Children's Hospital Transfers From Referring Emergency Departments: Which Patients Bypassed the Pediatric Emergency Department?

OBJECTIVES: Children are increasingly transferred from emergency departments (EDs) to children's hospitals for inpatient care. The existing literature on the use of direct admission (DA) specifically among pediatric patients transferred from referring EDs remains sparse.The objective of this study was to identify demographic, clinical, and contextual factors associated with the use of direct-to-inpatient versus ED-to-inpatient admission among patients transferred to children's hospitals from EDs. METHODS: This was a retrospective chart review of nontrauma patients admitted to inpatient services at a single tertiary children's hospital after interfacility transfer from EDs between July 1, 2016, and June 30, 2017. Characteristics of the patient population and referring EDs were described; unadjusted associations between rates of DA and the demographic, clinical, and contextual variables of encounters were performed; and a logistic model quantified the relevant associations as odds ratios (ORs). RESULTS: Of 2939 study encounters, 78% resulted in DA. Among White patients, private insurance was associated with decreased direct admission (OR, 0.5; 95% confidence interval [CI], 0.4-0.8). Younger patients and patients with respiratory diagnoses (OR, 3.9; 95% CI, 2.8-5.3) had increased likelihood of DA. Patients with gastrointestinal diagnoses had decreased likelihood of DA (OR, 0.6; 95% CI, 0.4-0.7). CONCLUSIONS: At a tertiary hospital with a high rate of DA among patients transferred from other EDs, we identified factors that were associated with the use of direct versus ED admission. Our results identify specific populations in which future work could inform admission processes for interfacility transfers.

Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training.

PURPOSE: To describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees. METHODS: We conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training. RESULTS: Forty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited "time" (55%, n = 136/243) most frequently as a barrier. CONCLUSIONS: Our needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.

Telehealth Utilization in Response to the COVID-19 Pandemic: Current State of Medical Provider Training.

Background: The COVID-19 pandemic accelerated the development of telehealth services and thus the need for telehealth education and training to support rapid implementation at scale. A national survey evaluating the current state of the telehealth landscape was deployed to organizational representatives, and included questions related to education and training. Materials and Methods: In the summer of 2020, 71 survey participants (31.8%) completed an online survey seeking to determine the utilization of telehealth services across institutional types and locations. This included data collected to specifically compare the rates and types of formal telehealth education provided before and during the pandemic. Results: Thirty percent of organizations reported no telehealth training before COVID-19, with those in suburban/rural settings significantly less likely to provide any training (55% vs. 82%) compared with urban. Pandemic-related training changes applied to 78% of organizations, with more change happening to those without any training before COVID-19 (95%). Generally, organizations offering training before the pandemic reported deploying COVID-19-related telehealth services, while a higher percentage of those without any training beforehand reported that they either did not plan on providing these services or were in the early planning stages. Discussion: Telehealth education is moving from elective to essential based on the need to prepare and certify the workforce to support high-quality telehealth services. Conclusions: As telehealth continues to evolve to meet the future health care service needs of patients and providers, education and training will advance to meet the needs of everyday clinical encounters and broader public health initiatives.

Pediatric Telehealth in the COVID-19 Pandemic Era and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented demand for health care at a distance, and telehealth (the delivery of patient care using telecommunications technology) became more widespread. Since our 2018 state-of-the-art review assessing the pediatric telehealth landscape, there have been many changes in technology, policy, payment, and physician and patient acceptance of this care model. Clinical best practices in telehealth, on the other hand, have remained unchanged during this time, with the primary difference being the need to implement them at scale.Because of the pandemic, underlying health system weaknesses that have previously challenged telehealth adoption (including inequitable access to care, unsustainable costs in a fee-for-service system, and a lack of quality metrics for novel care delivery modalities) were simultaneously exacerbated. Higher volume use has provided a new appreciation of how patients from underrepresented backgrounds can benefit from or be disadvantaged by the shift toward virtual care. Moving forward, it will be critical to assess which COVID-19 telehealth changes should remain in place or be developed further to ensure children have equitable access to high-quality care.With this review, we aim to (1) depict today's pediatric telehealth practice in an era of digital disruption; (2) describe the people, training, processes, and tools needed for its successful implementation and sustainability; (3) examine health equity implications; and (4) critically review current telehealth policy as well as future policy needs. The American Academy of Pediatrics (AAP) is continuing to develop policy, specific practice tips, training modules, checklists, and other detailed resources, which will be available later in 2021.

