Interhospital pediatric patient transfers-factors influencing rapid disposition after transfer

Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal

OBJECTIVE

Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies.

METHODS

We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated.

RESULTS

Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%.

CONCLUSION

Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications.

LEVEL OF EVIDENCE

Level 3 Case-series Laryngoscope, 2024.

Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems

OBJECTIVE

To describe the frequency and observed trends for all Indian Health Service (IHS) and tribal emergency department (ED) transfers to a pediatric referral center from January 1, 2017, to December 31, 2020, with a secondary analysis to describe trends in final dispositions, lengths of stay (LOS), and the most common primary ICD-10 diagnoses.

METHODS

We performed a retrospective chart review of IHS and tribal ED transfers to a pediatric referral center from 2017 to 2020 (n = 2433). The data were summarized using frequencies and percentages and we used generalized estimating equations to analyze patient characteristics over time.

RESULTS

IHS and tribal ED transfers accounted for 6.5%-7.1% of all transfers each year between 2017 and 2020 without significant changes over time. Within this group, 60% were admitted and 62% experienced a LOS greater than 24 h. The most common diagnostic code groups for these patients were respiratory conditions, injuries and poisonings, nonspecific abnormal clinical findings and labs, digestive system diseases, and nervous system diseases.

CONCLUSIONS

This study addresses important knowledge gaps regarding transfers from IHS and tribal EDs, highlights potential high-impact areas for pediatric readiness, and emphasizes the need for more granular data to inform resource allocation and educational interventions. Further studies are needed to delineate potentially avoidable transfers seen within this population.

Outcome of interhospital pediatric foreign body transfers

BACKGROUND

Children with foreign bodies are often transferred from general emergency departments (EDs) to children's hospitals for optimal management. Our objective was to describe the outcomes of interhospital pediatric foreign body transfers and examine factors associated with potentially avoidable transfers (PATs) in this cohort.

METHODS

We conducted a retrospective cohort study of children aged <18 years transferred to our hospital for the primary complaint of foreign body from January 1, 2020, to September 30, 2022. Data collected included demographics, diagnostic studies and interventions performed, and disposition. A transfer was considered a PAT if the patient was either discharged from the pediatric emergency department (PED), or from inpatient care within 24 h, did not require procedural sedation and any procedural intervention by a pediatric sub-specialist (other than a pediatric ED physician). Logistic regression analysis was performed to evaluate factors associated with PATs.

RESULTS

A total of 213 patients were analyzed based on eligibility criteria. The majority of patients were male (51.2%), pre-school age (59.2%), symptomatic (55.8%), and transferred from academic EDs (61%). Coins were the most common foreign bodies (30%), with the gastrointestinal tract (63.8%) being the most common location. Half of the non-respiratory and non-gastrointestinal foreign bodies were successfully removed in the PED. Over half (57.3%) of the patients were discharged from PED. Operative intervention was required in 82 (38.5%) patients, most commonly for coins (50%). 41.8% of transfers were deemed PATs. Presence of foreign body in the esophagus or respiratory tract (OR: 0.071, 95% CI: 0.025-0.200), symptoms at presentation (OR: 0.265, 95% CI: 0.130-0.542), magnet ingestions (OR: 0.208, 95% CI: 0.049-0.886) and transfers from community EDs (OR: 0.415, 95% CI: 0.194-0.885) were less likely associated with PATs. Button battery-related transfers were more likely associated with an avoidable transfer (OR: 6.681, 95% CI: 1.15-39.91).

CONCLUSIONS

PATs are relatively common among children transferred to a children's hospital for foreign bodies. Factors associated with PATs have been identified and may represent targets for interventions to avoid low value pediatric foreign body transfers.

Resource Utilization for Pediatric Patients Discharged After Interhospital Transfer

BACKGROUND

Transfers to a pediatric emergency department (ED) with subsequent discharge home should be optimized. Transfers to a pediatric ED (PED) from community and academic general EDs are compared with a focus upon subsequent resource utilization with the PED to identify patterns of resource and education needs within general EDs.

METHODS

Patients younger than 21 years transferred to a PED from general EDs over a 1-year period and discharged home were retrospectively reviewed. The referring institutions were categorized as academic or community. Demographic and clinical variables reflecting PED care were abstracted and referrals from the academic and community institutions were compared.

