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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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Boggs KM, Glew D, Rahman KN, Gao J, Boyle TP, Samuels-Kalow ME, Sullivan AF, Zachrison KS, Camargo CA. Pediatric Telehealth Use in U.S. Emergency Departments in 2019. Telemed J E Health 2023; 29:551-559. [PMID: 36103263 PMCID: PMC10079250 DOI: 10.1089/tmj.2022.0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 11/12/2022] Open
Abstract
Objectives: Little is known about the recent usage of pediatric telehealth across all emergency departments (EDs) in the United States. Building upon our prior work, we aimed to characterize the usage of ED pediatric telehealth in the pre-COVID-19 era. Methods: The 2019 National ED Inventory-USA survey characterized all U.S. EDs open in 2019. Among EDs reporting receipt of pediatric telehealth services, we selected a random sample (n = 130) for a second survey on pediatric telehealth usage (2019 ED Pediatric Telehealth Survey). We also recontacted a random sample of EDs that responded to a prior, similar 2017 ED Pediatric Telehealth Survey (n = 107), for a total of 237 EDs in the 2019 ED Pediatric Telehealth Survey sample. Results: Overall, 193 (81%) of the 237 EDs responded to the 2019 Pediatric Telehealth Survey. There were 149 responding EDs that confirmed pediatric telehealth receipt in 2019. Among these, few reported ever having a pediatric emergency medicine (PEM) physician (10%) or pediatrician (9%) available for emergency care. Although 96% of EDs reported availability of pediatric telehealth services 24 h per day, 7 days per week, the majority (60%) reported using services less than once per month and 20% reported using services every 3-4 weeks. EDs most frequently used pediatric telehealth to assist with placement and transfer coordination (91%). Conclusions: Most EDs receiving pediatric telehealth in 2019 had no PEM physician or pediatrician available. Most EDs used pediatric telehealth services infrequently. Understanding barriers to assimilation of telehealth once adopted may be important to enable improved access to pediatric emergency care expertise.
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Affiliation(s)
- Krislyn M. Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dorsey Glew
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kashfia N. Rahman
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jingya Gao
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tehnaz P. Boyle
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Ashley F. Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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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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Kothari SY, Haynes SC, Sigal I, Magana JN, Ruttan T, Kuppermann N, Horeczko T, Ludwig L, Karsteadt L, Chapman W, Pinette V, Marcin JP. Resources for Improving Pediatric Readiness and Quality of Care in Rural Communities and Emergency Departments. Pediatr Emerg Care 2022; 38:e1069-e1074. [PMID: 35226633 DOI: 10.1097/pec.0000000000002658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To share the process and products of an 8-year, federally funded grant from the Health Resources and Services Administration Emergency Medical Services for Children program to increase pediatric emergency readiness and quality of care provided in rural communities located within 2 underserved local emergency medical services agencies (LEMSAs) in Northern California. METHODS In 2 multicounty LEMSAs with 24 receiving hospital emergency departments, we conducted focus groups and interviews with patients and parents, first responders, receiving hospital personnel, and other community stakeholders. From this, we (a regional, urban children's hospital) provided a variety of resources for improving the regionalization and quality of pediatric emergency care provided by prehospital providers and healthcare staff at receiving hospitals in these rural LEMSAs. RESULTS From this project, we provided resources that included regularly scheduled pediatric-specific training and education programs, pediatric-specific quality improvement initiatives, expansion of telemedicine services, and cultural competency training. We also enhanced community engagement and investment in pediatric readiness. CONCLUSIONS The resources we provided from our regional, urban children's hospital to 2 rural LEMSAs facilitated improvements in a regionalized system of care for critically ill and injured children. Our shared resources framework can be adapted by other regional children's hospitals to increase readiness and quality of pediatric emergency care in rural and underserved communities and LEMSAs.