Attitudes and Perceptions of Telemedicine in Response to the COVID-19 Pandemic: A Survey of Naïve Healthcare Providers.

Introduction: Expansion of telemedicine enabled healthcare access during the COVID-19 pandemic. In response to in-person visit restrictions, our institution trained >1,000 clinicians in telemedicine. Little is known about telemedicine-naïve pediatric healthcare provider's perceptions as they adopted telemedicine practice. Methods: We conducted a cross-sectional survey of clinicians after expanding telemedicine practice at an independent children's hospital. The survey assessed experience with, concerns about, and intentions to continue telemedicine. Outpatient providers were included if they were first trained for telemedicine in response to COVID-19 and conducted at least one video visit, 3/21/2020-6/30/2020. Descriptive statistics were calculated; perceptions were compared across telemedicine activity level quartiles (based on proportions of visits delivered by video in June 2020) using Fisher's exact tests. Results: Of 609 survey responses, 305 (50.1%) met inclusion criteria, representing various roles and disciplines. Over half (54.1%) conducted >20 video visits 3/21/2020-6/30/2020. More than 75% of providers found telemedicine easy to learn. Providers with greater proportions of video visits in a typical week in June reported greater ease of incorporating telemedicine into clinical practice and greater intention to continue telemedicine practice in 6 months. Nearly all providers endorsed concerns. Patient care experiences reinforced technology-related concerns and alleviated liability and privacy concerns. Payer reimbursement was the leading influencer of anticipated future use of telemedicine. Discussion: Providers who conducted more telemedicine encounters reported greater ease of incorporating telemedicine into practice. Provider concerns were influenced by patient care experiences. Targeted training and quality improvement strategies are needed to sustain a robust post-pandemic telemedicine program.

One-Size-Fits All: A Scalable Solution to Formal Telemedicine Provider Training to Support the COVID-19 Pandemic Response.

Introduction: Formalized training in telemedicine addresses barriers to provider adoption and engagement and assures a level of competence for independent practice. We previously developed a blended-model training program, customizable according to role and specialty; this method of training was not feasible in the pandemic response. We describe the development and implementation of a multi- and interdisciplinary telemedicine provider training program enabling the rapid scaling of telemedicine at our institution. Methods: An existing curriculum was pared down to a 1-h session delivered synchronously, covering the foundational components of telemedicine practice. Supplemental materials were available for asynchronous learning via the hospital intranet. Completion of training was required of all clinicians who practice telemedicine. Results: We conducted 35 sessions for 1,070 providers over 12 weeks. Attendees included clinicians across numerous roles and specialties. Additional resources were created and available through the Telemedicine Virtual Handbook and housed in specific toolkits. Discussion: Telemedicine training is necessary for consistent, competent practice of telemedicine in pediatrics. We describe a training process that can be easily replicated and rapidly deployed to providers of telemedicine across roles and disciplines. Combining a mandatory and brief synchronous provider training session with a repository of online resources creates a foundation for consistent practice, while allowing for more individualized resources accessible on demand. Standardized telemedicine training followed by mechanisms for ongoing professional practice evaluation allow institutions to ensure consistent and competent practice of telemedicine. Further study is needed to determine the best modality for training, and optimal assessment tools according to professional role.

Telehealth in pediatric emergency medicine.

Modern technologies and contemporary clinical practice have set the stage for the integration of telehealth into existing models of healthcare. These models of telehealth care offer novel opportunities for advancing pediatric emergency care. In this manuscript, we introduce applications of telehealth in pediatric emergency medicine (PEM) with the pediatric emergency department (ED) both as originating site and distant site. We present barriers to adoption, implementation, and sustaining PEM telehealth programs, as well as strategies to overcome those. We discuss cost and finances as well as policy considerations and implications. Lastly, we review strategies for evaluation to assess program impact and ensure sustainability.

