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Pirrocco FA, Temkit H, Mechem C, Yeager K. Trends in pediatric emergency department transfers from Indian Health Service and tribal health systems. Acad Emerg Med 2024; 31:584-589. [PMID: 38644585 DOI: 10.1111/acem.14878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 04/23/2024]
Abstract
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.
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Affiliation(s)
- Fiona A Pirrocco
- Pediatric Emergency Department, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Hamy Temkit
- Clinical Research Department, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Cherisse Mechem
- Pediatric Emergency Department, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Karen Yeager
- Pediatric Emergency Department, Phoenix Children's Hospital, Phoenix, Arizona, USA
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Craig S, Foster J, Gallant J, Verma N, Krmpotic K. Pediatric Critical Care Referrals for Tertiary Inpatient and Transport Services in Canada's Maritime Provinces: A Retrospective Cohort Study. Air Med J 2024; 43:248-252. [PMID: 38821707 DOI: 10.1016/j.amj.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Accurate triage of children referred for tertiary pediatric critical care services is crucial to ensure optimal disposition and resource conservation. We aimed to explore the characteristics and level of care needs of children referred to tertiary pediatric critical care inpatient and transport services and the characteristics of referring physicians and hospitals to which these children present. METHODS We conducted a 1-year retrospective cohort study of children (< 16 years) with documented referral to pediatric critical care and specialized transport services at a tertiary pediatric hospital from regional (24/7 pediatrician on-call coverage) and community (no pediatric specialty services) hospitals in Canada's Maritime provinces. RESULTS We identified 205 documented referrals resulting in 183 (89%) transfers; 97 (53%) were admitted to the pediatric intensive care unit (PICU). Of 150 children transferred from centers with 24/7 pediatric specialist coverage, 45 (30%) were admitted to the tertiary hospital pediatric medical unit with no subsequent admission to the PICU. Of 20 children transferred from community hospitals and admitted to the tertiary hospital general pediatric medical unit, 9 (45%) bypassed proximate regional hospitals with specialist pediatric care capacity. The specialized pediatric critical care transport team performed 151 (83%) of 183 interfacility transfers; 83 (55%) were admitted to the PICU. CONCLUSION One third of the children accepted for interfacility transfer after pediatric critical care referral were triaged to a similar level of care as could be provided at the sending or nearest regional hospital. Improved utilization of pediatric expertise in regional hospitals may reduce unnecessary pediatric transports and conserve valuable health care resources.
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Affiliation(s)
- Stephanie Craig
- Department of Internal Medicine, Northern Ontario School of Medicine, Thunder Bay, Canada
| | - Jennifer Foster
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada; Department of Critical Care, Dalhousie University, Halifax, Canada
| | - Julien Gallant
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada
| | - Neeraj Verma
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada; Department of Critical Care, Dalhousie University, Halifax, Canada
| | - Kristina Krmpotic
- Department of Pediatric Critical Care, IWK Health, Halifax, Canada; Department of Critical Care, Dalhousie University, Halifax, Canada.
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Hayden EM, Samuels-Kalow M, Dutta S, Cohen A, Tune KN, Zachrison KS. Pediatric Patients Discharged After Transfer to a Pediatric Emergency Department: Opportunities for Telehealth? Ann Emerg Med 2024; 83:208-213. [PMID: 37737784 DOI: 10.1016/j.annemergmed.2023.08.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/11/2023] [Accepted: 08/25/2023] [Indexed: 09/23/2023]
Abstract
STUDY OBJECTIVE Interemergency department pediatric transfers can be costly, involve risk, and may be disruptive to patients and families. Telehealth could be a way to safely reduce the number of transfers. We made an estimate of the proportion of transfers of pediatric patients to our emergency department (ED) that may have been avoidable using telehealth. METHODS This was a retrospective analysis of electronic health record data of all pediatric patients (younger than 19 years) who were transferred to a single urban, academic medical center pediatric emergency department (PED) (annual pediatric volume approximately 15,000) between June 1, 2016, and December 29, 2021. We defined transfers as potentially avoidable with telehealth (the primary outcome) when the encounter at the receiving ED resulted in ED discharge and 1) met our definition of low-resource intensity (had no laboratory tests, diagnostic imaging, procedures, or consultations) or 2) could have used initial ED resources with telehealth guidance. RESULTS Among 4,446 PED patients received in transfer during the study period, 406 (9%) were low-resource intensity. Of the non-low-resource intensity encounters, as many as another 1,103 (24.8%) potentially could have been avoided depending on available telehealth and initial ED resources, ranging from 210 (4.7%) with only telehealth specialty consultation to 538 (7.4%) with imaging and telehealth specialty consultation, and up to 1,034 (23.3%) with laboratory, imaging, and telehealth specialty consultation. CONCLUSION Our results suggest that depending on available telehealth and initial ED resources, between 9% and 33% of pediatric inter-ED transfers may have been avoidable. This information may guide health system design and PED operations when considering implementing pediatric telehealth.