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Affiliation(s)
| | | | | | - Julia N Magana
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX
| | | | - Timothy Horeczko
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA
| | - Lorah Ludwig
- Emergency Medical Services for Children, Division of Child, Adolescent, and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD
| | | | | | - Vickie Pinette
- Sierra-Sacramento Valley Emergency Medical Services, Rocklin, CA
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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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Taylor MA, Lewis AE, Swendiman RA, Fenton SJ, Russell KW. Interest in Improving Access to Pediatric Trauma Care Through Telemedicine. J Med Syst 2021; 45:108. [PMID: 34755231 DOI: 10.1007/s10916-021-01789-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 11/01/2021] [Indexed: 11/25/2022]
Abstract
Despite improved outcomes at pediatric trauma centers (PTC), 90% of injured children are not treated at PTCs. Telemedicine may play a role in ensuring patients are transferred to the appropriate level of care. We aimed to determine the level of interest in trauma telemedicine with our PTC among referring facilities. A survey was conducted with the trauma program directors of 45 hospitals in Utah, which consisted of four multiple choice questions designed to determine interest in pediatric trauma telemedicine support, projected frequency of use, anticipated uses of telemedicine, and perceived barriers to implementation. Forty-one directors (91%) responded. 88% of directors were interested in developing a pediatric trauma telemedicine network. 20% estimated their center would use telemedicine more than once a week, 17% once a week, 24% once a month, and 37% a few times a year. The most frequently cited uses of a telemedicine program were triage/transfer decisions and provider support. Inadequate volume and insufficient funding were the most common perceived barriers. These data show there is a strong interest amongst hospitals in our state in pediatric trauma telemedicine. Inadequate volume to warrant a program and insufficient facility funding remain concerns for development of a program.
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Affiliation(s)
- Mark A Taylor
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA.
| | - Aislinn E Lewis
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | | | - Stephen J Fenton
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Katie W Russell
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
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The "non-preventable" preventable transfer? An analysis of the care from support services that injured children transferred to a level 1 pediatric trauma center receive. J Pediatr Surg 2021; 56:1638-1642. [PMID: 33234289 DOI: 10.1016/j.jpedsurg.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Almost 30% of pediatric trauma transfers to our facility have previously been shown to be potentially preventable transfers (PT). However, we sought to evaluate what care from support services these PT received during admission. METHODS Traumatically injured children transferred between January 2014 and June 2019 were retrospectively analyzed. A PT was defined as a child who was discharged within 36 h of arrival without surgical intervention or advanced imaging studies. PT that received support services were compared to those that did not to determine which patients may benefit from these services were their transfers prevented. RESULTS There were 3212 transfers, and 927 (29%) were PT. When compared to non-PT, PT were younger, closer to our hospital, and had a lower ISS, extremity or C-spine injury, or assault/non-accidental trauma mechanism. PT were less likely to have a chest injury or a CT at the referring hospital. Of the PT, 30% had a support service consulted. PT with higher ISS or a head injury was more likely to receive a consultation with a support service. CONCLUSIONS A significant proportion of these "preventable" transfers still receive important care from support services during their admission. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE III.
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8
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Taylor MA, Knochel ML, Proctor SJ, Brockmeyer DL, Runyon LA, Fenton SJ, Russell KW. Pediatric trauma telemedicine in a rural state: Lessons learned from a 1-year experience. J Pediatr Surg 2021; 56:385-389. [PMID: 33228973 DOI: 10.1016/j.jpedsurg.2020.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous research from our center has shown that 27% of the pediatric trauma transfers from referring facilities are potentially preventable. Our hospital is the only level 1 pediatric trauma center (PTC) in our state, and we are developing a pediatric trauma telehealth network to help keep certain injured children closer to home. We instituted a pediatric trauma telehealth program with a partnering community-based hospital in our state and aim to report our experience over the first year. METHODS All pediatric trauma patients that presented to our partnering hospital from January 2019 to February 2020 were reviewed. Disposition was: a) telehealth consultation, b) admission to the children's unit without a telehealth consultation per our head trauma protocol, or c) transfer without telehealth consultation. Data on demographics, hospital course, and disposition were collected via chart review. RESULTS Eight patients underwent telehealth consults and another 8 patients were admitted to the partnering hospital's children's unit based on the head trauma protocol without a telehealth consult. Patient's ages ranged from 7 months to 15 years. Of the patients that underwent telehealth consult, 7 presented with a head injury and 1 presented with a rib fracture/small pneumothorax. The patient with a pneumothorax was observed for 6 h and discharged home after a repeat chest x-ray was stable. All 15 patients with head injuries were observed and discharged from either the emergency department or children's unit after passing concussion testing. No patients required transfer to our PTC after observation, and none were readmitted. Fifty-six patients were transferred without telehealth consultation, and 3 of these patients could potentially have avoided transfer with a telehealth consultation. CONCLUSIONS Telehealth in pediatric trauma can be a safe mechanism for preventing the transfer of patients that can be safely observed at a partnering hospital. From a facility that transfers an average of 30 trauma patients per year to our hospital, this program prevented 16 such transfers. Development of a head trauma protocol in collaboration with a pediatric neurosurgeon leads to an unexpected number of patients being admitted to the partnering hospital for observation without utilization of a telehealth consultation. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mark A Taylor
- University of Utah, Department of Surgery, Salt Lake City, UT.
