Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers

Abstract

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

Telemedicine vs Telephone Consultations and Medication Prescribing Errors Among Referring Physicians

“…21,22 Although unmeasured confounders and protocol deviations could have contributed to biased results, the previously published baseline characteristics comparing patients who received consultations that adhered to the study group and those whose consultations deviated from the study group intervention were similar. 11 We also did not identify any significant differences by intention-to-treat, per-protocol, or treatment-received analyses. In addition, despite use of a previously validated medication error instrument, medication errors and their outcomes are somewhat subjective in nature, and the interrater reliability between pharmacists was only moderate, potentially impacting the validity of the findings.…”

“…This may be due to the inaccuracies, rounding errors by the CPOE, or even the discrepancies in acceptable dose by different pharmacologic references. 7,16 Although research suggests that telemedicine consultations can improve communication and quality of care and reduce unnecessary transfers, 11,17 the evidence supporting telemedicine to reduce medication errors is limited. One previous study 9 by our group found that using telemedicine consultations in the ED was associated with decreased physician-related medication errors.…”

“…Video telemedicine consultations typically involved some combination of the treating physician, nurses, and respiratory therapists in addition to the patient and parent or guardian (when present). More details on the technological specifications of the video telemedicine setup and integration into workflow have been reported elsewhere …”

“…From previous experience conducting pediatric telemedicine emergency consultations, we expected approximately 2% of all pediatric ED encounters at participating EDs to result in pediatric specialty consultation, and 25% of these to receive a pediatric critical care consultation. Sample size calculations were determined for a previously reported outcome of this study, interfacility transfer rates . The planned enrollment of at least 448 patients provided at least 80% power to detect a clinically important adjusted odds ratio of 0.3 for the medication error outcome.…”

“…Telemedicine vs Telephone Consultations and Medication Prescribing Errors calculations were determined for a previously reported outcome of this study, interfacility transfer rates. 11 The planned enrollment of at least 448 patients provided at least 80% power to detect a clinically important adjusted odds ratio of 0.3 for the medication error outcome. This calculation assumed that approximately 10% of medications during the telephone-only periods would result in a physician-related error (defined later), on the basis of previously reported error incidences.…”