1
|
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.
Collapse
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
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Schumacher S, Mitzlaff B, Mohrmann C, Fiedler KM, Heep A, Beske F, Hoffmann F, Lange M. Characteristics and special challenges of neonatal emergency transports. Early Hum Dev 2024; 192:106012. [PMID: 38648678 DOI: 10.1016/j.earlhumdev.2024.106012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
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.
Collapse
Affiliation(s)
- S Schumacher
- Department of Pediatrics, Klinikum Leer, Leer, Germany
| | - B Mitzlaff
- Institute for Emergency Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - C Mohrmann
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - K M Fiedler
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - A Heep
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - F Beske
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany
| | - F Hoffmann
- Department of Healthcare Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M Lange
- Department of Pediatrics, Elisabeth Children's Hospital, University of Oldenburg, Oldenburg, Germany.
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Kendrick T, Nassar N, Stirling C. Outcomes of medically retrieved infants with bronchiolitis in high-income countries: A scoping review. Aust Crit Care 2024; 37:346-353. [PMID: 37752031 DOI: 10.1016/j.aucc.2023.07.035] [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: 03/08/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 09/28/2023] Open
Abstract
INTRODUCTION Bronchiolitis is the most common respiratory infection and reason for hospitalisation in infancy; however, outcomes of infants with bronchiolitis who require interhospital transfer by specialist medical retrieval services are poorly understood. OBJECTIVES The objective of this study was to summarise current evidence of the rate, therapy, and outcomes of infants with bronchiolitis who required medical retrieval for ongoing management. REVIEW METHOD A scoping literature review informed by the Joanna Briggs Institute methodology was used including published studies in any language covering the period 1996 to December 2022 and grey literature sources comprised of reports from retrieval services in high-income countries with comparable healthcare systems. DATA SOURCES Medline, CINAHL, and the Cochrane Database of Systematic Reviews electronic databases were the sources for published studies. Grey literature sources were retrieval service web pages/social media sites from Australia, Canada, New Zealand, the United Kingdom, and the United States of America. RESULTS Searching identified 12 677 records, with 12 069 ineligible records and 286 duplicates excluded at screening. Of the 72 papers included for title and abstract review, 16 were selected for full-text review. Six papers fulfilled inclusion criteria. Infants with bronchiolitis were the primary focus of three studies. Transfer rate was reported in four studies, ranging from 4.3% to 18.5%. Use of respiratory therapy was variably reported and was associated with prematurity. Outcomes following retrieval such as respiratory therapies, days on therapies, length of stay in the intensive care unit, and hospital length of stay were only reported in two studies. Of 103 identified medical retrieval services and data registries, no reports were found that included information on the number of transfers or outcomes for infants with bronchiolitis. CONCLUSIONS Up to one in five infants with bronchiolitis require medical retrieval. Only two published studies and no reports reported on the number and outcomes of infants. Given the frequency and severity of bronchiolitis, understanding indications for medical retrieval and outcomes of those infants may help to better target care and interventions for this common illness. Benefits could include diminishing the costly burden to families and the healthcare system of avoidable medical retrieval and interhospital transfer.
Collapse
Affiliation(s)
- Tina Kendrick
- NSW Newborn and Paediatric Emergency Transport Service, The Sydney Children's Hospitals Network, Australia; School of Nursing, University of Tasmania, Hobart TAS, Australia; Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.
| | - Natasha Nassar
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | | |
Collapse
|
6
|
Dean K, Chang C, McKenna E, Nott S, Hunter A, Tall JA, Setterfield M, Addis B, Webster E. A retrospective observational study of vCare: a virtual emergency clinical advisory and transfer service in rural and remote Australia. BMC Health Serv Res 2024; 24:100. [PMID: 38238698 PMCID: PMC10797963 DOI: 10.1186/s12913-023-10425-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 12/03/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Provision of critical care in rural areas is challenging due to geographic distance, smaller facilities, generalist skill mix and population characteristics. Internationally, the amalgamation telemedicine and retrieval medicine services are developing to overcome these challenges. Virtual emergency clinical advisory and transfer service (vCare) is one of these novel services based in New South Wales, Australia. We aim to describe patient encounters with vCare from call initiation at the referring site to definitive care at the accepting site. METHODS This retrospective observational study reviewed all patients using vCare in rural and remote Australia for clinical advice and/or inter-hospital transfer for higher level of care between February and March 2021. Data were extracted from electronic medical records and included remoteness of sites, presenting complaint, triage category, camera use, patient characteristics, transfer information, escalation of therapeutic intervention and outcomes. Data were summarised using cross tabulation. RESULTS 1,678 critical care patients were supported by vCare, with children (12.5%), adults (50.6%) and older people (36.9%) evenly split between sexes. Clinicians mainly referred to vCare for trauma (15.1%), cardiac (16.1%) and gastroenterological (14.8%) presentations. A referral to vCare led to an escalation of invasive intervention, skill, and resources for patient care. vCare cameras were used in 19.8% of cases. Overall, 70.5% (n = 1,139) of patients required transfer. Of those, 95.1% were transferred to major regional hospitals and 11.7% required secondary transfer to higher acuity hospitals. Of high-urgency referrals, 42.6% did not receive high priority transport. Imaging most requested included CT and MRI scans (37.2%). Admissions were for physician (33.1%) and surgical care (23.3%). The survival rate was 98.6%. CONCLUSION vCare was used by staff in rural and remote facilities to support decision making and care of patients in a critical condition. Issues were identified including low utilisation of equipment, heavy reliance on regional sites and high rates of secondary transfer. However, these models are addressing a key gap in the health workforce and supporting rural and remote communities to receive care.
Collapse
Affiliation(s)
- Kimberley Dean
- Orange Health Service, Western NSW Local Health District, 1530 Forest Road, Orange, NSW, 2800, Australia
| | - Cynthia Chang
- Maitland Hospital, Hunter New England Local Health District, 51 Metford Rd, Metford, NSW, 2323, Australia
| | - Erin McKenna
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
| | - Shannon Nott
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
- Western NSW Local Health District, 7 Commercial Ave, Dubbo, NSW, 2830, Australia
| | - Amanda Hunter
- vCare Western NSW Local Health District, PO Box 739, Dubbo, NSW, 2830, Australia
| | - Julie A Tall
- Health Intelligence Unit, Western NSW Local Health District, Ward 22, Bloomfield Campus, Locked Bag 6008, Orange, NSW, 2800, Australia
| | - Madeline Setterfield
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
| | - Bridget Addis
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
| | - Emma Webster
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia.
| |
Collapse
|
7
|
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 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.
Collapse
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
- Adult and Child Consortium for Health Outcomes Research and Delivery Science
- University of Colorado School of Medicine, Aurora, Colorado
| | - Mark S Brittan
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado Denver, Aurora Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science
- University of Colorado School of Medicine, 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
| |
Collapse
|
8
|
Bhatnagar A, Mackman S, Van Arendonk KJ, Thalji SZ. Associations between Hospital Setting and Outcomes after Pediatric Appendectomy. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1908. [PMID: 38136110 PMCID: PMC10741462 DOI: 10.3390/children10121908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/02/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
Prior studies of associations between hospital location and outcomes for pediatric appendectomy have not adjusted for significant differences in patient and treatment patterns between settings. This was a cross-sectional analysis of pediatric appendectomies in the 2016 Kids' Inpatient Database (KID). Weighted multiple linear and logistic regression models compared hospital location (urban or rural) and academic status against total admission cost (TAC), length of stay (LOS), and postoperative complications. Patients were stratified by laparoscopic (LA) or open (OA) appendectomy. Among 54,836 patients, 39,454 (73%) were performed at an urban academic center, 11,642 (21%) were performed at an urban non-academic center, and 3740 (7%) were performed at a rural center. LA was utilized for 49,011 (89%) of all 54,386 patients: 36,049 (91%) of 39,454 patients at urban academic hospitals, 10,191 (87%) of 11,642 patients at urban non-academic centers, and 2771 (74%) of 3740 patients at rural centers (p < 0.001). On adjusted analysis, urban academic centers were associated with an 18% decreased TAC (95% CI -0.193--0.165; p < 0.001) despite an 11% increased LOS (95% CI 0.087-0.134; p < 0.001) compared to rural centers. Urban academic centers were associated with a decreased odds of complication among patients who underwent LA (OR 0.787, 95% CI 0.650-0.952) but not after OA. After adjusting for relevant patient and disease-related factors, urban academic centers were associated with lower costs despite longer lengths of stay compared to rural centers. Urban academic centers utilized LA more frequently and were associated with decreased odds of postoperative complications after LA.
Collapse
Affiliation(s)
| | - Sean Mackman
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| | - Kyle J. Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Sam Z. Thalji
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
| |
Collapse
|
9
|
Schmucker KA, Morris CS, Tisherman RT, Manole M, Arora G, Dunnick J. Patient Characteristics Associated with Hospital Admission or Antiarrhythmic Medication Changes After Emergency Department Evaluation of Supraventricular Tachycardia. Pediatr Cardiol 2023; 44:1710-1715. [PMID: 37561172 DOI: 10.1007/s00246-023-03257-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED. DESIGN/METHODS A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children's hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications. RESULTS We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4). CONCLUSIONS Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.