| | - Miguel L Knochel
- University of Utah, Department of Pediatrics, Salt Lake City, UT
| | | | | | - Lisa A Runyon
- Primary Children's Hospital, Department of Pediatric Surgery, Salt Lake City, UT
| | | | - Katie W Russell
- University of Utah, Department of Surgery, Salt Lake City, UT
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Zachrison KS, Boggs KM, Hayden EM, Cash RE, Espinola JA, Samuels‐Kalow ME, Sullivan AF, Mehrotra A, Camargo CA. Factors associated with emergency department adoption of telemedicine: 2014 to 2018. J Am Coll Emerg Physicians Open 2020; 1:1304-1311. [PMID: 33392537 PMCID: PMC7771831 DOI: 10.1002/emp2.12233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Telemedicine is used by emergency departments (EDs) to connect patients with specialty consultation and resources not available locally. Despite its utility, uptake of telemedicine in EDs has varied. We studied characteristics associated with telemedicine adoption during a 4-year period. METHODS We analyzed data from the 2014 National Emergency Department Inventory (NEDI)-New England survey and follow-up data from 2016 and 2017 NEDI-USA and 2018 NEDI-New England surveys, with data from the Center for Connected Health Policy. Among EDs not using telemedicine in 2014, we examined characteristics associated with adoption by 2018. RESULTS Of the 159 New England EDs with available data, 80 (50%) and 125 (79%) reported telemedicine receipt in 2014 and 2018, respectively. Among the 79 EDs without telemedicine in 2014, academic EDs were less likely to adopt by 2018 (odds ratio, 0.12; 95% confidence interval, 0.03-0.46). State policy environment was not associated with likelihood of adoption. In 2018, all 7 freestanding EDs received telemedicine, whereas only 1 of 9 academic EDs (11%) did. CONCLUSIONS Telemedicine use by EDs continues to grow rapidly and by 2018, >3 quarters of EDs in our sample were receiving telemedicine. From 2014 to 2018, the initiation of telemedicine receipt was less common among higher volume and academic EDs.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Krislyn M. Boggs
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Emily M. Hayden
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Rebecca E. Cash
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Janice A. Espinola
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Margaret E. Samuels‐Kalow
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Ashley F. Sullivan
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Ateev Mehrotra
- Department of Healthcare PolicyHarvard Medical SchoolBostonMassachusettsUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
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Joseph JW, Kennedy M, Nathanson LA, Wardlow L, Crowley C, Stuck A. Reducing Emergency Department Transfers from Skilled Nursing Facilities Through an Emergency Physician Telemedicine Service. West J Emerg Med 2020; 21:205-209. [PMID: 33207167 PMCID: PMC7673904 DOI: 10.5811/westjem.2020.7.46295] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/11/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Transfers of skilled nursing facility (SNF) residents to emergency departments (ED) are linked to morbidity, mortality and significant cost, especially when transfers result in hospital admissions. This study investigated an alternative approach for emergency care delivery comprised of SNF-based telemedicine services provided by emergency physicians (EP). We compared this on-site emergency care option to traditional ED-based care, evaluating hospital admission rates following care by an EP. Methods We conducted a retrospective, observational study of SNF residents who underwent emergency evaluation between January 1, 2017–January 1, 2018. The intervention group was comprised of residents at six urban SNFs in the Northeastern United States, who received an on-demand telemedicine service provided by an EP. The comparison group consisted of residents of SNFs that did not offer on-demand services and were transferred via ambulance to the ED. Using electronic health record data from both the telemedicine and ambulance transfers, our primary outcome was the odds ratio (OR) of a hospital admission. We also conducted a subanalysis examining the same OR for the three most common chronic disease-related presentations found among the telemedicine study population. Results A total of 4,606 patients were evaluated in both the SNF-based intervention and ED-based comparison groups (n=2,311 for SNF based group and 2,295 controls). Patients who received the SNF-based acute care were less likely to be admitted to the hospital compared to patients who were transferred to the ED in our primary and subgroup analyses. Overall, only 27% of the intervention group was transported to the ED for additional care and presumed admission, whereas 71% of the comparison group was admitted (OR for admission = 0.15 [9% confidence interval, 0.13–0.17]). Conclusion The use of an EP-staffed telemedicine service provided to SNF residents was associated with a significantly lower rate of hospital admissions compared to the usual ED-based care for a similarly aged population of SNF residents. Providing SNF-based care by EPs could decrease costs associated with hospital-based care and risks associated with hospitalization, including cognitive and functional decline, nosocomial infections, and falls.
