Association of Insurance With Use of Emergency Medical Services Among Children.

OBJECTIVE: The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED). METHODS: In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings. RESULTS: Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results. CONCLUSIONS: In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

Telemedicine for Interfacility Nurse Handoffs.

OBJECTIVE: To compare nurse preparedness and quality of patient handoff during interfacility transfers from a pretransfer emergency department to a PICU when conducted over telemedicine versus telephone. DESIGN: Cross-sectional nurse survey linked with patient electronic medical record data using multivariable, multilevel analysis. SETTING: Tertiary PICU within an academic children's hospital. PARTICIPANTS: PICU nurses who received a patient handoff between October 2017 and July 2018. INTERVENTIONS: None. MAIN RESULTS AND MEASUREMENTS: Among 239 eligible transfers, 106 surveys were completed by 55 nurses (44% survey response rate). Telemedicine was used for 30 handoffs (28%), and telephone was used for 76 handoffs (72%). Patients were comparable with respect to age, sex, race, primary spoken language, and insurance, but handoffs conducted over telemedicine involved patients with higher illness severity as measured by the Pediatric Risk of Mortality III score (4.4 vs 1.9; p = 0.05). After adjusting for Pediatric Risk of Mortality III score, survey recall time, and residual clustering by nurse, receiving nurses reported higher preparedness (measured on a five-point adjectival scale) following telemedicine handoffs compared with telephone handoffs (3.4 vs 3.1; p = 0.02). There were no statistically significant differences in both bivariable and multivariable analyses of handoff quality as measured by the Handoff Clinical Evaluation Exercise. Handoffs using telemedicine were associated with increased number of Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver components (3.3 vs 2.8; p = 0.04), but this difference was not significant in the adjusted analysis (3.1 vs 2.9; p = 0.55). CONCLUSIONS: Telemedicine is feasible for nurse-to-nurse handoffs of critically ill patients between pretransfer and receiving facilities and may be associated with increased perceived and objective nurse preparedness upon patient arrival. Additional research is needed to demonstrate that telemedicine during nurse handoffs improves communication, decreases preventable adverse events, and impacts family and provider satisfaction.

Association Between Insurance and Transfer of Injured Children From Emergency Departments.

OBJECTIVES: To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status. METHODS: We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission. RESULTS: Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1-1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0-1.5). A patient's insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED's proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8-1.1). CONCLUSIONS: Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.