Collapse
Affiliation(s)
- Kyle A Schmucker
- Department of Pediatrics, Division of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Caroline S Morris
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, USA
| | | | - Mioara Manole
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Guarav Arora
- Department of Pediatrics, Division of Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer Dunnick
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Leyenaar JK, Freyleue SD, Arakelyan M, Goodman DC, O’Malley AJ. Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019. JAMA Netw Open 2023; 6:e2331807. [PMID: 37656457 PMCID: PMC10474556 DOI: 10.1001/jamanetworkopen.2023.31807] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/07/2023] [Indexed: 09/02/2023] Open
Abstract
Importance National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. Objective To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. Design, Setting, and Participants This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Exposures Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. Main Outcomes and Measures The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. Results The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Conclusions and Relevance Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.
Collapse
Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - Seneca D. Freyleue
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mary Arakelyan
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Dartmouth Health Children’s, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| |
Collapse
|
12
|
Ndebwanimana V, Beeman A, Gallaer A, Uwamahoro C, Uwamahoro D, Ritz C, Lewis S, Hoyt SD, Jean Paul N, Gonsalves-Domond G, Odoom E, Vital M, Martin KD. "EM Doc On Call:" A Pilot Study to Improve Interhospital Transfers in Rwanda. Prehosp Disaster Med 2023; 38:456-462. [PMID: 37340758 PMCID: PMC10445112 DOI: 10.1017/s1049023x23005927] [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: 03/10/2023] [Revised: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 06/22/2023]
Abstract
INTRODUCTION Treatment of seriously ill patients is often complicated by prolonged or complex transfers between hospitals in sub-Saharan Africa. Difficulties or inefficiency in these transfers can lead to poor outcomes for patients. "On-call" triage systems have been utilized to facilitate communication between facilities and to avoid poor outcomes associated with patient transfer. This study attempts to examine the effects of a pilot study to implement such a system in Rwanda. METHODS Data collection occurred prospectively in two stages, pre-intervention and intervention, in the emergency department (ED) at Kigali University Teaching Hospital (CHUK). All patients transferred during the pre-determined timeframe were enrolled. Data were collected by ED research staff via a standardized form. Statistical analysis was performed using STATA version 15.0. Differences in characteristics were assessed using χ2 or Fisher's exact tests for categorical variables and independent sample t-tests for normally distributed continuous variables. RESULTS During the "on call" physician intervention, the indication for transfer was significantly more likely to be for critical care (P <.001), transfer times were faster (P <.001), patients were more likely to be displaying emergency signs (P <.001), and vital signs were more likely to be collected prior to transport (P <.001) when compared to the pre-interventional phase. CONCLUSION The "[Emergency Medicine] EM Doc On Call" intervention was associated with improved timely interhospital transfer and clinical documentation in Rwanda. While these data are not definitive due to multiple limitations, it is extremely promising and worthy of further study.
Collapse
Affiliation(s)
- Vincent Ndebwanimana
- Accident and Emergency, Kigali University Teaching Hospital, Kigali, Rwanda
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Aly Beeman
- Warren Alpert Medical School at Brown University, Providence, Rhode IslandUSA
| | - Alexander Gallaer
- Department of Emergency Medicine, University of Utah, Salt Lake City, UtahUSA
| | - Chantal Uwamahoro
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Doris Uwamahoro
- Accident and Emergency, Kigali University Teaching Hospital, Kigali, Rwanda
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Cody Ritz
- MD/MPH Program, Drexel University College of Medicine, Philadelphia, PennsylvaniaUSA
| | - Samuel Lewis
- Department of Emergency Medicine, University of Washington, Seattle, WashingtonUSA
| | - Savanna Dayne Hoyt
- Northeast Ohio Medical University College of Medicine, Rootstown, OhioUSA
| | - Nzabandora Jean Paul
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | | | - Enyonam Odoom
- Warren Alpert Medical School at Brown University, Providence, Rhode IslandUSA
| | - Mutijima Vital
- Department of Anesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Kyle Denison Martin
- Warren Alpert Medical School at Brown University, Providence, Rhode IslandUSA
| |
Collapse
|
13
|
McDaniel CE, Leyenaar JK, Bryan MA, Test M, Sullivan E. Urban-rural disparities in interfacility transfers for children during COVID-19. J Rural Health 2023; 39:611-616. [PMID: 36710077 PMCID: PMC11132630 DOI: 10.1111/jrh.12746] [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] [Indexed: 01/31/2023]
Abstract
PURPOSE We aimed to identify temporal trends and differences in urban and rural pediatric interfacility transfers (IFTs) before and during the COVID-19 pandemic. METHODS We conducted a cross-sectional analysis of IFT among children <18 years from January 2019 to June 2022 using the Pediatric Health Information System. The primary outcome was IFTs from general hospitals to referral children's hospitals. The primary exposure was patient rurality, defined by Rural-Urban Commuting Area codes. We categorized IFTs into medical, surgical, and mental health diagnoses and analyzed trends by month. We calculated observed-to-expected (O-E) ratios of pre-pandemic (March 2019-Feb 2020) transfers compared to pandemic year 1 (March 2020-Feb 2021) and year 2 (March 2021-February 2022) using Poisson modeling. FINDINGS Of 419,250 IFTs, 18.8% (n = 78,751) were experienced by rural-residing children. The O-E ratio of IFT in year 1 for urban children was 14.0% (95% confidence interval [CI] 13.8, 14.2) and 14.8% (95% CI 14.4, 15.3) for rural children compared to pre-pandemic (P = .0001). In year 2, transfers rebounded with IFTs for rural-residing children increasing more than urban-residing children (101.7% [95% CI 100.1, 103.4] compared to 90.7% [95% CI 89.0, 90.4], P < .0001). For mental-health indications in year 2, rural transfer ratios were higher than urban, 126.8% (95% CI, 116.7, 137.6) compared to 113.7% (95% CI 109.9, 117.6), P = .0168. CONCLUSIONS Pediatric IFTs decreased dramatically during pandemic year 1. In year 2, while medical and surgical transfers continued to lag pre-pandemic volumes, transfers for mental health indications significantly exceeded pre-pandemic levels, particularly among rural-residing children.
Collapse
Affiliation(s)
- Corrie E. McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - JoAnna K. Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Matthew Test
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Erin Sullivan
- Seattle Children’s Research Institute, Seattle, Washington, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Rangwala SD, Han JS, Ding L, Mack WJ, Krieger MD, Attenello FJ. Interhospital transfer of pediatric patients with malignant brain tumor not associated with increased mortality, but safe routine discharge. J Neurosurg Pediatr 2023; 31:124-131. [PMID: 36401543 DOI: 10.3171/2022.10.peds22124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Interhospital transfer (IHT) to obtain a higher level of care for pediatric patients requiring neurosurgical interventions is common. Pediatric patients with malignant brain tumors often require subspecialty care commonly provided at specialized centers. The authors aimed to assess the impact of IHT in pediatric neurosurgical patients with malignant brain tumors to identify areas of improvement in treatment of this patient population. METHODS Pediatric patients (age < 19 years) with malignant primary brain tumors undergoing craniotomy for resection between 2010 and 2018 were retrospectively identified in the Nationwide Readmissions Database. Patient and hospital data for each index admission provided by the Nationwide Readmissions Database was analyzed by univariate and multivariate analyses. Further analysis evaluated association of IHT on specific patient- or hospital-related characteristics. RESULTS In a total of 2279 nonelective admissions for malignant brain tumors in pediatric patients, the authors found only 132 patients (5.8%) who underwent IHT for a higher level of care. There is an increased likelihood of transfer when a patient is younger (< 7 years old, p = 0.006) or the disease process is more severe, as characterized by higher pediatric complex chronic conditions (p = 0.0004) and increased all patient refined diagnosis-related group mortality index (p = 0.02). Patients who are transferred (OR 1.87, 95% CI 1.04-3.35; p = 0.04) and patients who are treated at pediatric centers (OR 6.89, 95% CI 4.23-11.22; p < 0.0001) are more likely to have a routine discharge home. On multivariate analysis, transfer status was not associated with a longer length of stay (incident rate ratio 1.04, 95% CI 0.94-1.16; p = 0.5) or greater overall costs per patient ($20,947.58, 95% CI -$35,078.80 to $76,974.00; p = 0.50). Additionally, IHT is not associated with increased likelihood of death or major complication. CONCLUSIONS IHT has a significant role in the outcome of pediatric patients with malignant brain tumors. Transfer of this patient population to hospitals providing subspecialized care results in a higher level of care without a significant burden on overall costs, risks, or mortality.