RESULTS

Among 5675 interfacility transfers, 1603 (28.2%) were discharged home from the PED. Most patients were transferred from a community ED (n = 1081, 67.4%). Laboratory testing, ancillary studies, and medication administration did not differ between patients transferred from an academic or community ED. Patients from a community ED were more likely to have a procedure performed (44% vs 39%, P = 0.04). Patients from a community ED were also more likely to have high resource utilization in the PED (61% vs 55%, P = 0.03).

DISCUSSION

Most children transferred to a PED from a general ED required few resources in the PED before discharge home. The pattern of care delivered in the PED differed by the designation of the transferring ED providing insight into the differential educational and resource needs of general EDs in caring for pediatric patients.

Children's Hospital Transfers From Referring Emergency Departments: Which Patients Bypassed the Pediatric Emergency Department?

OBJECTIVES

Children are increasingly transferred from emergency departments (EDs) to children's hospitals for inpatient care. The existing literature on the use of direct admission (DA) specifically among pediatric patients transferred from referring EDs remains sparse.The objective of this study was to identify demographic, clinical, and contextual factors associated with the use of direct-to-inpatient versus ED-to-inpatient admission among patients transferred to children's hospitals from EDs.

METHODS

This was a retrospective chart review of nontrauma patients admitted to inpatient services at a single tertiary children's hospital after interfacility transfer from EDs between July 1, 2016, and June 30, 2017. Characteristics of the patient population and referring EDs were described; unadjusted associations between rates of DA and the demographic, clinical, and contextual variables of encounters were performed; and a logistic model quantified the relevant associations as odds ratios (ORs).

RESULTS

Of 2939 study encounters, 78% resulted in DA. Among White patients, private insurance was associated with decreased direct admission (OR, 0.5; 95% confidence interval [CI], 0.4-0.8). Younger patients and patients with respiratory diagnoses (OR, 3.9; 95% CI, 2.8-5.3) had increased likelihood of DA. Patients with gastrointestinal diagnoses had decreased likelihood of DA (OR, 0.6; 95% CI, 0.4-0.7).

CONCLUSIONS

At a tertiary hospital with a high rate of DA among patients transferred from other EDs, we identified factors that were associated with the use of direct versus ED admission. Our results identify specific populations in which future work could inform admission processes for interfacility transfers.

Pediatric Patients Brought by Emergency Medical Services to the Emergency Department: An Analysis From the National Hospital Ambulatory Medical Care Survey

BACKGROUND/OBJECTIVE

To describe the epidemiology of emergency department (ED) visits by pediatric patients transported from the out-of-hospital setting (ie, scene) by emergency medical services (EMS), and identify factors associated with EMS transport.

METHODS

We performed a cross-sectional study of ED visits from 2014 to 2017 utilizing a nationally representative probability sample survey of visits to US EDs. We included pediatric patients (<18 years old) and compared encounters transported from the scene by EMS to those who arrived to the ED by all other means. We performed multivariable logistic regression to identify factors associated with scene EMS transport.

RESULTS

Of 130.2 million pediatric ED encounters, 4.7 million (3.8%) arrived by EMS. Most patients were White (61.1%), non-Hispanic (77.5%), and publicly insured (52.2%). Multivariable analysis demonstrated associations with EMS transport: Black (vs White) race (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.16-1.89), ages 1 to younger than 5 years (aOR, 0.52; 95% CI, 0.37-0.72) and 5 to younger than 12 years (aOR, 0.56; 95% CI, 0.40-0.80) (vs adolescents), pediatric (aOR, 0.60; 95% CI, 0.42-0.85) and nonmetropolitan hospital status (aOR, 0.52; 95% CI, 0.35-0.78), blood testing (aOR, 2.34; 95% CI, 1.71-3.19), time to evaluation (31-60 minutes [aOR, 0.56; 95% CI, 0.39-0.80] and >60 minutes [aOR, 0.51; 95% CI, 0.33-0.77] compared with 0-30 minutes), admission (aOR, 3.20; 95% CI, 2.33-4.38), and trauma (1.80; 95% CI, 1.43-2.28).

CONCLUSIONS

Four percent of pediatric ED patients are transported to the ED by EMS from the scene. These patients receive a rapid and resource intense diagnostic evaluation, suggesting that higher acuity. Black patients, adolescents, and those with trauma were more likely to be transported by EMS.

