Improving pretransport care of pediatric emergency patients: an assessment of referring hospital care

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU

BACKGROUND

Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers.

METHODS

I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians.

RESULTS

Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use.

CONCLUSION

I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Characteristics and special challenges of neonatal emergency transports

BACKGROUND

As a rule, newborns do not require special medical care. If unexpected complications occur peripartum or postpartum, support from and transport to specialised neonatal hospitals might be needed.

METHODS

In a retrospective study, all transport protocols of a supraregional paediatric‑neonatological maximum care hospital in northwestern Germany from 01.10.2018 through 30.09.2021 were analysed. The particular focus was on transports of newborns (<7 days) and the leading symptoms that led to contact.

RESULTS

A total of 299 patients were included (average age of 15.4 h, 61.6 % males). The average complete transport time was approximately 2 h. Five leading neonatal diseases (respiratory, infectious, asphyxia, cardiac, haematological) were found to represent the causes of >80 % of transfers. Respiratory adaptation disorders are the main reason for transferring a newborn to a centre, whereas asphyxia is the most severe condition. The various symptoms differ in their time of onset, a factor which must be taken into account in practice. Differences were also found between different types of hospitals: while a large proportion of transports were carried out from maternity hospitals (80.6 %), children transported from children's hospitals were generally more severely ill.

DISCUSSION

Transfers of neonates, especially from maternity hospitals to neonatal intensive care units due to special neonatal diseases, are not rare. In times of increasingly scarce resources, the effective care of sick or at-risk neonates is essential. For low-population regions, this means professional cooperation between maximum care providers and smaller children's hospitals and maternity-only hospitals.

Reporting Outcomes of Pediatric Intensive Care Unit Patients to Referring Physicians via an Electronic Health Record-Based Feedback System

BACKGROUND

 Many critically ill children are initially evaluated in front-line settings by clinicians with variable pediatric training before they are transferred to a pediatric intensive care unit (PICU). Because clinicians learn from past performance, communicating outcomes of patients back to front-line clinicians who provide pediatric emergency care could be valuable; however, referring clinicians do not consistently receive this important feedback.

OBJECTIVES

 Our aim was to determine the feasibility, usability, and clinical relevance of a semiautomated electronic health record (EHR)-supported system developed at a single institution to deliver timely and relevant PICU patient outcome feedback to referring emergency department (ED) physicians.

METHODS

 Guided by the Health Information Technology Safety Framework, we iteratively designed, implemented, and evaluated a semiautomated electronic feedback system leveraging the EHR in one institution. After conducting interviews and focus groups with stakeholders to understand the PICU-ED health care work system, we designed the EHR-supported feedback system by translating stakeholder, organizational, and usability objectives into feedback process and report requirements. Over 6 months, we completed three cycles of implementation and evaluation, wherein we analyzed EHR access logs, reviewed feedback reports sent, performed usability testing, and conducted physician interviews to determine the system's feasibility, usability, and clinical relevance.

RESULTS

 The EHR-supported feedback process is feasible with timely delivery and receipt of feedback reports. Usability testing revealed excellent Systems Usability Scale scores. According to physicians, the process was well-integrated into their clinical workflows and conferred minimal additional workload. Physicians also indicated that delivering and receiving consistent feedback was relevant to their clinical practice.

CONCLUSION

 An EHR-supported system to deliver timely and relevant PICU patient outcome feedback to referring ED physicians was feasible, usable, and important to physicians. Future work is needed to evaluate impact on clinical practice and patient outcomes and to investigate applicability to other clinical settings involved in similar care transitions.

Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method

Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.

Pediatric Conditions Requiring Interfacility Transport From Emergency Departments: A Statewide Study of Regionalization

OBJECTIVES

Pediatric care is increasingly regionalized, increasing rates of interfacility transport (IFT). However, it is unknown what conditions most frequently require IFT. This study's objective was to identify high-frequency pediatric conditions requiring IFT.

METHODS

This is a statewide retrospective observational study from 2010 to 2012 of pediatric patients (<18 years of age) who underwent IFT in Maryland. Patients were identified from the Health Care Utilization Project's database using probabilistic linkage. This study identified the 20 most common pediatric IFT conditions, and the conditions with the highest IFT rates.

