Quality of Care of Children in the Emergency Department: Association with Hospital Setting and Physician Training

Dharmar, Madan; Marcin, James P.; Romano, Patrick S.; Andrada, Emily R.; Overly, Frank; Valente, Jonathan H.; Harvey, Danielle; Cole, Stacey L.; Kuppermann, Nathan

doi:10.1016/j.jpeds.2008.05.025

Cited by 68 publications

(36 citation statements)

References 40 publications

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“…Although most EDs provide high quality of care to children, particularly among the most seriously ill, literature suggests that care provided in nonchildren's hospitals may have lower ratings for quality of care and higher rates of adverse events, such as medication errors (13,(37)(38)(39). The use of telemedicine to access pediatric expertise has been shown to be well received as a potential solution to increase access to specialty care (19).…”

Section: Discussionmentioning

confidence: 99%

“…The higher severity of illness among children transferred from referring EDs can be partly explained by the lack of pediatric subspecialty expertise (11)(12)(13)(14), experience (11,14), equipment (14), and infrastructure in EDs (14) located within nontertiary children's hospitals. Lower annual pediatric volumes and the regionalization of pediatric specialty care make it difficult to maintain the sufficient infrastructure and clinical staff specialized in the care of seriously ill children.…”

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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: 99%

mentioning

confidence: 99%

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

Self Cite

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“…164,[176][177][178][179] This is especially true for infants and children with cardiovascular disease or illness. 180 In addition, the staff working in smaller, general EDs, including physicians, nurses, pharmacists, and support staff, are often less experienced in caring for children with congenital heart disease or other acquired cardiac conditions.…”

Section: Telecardiology In the Edmentioning

confidence: 99%

Telemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association

Satou¹,

Rheuban²,

Alverson³

et al. 2017

Circulation

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A dvancements in technology and broadband have revolutionized the current practice of medicine. The field of pediatric cardiology is no exception given the need for prompt diagnosis and reliance on cardiac imaging to identify infants and children with potentially life-threatening cardiovascular disease. As the relationship between telemedicine and pediatric cardiology has advanced, it has created a need to develop a broad, comprehensive document reviewing all the various aspects of telemedicine in pediatric cardiology. For more than a decade, a significant body of literature has been published describing individual experiences and practices, yet there remains no comprehensive statement or document summarizing this rapidly advancing field. In an effort to describe the collective experience and to provide structure and guidance for pediatric cardiology practitioners and healthcare providers, we have developed a scientific statement on the use of telemedicine in pediatric cardiology.Specific areas explored in this document include both neonatal and fetal teleechocardiography, implications for training community sonographers, pulse oximetry programs, qualitative improvement and appropriate use criteria initiatives, and remote electrophysiological monitoring. This document also includes teleconsultation and teleausculation, direct-to-consumer and home monitoring programs, and a look into the use of telemedicine and pediatric cardiology in the intensive care setting. Furthermore, a detailed review of the legislative, public policy, and legal aspects of telemedicine is provided, along with financial and reimbursement information.Several terms are used in the literature interchangeably; a brief explanation is provided to help readers of this document. The term telehealth is defined as the use of technology to bridge distances in any aspect of medicine; telemedicine is the specific application of technology to conduct clinical medicine at a distance. The term telecardiology is defined as the broad application of telemedicine in the field of cardiology specifically, and tele-echocardiography is the most common application used within this field. ECHOCARDIOGRAPHY AND TELEMEDICINEEchocardiography is the most commonly used noninvasive cardiovascular imaging modality and is considered to be both safe and cost-effective. Tele-echocardiography can be described as a process in which a provider or a technician obtains cardiovascular ultrasound images from a given patient and these images are subsequently transmitted to an offsite location where a cardiologist can provide further analysis and interpretation. Thus, tele-echocardiography enables expert interpretation and consultation in a rapid and potentially geographically disparate fashion, enabling prompt and accurate decision making involving triage, transport, and therapeutic priorities. Tele-echocardiography is now routinely used across the age and subspecialty spectrum in pediatric cardiology.

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“…This may be compromised due to the competing demands of general emergency medicine that compound evidence-topractice gaps across all medical fields. [5][6][7][8][9][10][11] Because specialized pediatric systems of care are not feasible in all ED settings, calls have been made to increase capacity of existing systems and providers to appropriately address pediatric emergency care needs. [12,13] We hypothesized that a targeted strategy to integrate evidence-based pediatric management recommendations into ED care systems would improve the evidence-to-practice gap within general community EDs.…”

Section: Introductionmentioning

confidence: 99%

Evidence based pediatric care closer to home: A mixed methods evaluation of a clinical pathways-based emergency outreach program

Jabbour

Reid

Irwin

et al. 2017

JHA

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Objective: While specialized pediatric care is not feasible in all Emergency Department (ED) settings, enhanced system capacity is needed to appropriately address pediatric emergency care needs. Our objective was to evaluate an innovative clinical pathway (CP) based regional ED outreach program within community EDs. Methods: This mixed-methods design includes pre/post chart audits, qualitative interviews, ED site audits, and website utilization metrics. The study was conducted in community-based hospital EDs within the region. ED nurses, physicians and administrators from eight hospitals participated in the study. The ED outreach program involved implementation of 3 CPs addressing common pediatric emergency presentations: asthma, croup and gastroenteritis. Primary outcomes from chart audits included presence of a CP-related document filed in relevant patient charts and the proportion of patients who received appropriate care as per the severity-based CP recommendations. Secondary outcomes included documented assessments of condition severity, use of specific treatments and hospital metrics. Results: ED health professionals value the outreach initiative and CPs. Site audits confirmed ED presence and knowledge of CP tools. However several adoption barriers were identified, including time, perceived threats to physician autonomy and infrequent opportunities for use. Chart audits demonstrated site-dependent, variable uptake of CP resources into ED workflows. In total, 1,274 health records were audited, with the following pre/post breakdowns: 203/211 (asthma), 131/193 (croup) and 291/245 (gastroenteritis). We could not evaluate our primary outcomes due to infrequent documentation of condition severity. Significant post-implementation improvements were demonstrated in gastroenteritis management. Median length of stay remained unchanged (asthma) or increased (croup, gastroenteritis). ED site was an important predictor of some asthma treatments and LOS for asthma (p < .001), croup (p = .01) and gastroenteritis (p < .001). Conclusions: CP documents were available in EDs, but may not be utilized as fully intended. Site heterogeneity may account for lack of significant change in several outcome variables.

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Quality of Care of Children in the Emergency Department: Association with Hospital Setting and Physician Training

Cited by 68 publications

References 40 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*

Telemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association

Evidence based pediatric care closer to home: A mixed methods evaluation of a clinical pathways-based emergency outreach program

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