Profiling Pediatric Potentially Avoidable Transfers Using Procedure and Diagnosis Codes

OBJECTIVES

While hospital-hospital transfers of pediatric patients are often necessary, some pediatric transfers are potentially avoidable. Pediatric potentially avoidable transfers (PATs) represent a process with high costs and safety risks but few, if any, benefits. To better understand this issue, we described pediatric interfacility transfers with early discharges.

METHODS

We conducted a descriptive study using electronic medical record data at a single-center over a 12-month period to examine characteristics of pediatric patients with a transfer admission source and early discharge. Among patients with early discharges, we performed descriptive statistics for PATs defined as patient transfers with a discharge home within 24 hours without receiving any specialized procedures or diagnoses.

RESULTS

Of the 2,415 pediatric transfers, 31.4% were discharged home within 24 hours. Among transferred patients with early discharges, 356 patients (14.7% of total patient transfers) received no specialized procedures or diagnoses. Direct admissions were categorized as PATs 1.9-fold more frequently than transfers arriving to the emergency department. Among transferred direct admissions, PAT proportions to the neonatal intensive care unit (ICU), pediatric ICU, and non-ICU were 5.1%, 17.3%, and 27.3%, respectively. Respiratory infections, asthma, and ill-defined conditions (eg, fever, nausea with vomiting) were the most common PAT diagnoses.

CONCLUSIONS

Early discharges and PATs are relatively common among transferred pediatric patients. Further studies are needed to identify the etiologies and clinical impacts of PATs, with a focus on direct admissions given the high frequency of PATs among direct admissions to both the pediatric ICU and non-ICU.

Emergency Department Pediatric Readiness and Potentially Avoidable Transfers

OBJECTIVE

To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components.

STUDY DESIGN

This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates.

RESULTS

After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan.

CONCLUSIONS

Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.

Availability of Inpatient Pediatric Surgery in the United States

BACKGROUND

In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery.

METHODS

A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth.

RESULTS

Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation.

CONCLUSIONS

Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers.

EDITOR’S PERSPECTIVE

Pediatric Conditions Requiring Minimal Intervention or Observation After Interfacility Transfer

Increasing regionalization of pediatric care has led to interfacility transfer of children with general pediatric conditions at rates similar to those of high-risk adults, which may delay appropriate treatment. We sought to identify common medical diagnoses that did not require significant advanced intervention and that had high rates of discharge within 1 day of interfacility transfer. Using the Pediatric Health Information System (PHIS) database, we identified all transfers into PHIS-participating children's hospitals in 2019. We excluded encounters for mental health, labor/maternity, primary newborn diagnoses, and direct admissions to an intensive care unit. Eligible encounters were categorized by duration of hospitalization and basic vs advanced intervention after transfer. Of 286,905 transfers, 197,386 (68.6%) met inclusion criteria. Cough, febrile seizures, croup, and allergic reactions required advanced interventions <10% of the time, and patients with these diagnoses were most commonly discharged within 1 day after transfer. These conditions are potential targets for building pediatric capacity in non-pediatric hospitals.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

OBJECTIVE

To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer.

STUDY DESIGN

Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ² statistics.

RESULTS

Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions.

CONCLUSIONS

Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.

Factors associated with avoidable interhospital transfers for children with a minor head injury

INTRODUCTION

Children with minor head injuries (MHI) are routinely transferred to a pediatric trauma center for definitive care. Unwarranted transfers result in minimal benefit to the patient and add substantially to healthcare costs. The purpose of this study is to explore the factors associated with avoidable interhospital transfers of children with MHI.

METHODS

We conducted a retrospective cohort study of children <18 years of age transferred to our pediatric emergency department (PED) for MHI between January 2013 and December 2018. Patients transferred for non-accidental trauma, and those with a history of coagulopathies, underlying neurological conditions, intraventricular shunts and developmental delay were excluded. Transfers were categorized as avoidable if none of the following interventions were required at our PED: procedural sedation, anticonvulsant initiation, subspecialty consultation, intensive care unit admission or hospital admission for ≥2 nights, intubation or operative intervention. We collected demographics, injury mechanism, neuroimaging results, interventions performed and PED disposition. Binary logistic regression was conducted to provide adjusted associations between patient characteristics and the risk of avoidable interhospital transfers.

