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Pediatric interhospital transport: diagnostic discordance and hospital mortality
Corey Philpot1, Susan Day, Karen Marcdante
1Medical College of Wisconsin Department of Pediatrics and Children's Hospital of Wisconsin, Milwaukee, WI, USA. PhilpoC@shmc.org
Objectives:
Determine the rate of discordance between the reason for transport (determined by referring institution) and the final diagnosis (determined by accepting institution), identify factors associated with diagnostic discordance, and determine whether diagnostic discordance is associated with mortality and morbidity.
Design:
Cross-sectional analysis of prospectively collected transport data using an existing multicenter database.
Setting:
Interfacility transport of neonatal and pediatric patients referred to five tertiary centers during years 1998-2000.
Patients:
Patients were 4,905 neonatal and pediatric patients undergoing interhospital transport ultimately assigned to a general or intensive level of care based on initial triage information.
Interventions:
None.
Measurements And Main Results:
Discordant events were categorized by diagnosis, referring hospital location, and physician type. Discordance between primary reason for transport and discharge diagnosis category occurred in 474 (11.5%) transport events (95% confidence interval 10.5-12.5). Significant predictors of diagnostic discordance included diagnoses of gastrointestinal, metabolic, multi-trauma with head injury, multi-trauma without head injury, renal, and toxicology. Acute care, referring physician, and emergency department subpopulations demonstrated similar discordance rates. One hundred ten (2.7%) patients experienced at least one unplanned event (unintended extubation, intubation requiring more than attempts, loss of intravenous access, malpositioned endotracheal tube, medication error, pneumothorax). Of the 474 patients given discordant diagnoses, 16 (3.4%) experienced at least one unplanned event compared with 94 of 3,645 (2.6%) of patients given concordant diagnoses. Hospital mortality for all transport events was 6% (95% confidence interval 5.3-6.7). Of the total discordant population, 37 of 474 died compared with 207 of 3,645 of those with concordant diagnoses (7.8% vs. 5.7%, p = .065). When adjusted for severity, age, and diagnosis, the increased mortality was not statistically significant.
Conclusions:
Discordance between primary reason for transport and diagnosis category is common in the pediatric interhospital transport population. Although discordance does not appear to lead to increased mortality, further study is needed to determine the impact of diagnostic discordance on other patient outcomes.