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Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - Margaret Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Ari Cohen
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - K Noelle Tune
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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Dunbar KS, Fox SN, Thomas JF, Brittan MS, Soskolne G, Cotter JM. When to Transfer: Predictors of Pediatric High Flow Nasal Cannula Failure at a Community Hospital. Hosp Pediatr 2024; 14:45-51. [PMID: 38093648 PMCID: PMC11321470 DOI: 10.1542/hpeds.2023-007298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2024]
Abstract
OBJECTIVES To identify risk factors of high flow nasal cannula (HFNC) failure at a US pediatric hospital without a co-located ICU. METHODS Retrospective cohort study of patients aged 0 to 18 years who were started on HFNC in the emergency department or inpatient unit at a community hospital over a 16-month period. Children with chronic medical conditions were excluded. Outcome was HFNC failure, defined as HFNC need greater than floor limit, noninvasive positive pressure, or mechanical ventilation. In bivariate analysis, we compared demographic and clinical factors between those with and without failure. We included variables in a multivariable model on the basis of statistical significance. We used Poisson regression with robust error variance to calculate the adjusted relative risk (aRR) of failure for each variable. RESULTS Of 195 children, 51% had HFNC failure. In adjusted analysis, failure was higher in all age groups <12 months as compared with older children. For example, children aged 3 to 5 months had a higher risk of failure compared with patients 12 months or older (aRR 1.85, confidence interval [CI] 1.34-2.54). Patients with an asthma exacerbation had a higher risk of failure (aRR 1.39, CI 1.03-1.88). Patients whose respiratory rate or heart rate did not improve also had a higher risk of failure (aRR 1.73, CI 1.24-2.41; aRR 1.47, CI 1.14-1.90). CONCLUSIONS Patients who were younger, had asthma, and did not have improved respiratory rate or heart rate after HFNC were more likely to experience HFNC failure.
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Affiliation(s)
- Kimiko S. Dunbar
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah N. Fox
- University of Colorado School of Medicine, Aurora, Colorado
| | - Jacob F. Thomas
- University of Colorado School of Medicine, Aurora, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Mark S. Brittan
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Gayle Soskolne
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
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Arora R, Spencer P, Barran D, Merolla DM, Kannikeswaran N. Outcome of interhospital pediatric foreign body transfers. Am J Emerg Med 2023; 74:73-77. [PMID: 37793195 DOI: 10.1016/j.ajem.2023.09.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023] Open
Abstract
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.
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Affiliation(s)
- Rajan Arora
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, United States of America.
| | - Priya Spencer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, United States of America.
| | - Diniece Barran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, United States of America.
| | - David M Merolla
- Department of Sociology, Wayne State University, Detroit, MI, United States of America.
| | - Nirupama Kannikeswaran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, United States of America.