RESULTS

We analyzed 1078 transfers for MHI, of which 450 (42%) transfers were classified as avoidable. Children in the avoidable transfer group tended to be younger, less likely to have experienced loss of consciousness, and more likely to belong to the the group at lowest risk for a clinically important traumatic brain injury (ciTBI). Our multivariable model determined that children less than 2 years of age (OR = 1.75; 95% CI = 1.3-2.37), low-risk group for ciTBI (OR = 1.66; 95% CI = 1.22-0.1), and a positive head CT at the transferring hospital (OR = 0.06; 95% CI = 0.02-0.1) were all significantly associated with avoidable transfers.

CONCLUSION

There is a high rate of avoidable transfers in children with MHI. Focused interventions targeting risk factors associated with avoidable transfers may reduce unwarranted interhospital transfers.

Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods

Background: Despite the recognized benefits of telemedicine use for pediatric emergency consultations, there are barriers to the widespread uptake of this technology. Quality improvement methods can be used to rapidly test implementation strategies. Our objective was to test telemedicine implementation strategies in real-world application using quality improvement methods. Our quality improvement aim was to achieve high rates of telemedicine use for pediatric transfer consultations. Methods: A multidisciplinary multisite improvement team identified that key drivers of increasing telemedicine use included telemedicine resource awareness, streamlined telemedicine workflow, provider buy-in, and data transparency. Interventions focused on telemedicine trainings, disseminating telemedicine uptake data, telemedicine reminders, telemedicine test calls, and preparing for telemedicine use for every transfer consultation. The outcome measure was percentage of pediatric emergency transfer consultations that used telemedicine. The balancing measure was time (minutes) from the initial transfer center call to completion of the consultation. Results: Multiple plan-do-study-act cycles were associated with special cause variation, with an upward shift in mean percentage of telemedicine use from 5% to 22%. Time from initial call to consultation completion remained unchanged. Conclusion: Our study supports the use of quality improvement methods to test telemedicine implementation strategies for pediatric telemedicine emergency consultations.

Predictors of Potentially Unnecessary Transfers to Pediatric Emergency Departments

OBJECTIVES

With soaring US health care costs, identifying areas for reducing cost is prudent. Our objective was to identify the burden of potentially unnecessary pediatric emergency department (ED) transfers and factors associated with these transfers.

METHODS

We performed a retrospective analysis of Pediatric Hospital Information Systems data. We performed a secondary analysis of all patients ≤19 years transferred to 46 Pediatric Hospital Information Systems-participating hospital EDs (January 1, 2013, to December 31, 2014). The primary outcome was the proportion of potentially unnecessary transfers from any ED to a participating ED. Necessary ED-to-ED transfers were defined a priori as transfers with the disposition of death or admission >24 hours or for patients who received sedation, advanced imaging, operating room, or critical care charges.

RESULTS

Of 1 819 804 encounters, 1 698 882 were included. A total of 1 490 213 (87.7%) encounters met our definition for potentially unnecessary transfer. In multivariate analysis, age 1 to 4 years (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.34-1.39), female sex (OR, 1.08; 95% CI, 1.07-1.09), African American race (OR, 1.51; 95% CI, 1.49-1.53), urban residence (OR, 1.75; 95% CI, 1.71-1.78), and weekend transfer (OR, 1.06; 95% CI, 1.05-1.07) were positively associated with potentially unnecessary transfer. Non-Hispanic ethnicity (OR, 0.756; 95% CI, 0.76-0.78), nonminor severity (OR, 0.23; 95% CI, 0.23-0.24), and commercial insurance (OR, 0.86; 95% CI, 0.84-0.87) were negatively associated.

CONCLUSIONS

There are disparities among pediatric ED-to-ED transfers; further research is needed to investigate the cause. Additional research is needed to evaluate how this knowledge could mitigate potentially unnecessary transfers, decrease resource consumption, and limit the burden of these transfers on patients and families.

Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis

OBJECTIVES

The appropriateness of interfacility transfer admissions for bronchiolitis to pediatric centers is uncertain. We characterized avoidable transfer admissions for bronchiolitis. We hypothesized that a higher proportion of hospitalized infants transferred from a community emergency department (ED) or hospital (transfer admission) would be discharged within 48 hours with little or no intervention, compared with direct admissions from an enrolling ED (nontransfer admission).