RESULTS

Probabilistic linkage was successful for 2254 records. The largest age category was 0 to 4 years (43%). The top 3 IFT conditions were asthma (13.5%), epilepsy (8.5%), and diabetes mellitus (6.6%). Diabetes mellitus had the highest IFT rate (24%), followed by appendicitis (15.5%) and internal obstruction (14.4%).

CONCLUSIONS

Specific pediatric conditions commonly require IFT and had high IFT rates in this statewide study. In addition, the largest age group undergoing IFT was young children (0 to 4 years of age). This study provides specific detail regarding conditions and ages impacted by IFT, and emergency medical services should consider incorporating these findings into transport destination algorithms. In addition, public health stakeholders should address implications of the concentration of care for these common pediatric conditions and younger age groups.

Reasons for Interfacility Emergency Department Transfer and Care at the Receiving Facility

OBJECTIVES

The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility.

METHODS

We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer.

RESULTS

Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission.

CONCLUSIONS

Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality Improvement and Safety in Pediatric Emergency Medicine

Pediatric emergency medicine quality work continues to focus on the National Academies of Sciences, Engineering, and Medicine's 6 domains of quality, with a need for specific emphasis on equity and patient centeredness. Adopting the principles of high-reliability organizations, pediatric emergency departments should become increasing transparent with benchmarking and collaboration across institutions in order to develop an infrastructure for quality and safety to improve the care of pediatric patients in the emergency department.

Variation in Pediatric Care Between Academic and Nonacademic US Emergency Departments, 1995-2010

OBJECTIVES

The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs).

METHODS

We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED).

RESULTS

From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%).

CONCLUSION

Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.

Retrospective Evaluation of Risk Factors for Pediatric Secondary Transport

OBJECTIVE

Emergency medical services (EMS) typically transports patients to the nearest emergency department (ED). After initial presentation, children who require specialized care must undergo secondary transport, exposing them to additional risks and delaying definitive treatment. EMS direct transport protocols exist for major trauma and certain adult medical conditions, however the same cannot be said for pediatric medical conditions or injuries that do not meet trauma center criteria ('minor trauma'). To explore the utility of such future protocols, we sought to first describe the pediatric secondary transport population and examine prehospital risk factors for secondary transport.

METHODS

Pediatric secondary transport patients aged 0-18 years were identified. Patients meeting state EMS trauma protocol criteria or who were clinically unstable were excluded. Data were abstracted by chart review of EMS, community hospital ED, and specialty hospital records. Patients were compared to control patients with similar conditions who did not require secondary transport.

RESULTS

This study identified 211 medical or minor trauma pediatric secondary transport patients between 2013 and 2014. The three most prevalent conditions were seizure (n = 52), isolated orthopedic injury (n = 49), and asthma/respiratory distress (n = 27). Increased odds of secondary transport for seizure patients were associated with administration of supplemental oxygen, glucose measurement, and online medical direction; for isolated orthopedic injuries, online medical direction; and for asthma/respiratory distress, administration of supplemental oxygen, and online medical direction. Decreased odds of secondary transport for seizure patients were associated with a higher GCS; for isolated orthopedic injuries, increased age and oxygen saturation; and for asthma/respiratory distress, administration of albuterol only.

CONCLUSIONS

Children with seizures, isolated orthopedic injuries, and asthma/respiratory distress comprised the majority of the medical or minor trauma pediatric secondary transport population. Each of those conditions had specific risk factors for secondary transport. This study's results provide information to guide future prospective studies and the development of direct transport protocols for those populations.

Pediatric Specialty Transport Teams Are Not Associated With Decreased 48-Hour Pediatric Intensive Care Unit Mortality: A Propensity Analysis of the VPS, LLC Database

OBJECTIVE

The purpose of this study was to determine if pediatric specialty pediatric team (SPT) interfacility-transported children from community emergency departments to a pediatric intensive care unit (PICU) have improved 48-hour mortality.

