Appropriateness of Disposition Following Telemedicine Consultations in Rural Emergency Departments

Yang, Nikki H.; Dharmar, Madan; Kuppermann, Nathan; Romano, Patrick S.; Nesbitt, Thomas S.; Hojman, Nayla M.; Marcin, James P.

doi:10.1097/pcc.0000000000000337

Cited by 42 publications

(48 citation statements)

References 27 publications

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“…Without detailed information on the therapies and interventions performed in the EDs as a result of the telemedicine consultations, we are unable to directly attribute the lower PRISM III scores on arrival to the PICU to the telemedicine program. However, our claim finds support in prior research showing that pediatric critical care telemedicine programs in EDs were effective in lowering transfer rates of children to facilities providing higher levels of care (21). Fourth, we considered the intervention in this study to be the telemedicine program and not the specific consultation modality-so not all patients transferred from EDs with telemedicine received a telemedicine consultation.…”

Section: Discussionmentioning

confidence: 57%

“…of telemedicine to support the care of seriously ill children in referring EDs results in higher provider and patient satisfaction (16)(17)(18)(19), improved clinical outcomes (20), fewer medication errors (12), and higher quality of medical care (17,21). Pediatric telemedicine consultations can sometimes obviate unnecessary transfers (20)(21)(22)(23), facilitate timely and appropriate stabilization prior to and during the transfer process (22,23), and may result in lower severity of illness at admission to the PICU and improved outcomes.…”

mentioning

confidence: 99%

“…Pediatric telemedicine consultations can sometimes obviate unnecessary transfers (20)(21)(22)(23), facilitate timely and appropriate stabilization prior to and during the transfer process (22,23), and may result in lower severity of illness at admission to the PICU and improved outcomes.…”

mentioning

confidence: 99%

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Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU*

Dayal

Hojman

Kissee

et al. 2016

Pediatric Critical Care Medicine

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Objectives: To compare the severity of illness and outcomes among children admitted to a children’s hospital PICU from referring emergency departments with and without access to a pediatric critical care telemedicine program. Design: Retrospective cohort study. Setting: Tertiary academic children’s hospital PICU. Patients: Pediatric patients admitted directly to the PICU from referring emergency departments between 2010 and 2014. Interventions: None. Measurements: Demographic factors, severity of illness, and clinical outcomes among children receiving care in emergency departments with and without access to pediatric telemedicine, as well as a subcohort of children admitted from emergency departments before and after the implementation of telemedicine. Main Results: Five hundred eighty-two patients from 15 emergency departments with telemedicine and 524 patients from 60 emergency departments without telemedicine were transferred and admitted to the PICU. Children admitted from emergency departments using telemedicine were younger (5.6 vs 6.9 yr; p< 0.001) and less sick (Pediatric Risk of Mortality III score, 3.2 vs 4.0; p < 0.05) at admission to the PICU compared with children admitted from emergency departments without telemedicine. Among transfers from emergency departments that established telemedicine programs during the study period, children arrived significantly less sick (mean Pediatric Risk of Mortality III scores, 1.2 units lower; p = 0.03) after the implementation of telemedicine (n = 43) than before the implementation of telemedicine (n = 95). The observed-to-expected mortality ratios of posttelemedicine, pretelemedicine, and no-telemedicine cohorts were 0.81 (95% CI, 0.53–1.09), 1.07 (95% CI, 0.53–1.60), and 1.02 (95% CI, 0.71–1.33), respectively. Conclusions: The implementation of a telemedicine program designed to assist in the care of seriously ill children receiving care in referring emergency departments was associated with lower illness severity at admission to the PICU. This study contributes to the body of evidence that pediatric critical care telemedicine programs assist referring emergency departments in the care of critically ill children and could result in improved clinical outcomes.

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Section: Discussionmentioning

confidence: 57%

mentioning

confidence: 99%

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Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU*

Dayal

Hojman

Kissee

et al. 2016

Pediatric Critical Care Medicine

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“…Some authors have cited criticisms of community emergency care to advocate more strongly for routine emergency pediatric telemedicine usage . While this may be very appropriate to improve care for the critically ill and for certain other conditions, our findings suggest that simpler, less costly alternatives may effectively address some overtransfers without unnecessary consultation or supervision. While sufficient, real‐time video telemedicine may not be necessary to accurately risk stratify seizure, fracture, or traumatic brain injury patients, while it may improve transfer performance for children with respiratory infections or wheezing.…”