METHODS

We analyzed a 17-center, prospective infant cohort (age <1 year) hospitalized for bronchiolitis (2011-2014). An avoidable transfer admission (primary outcome) was hospitalization for <48 hours without an intervention for severe illness in which a pediatric specialist could be beneficial (oxygen, advanced airway management, life support). Parenteral fluids and routine medications were excluded. We compared admissions by patient, ED, inpatient, and transferring hospital characteristics to identify factors associated with avoidable transfer admissions. Multivariable logistic regression was used to identify predictors of avoidable transfer admission.

RESULTS

Among 1007 infants, 558 (55%) were nontransfer admissions, 164 (16%) were transfer admissions, and 204 (20%) were referrals from clinics; 81 (8%) were missing referral type. Significantly fewer transferred infants were hospitalized for <48 hours with little or no intervention (40 of 164; 24% [95% confidence interval 18%-32%]) than nontransferred infants (199 of 558; 36% [95% confidence interval 32%-40%]; P = .007). Avoidable transfer admissions were more likely to be children of color, have nonprivate insurance, receive fewer ED interventions, and originate from small EDs. A multivariable model revealed that minority race and/or ethnicity, normal oxygenation, and small ED transfers increased odds of avoidable transfer admission.

CONCLUSIONS

Although most transferred infants hospitalized for bronchiolitis required interventions for severe illness, 1 in 4 admissions were potentially avoidable.

Trends in Regionalization of Emergency Care for Common Pediatric Conditions

BACKGROUND

For children who cannot be discharged from the emergency department, definitive care has become less frequent at most hospitals. It is uncertain whether this is true for common conditions that do not require specialty care. We sought to determine how the likelihood of definitive care has changed for 3 common pediatric conditions: asthma, croup, and gastroenteritis.

METHODS

We used the Nationwide Emergency Department Sample database to study children <18 years old presenting to emergency departments in the United States from 2008 to 2016 with a primary diagnosis of asthma, croup, or gastroenteritis, excluding critically ill patients. The primary outcome was referral rate: the number of patients transferred among all patients who could not be discharged. Analyses were stratified by quartile of annual pediatric volume. We used logistic regression to determine if changes over time in demographics or comorbidities could account for referral rate changes.

RESULTS

Referral rates increased for each condition in all volume quartiles. Referral rates were greatest in the lowest pediatric volume quartile. Referral rates in the lowest pediatric volume quartile increased for asthma (13.6% per year; 95% confidence interval [CI] 5.6%-22.2%), croup (14.8% per year; 95% CI 2.6%-28.3%), and gastroenteritis (16.4% per year; 95% CI 3.5%-31.0%). Changes over time in patient age, sex, comorbidities, weekend presentation, payer mix, urban-rural location of presentation, or area income did not account for these findings.

CONCLUSIONS

Increasing referral rates over time suggest decreasing provision of definitive care and regionalization of inpatient care for 3 common, generally straightforward conditions.

Pediatric Emergency Room Transfers: Are They Warranted?

BACKGROUND

Emergency room transfers to a higher level of care are a vital component of modern health care, as optimal care of patients requires providing access to specialized personnel and facilities. However, literature has shown that orthopaedic transfers to a higher level of care facility are frequently unnecessary. The purpose of this study was to assess the appropriateness of pediatric orthopaedic transfers to a tertiary care center and the factors surrounding these transfers.

METHODS

All pediatric orthopaedic transfers to the pediatric emergency department (ED) were evaluated over a 4-year period. A retrospective chart review was performed to assess the factors surrounding the transfer including patient demographics, time of transfer, day of transfer, insurance status, outcome of transfer, and diagnosis. Three independent variables were utilized to assess the appropriateness of the transfer: the need for an operative procedure, the need for conscious sedation, and the need for a closed reduction in the ED.

RESULTS

A total of 218 pediatric orthopaedic emergency room transfers were evaluated, of which 86% of them involved an acute fracture. Twenty-seven percent (59/218) of the transfers occurred on the weekend, with over half (61%) of these transfers being initiated between 6 PM and 6 AM. Approximately half (47%) of the transfers involved patients with Medicaid. Fifty-five percent (120/218) of cases required a procedure in the operating room and 22% (49/218) had a closed reduction performed in the ED. Conscious sedation was provided in the ED for 22% (48/218) of patients. Twenty-two percent (47/218) of transfers did not require a trip to the operating room, conscious sedation, nor a closed reduction procedure in the ED.