Collapse
Affiliation(s)
| | - Jane S Han
- Departments of1Neurological Surgery, and
| | - Li Ding
- 2Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles; and
| | | | - Mark D Krieger
- 3Division of Neurological Surgery, Department of Surgery, Children's Hospital of Los Angeles, California
| | | |
Collapse
|
16
|
Marcin JP, Sauers-Ford HS, Mouzoon JL, Haynes SC, Dayal P, Sigal I, Tancredi D, Lieng MK, Kuppermann N. Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers: A Cluster-Randomized Crossover Trial. JAMA Netw Open 2023; 6:e2255770. [PMID: 36780158 PMCID: PMC9926323 DOI: 10.1001/jamanetworkopen.2022.55770] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
IMPORTANCE Pediatric referral centers are increasingly using telemedicine to provide consultations to help care for acutely ill children presenting to rural and community emergency departments (EDs). These pediatric telemedicine consultations may help improve physician decision-making and may reduce the frequency of overtriage and interfacility transfers. OBJECTIVE To examine the use of pediatric critical care telemedicine vs telephone consultations associated with risk-adjusted transfer rates of acutely ill children from community and rural EDs. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized crossover trial was conducted between November 18, 2015, and March 26, 2018. Analyses were conducted from January 19, 2018, to July 23, 2022, 2022. Participants included acutely ill children aged 14 years and younger presenting to a participating ED in 15 rural and community EDs in northern California. INTERVENTIONS Participating EDs were randomized to use telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine:1 telephone) crossover treatment assignment sequences. MAIN OUTCOMES AND MEASURES Intention-to-treat, treatment-received, and per-protocol analyses were performed to determine the risk of transfer using mixed effects Poisson regression analyses with random intercepts for presenting EDs to account for hospital-level clustering. RESULTS A total of 696 children (392 boys [56.3%]; mean [SD] age, 4.2 [4.6] years) were enrolled. Of the 537 children (77.2%) assigned to telemedicine, 251 (46.7%) received the intervention. In the intention-to-treat analysis, patients assigned to the telemedicine arm were less likely to be transferred compared with patients assigned to the telephone arm after adjusting for patient age, severity of illness, and hospital study period (risk rate [RR], 0.93; 95% CI, 0.88-0.99). The adjusted risk of transfer was significantly lower in the telemedicine arm compared with the telephone arm in both the treatment-received analysis (RR, 0.81; 95% CI, 0.71-0.94) and the per-protocol analysis (RR, 0.79; 95% CI, 0.68-0.92). CONCLUSIONS AND RELEVANCE In this randomized trial, the use of telemedicine to conduct consultations for acutely ill children in rural and community EDs resulted in less frequent overall interfacility transfers than consultations done by telephone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02877810.
Collapse
Affiliation(s)
- James P. Marcin
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Hadley S. Sauers-Ford
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jamie L. Mouzoon
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Sarah C. Haynes
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Parul Dayal
- Genentech Inc, South San Francisco, California
| | - Ilana Sigal
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Daniel Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Monica K. Lieng
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Taraschenko O. National Patterns of Interfacility Transfers for Seizure-Related Emergencies: Could the Utilization of Transfer Networks for Seizures Be Optimized? Neurology 2022; 99:1081-1082. [PMID: 36220599 DOI: 10.1212/wnl.0000000000201530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/21/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Olga Taraschenko
- From the Comprehensive Epilepsy Program, Department of Neurological Sciences, University of Nebraska Medical Center, 988435 Nebraska Medical Center, Omaha, NE.
| |
Collapse
|
19
|
Osmanlliu E, Burstein B, Tamblyn R, Buckeridge DL. Assessing the potential for virtualizable care in the pediatric emergency department. J Telemed Telecare 2022:1357633X221133415. [PMID: 36408736 DOI: 10.1177/1357633x221133415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
INTRODUCTION There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care. METHODS This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018-12/2019). Three definitions of virtualizable care were developed: (1) a definition based on "resource use" classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a "diagnostic definition" based on primary ED diagnosis; and (3) a stringent "combined definition" by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability. RESULTS There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%-38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16-1.37), non-Canadian citizenship (aOR 1.10-1.18), ethnocultural vulnerability (aOR 1.14-1.22), and a consultation for head trauma (aOR 3.50-4.60) were associated with higher telemedicine suitability across definitions. DISCUSSION There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.
Collapse
Affiliation(s)
- Esli Osmanlliu
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- Pediatric Emergency Medicine Division, 12367McGill University Health Center, McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| | - Brett Burstein
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- Pediatric Emergency Medicine Division, 12367McGill University Health Center, McGill University, Montréal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| |
Collapse
|
20
|
Van Schaik G, Self WH, Hennessy C, Ward MJ. Potentially avoidable interfacility transfers following reduced emergency department volumes due to COVID-19 "Safer-at-Home" orders. Am J Emerg Med 2022; 61:68-73. [PMID: 36057211 PMCID: PMC9389782 DOI: 10.1016/j.ajem.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We sought to assess if a state-wide lockdown implemented due to COVID-19 was associated with increased odds of being a potentially avoidable transfer (PAT). METHODS We conducted a retrospective observational analysis using hospital administrative data of interfacility ED-to-ED transfers to a single, quaternary care adult ED after "Safer at Home" orders were issued March 23rd, 2020 in [Blinded for submission]. Using the PAT classification to identify transfers rapidly discharged from the ED or hospital and may not require in-person care, we used a multivariable logistic regression model to examine the association of the lockdown order with odds of a transfer being a PAT. We compared the period January 1, 2018 to March 23, 2020 with March 24, 2020 to September 30, 2020, adjusting for seasonality, patient, and situational factors. RESULTS There were 20,978 ED-to-ED transfers from during this period that were eligible and 4806 (23%) that met PAT criteria. While the first month post-lockdown saw a decrease in PATs (28%), this was not sustained. In the multivariable model there was a significant seasonal effect; May through September had the highest number of transfers as well as PATs. After adjusting for seasonality, the lockdown was not associated with PATs (adjusted odds ratio [aOR] 0.99, 95% CI 0.2, 5.2) and PATs decreased over time. CONCLUSIONS We did not find an effect of the COVID-19 lockdown on PATs though there was a considerable seasonal effect and an overall downward trend in PATs over time.
Collapse
Affiliation(s)
- Graham Van Schaik
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, United States of America; VA Tennessee Valley Healthcare System, United States of America; Department of Biomedical Informatics, Vanderbilt University Medical Center, United States of America; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States of America.
| |
Collapse
|
21
|
Mechas C, Mayer R, Iwinski H, Riley SA, Talwalkar V, Prusick V, Walker JL, Muchow RD, Hubbard E, Zuelzer D. The Costs of Interfacility Transfers for Nonurgent Pediatric Supracondylar Fractures. J Pediatr Orthop 2022; 42:e727-e731. [PMID: 35543599 DOI: 10.1097/bpo.0000000000002177] [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: 02/07/2023]
Abstract
BACKGROUND Unnecessary transfers of nonemergent pediatric musculoskeletal injuries to regional trauma centers can be costly. The severity of fracture displacement in supracondylar humerus fractures dictates the risk of complications, the urgency of transfer and the need for surgical treatment. The purpose of this study is to examine the transfer patterns of Gartland type II pediatric supracondylar humerus fractures to identify strategies for improving patient care, improving health care system efficiency, and reducing costs. We hypothesize that there will be a high rate of unnecessary, emergent transfers resulting in increased cost. METHODS We retrospectively identified all pediatric patients that underwent treatment for a supracondylar humerus fracture between 2013 and 2018. Patient demographics, injury characteristics, chronological data, and surgical data were collected and analyzed from ambulance run sheets, transferring hospital records, and electronic medical records. Transfer distances were estimated using Google-Maps, while transfer costs were estimated using Internal Revenue Service (IRS) standard mileage rates and the American Ambulance Association Medicare Rate Calculator. A student t test was used to evaluate different treatment groups. RESULTS Sixty-two patients had available and complete transfer data, of which 44 (71%) patients were safely transferred via private vehicle an average distance of 51.8 miles, and 18 (29%) patients were transferred via ambulance on an average distance of 55.6 miles ( P =0.76). The average transfer time was 4.1 hours by private vehicle, compared with 3.9 hours by ambulance ( P =0.56). The average estimated cost of transportation was $28.23 by private vehicle, compared with $647.83 by ambulance ( P =0.0001). On average, it took 16.1 hours after injury to undergo surgery and 25.7 hours to be discharged from the hospital, without a significant difference in either of these times between groups. There were no preoperative or postoperative neurovascular deficits. CONCLUSION Patients with isolated Gartland type II supracondylar humerus fractures that are transferred emergently via ambulance are subjected to a significantly greater financial burden with no demonstrable improvement in the quality of their care, since prior research has shown these injuries can safely be treated on an outpatient basis. Potential options to help limit costs could include greater provider education, telemedicine and improved coordination of care. LEVEL OF EVIDENCE Level III (retrospective comparative study).