Integrated Multimodality Telemedicine to Enhance In-Home Care of Infants During the Interstage Period.

Performing interstage home monitoring using digital platforms (teleIHM) is becoming commonplace but, when used alone, may still require frequent travel for in-person care. We evaluated the acceptability, feasibility, and added value of integrating teleIHM with synchronous telemedicine video visits (VVs) and asynchronous video/photo sharing (V/P) during the interstage period. We conducted a descriptive program evaluation of patient-families receiving integrated multimodality telemedicine (teleIHM + VV + V/P) interstage care from 7/15/2018 to 05/15/2020. First, provider focus groups were conducted to develop a program logic model. Second, patient characteristics and clinical course were reviewed and analyzed with univariate statistics. Third, semi-structured qualitative interviews of family caregivers' experiences were assessed using applied thematic analysis. Within the study period, 41 patients received teleIHM + VV + V/P care, of which 6 were still interstage and 4 died. About half (51%) of patients were female and 54% were a racial/ethnic minority. Median age was 42 days old (IQR 25, 58) at interstage start, with a median of 113 total days (IQR 72, 151). A total of 551 VVs were conducted with a median 12 VVs (IQR 7, 18) per patient. Parents sent a median 2 pictures (IQR 0-3, range 0-82). Qualitatively, families reported an adjustment period to teleIHM, but engaged favorably with telemedicine overall. Families felt reassured by the oversight routine telemedicine provided and identified logistical and clinical value to VVs above teleIHM alone, while acknowledging trade-offs with in-person care. Integration of multimodality telemedicine is a feasible and acceptable approach to enhance in-home care during the interstage period.

A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine?

OBJECTIVE: To characterize children who experienced interfacility emergency department (ED) transfers with discharge home, and identify care potentially amenable to telemedicine in lieu of transfer. STUDY DESIGN: Retrospective cohort study (July 2016 to June 2017) of patients transferred from general EDs to an academic pediatric ED and discharged home. The primary outcome was care potentially amenable to telemedicine defined as pediatric emergency medicine (PEM) provider assessment without other in-person subspecialty evaluation, diagnostic evaluation available in a general ED (electrocardiogram, point-of-care, or urine tests), and/or referrals and medications available in a general ED. Analysis included descriptive and χ2 statistics. RESULTS: Of the 1733 patients transferred, 529 (31%) were discharged home and 22% of those discharged home had care potentially amenable to telemedicine. Patients amenable to telemedicine were more likely to be <2 years old (32% vs 17%; P = .002) and to have neurologic (29% vs 17%; P = .005), respiratory (16% vs 4%; P < .001), or urinary (5% vs 1%; P = .004) diagnoses than those whose care was not. Eight in 10 patients received their entire diagnostic evaluation before transfer and one-half received only a PEM provider assessment. An additional 281 cases were evaluated by a subspecialist in person, received routine imaging, or routine interventions. CONCLUSIONS: Children receiving care potentially amenable to telemedicine in lieu of transfer often received their entire diagnostic evaluation before transfer; PEM provider assessment was the mainstay of care after transfer. These findings have implications for informing telemedicine to improve access to PEM expertise and potentially decrease some interfacility transfers.

Emergency Care Connect: Extending Pediatric Emergency Care Expertise to General Emergency Departments Through Telemedicine.

Increasingly, children with common and lower-acuity conditions are being transferred from general emergency departments (EDs) to pediatric centers for subspecialty care. While transferring children with high-risk conditions has benefit, transferring children with common conditions may expose them to redundant care and added costs. Emergency Care Connect (ECC) is a novel telemedicine program that uses videoconferencing to connect general ED and urgent care providers to pediatric emergency medicine physicians with the goal of keeping children in their communities for definitive care, when safe and feasible. ECC objectives are to: 1) facilitate transfer decision-making for children receiving care in general ED and urgent care sites and 2) increase access to pediatric providers for real-time management, regardless of disposition. In its first 20 months, ECC partnered with 4 general EDs and 1 urgent care location, which together made 1327 contacts with our pediatric center, of which 202 (15%) became ECC consultations for 200 unique patients. Of those consultations, 71% patients remained locally for treatment and 25% experienced a care plan change. Overall, ECC was rated highly by surveyed families and providers. Barriers to implementation, such as lack of familiarity with telemedicine and fears of changes in workflow, were overcome with strong institutional support and frequent, sustained stakeholder engagement. With greater adoption of this model, ECC and programs like it have the potential to allow more children to be treated in their communities, minimize preventable transfers, and reserve beds in children's hospitals for those with potentially higher risk and more medically complex conditions.