CONCLUSION

The vast majority of pediatric orthopaedic transfers are warranted as they required operative intervention, a closed reduction maneuver, or conscious sedation in the ED.

LEVEL OF EVIDENCE

Level III-Therapeutic.

Developing and Validating a Pediatric Potentially Avoidable Transfer Quality Metric

This study aimed to evaluate a quality metric that identifies pediatric potentially avoidable transfers from diagnosis and procedure codes. Using physician medical record review as the gold standard, the following steps were used: (1) develop the initial metric definition, (2) estimate initial metric definition operating characteristics, (3) refine this definition to optimize the c-statistic, and (4) validate this optimized metric definition using a separate sample. The initial metric using Sample A patient transfers had a c-statistic of 0.63 (95% confidence interval = 0.53-0.73). Following 22 revisions, the optimized metric definition was a transfer discharged within 24 hours that did not receive any of a select list of 60 268 specialized diagnoses or procedures. The optimized metric on Sample B demonstrated a sensitivity of 80.6%, specificity of 85.7%, and c-statistic of 0.83 (95% confidence interval = 0.75-0.91). The quality metric developed and validated in this study demonstrated satisfactory operating characteristics, providing a feasible means to measure this important outcome.

Reliability of Smartphone-Based Instant Messaging Application for Diagnosis, Classification, and Decision-making in Pediatric Orthopedic Trauma

OBJECTIVE

Smartphones have the ability to capture and send images, and their use has become common in the emergency setting for transmitting radiographic images with the intent to consult an off-site specialist. Our objective was to evaluate the reliability of smartphone-based instant messaging applications for the evaluation of various pediatric limb traumas, as compared with the standard method of viewing images of a workstation-based picture archiving and communication system (PACS).

METHODS

X-ray images of 73 representative cases of pediatric limb trauma were captured and transmitted to 5 pediatric orthopedic surgeons by the Whatsapp instant messaging application on an iPhone 6 smartphone. Evaluators were asked to diagnose, classify, and determine the course of treatment for each case over their personal smartphones. Following a 4-week interval, revaluation was conducted using the PACS. Intraobserver agreement was calculated for overall agreement and per fracture site.

RESULTS

The overall results indicate "near perfect agreement" between interpretations of the radiographs on smartphones compared with computer-based PACS, with κ of 0.84, 0.82, and 0.89 for diagnosis, classification, and treatment planning, respectively. Looking at the results per fracture site, we also found substantial to near perfect agreement.

CONCLUSIONS

Smartphone-based instant messaging applications are reliable for evaluation of a wide range of pediatric limb fractures. This method of obtaining an expert opinion from the off-site specialist is immediately accessible and inexpensive, making smartphones a powerful tool for doctors in the emergency department, primary care clinics, or remote medical centers, enabling timely and appropriate treatment for the injured child. This method is not a substitution for evaluation of the images in the standard method over computer-based PACS, which should be performed before final decision-making.

Parent Perceptions on Transfers to Pediatric Emergency Departments and the Role of Telemedicine

OBJECTIVE

Real-time audiovisual consultation (telemedicine) has been proven feasible and is a promising alternative to interfacility transfer. We sought to describe caregiver perceptions of the decision to transfer his or her child to a pediatric emergency department and the potential use of telemedicine as an alternative to transfer.

METHODS

Semistructured interviews of caregivers of patients transferred to a pediatric emergency department. Purposive sampling was used to recruit caregivers of patients who were transferred from varying distances and different times of the day. Interviews were conducted in person or on the phone by a trained interviewer. Interviews were recorded, transcribed, and analyzed using modified grounded theory.

RESULTS

Twenty-three caregivers were interviewed. Sixteen (70%) were mothers; 57% of patients were transported from hospitals outside of the city limits. Most caregivers reported transfer for a specific resource need, such as a pediatric subspecialist. Generally, caregivers felt that the decision to transfer was made unilaterally by the treating physician, although most reported feeling comfortable with the decision. Almost no one had heard about telemedicine; after hearing a brief description, most were receptive to the idea. Caregivers surmised that telemedicine could reduce the risks and cost associated with transfer. However, many felt telemedicine would not be applicable to their particular situation.

