Impact of critical care telemedicine consultations on children in rural emergency departments.

OBJECTIVES: To compare the quality of care delivered to critically ill and injured children receiving telemedicine, telephone, or no consultation in rural emergency departments. DESIGN: Retrospective chart review with concurrent surveys. SETTING AND PARTICIPANTS: Three hundred twenty patients presenting in the highest triage category to five rural emergency departments with access to pediatric critical care consultations from an academic children's hospital. MEASUREMENTS AND MAIN RESULTS: Quality of care was independently rated by two pediatric emergency medicine physicians applying a previously validated 7-point implicit quality review tool to the medical records. Quality was compared using multivariable linear regression adjusting for age, severity of illness, and temporal trend. Referring physicians were surveyed to evaluate consultation-related changes in their care. Parents were also surveyed to evaluate their satisfaction and perceived quality of care. In the multivariable analysis, with the no-consultation cohort as the reference, overall quality was highest among patients who received telemedicine consultations (n=58; ß=0.50 [95% CI, 0.17-0.84]), intermediate among patients receiving telephone consultation (n=63; ß=0.12 [95% CI, -0.14 to 0.39]), and lowest among patients receiving no consultation (n=199). Referring emergency department physicians reported changing their diagnosis (47.8% vs 13.3%; p<0.01) and therapeutic interventions (55.2% vs 7.1%; p<0.01) more frequently when consultations were provided using telemedicine than telephone. Parent satisfaction and perceived quality were significantly higher when telemedicine was used, compared with telephone, for six of the seven measures. CONCLUSIONS: Physician-rated quality of care was higher for patients who received consultations with telemedicine than for patients who received either telephone or no consultation. Telemedicine consultations were associated with more frequent changes in diagnostic and therapeutic interventions, and higher parent satisfaction, than telephone consultations.

Comparison of methohexital and pentobarbital as sedative agents for pediatric emergency department patients for computed tomography.

OBJECTIVES: To determine if there are differences in the duration of sedation between pediatric emergency department (PED) patients receiving methohexital and PED patients receiving pentobarbital for the purpose of obtaining a head computed tomographic (CT) scan. METHODS: Retrospective cohort study of PED patients receiving either methohexital or pentobarbital for a sedated head CT. Data were collected on patient demographics and medical condition, indications for head CT, duration of sedation, medication dosage, and medication adverse events. Primary analyses investigated whether there were differences between the 2 groups. Secondary analysis determined whether the need for additional sedative doses contributed to observed differences between groups. RESULTS: The patients receiving methohexital completed their head CT more quickly and needed less total sedation monitoring than those receiving pentobarbital. The need for additional doses of medication does not appear to be responsible for the observed difference. Adverse medication events were minor and comparable between groups. CONCLUSIONS: Methohexital may be superior to pentobarbital for the purpose of sedating PED patients for head CT.

Quality of care of children in the emergency department: association with hospital setting and physician training.

OBJECTIVE: To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors. STUDY DESIGN: This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training. RESULTS: A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = -3.23; 95% confidence interval [CI] = -4.48 to -1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the "other" category (difference = -3.34, 95% CI = -5.40 to -1.27 and -3.12, 95% CI = -5.25 to -0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = -2.75; 95% CI = -5.40 to -0.05). Older children received better care. CONCLUSIONS: The quality of care provided to children is associated with age, hospital setting, and physician training.

A new implicit review instrument for measuring quality of care delivered to pediatric patients in the emergency department.

BACKGROUND: There are few outcomes experienced by children receiving care in the Emergency Department (ED) that are amenable to measuring for the purposes of assessing of quality of care. The purpose of this study was to develop, test, and validate a new implicit review instrument that measures quality of care delivered to children in EDs. METHODS: We developed a 7-point structured implicit review instrument that encompasses four aspects of care, including the physician's initial data gathering, integration of information and development of appropriate diagnoses; initial treatment plan and orders; and plan for disposition and follow-up. Two pediatric emergency medicine physicians applied the 5-item instrument to children presenting in the highest triage category to four rural EDs, and we assessed the reliability of the average summary scores (possible range of 5-35) across the two reviewers using standard measures. We also validated the instrument by comparing this mean summary score between those with and without medication errors (ascertained independently by two pharmacists) using a two-sample t-test. RESULTS: We reviewed the medical records of 178 pediatric patients for the study. The mean and median summary score for this cohort of patients were 27.4 and 28.5, respectively. Internal consistency was high (Cronbach's alpha of 0.92 and 0.89). All items showed a significant (p < 0.005) positive correlation between reviewers using the Spearman rank correlation (range 0.24 to 0.39). Exact agreement on individual items between reviewers ranged from 70.2% to 85.4%. The Intra-class Correlation Coefficient for the mean of the total summary score across the two reviewers was 0.65. The validity of the instrument was supported by the finding of a higher score for children without medication errors compared to those with medication errors which trended toward significance (mean score = 28.5 vs. 26.0, p = 0.076). CONCLUSION: The instrument we developed to measure quality of care provided to children in the ED has high internal consistency, fair to good inter-rater reliability and inter-rater correlation, and high content validity. The validity of the instrument is supported by the fact that the instrument's average summary score was lower in the presence of medication errors, which trended towards statistical significance.