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Affiliation(s)
- Joshua W Joseph
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Maura Kennedy
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Larry A Nathanson
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | | | | | - Amy Stuck
- West Health Institute, La Jolla, California
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Lyria Hoa MH, Ong YKG, Pek JH. Trauma transfers to the pediatric emergency department - Is it necessary? Turk J Emerg Med 2020; 20:12-17. [PMID: 32355896 PMCID: PMC7189817 DOI: 10.4103/2452-2473.276379] [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: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES: Pediatric trauma patients presenting to general emergency departments (EDs) may be transferred to pediatric EDs for further management. Unnecessary transfers increase health-care costs, add to workload, and decrease satisfaction. We, therefore, aimed to evaluate the proportion of unnecessary pediatric trauma transfers and describe patient characteristics of these transfers at the pediatric ED. METHODS: A retrospective chart review of cases with trauma-related diagnoses was carried out from January to April 2017. Information regarding patient demographics, diagnosis, and clinical progress was collected. A transfer was defined as unnecessary if the patient was discharged from the pediatric ED without any therapeutic procedure performed. RESULTS: There were 117 cases of trauma transfers. The mean age was 8.3 ± 4.9 years, and 77 (65.8%) patients were male. Ninety-five (81.2%) transfers were from restructured hospitals. Thirty-one (26.5%) cases were admitted to the hospital. Thirty-four (29.1%) cases were unnecessary transfers. The length of stay in the ED for these transferred cases was 118.4 ± 87.1 min. Referring ED was not significantly associated with discharge (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 0.43–3.83, P = 0.792), discharge without any therapeutic procedure performed (OR: 1.47, 95% CI: 0.50–4.31, P = 0.591), or length of stay (mean difference: 22.3 min, 95% CI: 84.5–39.9, P = 0.471). CONCLUSION: About a third of trauma transfers were unnecessary. Further collaborative efforts would be necessary to further define the situation in different health-care settings and exact reasons elucidated so that targeted interventions could be implemented to improve pediatric trauma care.
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Affiliation(s)
- Min Hui Lyria Hoa
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Yong-Kwang Gene Ong
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
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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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Brova M, Boggs KM, Zachrison KS, Freid RD, Sullivan AF, Espinola JA, Boyle T, Camargo CA. Pediatric Telemedicine Use in United States Emergency Departments. Acad Emerg Med 2018; 25:1427-1432. [PMID: 30307078 DOI: 10.1111/acem.13629] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/29/2018] [Accepted: 10/06/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The receipt of remote clinical care for children via telecommunications (pediatric telemedicine) appears to improve access to and quality of care in U.S. emergency departments (EDs), but the actual prevalence and characteristics of pediatric telemedicine receipt remain unclear. We determined the prevalence and current applications of pediatric telemedicine in U.S. EDs, focusing on EDs that received telemedicine from clinicians at other facilities. METHODS We surveyed all 5,375 U.S. EDs to characterize emergency care in 2016. We then randomly surveyed 130 (39%) of the 337 EDs who reported receiving pediatric telemedicine. The second survey was administered by phone to ED directors primarily. It confirmed that the ED received pediatric telemedicine services in 2017 and asked about ED staffing and the nature, purpose, and concerns with pediatric telemedicine implementation. RESULTS The first survey (4,507/5,375, 84% response) showed that 337 (8%) EDs reported receiving pediatric telemedicine. Among the randomly sampled EDs completing the second survey (107/130, 82% response), 96 (90%) confirmed 2016 use and 89 (83%) confirmed 2017 use. Reasons for discontinuation included technical and scheduling concerns. Almost all who confirmed their pediatric telemedicine use in 2017 also reported 24/7 availability (98%). The most widely reported use was for patient placement and transfer coordination (80%). Many EDs (39%) reported no challenges with implementing pediatric telemedicine and described its utility. However, the most frequently reported challenges were process concerns (30%), such as concerns about slowing or interrupting providers' work flow and technological concerns (14%). CONCLUSION Few EDs receive telemedicine for the delivery of pediatric emergency care nationally. Among EDs that do use telemedicine for pediatric care, many report process concerns. Addressing these barriers through focused education or interventions may support EDs in further developing and optimizing this technological adjunct to pediatric emergency care.