CONCLUSIONS

In this sample, caregivers were comfortable with the decision to transfer their child and identified potential benefits of telemedicine as either an adjunct to or replacement of transfer. As hospitals use advanced technology, providers should consider families' opinions about risks and out-of-pocket costs and tailoring explanations to address individual situations.

Profile of Interfacility Emergency Department Transfers: Transferring Medical Providers and Reasons for Transfer

OBJECTIVES

The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers.

METHODS

We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training.

RESULTS

The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest.

CONCLUSIONS

Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

IMPORTANCE

Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend.

OBJECTIVES

To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included.

MAIN OUTCOMES AND MEASURES

Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals.

RESULTS

There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%).

CONCLUSIONS AND RELEVANCE

In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

The authors looked at all of the pediatric patients with a head injury who were transferred from other hospitals to their own over 12 years and tried to identify factors that would allow patients to stay closer to home at their local hospitals and not be transferred. Many patients with isolated, nondisplaced skull fractures or negative CT imaging likely could have avoided transfer. While hospitals should be cautious, this may help families stay closer to home.

Do Emergency Physicians Improve the Appropriateness of Emergency Transfer in Rural Areas?

BACKGROUND

Until recently, there have been few studies on the transfer of patients from emergency departments (EDs) overall, as such studies were limited primarily to trauma patients.

OBJECTIVES

The purpose of this study was to investigate the association between the specialty of the primary referring physician and the appropriateness of the emergency transfer (AET).

METHODS

This was a retrospective, observational study performed at two level-3 EDs in a rural area. A transfer to a higher-level ED for the purpose of patient stabilization was defined as an emergency transfer, and transfers were classified as "appropriate" when the emergency status of the patient could not be resolved by the referring ED. The primary outcome was AET, which was reviewed by an expert panel for reliability. Statistically significant variables were selected as covariates based on the results of a univariate analysis, and a multivariate logistic regression analysis was performed to estimate the odds ratios (ORs) with 95% confidence intervals (CIs) on the AET.

RESULTS

A total of 1325 patients underwent transfer to another hospital from the two EDs. Of these, 1003 were classified into the emergency transfer group. In both EDs, the incidence of appropriate emergency transfers was significantly higher when the primary referring physician was an emergency physician (OR 4.005, 95% CI 2.619-6.125 and OR 4.006, 95% CI 1.696-9.459 for each hospital, respectively).

CONCLUSION

There was a positive association between the specialty of the primary referring physician and the AET among EDs located in rural areas making patient transfers.

Availability of Definitive Hospital Care for Children

IMPORTANCE

Timely and efficient access to hospital care is essential for the health and well-being of children. As insurance networks, accountable care organizations, and alternative payment methods evolve, these new systems of care must continue to serve the needs of children.

OBJECTIVE

To test the hypothesis that the availability of definitive pediatric hospital care is significantly more limited than adult care and is decreasing disproportionately.

DESIGN

This study used case mix data during fiscal years 2004 through 2014 to measure transfer frequency and identify the site of care completion for all patients seen in acute care hospitals throughout Massachusetts. Patterns of care among children were then compared with patterns of care among adults. Participants were all patients seen in an emergency department or admitted to a hospital from 2004 through 2014, including more than 34 million encounters.

MAIN OUTCOMES AND MEASURES

Hospital Capability Index and Regionalization Index for all acute care hospitals and all conditions within the Clinical Classifications Software of the Healthcare Cost and Utilization Project.

RESULTS

Over the study period, the Commonwealth of Massachusetts hospital system was composed of 66 acute care hospitals. After excluding newborns and mental health conditions, there were 34 511 312 encounters, with 25 226 014 emergency department visits and 9 285 298 observation or full admissions. From 2004 through 2014, care for adults and children concentrated among hospitals but much more so for pediatric care. The number of children requiring care in more than one hospital increased 36.2% (from 7190 to 9793). The median (interquartile range [IQR]) Hospital Capability Index, reflecting the likelihood of a hospital completing a patient's care without transfer, decreased 10.8% (from 0.74 [IQR, 0.65-0.81] to 0.66 [IQR, 0.53-0.76]) for adult care and 65.0% (0.20 [IQR, 0.05-0.34] to 0.07 [IQR, 0.01-0.23]) for pediatric care. Almost all of the shift was from nonacademic to academic hospitals. The median Regionalization Index, reflecting the degree to which care for specific conditions is regionalized, was very high for pediatric conditions and further increased from 0.79 (IQR, 0.67-0.91) to 0.87 (IQR, 0.80-0.91). Over the same decade, the mean Regionalization Index for adult conditions was low and increased modestly from 0.25 (IQR, 0.14-0.39) to 0.32 (IQR, 0.19-0.46). Among pediatric conditions, more than 75% were highly regionalized in 2014 compared with fewer than 50% in 2004.