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Bennett N, Mansour M, Farooqi A, DeLaroche AM. Resource Utilization for Pediatric Patients Discharged After Interhospital Transfer. Pediatr Emerg Care 2023; 39:148-153. [PMID: 35510721 DOI: 10.1097/pec.0000000000002746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Natasha Bennett
- From the Department of Pediatrics, Children's Hospital of Michigan
| | | | - Ahmad Farooqi
- Department of Pediatrics, Wayne State University School of Medicine
| | - Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
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Lee MO, Wall J, Saynina O, Camargo CA, Wang NE. Characteristics of Pediatric Patient Transfers From General Emergency Departments in California From 2005 to 2018. Pediatr Emerg Care 2023; 39:20-27. [PMID: 36440988 DOI: 10.1097/pec.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Each year, approximately 300,000 pediatric patients are transferred out of emergency departments (EDs). Emergency department transfers may not only provide a higher level of care but also incur increased resource use and cost. Our objective was to identify hospital characteristics and patient demographics and conditions associated with ED transfer as well as the trend of transfers over time. METHODS This was a retrospective cohort study of pediatric visits to EDs in California using the California Office of Statewide Health Planning and Development ED data set (2005-2018). Hospitals were categorized based on inpatient pediatric capabilities. Patients were characterized by demographics and Clinical Classifications Software diagnostic categories. Regression models were created to analyze likelihood of outcome of transfer compared with admission. RESULTS Over the 14-year period, there were 38,117,422 pediatric visits to 364 EDs in California with a transfer rate of 1% to 2%. During this time, the overall proportion of pediatric transfers increased, whereas pediatric admissions decreased for all hospital types. Transfers were more likely in general hospitals without licensed pediatric beds (odds ratio [OR], 16.26; 95% confidence interval [CI], 15.87-16.67) and in general hospitals with licensed pediatric beds (OR, 3.54; 95% CI, 3.46-3.62) than in general hospitals with pediatric intensive care unit beds. Mental illness (OR, 61.00; 95% CI, 57.90-63.20), poisoning (OR, 11.78; 95% CI, 11.30-12.30), diseases of the circulatory system (OR, 6.13; 95% CI, 5.84-6.43), diseases of the nervous system (OR, 4.61; 95% CI, 4.46-4.76), and diseases of the blood and blood-forming organs (OR, 3.21; 95% CI, 3.62; 95% CI, 3.45-3.79) had increased odds of transfer. CONCLUSION Emergency departments in general hospitals without pediatric intensive care units and patients' Clinical Classifications Software category were associated with increased likelihood of transfer. A higher proportion of patients with complex conditions are transferred than those with common conditions. General EDs may benefit from developing transfer processes and protocols for patients with complex medical conditions.
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Affiliation(s)
- Moon O Lee
- From the Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jessica Wall
- Department of Pediatrics and Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Emergency Department, Seattle, WA
| | - Olga Saynina
- Stanford Center for Policy, Outcomes and Prevention, Stanford, CA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - N Ewen Wang
- From the Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
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Baca JE, Foster CC, Simon NJE, Lorenz D, Gregg ME, Schinasi DA. Children's Hospital Transfers From Referring Emergency Departments: Which Patients Bypassed the Pediatric Emergency Department? Pediatr Emerg Care 2022; 38:e1046-e1052. [PMID: 35226629 DOI: 10.1097/pec.0000000000002652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | | | - Norma-Jean E Simon
- Division of Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Doug Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Mary E Gregg
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
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Lieng MK, Marcin JP, Sigal IS, Haynes SC, Dayal P, Tancredi DJ, Gausche-Hill M, Mouzoon JL, Romano PS, Rosenthal JL. Association between emergency department pediatric readiness and transfer of noninjured children in small rural hospitals. J Rural Health 2022; 38:293-302. [PMID: 33734494 PMCID: PMC8489899 DOI: 10.1111/jrh.12566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Pediatric readiness scores may be a useful measure of a hospital's preparedness to care for children. However, there is limited evidence linking these scores with patient outcomes or other metrics, including the need for interfacility transfer. This study aims to determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of noninjured children (< 18 years old) presenting to emergency departments (EDs) in small rural hospitals in the state of California. METHODS Data from the National Pediatric Readiness Project assessment were linked with the California Office of Statewide Health Planning and Development's ED and inpatient databases to conduct a cross-sectional study of pediatric interfacility transfers. Hospitals were manually matched between these data sets. Logistic regression was performed with random intercepts for hospital and adjustment for patient-level confounders. FINDINGS A total of 54 hospitals and 135,388 encounters met the inclusion criteria. EDs with a high pediatric readiness score (>70) had lower adjusted odds of transfer (aOR: 0.55, 95% CI: 0.33-0.93) than EDs with a low pediatric readiness score (≤ 70). The pediatric readiness section with strongest association with transfer was the "policies, procedures, and protocols" section; EDs in the highest quartile had lower odds of transfer than EDs in the lowest quartile (aOR: 0.54, 95% CI: 0.31-0.91). CONCLUSIONS Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Additional studies are recommended to investigate other pediatric outcomes in relation to hospital ED pediatric readiness.