Collapse
Affiliation(s)
- Charles Mechas
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Ryan Mayer
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Henry Iwinski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Scott A Riley
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Vishwas Talwalkar
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Vincent Prusick
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Janet L Walker
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Ryan D Muchow
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | | | - David Zuelzer
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| |
Collapse
|
22
|
Nezu M, Shiima Y, Kurosawa H, Miyakoshi C. Outcomes of Pediatric Patients in Secondary Transport to Tertiary Hospital: A Retrospective Observational Study. Pediatr Emerg Care 2022; 38:283-289. [PMID: 35436767 DOI: 10.1097/pec.0000000000002711] [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 Emergency medical service (EMS) providers play an important role in determining which hospital to choose. To date, there is no evidence-based guideline to support their decisions, except for major trauma cases. Secondary transport is considered when a patient needs further investigation or treatment after primary transport, but this can delay treatment and put patients at unnecessary risk. The objective of this study was to investigate the outcomes of pediatric secondary transport patients to tertiary hospitals. METHODS This was a citywide population-based observational study conducted in Kobe, Japan. We reviewed the EMS registry to identify secondary transport patients younger than 19 years and investigated their clinical characteristics. We excluded cases of unknown hospital destinations, nontransported cases, and major trauma patients who followed a different protocol for a hospital destination. The primary endpoint was the hospital outcome 12 hours after transport. Because there was no link between the EMS patient transport data and the hospital medical records, a probabilistic linkage was performed to obtain the hospital outcomes. Patients who required secondary transport were compared with patients transported directly to tertiary hospitals. RESULTS A total of 13,720 pediatric patients were transported from the field by Kobe EMS between January 2013 and December 2015. Among them, 81 pediatric patients (0.6%) required secondary transport to tertiary hospitals within 24 hours of the primary transport, whereas a total of 3673 patients (27%) were transported directly to tertiary hospitals. Despite no apparent difference in prehospital severity, secondary transport patients were associated with higher hospitalization rates and a need for critical care compared with those who had direct transport. Seizure was the most common reason for the use of secondary transport, and 89% of the seizure patients were hospitalized after undergoing secondary transport; minor trauma was the second most common reason for the use of secondary transport, and 53% of the patients were hospitalized. CONCLUSIONS In this study, the characteristics of the secondary transport patients and hospital outcomes revealed a heterogeneity in pediatric prehospital transport. It is recommended that the development of pediatric EMS destination guidelines cover children's diverse conditions. Further studies are required, and linkages between prehospital and hospital data will help promote a better understanding of appropriate hospital destinations.
Collapse
Affiliation(s)
- Mari Nezu
- From the Department of Pediatrics, Kobe City Medical Center General Hospital
| | - Yuko Shiima
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital
| | - Hiroshi Kurosawa
- Division of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital
| | - Chisato Miyakoshi
- Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Hyogo, Japan
| |
Collapse
|
23
|
Smithson KB, Parham SG, Mears SC, Siegel ER, Crawley L, Sachleben BC. Transfers of pediatric patients with isolated injuries to a rural Level 1 Orthopedic Trauma Center in the United States: are they all necessary? Arch Orthop Trauma Surg 2022; 142:625-631. [PMID: 33394179 DOI: 10.1007/s00402-020-03679-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/28/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Pediatric fractures are difficult to manage and often result in expensive urgent transfers to a pediatric trauma center. Our study seeks to identify patients transferred with isolated acute orthopedic injuries to a Level 1 center in which no procedure occurred and the patient was discharged home. We sought to examine all patients who are transferred to a Level 1 pediatric trauma center for care of isolated orthopedic injuries, and to determine how often no procedure is performed after transfer. Identification of this group ahead of time could potentially lead to less avoidable transfers. METHODS AND METHODS A retrospective chart review of all patients with isolated orthopaedic injuries who were transferred to a Level 1 pediatric trauma center in a rural state within the United States over a 5-year period beginning January, 2011 and ending December, 2015. Demographic factors were collected for each patient as well as diagnosis and treatment at the trauma center. Patients were divided into two groups, those who underwent an operation or fracture reduction after admission and those that had no procedure performed. Patient demographics, fracture types and presentation characteristics were examined to attempt to determine factors related to the potentially avoidable transfers. RESULTS 1303 patients were identified who were transferred with isolated orthopedic fractures. Of these, 1113 (85.6%) patients underwent a procedure for their injuries, including 821 treated with surgical intervention and 292 treated with closed reduction of their fracture. 190 of 1303 (14.6%) of the patients transferred with isolated injuries had neither surgery nor a reduction performed. Identifying characteristics of the non-operative group were that they contained a substantially higher percentage of females, transfers by ambulance, fractures involving only the tibia, fracture types classified as other, and fractures from motor-vehicle accidents. DISCUSSION Approximately 14.6% of patients transferred to a pediatric Level 1 trauma center for isolated orthopedic injury underwent no surgery or fracture reductions and were discharged directly home. In particular, isolated tibia fractures were more frequently treated without reduction or surgery. In the future, telemedicine consultation for these specific injury types may limit unnecessary and costly transfers to a Level 1 pediatric trauma hospital.
Collapse
Affiliation(s)
- Kaleb B Smithson
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Sean G Parham
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA.
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Lee Crawley
- Department of Pediatric Emergency Medicine, Arkansas Children's Hospital, 1 Children's Way, Slot 512-16, Little Rock, AR, 72032, USA
| | - Brant C Sachleben
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA.,General Surgery Unit3D, Arkansas Children's Hospital, ACH Sturgis Building, Floor 3, Little Rock, AR, 72202, USA
| |
Collapse
|
24
|
Brown L, França UL, McManus ML. Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma. Acad Pediatr 2022; 22:29-36. [PMID: 34051373 DOI: 10.1016/j.acap.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To describe the current system of pediatric asthma care and identify potential options for unloading tertiary centers. METHODS Retrospective, cross-sectional study using 2014 inpatient and emergency department all-encounter administrative datasets from Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York. Study participants included children <18 with primary diagnosis of asthma. RESULTS There were 174,239 encounters for pediatric asthma, with 26,316 admissions and 3101 transfers. About 94.4% of transfers were admitted, with median stay length 2 days (interquartile range [IQR] 1.0-3.0). About 637 hospitals saw pediatric asthma, but 58.7% never admitted these patients. Fifty-four hospitals (8.5%) regularly received transfers; these hospitals were broadly capable pediatric centers (mean pediatric hospital capability indices = 0.82, IQR: 0.64-0.89). Two hundred nine facilities (32.8%) did not regularly receive transfers but were highly capable of caring for pediatric asthma (mean condition-specific capability = 0.92, IQR: 0.85-1.00). Median distance from transferring hospitals to the nearest pediatric center was 25.7 miles (IQR: 6.45-50.15) vs 18.0 miles (IQR: 8.35-29.25) to the nearest potential receiving hospital. Mean cost of a 2-day asthma admission in receiving hospitals was $3927 (IQR: $3083-$4894) versus $3427 (IQR: $2485-$4102) in potential receivers. CONCLUSIONS While nearly all acute care hospitals encounter children with asthma, more than half never admit them. Children are primarily transferred to a small subset of specialized centers, despite the existence, in many regions, of closer community hospitals with high pediatric asthma capability. In settings with long transfer distances and tertiary center crowding, a tiered system of hospital care for pediatric asthma may be feasible.
Collapse
Affiliation(s)
- Lauren Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School , Boston, Mass.
| | - Urbano L França
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School , Boston, Mass
| | - Michael L McManus
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School , Boston, Mass
| |
Collapse
|
25
|
Mangus CW, Canares T, Klein BL, Costabile P, Monroe D, Noje C, Stevens MW. Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment. Pediatr Emerg Care 2022; 38:e105-e110. [PMID: 32925174 DOI: 10.1097/pec.0000000000002167] [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 Many children seeking emergency care at community hospitals require transport to tertiary centers for definitive management. Interhospital transport via ambulance versus patient's own vehicle (POV) are 2 possible modes of transport; however, presence of a peripheral venous catheter (PIV) can determine transport by ambulance. Caregiver satisfaction, patient comfort, and PIV complications related to POV transport have not been described. OBJECTIVE The aims of the study were to examine caregivers' satisfaction and perceptions of POV transport in children with/without PIVs and to assess PIV-related complications during transport. METHODS We performed a mixed-methods, prospective cohort study of children who presented with low-acuity conditions to a community hospital and subsequently required transfer to a pediatric tertiary center. Caregivers of patients with/without PIVs were given the choice of transport by POV or ambulance. Surveys completed after transport used dichotomous, 5-point Likert scale, and open-ended responses to assess satisfaction, perceptions, and PIV-related complications. Responses were quantitatively and qualitatively analyzed accordingly. The receiving hospital assessed PIV integrity. RESULTS Sixty-nine of 78 eligible patients were enrolled; of those, 67 (97%) elected transport by POV and 55 (82%) completed surveys. Most caregivers had positive responses related to satisfaction, comfort, and safety. Results did not differ significantly between those with/without PIVs. The majority (96%) would choose POV transport again. There were no reported PIV complications; all PIVs were functional upon arrival. Qualitative analysis identified themes of comfort, convenience, and efficiency. CONCLUSIONS In select scenarios, interfacility transport by POV is preferred by families and doing so with a saline-locked PIV does not result in complications.