CONCLUSIONS AND RELEVANCE

Pediatric hospital care has become increasingly concentrated, and many children with common conditions are now less frequently treated in the community. This finding has significant implications for systemwide capacity management and should be specifically accounted for in public health activities, disaster planning, and determinations of network adequacy.

A Misdirected Patient Transfer Raises Emergency Medical Treatment and Labor Act Liability Issues

Children often require transfer to pediatric hospital emergency departments (EDs) after evaluation in community hospital EDs. Such transfers are regulated by the federal Emergency Medical Treatment and Labor Act. Unusual circumstances, such as logistical errors in the physical transfer of the patient, may increase Emergency Medical Treatment and Labor Act-related liability risks for hospitals and ED physicians.

Telemedicine: A Reliable Tool to Assess the Severity of Respiratory Distress in Children

BACKGROUND AND OBJECTIVES

Remote assessment of respiratory distress using telemedicine enabled audio-video conferencing (TM) is of value for medical decision-making. Our goal was to evaluate the interobserver reliability (IOR) of TM compared with face-to-face (FTF) assessment of respiratory distress in children.

METHODS

A prospective, cohort study was performed in pediatric emergency department from July 2012 to February 2013. Children (aged 0-18 years) who presented with signs of respiratory distress were included in the study. The respiratory score is a 4-item, 12-point scale (respiratory rate [1-3], retractions [0-3], dyspnea [0-3], and wheezing [0-3]) that assesses the severity of a child's respiratory distress. Each child was evaluated by a pair of observers from a pool of 25 observers. The first observer evaluated the patient FTF, and the second observer simultaneously and independently evaluated remotely via TM. The overall respiratory distress severity is based on the respiratory scale and reported as nonsevere (≤8) and severe (≥9) respiratory distress. The IOR reliability between FTF and TM assessment was measured using a 2-way mixed model, absolute agreement and average measure intraclass correlation coefficient (ICC).

RESULTS

Forty-eight patients and 135 paired observations were recorded. IOR between the FTF and TM groups for total respiratory score had an ICC of 0.95 (confidence interval 0.93-0.96) and for subscores, the ICC range was as follows: respiratory rate = 0.92, retractions = 0.85, dyspnea = 0.94, and wheezing = 0.77.

CONCLUSIONS

TM is a reliable tool to assess the severity of respiratory distress in children.

Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study

OBJECTIVES

Interhospital transfer is a common strategy to provide high-quality regionalized care in rural emergency departments (EDs), but several reports have highlighted problems with selection of children for transfer. The purpose of this study is to characterize the burden of potentially avoidable transfer (PAT) and to estimate the medical and family-oriented costs associated with PAT.

METHODS

This study was a cohort study of all children treated in Iowa EDs between 2004 and 2013. PAT was defined as a child who was transferred and then either discharged from the receiving ED or admitted for ≤ 1 day, without having any separately billed procedures performed. Costs of care were estimated from 1) medical costs, 2) ambulance transfer, and 3) family costs (travel and lodging).

RESULTS

Over 10 years, 2,117,317 children were included (1% transferred to another hospital). Only 63% were transferred to a designated children's hospital, and PATs were identified in 39% of all transfers. PAT was associated with $909 in additional cost. The conditions most strongly associated with PAT were seizure (additional cost $1,138), fracture ($814), isolated traumatic brain injury without extra-axial bleeding ($1,455), respiratory infection ($556), and wheezing ($804). Few of these charges are attributable to nonmedical family costs ($21).

CONCLUSIONS

Potentially avoidable pediatric interhospital transfer is common and is responsible for significant healthcare-related costs. Future work should focus on improving selection of children who benefit from interhospital transfer for high-yield conditions, to reduce the costly and distressing burden that PAT places on rural patients and their families.