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

Abstract

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.

Referring Hospital Characteristics Associated With Potentially Avoidable Emergency Department Transfers

“…Telemedicine offers another potential means of extending pediatric expertise to additional EDs. Prior studies report that telemedicine is of interest to parents experiencing transfers, may improve evaluation quality, and may reduce illness severity among children requiring transfer, although numerous barriers still face the uptake and sustainability of pediatric emergency telemedicine programs …”

Acceptability, Usability, and Effectiveness: A Qualitative Study Evaluating a Pediatric Telemedicine Program

“…Telemedicine has been available at our center for pediatric emergency consultations since 2003 . Our 121‐bed children's hospital, a quaternary care center located in Northern California, is the referral center for many children across a 33‐county region covering 65,000 square miles and serving approximately 6 million people . The children's hospital receives transfers from over 130 EDs and hospitals in the region and accepted over 2,500 patients as transfers in 2017.…”

Pediatric Telemedicine Use in United States Emergency Departments

“…Many children in the United States lack timely access to EDs with high pediatric readiness, which underscores the potential benefit of pediatric telemedicine adoption in EDs in enabling access to pediatric‐ready care where it otherwise would not be available . Further, pediatric telemedicine can improve equity and access to acute care in an urban setting, critical care quality in rural EDs, and stabilization of critical care transfers . Specifically, when compared with no consultations, pediatric telemedicine in rural EDs demonstrated higher physician‐rated quality of care and lower risk of physician‐related medication errors .…”

“…In emergency departments (EDs), receipt of telemedicine has led to higher patient satisfaction and better patient outcomes, especially when EDs lack in‐person specialist care (e.g., pediatric emergency medicine [PEM]) . Telemedicine use in referring EDs is associated with improved stabilization of children admitted to a pediatric intensive care unit (PICU) . Furthermore, pediatric critical care telemedicine consultations in rural EDs have demonstrated higher physician‐rated quality of care and lower risk of physician‐related ED medication errors compared with either telephone or no consultation, underscoring the value of telemedicine in this population Nevertheless, the prevalence, characteristics, and applications of receipt of pediatric telemedicine remain unclear.…”