Collapse
Affiliation(s)
- Courtney W Mangus
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Therese Canares
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Bruce L Klein
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | | | - David Monroe
- Department of Emergency Medicine, Howard County General Hospital, Columbia
| | - Corina Noje
- Department of Anesthesia and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martha W Stevens
- From the Departments of Pediatric and Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
26
|
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.
Collapse
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
| | | |
Collapse
|
27
|
Kissee JL, Huang Y, Dayal P, Yellowlees P, Sigal I, Marcin JP. Association Between Insurance and the Transfer of Children With Mental Health Emergencies. Pediatr Emerg Care 2021; 37:e1026-e1032. [PMID: 31274825 DOI: 10.1097/pec.0000000000001881] [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
OBJECTIVES This study sought to investigate the association between a patient's insurance coverage and a hospital's decision to admit or transfer pediatric patients presenting to the emergency department (ED) with a mental health disorder. METHODS This is a cross-sectional study of pediatric mental health ED admission and transfer events using the Healthcare Cost and Utilization Project 2014 Nationwide Emergency Department Sample. Children presenting to an ED with a primary mental health disorder who were either admitted locally or transferred to another hospital were included. Multivariable logistic regression models were used to adjust for confounders. RESULTS Nineteem thousand eighty-one acute mental health ED events among children were included in the analyses. The odds of transfer relative to admission were higher for children without insurance (odds ratio, 3.30; 95% confidence interval, 1.73-6.31) compared with patients with private insurance. The odds of transfer were similar for children with Medicaid compared with children with private insurance (odds ratio, 1.23; 95% confidence interval, 0.80-1.88). Transfer rates also varied across mental health diagnostic categories. Patients without insurance had higher odds of transfer compared with those with private insurance when they presented with depressive disorder, bipolar disorder, attention-deficit/conduct disorders, and schizophrenia. CONCLUSIONS Children presenting to an ED with a mental health emergency who do not have insurance are more likely to be transferred to another hospital than to be admitted and treated locally compared with those with private insurance. Future studies are needed to determine factors that may protect patients without insurance from disparities in access to care.
Collapse
|
28
|
Hayden EM, Davis C, Clark S, Joshi AU, Krupinski EA, Naik N, Ward MJ, Zachrison KS, Olsen E, Chang BP, Burner E, Yadav K, Greenwald PW, Chandra S. Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine. Acad Emerg Med 2021; 28:1452-1474. [PMID: 34245649 PMCID: PMC11150898 DOI: 10.1111/acem.14330] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. METHODS Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." RESULTS Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). CONCLUSION The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.
Collapse
Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Davis
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sunday Clark
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Aditi U Joshi
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Neel Naik
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Olsen
- Department of Emergency Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Elizabeth Burner
- Department of Emergency Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Peter W Greenwald
- Department of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Shruti Chandra
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
29
|
Rosenthal JL, Lieng MK, Marcin JP, Romano PS. Profiling Pediatric Potentially Avoidable Transfers Using Procedure and Diagnosis Codes. Pediatr Emerg Care 2021; 37:e750-e756. [PMID: 30893226 PMCID: PMC6752990 DOI: 10.1097/pec.0000000000001777] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES While hospital-hospital transfers of pediatric patients are often necessary, some pediatric transfers are potentially avoidable. Pediatric potentially avoidable transfers (PATs) represent a process with high costs and safety risks but few, if any, benefits. To better understand this issue, we described pediatric interfacility transfers with early discharges. METHODS We conducted a descriptive study using electronic medical record data at a single-center over a 12-month period to examine characteristics of pediatric patients with a transfer admission source and early discharge. Among patients with early discharges, we performed descriptive statistics for PATs defined as patient transfers with a discharge home within 24 hours without receiving any specialized procedures or diagnoses. RESULTS Of the 2,415 pediatric transfers, 31.4% were discharged home within 24 hours. Among transferred patients with early discharges, 356 patients (14.7% of total patient transfers) received no specialized procedures or diagnoses. Direct admissions were categorized as PATs 1.9-fold more frequently than transfers arriving to the emergency department. Among transferred direct admissions, PAT proportions to the neonatal intensive care unit (ICU), pediatric ICU, and non-ICU were 5.1%, 17.3%, and 27.3%, respectively. Respiratory infections, asthma, and ill-defined conditions (eg, fever, nausea with vomiting) were the most common PAT diagnoses. CONCLUSIONS Early discharges and PATs are relatively common among transferred pediatric patients. Further studies are needed to identify the etiologies and clinical impacts of PATs, with a focus on direct admissions given the high frequency of PATs among direct admissions to both the pediatric ICU and non-ICU.
Collapse
|
30
|
Symum H, Zayas-Castro JL. Characteristics and Outcomes of Pediatric Nonindex Readmission: Evidence From Florida Hospitals. Hosp Pediatr 2021; 11:1253-1264. [PMID: 34686583 DOI: 10.1542/hpeds.2020-005231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Increasing pediatric care regionalization may inadvertently fragment care if children are readmitted to a different (nonindex) hospital rather than the discharge (index) hospital. Therefore, this study aimed to assess trends in pediatric nonindex readmission rates, examine the risk factors, and determine if this destination difference affects readmission outcomes. METHODS In this retrospective cohort study, we use the Healthcare Cost and Utilization Project State Inpatient Database to include pediatric (0 to 18 years) admissions from 2010 to 2017 across Florida hospitals. Risk factors of nonindex readmissions were identified by using logistic regression analyses. The differences in outcomes between index versus nonindex readmissions were compared for in-hospital mortality, morbidity, hospital cost, length of stay, against medical advice discharges, and subsequent hospital visits by using generalized linear regression models. RESULTS Among 41 107 total identified readmissions, 5585 (13.6%) were readmitted to nonindex hospitals. Adjusted nonindex readmission rate increased from 13.3% in 2010% to 15.4% in 2017. Patients in the nonindex readmissions group were more likely to be adolescents, live in poor neighborhoods, have higher comorbidity scores, travel longer distances, and be discharged at the postacute facility. After risk adjusting, no difference in in-hospital mortality was found, but morbidity was 13% higher, and following unplanned emergency department visits were 28% higher among patients with nonindex readmissions. Length of stay, hospital costs, and against medical advice discharges were also significantly higher for nonindex readmissions. CONCLUSIONS A substantial proportion of children experienced nonindex readmissions and relatively poorer health outcomes compared with index readmission. Targeted strategies for improving continuity of care are necessary to improve readmission outcomes.
Collapse
Affiliation(s)
- Hasan Symum
- Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
| | - José L Zayas-Castro
- Department of Industrial and Management Systems Engineering, University of South Florida, Tampa, Florida
| |
Collapse
|
31
|
Urquhart PD, Holland AJA. Supply and demand: an audit of specialty paediatric surgical outreach. ANZ J Surg 2021; 91:1337-1341. [PMID: 34402172 DOI: 10.1111/ans.16603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Philip D Urquhart
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Andrew J A Holland
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Sydney Medical School, The Children's Hospital at Westmead Clinical School, The Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| |
Collapse
|
32
|
Lieng MK, Marcin JP, Dayal P, Tancredi DJ, Swanson MB, Haynes SC, Romano PS, Sigal IS, Rosenthal JL. Emergency Department Pediatric Readiness and Potentially Avoidable Transfers. J Pediatr 2021; 236:229-237.e5. [PMID: 34000284 PMCID: PMC8830940 DOI: 10.1016/j.jpeds.2021.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/06/2021] [Accepted: 05/09/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine the association between potentially avoidable transfers (PATs) and emergency department (ED) pediatric readiness scores and the score's associated components. STUDY DESIGN This cross-sectional study linked the 2012 National Pediatric Readiness Project assessment with individual encounter data from California's statewide ED and inpatient databases during the years 2011-2013. A probabilistic linkage, followed by deterministic heuristics, linked pretransfer, and post-transfer encounters. Applying previously published definitions, a transferred child was considered a PAT if they were discharged within 1 day from the ED or inpatient care and had no specialized procedures. Analyses were stratified by injured and noninjured children. We compared PATs with necessary transfers using mixed-effects logistic regression models with random intercepts for hospital and adjustment for patient and hospital covariates. RESULTS After linkage, there were 6765 injured children (27% PATs) and 18 836 noninjured children (14% PATs) who presented to 283 hospitals. In unadjusted analyses, a 10-point increase in pediatric readiness was associated with lower odds of PATs in both injured (OR 0.93, 95% CI 0.90-0.96) and noninjured children (OR 0.90, 95% CI 0.88-0.93). In adjusted analyses, a similar association was detected in injured patients (aOR 0.92, 95% CI 0.86-0.98) and was not detected in noninjured patients (aOR 0.94, 95% CI 0.88-1.00). Components associated with decreased PATs included having a nurse pediatric emergency care coordinator and a quality improvement plan. CONCLUSIONS Hospital ED pediatric readiness is associated with lower odds of a PAT. Certain pediatric readiness components are modifiable risk factors that EDs could target to reduce PATs.