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Affiliation(s)
- Monica Brova
- Department of Epidemiology Boston University School of Public Health Boston MA
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Krislyn M. Boggs
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Kori S. Zachrison
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Rachel D. Freid
- Department of Environmental Health Boston University School of Public Health Boston MA
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Ashley F. Sullivan
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Janice A. Espinola
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Tehnaz P. Boyle
- Department of Pediatrics Division of Pediatric Emergency Medicine Boston Medical Center Boston MA
| | - Carlos A. Camargo
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
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Ray KN, Olson LM, Edgerton EA, Ely M, Gausche-Hill M, Schmuhl P, Wallace DJ, Kahn JM. Access to High Pediatric-Readiness Emergency Care in the United States. J Pediatr 2018; 194:225-232.e1. [PMID: 29336799 PMCID: PMC5826844 DOI: 10.1016/j.jpeds.2017.10.074] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/17/2017] [Accepted: 10/26/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the geographic accessibility of emergency departments (EDs) with high pediatric readiness by assessing the percentage of US children living within a 30-minute drive time of an ED with high pediatric readiness, as defined by collaboratively developed published guidelines. STUDY DESIGN In this cross-sectional analysis, we examined geographic access to an ED with high pediatric readiness among US children. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) of US hospitals based on the 2013 National Pediatric Readiness Project (NPRP) survey. A WPRS of 100 indicates that the ED meets the essential guidelines for pediatric readiness. Using estimated drive time from ZIP code centroids, we determined the proportions of US children living within a 30-minute drive time of an ED with a WPRS of 100 (maximum), 94.3 (90th percentile), and 83.6 (75th percentile). RESULTS Although 93.7% of children could travel to any ED within 30 minutes, only 33.7% of children could travel to an ED with a WPRS of 100, 55.3% could travel to an ED with a WPRS at or above the 90th percentile, and 70.2% could travel to an ED with a WPRS at or above the 75th percentile. Among children within a 30-minute drive of an ED with the maximum WPRS, 90.9% lived closer to at least 1 alternative ED with a WPRS below the maximum. Access varied across census divisions, ranging from 14.9% of children in the East South Center to 56.2% in the Mid-Atlantic for EDs scoring a maximum WPRS. CONCLUSION A significant proportion of US children do not have timely access to EDs with high pediatric readiness.
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Affiliation(s)
- Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Lenora M. Olson
- National Emergency Medical Services for Children Data Analysis Resource Center, Salt Lake City, UT; Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Elizabeth A. Edgerton
- Emergency Medical Services for Children and Injury Prevention, Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Michael Ely
- National Emergency Medical Services for Children Data Analysis Resource Center, Salt Lake City, UT; Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Marianne Gausche-Hill
- Department of Emergency Medicine and Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine, UCLA, Los Angeles, CA; the Los Angeles County Emergency Medical Services Agency; Santa Fe Springs, CA
| | - Patricia Schmuhl
- National Emergency Medical Services for Children Data Analysis Resource Center, Salt Lake City, UT; Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - David J. Wallace
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA,Department of Emergency Medicine, University of Pittsburgh School of Medicine, PA
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA,Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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