Using Immersive Simulation to Engage Pediatric Residents in Difficult Conversations and the Disclosure of Patient Safety Events.

Background Full disclosure of patient safety events (PSE) is desired by patients and their families, is required by the Joint Commission and many state laws, and is vital to improving patient outcomes. A key barrier to consistent disclosure of patient safety events is a self-reported lack of proper training. Physicians must be trained to recognize when a PSE has occurred and effectively carry out disclosure, all while caring for a patient who is actively experiencing the consequences of an unintended outcome. Immersive simulation provides the opportunity to practice this complex skill. Objective To develop and evaluate a simulation-based workshop for pediatric residents on the disclosure of patient safety events. Methods A workshop in PSE disclosure was developed according to literature review, expert consultation, and feedback from hospital administration. The three-hour workshop included a simulated PSE with a subsequent standardized debriefing, interactive didactic session, and additional simulation-based hands-on practice in disclosure. Participants completed an anonymous survey at one-week and three-months post workshop, assessing workshop satisfaction, subsequent clinical experience, and perceived change to their practice. Results During the one-year study period, 27/31 (87.0%) second year residents completed the workshop. At the one-week follow-up, all study participants reported increased confidence and preparedness in their ability to lead the initial disclosure conversation. All study participants felt that the simulated scenarios were realistic and relevant to their current clinical duties and 33.3% (n=9) stated that they would like to repeat this workshop prior to completion of their training. At the three-month follow-up, 29.6% (N=8) of study participants reported involvement in the disclosure of a patient safety event since the workshop with all eight reporting feeling adequately prepared by the workshop for this experience. Study participants indicated that post training they were more likely to engage the attending physician, risk management and patient relations in the disclosure conversation (p <=0.05). The estimated cost of this simulation training for 27 residents was $6,993, not accounting for the 39 hours per clinician facilitator. Conclusions Immersive simulation is uniquely suited for teaching difficult conversation skills that are encountered during acute care, including the disclosure of patient safety events. While hands-on practice is critical, faculty and simulation resources required for continued implementation may not be sustainable long-term. Future training curricula should leverage creative and innovative adult-learning techniques to reach a wide range of members of the care team with less resource utilization.

Virtual Reality for Pediatric Sedation: A Randomized Controlled Trial Using Simulation.

INTRODUCTION: Team training for procedural sedation for pediatric residents has traditionally consisted of didactic presentations and simulated scenarios using high-fidelity mannequins. We assessed the effectiveness of a virtual reality module in teaching preparation for and management of sedation for procedures. METHODS: After developing a virtual reality environment in Second Life® (Linden Lab, San Francisco, CA) where providers perform and recover patients from procedural sedation, we conducted a randomized controlled trial to assess the effectiveness of the virtual reality module versus a traditional web-based educational module. A 20 question pre- and post-test was administered to assess knowledge change. All subjects participated in a simulated pediatric procedural sedation scenario that was video recorded for review and assessed using a 32-point checklist. A brief survey elicited feedback on the virtual reality module and the simulation scenario. RESULTS: The median score on the assessment checklist was 75% for the intervention group and 70% for the control group (P = 0.32). For the knowledge tests, there was no statistically significant difference between the groups (P = 0.14). Users had excellent reviews of the virtual reality module and reported that the module added to their education. CONCLUSIONS: Pediatric residents performed similarly in simulation and on a knowledge test after a virtual reality module compared with a traditional web-based module on procedural sedation. Although users enjoyed the virtual reality experience, these results question the value virtual reality adds in improving the performance of trainees. Further inquiry is needed into how virtual reality provides true value in simulation-based education.