ImportancePediatric 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.ObjectiveTo 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 ParticipantsA 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.InterventionsParticipating 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 MeasuresIntention-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.ResultsA 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 RelevanceIn 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 RegistrationClinicalTrials.gov Identifier: NCT02877810

Purpose Pediatric readiness scores may be a useful measure of a hospital's preparedness to care for children. However, there is limited evidence linking these scores with patient outcomes or other metrics, including the need for interfacility transfer. This study aims to determine the association of pediatric readiness scores with the odds of interfacility transfer among a cohort of noninjured children (< 18 years old) presenting to emergency departments (EDs) in small rural hospitals in the state of California. Methods Data from the National Pediatric Readiness Project assessment were linked with the California Office of Statewide Health Planning and Development's ED and inpatient databases to conduct a cross‐sectional study of pediatric interfacility transfers. Hospitals were manually matched between these data sets. Logistic regression was performed with random intercepts for hospital and adjustment for patient‐level confounders. Findings A total of 54 hospitals and 135,388 encounters met the inclusion criteria. EDs with a high pediatric readiness score (>70) had lower adjusted odds of transfer (aOR: 0.55, 95% CI: 0.33–0.93) than EDs with a low pediatric readiness score (≤ 70). The pediatric readiness section with strongest association with transfer was the “policies, procedures, and protocols” section; EDs in the highest quartile had lower odds of transfer than EDs in the lowest quartile (aOR: 0.54, 95% CI: 0.31–0.91). Conclusions Pediatric patients presenting to EDs at small rural hospitals with high pediatric readiness scores may be less likely to be transferred. Additional studies are recommended to investigate other pediatric outcomes in relation to hospital ED pediatric readiness.

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Objective: To compare nurse preparedness and quality of patient handoff during interfacility transfers from a pretransfer emergency department to a PICU when conducted over telemedicine versus telephone. Design: Cross-sectional nurse survey linked with patient electronic medical record data using multivariable, multilevel analysis. Setting: Tertiary PICU within an academic children’s hospital. Participants: PICU nurses who received a patient handoff between October 2017 and July 2018. Interventions: None. Main Results and Measurements: Among 239 eligible transfers, 106 surveys were completed by 55 nurses (44% survey response rate). Telemedicine was used for 30 handoffs (28%), and telephone was used for 76 handoffs (72%). Patients were comparable with respect to age, sex, race, primary spoken language, and insurance, but handoffs conducted over telemedicine involved patients with higher illness severity as measured by the Pediatric Risk of Mortality III score (4.4 vs 1.9; p = 0.05). After adjusting for Pediatric Risk of Mortality III score, survey recall time, and residual clustering by nurse, receiving nurses reported higher preparedness (measured on a five-point adjectival scale) following telemedicine handoffs compared with telephone handoffs (3.4 vs 3.1; p = 0.02). There were no statistically significant differences in both bivariable and multivariable analyses of handoff quality as measured by the Handoff Clinical Evaluation Exercise. Handoffs using telemedicine were associated with increased number of Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver components (3.3 vs 2.8; p = 0.04), but this difference was not significant in the adjusted analysis (3.1 vs 2.9; p = 0.55). Conclusions: Telemedicine is feasible for nurse-to-nurse handoffs of critically ill patients between pretransfer and receiving facilities and may be associated with increased perceived and objective nurse preparedness upon patient arrival. Additional research is needed to demonstrate that telemedicine during nurse handoffs improves communication, decreases preventable adverse events, and impacts family and provider satisfaction.