Collapse
Affiliation(s)
- Monica K Lieng
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA.
| | - James P Marcin
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Parul Dayal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Morgan B Swanson
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Sarah C Haynes
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Patrick S Romano
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Ilana S Sigal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| | - Jennifer L Rosenthal
- Department of Pediatrics, University of California, Davis Health, Sacramento, CA
| |
Collapse
|
33
|
Schmucker KA, Camp EA, Jones JL, Ostermayer DG, Shah MI. Factors associated with destination of pediatric EMS transports. Am J Emerg Med 2021; 50:360-364. [PMID: 34455256 DOI: 10.1016/j.ajem.2021.08.047] [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: 06/02/2021] [Revised: 08/03/2021] [Accepted: 08/18/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Pediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers 'decisions about where to transport children are unknown. Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints. METHODS We performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0-17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination. RESULTS We identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present. CONCLUSIONS We found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.
Collapse
Affiliation(s)
- Kyle A Schmucker
- University of Pittsburgh Medical Center, Department of Pediatrics, Section of Emergency Medicine, Pittsburgh, PA, USA.
| | - Elizabeth A Camp
- Baylor College of Medicine, Department of Pediatrics, Section of Emergency Medicine, Houston, TX, USA
| | - Jennifer L Jones
- Baylor College of Medicine, Department of Pediatrics, Section of Emergency Medicine, Houston, TX, USA
| | - Daniel G Ostermayer
- University of Texas Health Science Center, McGovern Medical School, Department of Emergency Medicine, Houston, TX, USA
| | - Manish I Shah
- Baylor College of Medicine, Department of Pediatrics, Section of Emergency Medicine, Houston, TX, USA
| |
Collapse
|
34
|
McDaniel CE, Leyenaar J, Sullivan E, Desai S, Kessler L. Pediatric Conditions Requiring Minimal Intervention or Observation After Interfacility Transfer. J Hosp Med 2021; 16:412-415. [PMID: 34197305 DOI: 10.12788/jhm.3656] [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] [Received: 02/25/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022]
Abstract
Increasing regionalization of pediatric care has led to interfacility transfer of children with general pediatric conditions at rates similar to those of high-risk adults, which may delay appropriate treatment. We sought to identify common medical diagnoses that did not require significant advanced intervention and that had high rates of discharge within 1 day of interfacility transfer. Using the Pediatric Health Information System (PHIS) database, we identified all transfers into PHIS-participating children's hospitals in 2019. We excluded encounters for mental health, labor/maternity, primary newborn diagnoses, and direct admissions to an intensive care unit. Eligible encounters were categorized by duration of hospitalization and basic vs advanced intervention after transfer. Of 286,905 transfers, 197,386 (68.6%) met inclusion criteria. Cough, febrile seizures, croup, and allergic reactions required advanced interventions <10% of the time, and patients with these diagnoses were most commonly discharged within 1 day after transfer. These conditions are potential targets for building pediatric capacity in non-pediatric hospitals.
Collapse
Affiliation(s)
- Corrie E McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - JoAnna Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Erin Sullivan
- Seattle Children's Research Institute, Seattle, Washington
| | - Sanyukta Desai
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Larry Kessler
- Seattle Children's Research Institute, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| |
Collapse
|
35
|
Kim YJ, Hong JS, Hong SI, Kim JS, Seo DW, Ahn R, Jeong J, Lee SW, Moon S, Kim WY. The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016-2018. J Korean Med Sci 2021; 36:e172. [PMID: 34184436 PMCID: PMC8239427 DOI: 10.3346/jkms.2021.36.e172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/31/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. METHODS This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016-2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. RESULTS We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). CONCLUSION The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.
Collapse
Affiliation(s)
- Youn Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Seok Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seok In Hong
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - June Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungwoo Moon
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Abstract
Community hospital inpatient pediatric programs face a variety of challenges including financial instability, variable censuses, difficulty maintaining qualified staff, and a lack of focus for the hospital. With the addition of new payment models, such as bundled payments and global budgets, along with a global pandemic, the future of community hospital pediatric inpatient care is uncertain at best. In this article we summarize the challenges, opportunities, and potential solutions to maintaining high-quality care for hospitalized children in community hospitals.
Collapse
Affiliation(s)
- Scott D Krugman
- The Herman & Walter Samuelson Children's Hospital at Sinai, Baltimore, Maryland; and
| | - Daniel A Rauch
- School of Medicine, Tufts University and Tuft's Children's Hospital, Boston, Massachusetts
| |
Collapse
|
38
|
Varma S, Schinasi DA, Ponczek J, Baca J, Simon NJE, Foster CC, Davis MM, Macy M. A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine? J Pediatr 2021; 230:126-132.e1. [PMID: 33152370 DOI: 10.1016/j.jpeds.2020.10.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/13/2020] [Accepted: 10/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. STUDY DESIGN Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. RESULTS Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. CONCLUSIONS Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.
Collapse
Affiliation(s)
- Selina Varma
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Dana A Schinasi
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Telemedicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacqueline Ponczek
- Division of Hospital-Based Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacqueline Baca
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Norma-Jean E Simon
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Carolyn C Foster
- Department of Telemedicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann & J. Milburn Smith Child Health Research, Outreach and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Matthew M Davis
- Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann & J. Milburn Smith Child Health Research, Outreach and Advocacy Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital, Chicago, IL
| | - Michelle Macy
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Telemedicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Division of Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| |
Collapse
|
39
|
Cane R, Kerns E, Maskin L, Natt B, Sieczkowski L, Biondi E, McCulloh RJ. Comparing Patterns of Care for Febrile Infants at Community and University-Affiliated Hospitals. Hosp Pediatr 2021; 11:231-238. [PMID: 33602793 DOI: 10.1542/hpeds.2020-000778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Most children in the United States receive treatment in community hospitals, but descriptions of clinical practice patterns in pediatric care in this setting are lacking. Our objectives were to compare clinical practice patterns primarily between community and university-affiliated hospitals and secondarily by number of pediatric beds before and during participation in a national practice standardization project. METHODS We performed a retrospective secondary analysis on data from 126 hospitals that participated in the American Academy of Pediatrics' Value in Inpatient Pediatrics Reducing Excessive Variability in the Infant Sepsis Evaluation project, a national quality improvement project conducted to improve care for well-appearing febrile infants aged 7 to 60 days. Four use measures were compared by hospital type and by number of non-ICU pediatric beds. RESULTS There were no differences between community and university-affiliated hospitals in the odds of hospital admission, average length of stay, or odds of cerebrospinal fluid culture. The odds of chest radiograph at community hospitals were higher only during the baseline period. There were no differences by number of pediatric beds in odds of admission or average length of stay. For hospitals with ≤30 pediatric beds, the odds of chest radiograph were higher and the odds of cerebrospinal fluid culture were lower compared with hospitals >50 beds during both study periods. CONCLUSIONS In many key aspects, care for febrile infants does not differ between community and university-affiliated hospitals. Clinical practice may differ more by number of pediatric beds.
Collapse
Affiliation(s)
- Rachel Cane
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland;
| | - Ellen Kerns
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| | - Lauren Maskin
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| | - Beth Natt
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Lisa Sieczkowski
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| | - Eric Biondi
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, Maryland
| | - Russell J McCulloh
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska.,Children's Hospital and Medical Center, Omaha, Nebraska; and
| |
Collapse
|
40
|
Hayden EM, Boggs KM, Espinola JA, Camargo CA, Zachrison KS. Telemedicine Facilitation of Transfer Coordination From Emergency Departments. Ann Emerg Med 2020; 76:602-608. [PMID: 32534835 PMCID: PMC7252127 DOI: 10.1016/j.annemergmed.2020.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/30/2020] [Accepted: 04/14/2020] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVE Interhospital transfers are costly to patients and to the health care system. The use of telemedicine may enable more efficient systems by decreasing transfers or diverting transfers from crowded referral emergency departments (EDs) to alternative appropriate facilities. Our primary objective is to describe the prevalence of telemedicine for transfer coordination among US EDs, the ways in which it is used, and characteristics of EDs that use telemedicine for transfer coordination. METHODS We used the 2016 National Emergency Department Inventory-USA survey to identify telemedicine-using EDs. We then surveyed all EDs using telemedicine for transfer coordination and a sample of EDs using telemedicine for other clinical applications. We used a multivariable logistic regression model to identify characteristics independently associated with use of telemedicine for transfer coordination. RESULTS Of the 5,375 EDs open in 2016, 4,507 responded to National Emergency Department Inventory-USA (84%). Only 146 EDs used telemedicine for transfer coordination; of these, 79 (54%) used telemedicine to assist with clinical care for local admission, 117 (80%) to assist with care before transfer, and 92 (63%) for arranging transfer to a different hospital. Among telemedicine-using EDs, lower ED annual visit volume (odds ratio 5.87, 95% CI 2.79 to 12.36) was independently associated with use of telemedicine for transfer coordination. CONCLUSION Although telemedicine has potential to improve efficiency of regional emergency care systems, it is infrequently used for coordination of transfer between EDs. When used, it is most often to assist with clinical care before transfer.