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Affiliation(s)
- Monica K. Lieng
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - James P. Marcin
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Ilana S. Sigal
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Sarah C. Haynes
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Parul Dayal
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Daniel J. Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Marianne Gausche-Hill
- Department of Pediatrics, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Jamie L. Mouzoon
- Department of Pediatrics, University of California Davis, Sacramento, California
| | - Patrick S. Romano
- Department of Pediatrics, University of California Davis, Sacramento, California
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Wright MK, Gong W, Hart K, Self WH, Ward MJ. Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study. J Am Coll Emerg Physicians Open 2021; 2:e12385. [PMID: 33733247 PMCID: PMC7936794 DOI: 10.1002/emp2.12385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/08/2021] [Accepted: 01/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers. METHODS We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED-to-ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED-to-ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality. RESULTS Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED-to-ED transfers for adults aged 18-64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight). CONCLUSIONS Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.
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Affiliation(s)
- Megan K. Wright
- Vanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Wu Gong
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Kimberly Hart
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Wesley H. Self
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Michael J. Ward
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- VA Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
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Minor head injury transfers: Trends and outcomes. Am J Emerg Med 2021; 45:80-85. [PMID: 33676080 DOI: 10.1016/j.ajem.2021.02.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Children with traumatic head injury are often transferred from community Emergency Departments (ED) to a Pediatric Emergency Department (PED). The primary objective of this study was to describe the outcomes of minor head injury (MHI) transfers to a PED. The secondary objective was to report Computed Tomography (CT) utilization rates for MHI. METHODS We conducted a retrospective study of children aged ≤18 years transferred to our PED for MHI from 2013 to 2018. Patients with Glasgow Coma Scale (GCS) < 14, coagulopathies, history of brain mass/shunt and suspected non-accidental trauma were excluded. Data collected included demographics, interventions performed, and disposition. MHI risk stratification and clinically important traumatic brain injury (ciTBI) were defined per the Pediatric Emergency Care Applied Research Network (PECARN) head injury guidelines. Descriptive statistics were reported using general measures of frequency and central tendency. RESULTS A total of 1078 children with MHI were analyzed based on eligibility criteria. The majority of patients were male (62%) and ≥ 2 years of age (69.3%). Subspecialist consultation (57.2%) and neuroimaging (27.4%) were the most commonly performed interventions in the PED. Only 14 children (1.3%) required neurosurgical intervention. One-third of the transferred patients required no additional work-up. Two-thirds of the patients (66.6%) were directly discharged from the PED. Though the total number of MHI transfers per year declined steadily during the study period (from 271/year to 119/year), CT head utilization remained relatively similar across the study years (60.3% to 70.8%). A higher proportion of children received CT in the ED when compared to the PED for low-risk (28.9% vs 15.8%) and intermediate-risk groups (42.8% vs 29.4%). CONCLUSIONS The majority of pediatric MHI transfers are discharged home following a subspecialty consultation and/or neuroimaging. Despite guidelines and a low incidence of ciTBI, CT utilization remains high in the intermediate and low risk MHI groups, especially in the community settings. Targeted interventions are needed to reduce the potentially avoidable transfers and low-value performance of CT in children with MHI.
