By Dorothy Brooks
When critically ill children present to EDs in rural or community hospitals that lack access to specialty pediatric care, the solution often is to transfer them to a regional pediatric facility, which could be hours away from a patient’s home. This creates travel burdens and added expense for families and payors. But new research suggests that at least some of these interfacility transfers can be safely avoided by incorporating telemedicine consultations with pediatric specialists.
Researchers from UC Davis Health conducted a randomized, controlled trial in which they compared the effects of using the current standard of care — phone consults with pediatric specialists — with telemedicine consults. The trial included 15 EDs in rural and community hospitals in Northern California, which were randomized to use either phone or telemedicine consults while caring for critically ill pediatric patients.
Investigators were interested in whether these young patients would be transferred to UC Davis Children’s Hospital, the only pediatric referral center in the region for young patients with high-acuity concerns, following either phone or telemedicine consults. Out of 696 children, the researchers reported 84% assigned to telemedicine consults were transferred to UC Davis and 90.6% assigned to phone consults were transferred. The adjusted risk of transfer was 7% lower among the telemedicine arm than the phone cohort.1
James Marcin, MD, MPH, lead study author, says he and colleagues found that by supporting emergency providers with a low-cost telemedicine intervention, many children can be successfully evaluated and treated in their rural or community hospitals. They can be discharged or admitted locally for care, preventing the need for interfacility transfers and all the expense and inconvenience that go along with such.
Further, Marcin notes there is ample room for health systems to leverage telemedicine in this way. While telemedicine has exploded in the outpatient setting in recent years, telemedicine communication between hospitals remains uncommon beyond its use to treat stroke patients. “It should be required because the technology is relatively easy. If you had a really sick kid and you went to your hospital where they don’t have pediatricians, you would expect them to be able to have a service like this,” says Marcin, vice chair for pediatric clinical research at UC Davis Children’s Hospital.
While pediatric specialty care expertise delivered via phone may be adequate for some cases, telemedicine is particularly beneficial when a visual examination of the patient can yield important information. “For example, when a child has difficulty breathing, that is something that is a little bit difficult to describe effectively,” says Marcin, director of the UC Davis Center for Health and Technology. “Someone might say that the condition is severe, and someone else might say it is moderate.”
A visual examination also is important when evaluating a child with encephalopathy or an altered level of consciousness. On a phone call, parents might report their child is “sleepy” or “just not acting right.” Such descriptions that might be too subjective for a specialty clinician; thus, a telemedicine consult could allow a visual exam to help the clinician. “We like the addition of video when we are talking to a provider, a patient, and a family, and we are contemplating not transferring the child,” Marcin explains. “Seeing the patient helps us be more confident in that decision.”
Knowing when a child can be treated safely locally is important because there are fewer pediatric beds in less populated areas, especially as pediatric care becomes more regionalized and dependent on larger children’s hospitals. “Clinicians tend to err on the side of safety [with children], which is very understandable,” Marcin notes. “But we also know that between 20% and 30% of the kids who are transferred to children’s hospitals — sometimes going very long distances and at great inconvenience to the families ... are deemed potentially avoidable transfers. If we can get pediatric specialists more involved virtually at the bedside, we can be a little bit better in our decision-making.”
Marcin emphasizes that when emergency providers at rural or community hospitals used telemedicine consults, that did not affect the number of children requiring transfer directly to the ICU. “The biggest impact was on the lower-severity cases,” he reports.
Further, Marcin notes local ED clinicians and parents always can request a transfer. “The goal isn’t necessarily to avoid a transfer. The goal is to try to provide the most appropriate care,” he says.
Marcin admits it can take time for emergency providers working at smaller hospitals to become comfortable with consulting outside specialists. Over time, most appreciate access to expertise they cannot access locally.
In their study, Marcin and colleagues found families rated their experience higher, on average, when there was a telemedicine consultation, regardless of whether a transfer occurred. Marcin suggests families might be comforted by an expert from a children’s hospital weighing in virtually about whether the ED care is appropriate.
Added comfort is one of the benefits families have experienced from telemedicine consultations when they bring their children to the ED at Woodland (CA) Memorial Hospital, explains the department’s director, Justin Chatten-Brown, MD.
“We have been providing pediatric telemedicine consultations through our partnership with UC Davis since we were enrolled in a pilot pediatric teletrauma project three years ago,” he says. “Working at a suburban community hospital ED, we recognized the need to partner with specialists we don’t have access to locally. Pediatrics care can be especially challenging, given the lack of volume locally and capacity regionally.”
Chatten-Brown notes the UC Davis partnership has provided eyes on patient evaluations, leading to more rapid assessment and fluid communication. Additionally, it has helped both the hospital and families avoid unnecessary transfers while also providing direction to families regarding appropriate outpatient resources.
“I use telemedicine consultation any time a patient’s needs have exceeded the limits of our capability locally, or I am uncertain as to the needs of a patient and want specialty consultation,” Chatten-Brown shares. “Multitrauma pediatric cases are obvious [examples], but I have also had several very unusual pediatric stroke cases in the last several years where teleconsultation was extremely helpful.”
Chatten-Brown estimates providers in his ED leverage telemedicine consultations for pediatric cases two to three times a month. Still, he admits there were some early challenges involved with implementing the approach, particularly regarding IT-EMR integration. “We worked for quite a while to iron out the kinks and ensure that imaging could be accessed remotely, in addition to enabling the ability to beam into patient rooms,” he says.
Chatten-Brown says using this approach requires the right partner, which could be within a healthcare system or with a nearby academic center. “Building those relationships is critical. IT, radiology, and the EMR will need to support the adoption process, and you need good bandwidth and space for [the technology],” he explains.
REFERENCE
1. Marcin JP, Sauers-Ford HS, Mouzoon JL, et al. Impact of tele-emergency consultations on pediatric interfacility transfers: A cluster-randomized crossover trial. JAMA Netw Open 2023;6:e2255770.
When critically ill children present to EDs in rural or community hospitals that lack access to specialty pediatric care, the solution often is to transfer them to a regional pediatric facility, which could be hours away from a patient’s home. This creates travel burdens and added expense for families and payors. But new research suggests that at least some of these interfacility transfers can be safely avoided by incorporating telemedicine consultations with pediatric specialists.
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