Collapse
Affiliation(s)
- Emily M Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
41
|
Thinnes R, Swanson MB, Wetjen K, Harland KK, Mohr NM. Preferences for emergency medical service transport after childhood injury: An emergency department-based multi-methods study. Injury 2020; 51:1961-1969. [PMID: 32507453 PMCID: PMC7508417 DOI: 10.1016/j.injury.2020.04.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/09/2020] [Accepted: 04/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pre-hospital emergency medical services (EMS) transport can be associated with benefits following pediatric injury. However, many pediatric trauma patients do not use EMS. The objective of this study was to elucidate guardians' decision factors for pre-hospital transport for children after injury. METHODS This is a multi-methods study of pediatric trauma patients (≤14 years) and their guardians presenting to the ED of a Level I Pediatric Trauma Center via both EMS and non-EMS modalities. Demographic information and injury characteristics were collected. Semi-structured interviews were conducted, and qualitative codes were identified and assigned into themes. RESULTS (Quantitative): Of the 29 child-guardian pairs, five participants initially presented by EMS, 18 were admitted, and the majority (66%) sustained mild injuries. Guardians' assessment of their child's injury severity did not correlate with Injury Severity Score (ISS). Neither EMS status (did or did not use EMS to transport to first hospital) nor rurality status of participants' place of residence were associated with disparate management in any of the three scenarios. (QUALITATIVE) Five themes emerged, which informed guardians' transport decisions: Factors Related to the Nature of the Patient's Injury, Guardian Attributes and Prior Experiences, Access and Availability of EMS, Perceived Risks and Benefits of EMS and Hospital, and Collaborative Decision-Making. Injury characteristics and contextual factors, like perceived EMS response times and advice from family or medical providers, were considered in choices about EMS utilization and hospital selection. Despite the view that EMS response times were important in determining what to do following injury, both EMS and non-EMS users were largely unfamiliar with the capabilities of EMS in their area. Finally, guardians described cost to be a theoretical risk of EMS use, and a few cited this as a factor contributing to their decision-making. CONCLUSIONS Guardians used a variety of considerations to make transport decisions, including the five themes identified above. Future studies could explore modalities to disseminate information about pre-hospital decision-making for guardians and determine the relationship between EMS utilization and patient outcomes.
Collapse
Affiliation(s)
- Robert Thinnes
- University of Iowa, Carver College of Medicine, Iowa City, IA
| | - Morgan B. Swanson
- University of Iowa, College of Public Health, Department of Epidemiology; Carver College of Medicine, Department of Emergency Medicine, Iowa City, IA
| | - Kristel Wetjen
- University of Iowa, Stead Family Children’s Hospital, Department of Surgery, Division of Pediatric Surgery, Iowa City, IA
| | - Karisa K. Harland
- University of Iowa, College of Public Health, Department of Epidemiology; Carver College of Medicine, Department of Emergency Medicine, Iowa City, IA
| | - Nicholas M. Mohr
- University of Iowa, College of Public Health, Department of Epidemiology; Carver College of Medicine, Department of Emergency Medicine; Department of Anesthesia Critical Care, Iowa City, IA
| |
Collapse
|
42
|
Ward MM, Carter KD, Ullrich F, Merchant KAS, Natafgi N, Zhu X, Weigel P, Heppner S, Mohr NM. Averted Transfers in Rural Emergency Departments Using Telemedicine: Rates and Costs Across Six Networks. Telemed J E Health 2020; 27:481-487. [PMID: 32835620 DOI: 10.1089/tmj.2020.0080] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: This analysis identified the rate of transfers and averted transfers and their associated costs across multiple emergency department telemedicine (teleED) networks. Methods: This study is a prospective cohort analysis in six teleED networks operating in 65 hospitals in 11 states across the United States. Each submitted uniform data on all teleED encounters for a 26-month period to a data co-ordinating center. Averted transfers were identified if an encounter met specific criteria. Cost savings from averted transfers were estimated from hospital-specific costs of transferred patients. Results: A total of 4,324 teleED encounters were reported. Excluding patients who died, 1,934 (46.2%) were transferred to another inpatient facility. Records of the remaining 2,248 teleED patients were examined and 882 (39.2% of nontransfers; 20.4% of all teleED cases) teleED patients met the criteria for an averted transfer. Of the averted transfer cases, 53.3% were admitted to the local inpatient facility, and 43.5% were discharged. Patients who averted transfer had lower levels of severity and less billed services than those who were transferred. Transport savings for averted transfers were estimated to total $1,074,663 annually across the six teleED networks. Average estimated transport savings were $2,673 for each averted transfer. Conclusions: In a large cohort of teleED cases, 39% of nontransfer cases were averted transfers (20% of all teleED cases). Importantly, 43% of these patients were routinely discharged rather than being transferred. Averted transfers saved on average $2,673 in avoidable transport costs per patient, with 63.6% of these cost savings accruing to public insurance.
Collapse
Affiliation(s)
- Marcia M Ward
- Department of Health Management and Policy and College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Knute D Carter
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy and College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Kimberly A S Merchant
- Department of Health Management and Policy and College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Nabil Natafgi
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Xi Zhu
- Department of Health Management and Policy and College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Paula Weigel
- Department of Health Management and Policy and College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Sarah Heppner
- Office of Rural Health Policy, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Nicholas M Mohr
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA.,Department of Emergency Medicine and Division of Critical Care, College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Department of Anesthesia, Division of Critical Care, College of Medicine, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
43
|
Foster CC, Macy ML, Simon NJ, Stephen R, Lehnig K, Bohling K, Schinasi DA. Emergency Care Connect: Extending Pediatric Emergency Care Expertise to General Emergency Departments Through Telemedicine. Acad Pediatr 2020; 20:577-584. [PMID: 32112864 DOI: 10.1016/j.acap.2020.02.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 02/14/2020] [Accepted: 02/21/2020] [Indexed: 01/08/2023]
Abstract
Increasingly, children with common and lower-acuity conditions are being transferred from general emergency departments (EDs) to pediatric centers for subspecialty care. While transferring children with high-risk conditions has benefit, transferring children with common conditions may expose them to redundant care and added costs. Emergency Care Connect (ECC) is a novel telemedicine program that uses videoconferencing to connect general ED and urgent care providers to pediatric emergency medicine physicians with the goal of keeping children in their communities for definitive care, when safe and feasible. ECC objectives are to: 1) facilitate transfer decision-making for children receiving care in general ED and urgent care sites and 2) increase access to pediatric providers for real-time management, regardless of disposition. In its first 20 months, ECC partnered with 4 general EDs and 1 urgent care location, which together made 1327 contacts with our pediatric center, of which 202 (15%) became ECC consultations for 200 unique patients. Of those consultations, 71% patients remained locally for treatment and 25% experienced a care plan change. Overall, ECC was rated highly by surveyed families and providers. Barriers to implementation, such as lack of familiarity with telemedicine and fears of changes in workflow, were overcome with strong institutional support and frequent, sustained stakeholder engagement. With greater adoption of this model, ECC and programs like it have the potential to allow more children to be treated in their communities, minimize preventable transfers, and reserve beds in children's hospitals for those with potentially higher risk and more medically complex conditions.
Collapse
Affiliation(s)
- Carolyn C Foster
- Department of Pediatrics, Northwestern Feinberg School of Medicine (CC Foster, ML Macy, R Stephen, and DA Schinasi), Chicago, Ill; Academic General Pediatrics and Primary Care, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster), Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster and ML Macy), Chicago, Ill; Telehealth Programs, Lurie Children's, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster, ML Macy, R Stephen, K Bohling, and DA Schinasi), Chicago, Ill.