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Lipsett SC, Porter JJ, Monuteaux MC, Watters K, Hudgins JD. Variation in the Management of Children With Deep Neck Infections. Hosp Pediatr 2021; 11:277-283. [PMID: 33536252 DOI: 10.1542/hpeds.2020-000315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Children with deep neck infections (DNIs) are increasingly being managed nonsurgically with intravenous antibiotics. Our objective was to examine variation in the management of children with DNIs across US children's hospitals. METHODS We conducted a retrospective cohort study using the Pediatric Health Information System database. Children ≤12 years of age hospitalized for retropharyngeal or parapharyngeal abscesses from 2010 to 2018 were included. Hospital variation in management modality and imaging use was described. Temporal trends in management modality were assessed by using logistic regression. Medical management alone versus a combination of medical and surgical management was assessed, and the characteristics of children in these 2 groups were compared. The relationship between hospital rates of initial medical management and failed medical management was assessed by using linear regression. RESULTS Hospitals varied widely in their rates of surgical management from 17% to 70%. The overall rate of surgical management decreased from 42.0% to 33.5% over the study period. Children managed surgically had higher rates of ICU admission (11.5% vs 3.2%; P < .001) and higher hospital charges ($25 241 vs $15 088; P < .001) compared with those managed medically alone. Seventy-three percent of children underwent initial medical management, of whom 17.9% went on to undergo surgery. Hospitals with higher rates of initial medical management had lower rates of failed medical management (β = -.43). CONCLUSIONS Although rates of surgical management of pediatric DNI are decreasing over time, there remains considerable variation in management across US children's hospitals. Children managed surgically have higher rates of resource use and costs.
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Affiliation(s)
- Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and .,Division of Emergency Medicine and
| | | | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Division of Emergency Medicine and
| | - Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts
| | - Joel D Hudgins
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; and.,Division of Emergency Medicine and
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Richard KR, Glisson KL, Shah N, Aban I, Pruitt CM, Samuy N, Wu CL. Predictors of Potentially Unnecessary Transfers to Pediatric Emergency Departments. Hosp Pediatr 2020; 10:424-429. [PMID: 32321739 DOI: 10.1542/hpeds.2019-0307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Kathleen R Richard
- Department of Pediatrics
- Huntsville Hospital for Women and Children, Huntsville, Alabama
| | | | | | - Immaculada Aban
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; and
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14
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Boyle TP, Macias CG, Wu S, Holmstrom S, Truschel LL, Espinola JA, Sullivan AF, Camargo CA. Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis. Hosp Pediatr 2020; 10:415-423. [PMID: 32269075 PMCID: PMC7187394 DOI: 10.1542/hpeds.2019-0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | | | - Susan Wu
- Children's Hospital Los Angeles, Los Angeles, California
| | - Sara Holmstrom
- Boston Children's Hospital, Boston, Massachusetts
- Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
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15
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Cushing AM, Bucholz E, Michelson KA. Trends in Regionalization of Emergency Care for Common Pediatric Conditions. Pediatrics 2020; 145:peds.2019-2989. [PMID: 32169895 PMCID: PMC7236317 DOI: 10.1542/peds.2019-2989] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Anna M Cushing
- Boston Children's Hospital, Boston, Massachusetts; and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Emily Bucholz
- Boston Children's Hospital, Boston, Massachusetts; and
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16
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Mangus CW, Klein BL, Miller M, Stewart D, Ryan LM. Repeat radiographic imaging in patients with long bone fractures transferred to a pediatric trauma center. J Investig Med 2018; 67:59-62. [PMID: 30367008 DOI: 10.1136/jim-2018-000877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2018] [Indexed: 11/04/2022]
Abstract
This study sought to determine the proportion of children with long bone fractures who undergo duplicate radiographic imaging after transfer to a pediatric trauma center (PTC) for further management. The secondary objective was to explore provider rationale and diagnostic yield of repeat X-rays. This was a single-site, retrospective cohort study conducted at a PTC. All patients, aged 0-21 years, who were transferred to the PTC for management of a long bone fracture were included. Electronic medical records were reviewed to determine the proportion of children who had repeat radiographic imaging and the provider rationale for obtaining this. T-test and Χ2 analyses were used to compare patients who had repeat X-rays with those who did not. During the study period, 309 patients (63% male, mean age 7.2±4.3 years) were transferred from 30 referring hospitals. Of these, 43% (n=133) underwent repeat radiographs. Patient age (p=0.9), gender (p=0.7), fracture location (p=0.19), and type of referring emergency department (pediatric vs general, p=0.3) were not significantly associated with repeat imaging. Rationale for repeat imaging could be ascertained in 31% of cases (n=41); the most common reasons were request by orthopedist (17%, n=23) and suboptimal original imaging (10%, n=13). Repeat imaging at the PTC did not reveal new or additional diagnoses in any case. Nearly half of the children in our study population undergo repeat and likely unnecessary imaging. Strategies to reduce repeat radiographs should be developed, as redundant imaging exposes patients to additional radiation and increases medical expense.