METHODS

This is a multicenter, historic cohort analysis of the VPS, LLC PICU clinical database (VPS, LLC, Los Angeles, CA) for all PICU directly admitted pediatric patients ≤ 18 years of age from January 1, 2007, to March 31, 2009. Categoric variables were analyzed by the chi-square and Mann-Whitney tests for non-normally distributed continuous variables. The propensity score was determined by multiple logistic regression analysis. Nearest neighbor matching developed emergency medical services SPT pairs by similar propensity score. Multiple regression analyses of the matched pairs determined the association of SPT with 48-hour PICU mortality. P values < .05 were considered significant.

RESULTS

This study included 3,795 PICU discharges from 12 hospitals. SPT-transported children were more severely ill, younger in age, and more likely to have a respiratory diagnosis (P < .0001). Unadjusted 48-hour PICU mortality was statistically significantly higher for SPT transports (2.04% vs. 0.070%, P = .0028). Multiple regressions adjusted for propensity score, illness severity, and PICU site showed no significant difference in 48-hour PICU mortality.

CONCLUSION

No significant difference in adjusted 48-hour PICU mortality for children transported by transport team type was discovered.

Caring for critically ill children in the community: a needs assessment

OBJECTIVE

The goal of this study was to identify barriers and facilitators to the optimal management of critically ill children who present initially to community hospitals and how best to support the needs of front-line healthcare providers in these settings prior to transfer to the regional academic paediatric health sciences centre.

METHODS

A qualitative needs assessment was performed in five community hospitals targeting healthcare providers in leadership and front-line roles who could discuss their experiences of managing critically ill children that had presented to their institutions. Focused individual and focus group interviews of physicians, nurses and respiratory therapists from the participating hospitals were conducted and analysed to identify common themes.

RESULTS

Five community hospitals participated in the study with a total of 57 participants and included 36 registered nurses, 4 respiratory therapists, 13 community hospital physicians and 4 paediatric intensive care specialists. Most participants did not report seeing more than one critically ill child per month. The management of very young paediatric patients was reported as a greater source of anxiety than patients presenting in cardiac arrest and despite being more frequently reported, respiratory conditions were identified as the most anxiety provoking and having the greatest educational need. The care required for a single critically ill child was often reported to render the emergency department staff incapable of meeting other patient care needs and was influenced by staffing resources, physical layout and access to proper equipment. Increased comfort and management ability was attributed to previous real-world experience and support from content experts in dealing with acutely ill children. Participants did not use web-based best practice guidelines.

CONCLUSIONS

This study identifies the need to fully understand the management realities of front-line caregivers of critically ill children in community hospital settings. We demonstrate the need to focus on the management of younger paediatric patients, technical skills development, practice of acute situations with less than optimal staffing resources, and access to facilitated real-world experiences with appropriate supervision and mentoring. Passive interventions such as web-based guidelines should not be used in isolation but as a support to ongoing exposure and engagement by content experts.

Interfacility transfers of noncritically ill children to academic pediatric emergency departments

OBJECTIVES

We aimed to characterize the demographics, diagnoses, and management of transferred patients who were directly discharged from the emergency department (ED) or admitted less than 24 hours.

METHODS

We conducted a retrospective, cross-sectional study of patients classified as interfacility ED transfers over a 12-month period in the Pediatric Health Information System database, an administrative database of 42 tertiary care pediatric US hospitals. The primary study outcomes were ED resource utilization at the receiving facility with a focus on children who were discharged directly from the ED or admitted less than 24 hours.

RESULTS

Overall, 24,905 interfacility transfers were identified, accounting for 1.3% of the ED volume of these academic pediatric centers. Of these, 24.7% were discharged directly from the ED and 17.0% were admitted for less than 24 hours. Among those directly discharged from the ED, the 3 most common complaints were orthopedic problems, nonsurgical abdominal pain, and viral gastroenteritis; 20.7% received no medical or procedural intervention. Among those admitted for less than 24 hours, the 3 most common complaints were orthopedic problems, traumatic head injury, and gastrointestinal conditions.

CONCLUSIONS

A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.