| | - Michelle L Macy
- Department of Pediatrics, Northwestern Feinberg School of Medicine (CC Foster, ML Macy, R Stephen, and DA Schinasi), Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster and ML Macy), Chicago, Ill; Telehealth Programs, Lurie Children's, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster, ML Macy, R Stephen, K Bohling, and DA Schinasi), Chicago, Ill; Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (ML Macy, N-J Simon, K Lehnig, and DA Schinasi), Chicago, Ill
| | - Norma-Jean Simon
- Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (ML Macy, N-J Simon, K Lehnig, and DA Schinasi), Chicago, Ill
| | - Rebecca Stephen
- Department of Pediatrics, Northwestern Feinberg School of Medicine (CC Foster, ML Macy, R Stephen, and DA Schinasi), Chicago, Ill; Telehealth Programs, Lurie Children's, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster, ML Macy, R Stephen, K Bohling, and DA Schinasi), Chicago, Ill; Hospital-Based Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (R Stephen), Chicago, Ill
| | - Katherine Lehnig
- Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (ML Macy, N-J Simon, K Lehnig, and DA Schinasi), Chicago, Ill
| | - Katie Bohling
- Telehealth Programs, Lurie Children's, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster, ML Macy, R Stephen, K Bohling, and DA Schinasi), Chicago, Ill
| | - Dana A Schinasi
- Department of Pediatrics, Northwestern Feinberg School of Medicine (CC Foster, ML Macy, R Stephen, and DA Schinasi), Chicago, Ill; Telehealth Programs, Lurie Children's, Ann & Robert H. Lurie Children's Hospital of Chicago (CC Foster, ML Macy, R Stephen, K Bohling, and DA Schinasi), Chicago, Ill; Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (ML Macy, N-J Simon, K Lehnig, and DA Schinasi), Chicago, Ill
| |
Collapse
|
44
|
Rosenthal JL, Sauers-Ford HS, Snyder M, Hamline MY, Benton AS, Joo S, Natale JE, Plant JL. Testing Pediatric Emergency Telemedicine Implementation Strategies Using Quality Improvement Methods. Telemed J E Health 2020; 27:459-463. [PMID: 32580661 DOI: 10.1089/tmj.2020.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Despite the recognized benefits of telemedicine use for pediatric emergency consultations, there are barriers to the widespread uptake of this technology. Quality improvement methods can be used to rapidly test implementation strategies. Our objective was to test telemedicine implementation strategies in real-world application using quality improvement methods. Our quality improvement aim was to achieve high rates of telemedicine use for pediatric transfer consultations. Methods: A multidisciplinary multisite improvement team identified that key drivers of increasing telemedicine use included telemedicine resource awareness, streamlined telemedicine workflow, provider buy-in, and data transparency. Interventions focused on telemedicine trainings, disseminating telemedicine uptake data, telemedicine reminders, telemedicine test calls, and preparing for telemedicine use for every transfer consultation. The outcome measure was percentage of pediatric emergency transfer consultations that used telemedicine. The balancing measure was time (minutes) from the initial transfer center call to completion of the consultation. Results: Multiple plan-do-study-act cycles were associated with special cause variation, with an upward shift in mean percentage of telemedicine use from 5% to 22%. Time from initial call to consultation completion remained unchanged. Conclusion: Our study supports the use of quality improvement methods to test telemedicine implementation strategies for pediatric telemedicine emergency consultations.
Collapse
Affiliation(s)
- Jennifer L Rosenthal
- Department of Pediatrics, University of California at Davis, Sacramento, California, USA
| | - Hadley S Sauers-Ford
- Department of Pediatrics, University of California at Davis, Sacramento, California, USA
| | - Moina Snyder
- Department of Pediatrics, Lodi Memorial Hospital, Lodi, California, USA
| | - Michelle Y Hamline
- Department of Pediatrics, University of California at Davis, Sacramento, California, USA
| | - Angela S Benton
- Department of Pediatrics, Lodi Memorial Hospital, Lodi, California, USA
| | - Sharon Joo
- Department of Pediatrics, Mercy Medical Center Redding Hospital, Redding, California, USA
| | - JoAnne E Natale
- Department of Pediatrics, University of California at Davis, Sacramento, California, USA
| | - Jennifer L Plant
- Department of Pediatrics, University of California at Davis, Sacramento, California, USA
| |
Collapse
|
45
|
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.
Collapse
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
| | | | | | | |
Collapse
|
46
|
Abstract
OBJECTIVES Pediatric patients living in rural, underserved areas have reduced access to medical care. There is a lack of research describing the use of telemedicine (TM) for general pediatric emergency medicine (PEM). In 2013, we established the Child Ready Virtual Pediatric Emergency Department Telehealth Network (CR-VPED), a PEM TM consultation service serving rural hospitals across the state of New Mexico. The aim of this article is to describe our experience for 6 years (2013-2018). METHODS We describe the process of establishing the CR-VPED Telehealth Network. We reviewed all the TM consultations completed from June 22, 2013, to September 6, 2018. In our review, we focus on patient demographics, medical complaint, transfer status, type of referring provider, and problems encountered with each TM consultation. RESULTS We had a total of 58 PEM TM consultations between June 22, 2013, and September 6, 2018. All consultations occurred at 6 of the 12 established sites. Most TM consultations (71%; 41/58) were with Indian Health Service sites. Among all TM consultations, patients ranged in age from 30 days to 17 years (mean, 54 months; median, 32 months). Only 26% (15/58) of the patients with TM consultations were transferred to the tertiary care hospital. There was a heterogeneous mix of chief complaints and diagnoses. Rash was the most common chief complaint (24%; 14/58). There was a mix of referring providers, with family medicine physicians being most common (31%; 18/58). Common technical issues were not properly recording the encounter into the electronic medical record (12%; 7/58) and difficulty logging into the CR-VPED Telehealth Network (9%; 5/58). CONCLUSIONS Previous studies have investigated the use of TM in pediatric acute care, but most studies have focused on critical care or subspecialty care in the office setting. Our experience with CR-VPED has shown that it has been feasible to provide general pediatric emergency care to patients in underserved, rural emergency departments across New Mexico. Patients requiring TM consultation were heterogeneous in age and presentation.
Collapse
|
47
|
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.
Collapse
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
| | | | | | | | | |
Collapse
|
48
|
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.
Collapse
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
| | | |
Collapse
|
49
|
Pediatric Traumatic Brain Injury in the United States: Rural-Urban Disparities and Considerations. Brain Sci 2020; 10:brainsci10030135. [PMID: 32121176 PMCID: PMC7139684 DOI: 10.3390/brainsci10030135] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/27/2020] [Accepted: 02/27/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) remains a primary cause of pediatric morbidity. The improved characterization of healthcare disparities for pediatric TBI in United States (U.S.) rural communities is needed to advance care. METHODS The PubMed database was queried using keywords (("brain/head trauma" OR "brain/head injury") AND "rural/underserved" AND "pediatric/child"). All qualifying articles focusing on rural pediatric TBI, including the subtopics epidemiology (N = 3), intervention/healthcare cost (N = 6), and prevention (N = 1), were reviewed. RESULTS Rural pediatric TBIs were more likely to have increased trauma and head injury severity, with higher-velocity mechanisms (e.g., motor vehicle collisions). Rural patients were at risk of delays in care due to protracted transport times, inclement weather, and mis-triage to non-trauma centers. They were also more likely than urban patients to be unnecessarily transferred to another hospital, incurring greater costs. In general, rural centers had decreased access to mental health and/or specialist care, while the average healthcare costs were greater. Prevention efforts, such as mandating bicycle helmet use through education by the police department, showed improved compliance in children aged 5-12 years. CONCLUSIONS U.S. rural pediatric patients are at higher risk of dangerous injury mechanisms, trauma severity, and TBI severity compared to urban. The barriers to care include protracted transport times, transfer to less-resourced centers, increased healthcare costs, missing data, and decreased access to mental health and/or specialty care during hospitalization and follow-up. Preventative efforts can be successful and will require an improved multidisciplinary awareness and education.
Collapse
|
50
|
Sacks B, Toomey B, de Winter A, Berkowitz RG. Unplanned inter-hospital transfers following elective paediatric surgery in a private hospital. ANZ J Surg 2020; 90:1030-1033. [PMID: 32072756 DOI: 10.1111/ans.15747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/28/2019] [Accepted: 01/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant number of surgeries in children are being performed in the private setting. Our aim was to determine the rate of unplanned inter-hospital transfers (IHTs) for paediatric patients undergoing elective surgical procedures in a private hospital without a paediatric intensive care unit to a tertiary hospital, and to investigate the reasons for these transfers. METHODS A retrospective clinical audit was performed searching hospital coded data of all patients aged 18 years or less at the date of admission, who underwent elective surgery between 1 January 2013 and 31 October 2018 at St Vincent's East Melbourne Private Hospital. RESULTS A total of 17 366 patients were identified, of whom 23 required IHT, with an overall transfer rate of 0.13%. Adenotonsillectomy had the highest IHT rate of 0.26%; however, operative specialty had no statistical correlation with IHT (P = 0.24) with a comparable transfer rate across all specialties. Hypoxia was the most frequent reason for IHT and was the cause in 16 out of 23 transfers (69%). Nine cases (39%) were transferred due to hypoxia while awake and seven (30%) due to hypoxia only while asleep. Three patients requiring IHT were identified as having preoperative acute respiratory illness. CONCLUSION Elective paediatric surgery undertaken at St Vincent's East Melbourne Private Hospital is safe and has a low IHT rate, with surgery involving the upper airway having a higher risk. In the paediatric population, hypoxia while awake is the most frequent cause for IHT.
Collapse
Affiliation(s)
- Brett Sacks
- St Vincent's Health, Department of Plastic and Reconstructive Surgery, Melbourne, Victoria, Australia
| | - Brigid Toomey
- St Vincent's East Melbourne Private Hospital, Melbourne, Victoria, Australia
| | | | - Robert G Berkowitz
- St Vincent's East Melbourne Private Hospital, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|