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Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers: A Cluster-Randomized Crossover Trial
James P Marcin1, Hadley S Sauers-Ford1, Jamie L Mouzoon1
1Department of Pediatrics, University of California, Davis School of Medicine, Sacramento.
Insights
Pediatric telemedicine consultations for critically ill children in rural emergency departments significantly reduced interfacility transfers compared to telephone consultations. This technology improves care access and reduces unnecessary transfers for better patient outcomes.
Area of Science:
- Medical Informatics
- Pediatric Critical Care
- Rural Health
Background:
- Pediatric referral centers increasingly use telemedicine for consultations in rural and community emergency departments (EDs).
- Telemedicine may improve physician decision-making and reduce overtriage and interfacility transfers for acutely ill children.
Purpose of the Study:
- To compare pediatric critical care telemedicine consultations with telephone consultations.
- To examine the association with risk-adjusted transfer rates of acutely ill children from rural and community EDs.
Main Methods:
- A cluster-randomized crossover trial involving 15 rural and community EDs in northern California.
- EDs were randomized to telemedicine or telephone consultations for pediatric critical care.
- Intention-to-treat, treatment-received, and per-protocol analyses used mixed effects Poisson regression.
Main Results:
- 696 children were enrolled; 537 were assigned to telemedicine.
- Intention-to-treat analysis showed telemedicine was associated with a lower risk of transfer (RR, 0.93; 95% CI, 0.88-0.99).
- Treatment-received and per-protocol analyses also demonstrated significantly lower adjusted transfer risks with telemedicine.
Conclusions:
- Telemedicine consultations for acutely ill children in rural EDs resulted in less frequent interfacility transfers than telephone consultations.
- This study supports the use of pediatric telemedicine to improve access to critical care and reduce unnecessary transfers.
Importance:
Pediatric 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.
Objective:
To 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 Participants:
A 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.
Interventions:
Participating 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 Measures:
Intention-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.
Results:
A 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 Relevance:
In 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 Registration:
ClinicalTrials.gov Identifier: NCT02877810.
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