for Healthcare Policy and Research University of California Davis Sacramento CA
| | - Laura R. Kair
- Department of Pediatrics University of California Davis Sacramento CA
| | - Gary M. Weinberg
- Center for Healthcare Policy and Research University of California Davis Sacramento CA
| | - James P. Marcin
- Department of Pediatrics University of California Davis Sacramento CA
| | | |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Access to care for children requiring pediatric general or specialty surgery or trauma care who live in rural areas remains a challenge in the United States. RECENT FINDINGS The expertise of specialists in tertiary centers can be extended to rural and underserved areas using telemedicine. There are challenges to making these resources available that need to be methodically approached to facilitate appropriate relationships between hospitals and providers. Programs, such as the National Pediatric Readiness Project and the HRSA Emergency Medical Services for Children Program enhance the capability of the emergency care system to function optimally, keep children at the home hospital if resources are available, facilitate transfer of patients and relationship building, and develop necessary transfer protocols and guidelines between hospitals. SUMMARY Telehealth services have the potential to enhance the reach of tertiary care for children in rural and underserved areas where surgical and trauma specialty care is not readily available, particularly when used to augment the objectives of national programs.
Collapse
|
8
|
Louie MC, Chang TP, Grundmeier RW. Recent Advances in Technology and Its Applications to Pediatric Emergency Care. Pediatr Clin North Am 2018; 65:1229-1246. [PMID: 30446059 DOI: 10.1016/j.pcl.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.
Collapse
Affiliation(s)
- Marisa C Louie
- Department of Emergency Medicine, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA; Department of Pediatrics, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA.
| | - Todd P Chang
- Pediatric Emergency Medicine, Keck School of Medicine at University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Boulevard Mailstop 113, Los Angeles, CA 90027, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Roberts Center, 2716 South Street, 15th Floor, Philadelphia, PA 19146, USA
| |
Collapse
|
9
|
Use of Telemedicine During Interhospital Transport of Children With Operative Intracranial Hemorrhage. Pediatr Crit Care Med 2018; 19:1033-1038. [PMID: 30134361 DOI: 10.1097/pcc.0000000000001706] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To analyze the impact of an intervention of using telemedicine during interhospital transport on time to surgery in children with operative intracranial hemorrhage. DESIGN We performed a retrospective chart review of children with intracranial hemorrhage transferred for emergent neurosurgical intervention between January 1, 2011 and December 31, 2016. We identified those patients whose neuroimaging was transmitted via telemedicine to the neurosurgical team prior to arrival at our center and then compared the telemedicine and nontelemedicine groups. Mann-Whitney U and Fisher exact tests were used to compare interval variables and categorical data. SETTING Single-center study performed at Johns Hopkins Hospital. PATIENTS Patients less than or equal to 18 years old transferred for operative intracranial hemorrhage. INTERVENTIONS Pediatric transport implemented routine telemedicine use via departmental smart phones to facilitate transfer of information and imaging and reduce time to definitive care by having surgical services available when needed. MEASUREMENTS AND MAIN RESULTS Fifteen children (eight in telemedicine group; seven in nontelemedicine group) met inclusion criteria. Most had extraaxial hemorrhage (87.5% telemedicine group; 85.7% nontelemedicine group; p = 1.0), were intubated pre transport (62.5% telemedicine group; 71.4% nontelemedicine group; p = 1.0), and arrived at our center's trauma bay during night shift or weekend (87.5% telemedicine group; 57.1% nontelemedicine group; p = 0.28). Median trauma bay Glasgow Coma Scale scores did not differ (eight in telemedicine group; seven in nontelemedicine group; p = 0.24). Although nonsignificant, when compared with the nontelemedicine group, the telemedicine group had decreased rates of repeat preoperative neuroimaging (37.5% vs 57%; p = 0.62), shorter median times from trauma bay arrival to surgery (33 min vs 47 min; p = 0.22) and from diagnosis to surgery (146.5 min vs 157 min; p = 0.45), shorter intensive care stay (2.5 vs 5 d) and hospitalization (4 vs 5 d), and higher home discharge rates (87.5% vs 57.1%; p = 0.28). CONCLUSIONS Telemedicine use during interhospital transport appears to expedite definitive care for children with intracranial hemorrhage requiring emergent neurosurgical intervention, which could contribute to improved patient outcomes.
Collapse
|
10
|
Mercier RJ, Birnbaum S. Potentially avoidable inter-hospital transfer for gynaecology consultation at a tertiary care centre: a retrospective study. J OBSTET GYNAECOL 2018; 39:164-169. [PMID: 30230392 DOI: 10.1080/01443615.2018.1468742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Inter-hospital transfers for consultation are common and costly in the USA. Our objective was to evaluate the inter-hospital transfers between the emergency departments (ED) for a gynaecology consultation and to identify markers for potentially avoidable transfers. We performed a retrospective chart review of all transfers accepted by a tertiary care hospital gynaecology service via the ED over two years. Our primary outcome was the designation of the transfer as 'potentially avoidable', defined as a patient discharged home directly from the ED, with no workup or treatment prior to their discharge. The Chi-square tests were used to assess what patient characteristics and medical diagnoses are associated with potentially avoidable transfers. Of 156 patients meeting the inclusion criteria, a total of 38 (24.4%) were potentially avoidable transfers. Women with potentially avoidable transfers were more likely to be pregnant than those whose transfers were necessary (63.2% vs. 40.7% p = .02), and more likely to specifically have a pregnancy of unknown location (PUL) or a complete abortion (p < .01).
Collapse
Affiliation(s)
- Rebecca J Mercier
- a Department of Obstetrics and Gynecology , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| | - Sandra Birnbaum
- a Department of Obstetrics and Gynecology , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| |
Collapse
|
11
|
The Current State of the Pediatric Emergency Medicine Workforce and Innovations to Improve Pediatric Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|