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Affiliation(s)
- Courtney W Mangus
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bruce L Klein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marlene Miller
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dylan Stewart
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leticia M Ryan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Jordan J, Linden JA, Maculatis MC, Hern HG, Schneider JI, Wills CP, Marshall JP, Friedman A, Yarris LM. Identifying the Emergency Medicine Personality: A Multisite Exploratory Pilot Study. AEM EDUCATION AND TRAINING 2018; 2:91-99. [PMID: 30051075 PMCID: PMC6001604 DOI: 10.1002/aet2.10078] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 11/27/2017] [Accepted: 12/06/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES This study aimed to understand the personality characteristics of emergency medicine (EM) residents and assess consistency and variations among residency programs. METHODS In this cross-sectional study, a convenience sample of residents (N = 140) at five EM residency programs in the United States completed three personality assessments: the Hogan Personality Inventory (HPI)-describing usual tendencies; the Hogan Development Survey (HDS)-describing tendencies under stress or fatigue; and the Motives, Values, and Preferences Inventory (MVPI)-describing motivators. Differences between EM residents and a normative population of U.S. physicians were examined with one-sample t-tests. Differences between EM residents by program were analyzed using one-way analysis of variance tests. RESULTS One-hundred forty (100%), 124 (88.6%), and 121 (86.4%) residents completed the HPI, HDS, and MVPI, respectively. For the HPI, residents scored lower than the norms on the adjustment, ambition, learning approach, inquisitive, and prudence scales. For the HDS, residents scored higher than the norms on the cautious, excitable, reserved, and leisurely scales, but lower on bold, diligent, and imaginative scales. For the MVPI, residents scored higher than the physician population norms on altruistic, hedonistic, and aesthetics scales, although lower on the security and tradition scales. Residents at the five programs were similar on 22 of 28 scales, differing on one of 11 scales of the HPI (interpersonal sensitivity), two of 11 scales of the HDS (leisurely, bold), and three of 10 scales of the MVPI (aesthetics, commerce, and recognition). CONCLUSIONS Our findings suggest that the personality characteristics of EM residents differ considerably from the norm for physicians, which may have implications for medical students' choice of specialty. Additionally, results indicated that EM residents at different programs are comparable in many areas, but moderate variation in personality characteristics exists. These results may help to inform future research incorporating personality assessment into the resident selection process and the training environment.
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Affiliation(s)
- Jaime Jordan
- Department of Emergency MedicineDavid Geffen School of Medicine at UCLADepartment of Emergency MedicineHarbor‐UCLA Medical CenterTorranceCA
| | - Judith A. Linden
- Department of Emergency MedicineBoston University School of MedicineBoston Medical CenterBostonMA
| | | | - H. Gene Hern
- Department of Emergency MedicineUCSF School of MedicineOaklandCA
- Alameda Health System–Highland HospitalOaklandCA
| | - Jeffrey I. Schneider
- Department of Emergency MedicineBoston University School of MedicineBoston Medical CenterBostonMA
| | - Charlotte P. Wills
- Department of Emergency MedicineUCSF School of MedicineOaklandCA
- Alameda Health System–Highland HospitalOaklandCA
| | - John P. Marshall
- Department of Emergency Medicine, Maimonides Medical CenterBrooklynNY
| | | | - Lalena M. Yarris
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOR
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18
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Rees CA, Pryor S, Choi B, Senthil MV, Tsarouhas N, Myers SR, Monuteaux MC, Bachur RG, Li J. The influence of insurance type on interfacility pediatric emergency department transfers. Am J Emerg Med 2017; 35:1907-1909. [DOI: 10.1016/j.ajem.2017.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022] Open
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