Section: Discussionmentioning

confidence: 70%

Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study

Mohr

Harland

Shane

et al. 2016

Academic Emergency Medicine

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Objectives: Interhospital transfer is a common strategy to provide high-quality regionalized care in rural emergency departments (EDs), but several reports have highlighted problems with selection of children for transfer. The purpose of this study is to characterize the burden of potentially avoidable transfer (PAT) and to estimate the medical and family-oriented costs associated with PAT.Methods: This study was a cohort study of all children treated in Iowa EDs between 2004 and 2013. PAT was defined as a child who was transferred and then either discharged from the receiving ED or admitted for ≤ 1 day, without having any separately billed procedures performed. Costs of care were estimated from 1) medical costs, 2) ambulance transfer, and 3) family costs (travel and lodging).Results: Over 10 years, 2,117,317 children were included (1% transferred to another hospital). Only 63% were transferred to a designated children's hospital, and PATs were identified in 39% of all transfers. PAT was associated with $909 in additional cost. The conditions most strongly associated with PAT were seizure (additional cost $1,138), fracture ($814), isolated traumatic brain injury without extra-axial bleeding ($1,455), respiratory infection ($556), and wheezing ($804). Few of these charges are attributable to nonmedical family costs ($21).Conclusions: Potentially avoidable pediatric interhospital transfer is common and is responsible for significant healthcare-related costs. Future work should focus on improving selection of children who benefit from interhospital transfer for high-yield conditions, to reduce the costly and distressing burden that PAT places on rural patients and their families.ACADEMIC EMERGENCY MEDICINE 2016;23:885-894 © 2016 by the Society for Academic Emergency Medicine A ccess to pediatric emergency care is limited in rural America. 1,2 Rural emergency departments (EDs) often are not staffed by residency-trained emergency physicians, and very few have dedicated pediatric emergency medicine providers. 3,4 Many specialists restrict their practice to adult patients. 5 As a result, many pediatric ED patients are transferred to tertiary centers for evaluation and management. In a single-center study, children who were transferred from a facility with a nonpediatric provider were significantly more likely to be discharged from the pediatric ED without any further testing or treatment and much less likely to be admitted. 6 A review of data from the Pediatric Health Information System showed that approximately 40% of children transferred to tertiary care pediatric hospitals were directly discharged after transfer or hospitalized for less than 24 hours, defining a group of potentially avoidable transfers. 7 Potentially avoidable transfers can represent a risky and costly practice that does not improve pediatric

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“…In addition, in a separate analysis of different emergency departments participating in this telemedicine network, researchers found that the frequency of medication errors was significantly lower (3.4%) than the rate of medication errors among children receiving telephone consultations (10.8%) and when no consultations were obtained (12.5%) (73). Finally, when the appropriateness of interfacility transfers were evaluated using previously validated pediatric emergency medicine prediction models, researchers found that the use of telemedicine resulted in more appropriate rates of admissions, specifically reducing the frequency of admission for children who could be managed in an ambulatory or local hospital setting (74).…”

Section: Emergency Departmentmentioning

confidence: 99%

Addressing health disparities in rural communities using telehealth

2015

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The regionalization of pediatric services has resulted in differential access to care, sometimes creating barriers to those living in underserved, rural communities. These disparities in access contribute to inferior healthcare outcomes among infants and children. We review the medical literature on telemedicine and its use to improve access and the quality of care provided to pediatric patients with otherwise limited access to pediatric subspecialty care. We review the use of telemedicine for the provision of pediatric subspecialty consultations in the settings of ambulatory care, acute and inpatient care, and perinatal and newborn care. Studies demonstrate the feasibility and efficiencies gained with models of care that use telemedicine. By providing pediatric subspecialty care in more convenient settings such as local primary care offices and community hospitals, pediatric patients are more likely to receive care that adheres to evidence-based guidelines. In many cases, telemedicine can significantly improve provider, patient, and family satisfaction, increase measures of quality of care and patient safety, and reduce overall costs of care. Models of care that use telemedicine have the potential to address pediatric specialists' geographic misdistribution and address disparities in the quality of care delivered to children in underserved communities.

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Appropriateness of Disposition Following Telemedicine Consultations in Rural Emergency Departments

Cited by 42 publications

References 27 publications

Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU*

Impact of Telemedicine on Severity of Illness and Outcomes Among Children Transferred From Referring Emergency Departments to a Children’s Hospital PICU*

Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study

Addressing health disparities in rural communities using telehealth

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