Reasons for Interfacility Emergency Department Transfer and Care at the Receiving Facility.

OBJECTIVES: The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility. METHODS: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer. RESULTS: Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission. CONCLUSIONS: Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

Profile of Interfacility Emergency Department Transfers: Transferring Medical Providers and Reasons for Transfer.

OBJECTIVES: The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers. METHODS: We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training. RESULTS: The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest. CONCLUSIONS: Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

A Transparent Tracking System for Competency-Based Orientation: One Children's Hospital Transport Unit Experience.

When nurses are hired for positions that require lengthy, highly specialized in-house orientation, their failure to complete orientation on time can lead to staffing shortages. In this article, we report the use of a transparent tracking system to monitor nurses' progress through a competency-based orientation program. By monitoring progress and detecting lapses, immediate remediation can be offered to those who need it, and staffing shortages thereby are avoided.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway.

BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

The influence of insurance type on interfacility pediatric emergency department transfers.

BACKGROUND: Disparities exist in the care children receive in the emergency department (ED) based on their insurance type. It is unknown if these differences exist among children transferred from outside EDs to pediatric tertiary care EDs. OBJECTIVE: To compare reasons for transfer and services received at pediatric tertiary care EDs between children with private and public insurance. METHODS: We performed a secondary analysis of a multicenter survey of ED providers transferring patients to pediatric tertiary care EDs in three major U.S. cities. Risk differences (RD) and 95% confidence intervals (CI) were calculated to compare reasons for transfer and care received at pediatric tertiary care EDs based on insurance type. RESULTS: There were 561 surveys completed by transferring providers describing reasons for transfer to pediatric tertiary care EDs with 52.2% of patients with private insurance and 47.8% with public insurance. We found no significant differences between privately and publicly insured children in reason for transfer for subspecialty consultation or need for admission. We found no significant differences in frequency of admission, radiologic studies, or ED procedures at the receiving facilities. However, a greater proportion of privately insured children had a subspecialty consultation at receiving facilities compared to publicly insured children (RD 9.7, 95% CI 2.0 to 17.4). CONCLUSIONS: Transferred pediatric patients with private insurance were more likely to have subspecialty consultations than children with public insurance. Further studies are needed to better characterize the interplay between patients' insurance type and both the request for, and the provision of, ED subspecialty consultations.

Measuring patient flow in a children's hospital using a scorecard with composite measurement.

BACKGROUND: Although patient flow is a focus for improvement in hospitals, commonly used single or unaggregated measures fail to capture its complexity. Composite measures can account for multiple dimensions of performance but have not been reported for the assessment of patient flow. OBJECTIVES: To present and discuss the implementation of a composite measure system as a way to measure and monitor patient flow and improvement activities at an urban children's hospital. METHODS: A 5-domain patient flow scorecard with composite measurement was designed by an interdisciplinary workgroup using measures involved in multiple aspects of patient flow. RESULTS: The composite score measurement system provided improvement teams and administrators with a comprehensive overview of patient flow. It captured overall performance trends and identified operational domains and specific components of patient flow that required improvement. DISCUSSION: A patient flow scorecard with composite measurement holds advantages over a single or unaggregated measurement system, because it provides a holistic assessment of performance while also identifying specific areas in need of improvement.

Characteristics of the pediatric patients treated by the Pediatric Emergency Care Applied Research Network's affiliated EMS agencies.

OBJECTIVE: To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. METHODS: We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. RESULTS: Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. CONCLUSIONS: Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

Pediatric and neonatal interfacility transport: results from a national consensus conference.

The practice of pediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile ICUs capable of delivering state-of-the-art critical care during pediatric and neonatal transport. The most recent document regarding the practice of pediatric/neonatal transport is more than a decade old. The following article details changes in the practice of interfacility transport over the past decade and expresses the consensus views of leaders in the field of transport medicine, including the American Academy of Pediatrics' Section on Transport Medicine.

Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU.

OBJECTIVE: To describe the current practice of pediatric airway management at referring hospitals and the associated adverse events compared to a receiving tertiary pediatric ICU. METHOD: Retrospective chart and transport record review of all emergency critical care transports to our Pediatric ICU over 3 years. Data regarding tracheal intubation procedure, pre-defined adverse Tracheal Intubation Associated Events (TIAEs), and airway events before, during, and after the inter-hospital transport were collected using a standard National Emergency Airway Registry for children (NEAR4KIDS) definition. Tracheal intubation outcomes were compared to in-hospital P ICU intubations. RESULTS: 253/1489 (17%) of critical care transports had airway management, all by tracheal intubation. The most common condition was seizure (34%), followed by pulmonary/lower airway disease (16%). 49 (19%) had TIAEs; the most common event was mainstem bronchial intubation (13%). Incidence of TIAEs was similar to PICU (p=0.69). Thirteen had an inappropriate tracheal tube position upon PICU arrival, but none experienced accidental extubation during transport. An uncuffed tracheal tube was used in 108/172 (63%) of patients<8 years, significantly higher than PICU (20%, p<0.0001). 124 (49%) were extubated within 24 h, 153 (60%) within 48 h. Two patients had the tracheal tube changed to cuffed from uncuffed due to air leak. CONCLUSION: Provider reported adverse TIAEs are common during airway management in children requiring critical care transport, but not higher compared to PICU intubations. Most inter-hospital transport patients are intubated with an uncuffed tracheal tube. Subsequent tracheal tube change from uncuffed to cuffed tube is rarely required.

Subgaleal hematoma from hair braiding leads to the diagnosis of von Willebrand disease.

A 17-year-old male developed a swollen painful scalp hematoma after having his hair braided. This extensive hematoma was drained, but then reaccumulated. Because of this unusual complication, laboratory testing for a bleeding disorder was performed. This patient was diagnosed with type 1 von Willebrand disease. To our knowledge, this is the first case of von Willebrand disease presenting as a subgaleal hematoma. von Willebrand disease is a common inherited bleeding disorder which should be considered in patients with unusual bleeding.

Traumatic diaphragmatic rupture in a pediatric patient: a case report.

Diaphragmatic rupture following blunt abdominal trauma is an uncommon life-threatening injury in children. In addition to its high mortality rate, there is a significant amount of morbidity associated with this injury. Emergency medicine physicians must maintain a high index of suspicion for diaphragmatic rupture and its associated complications when evaluating victims of blunt abdominal trauma.

Prolonged QT syndrome in children: an uncommon but potentially fatal entity.

Prolonged QT syndrome may be either congenital, as in Jervell and Lange-Nielsen or Romano-Ward syndromes, or acquired in nature. Affected children are at risk for syncope, seizures, dysrhythmias and sudden death. Physicians should consider long QT syndrome (LQTS) in all patients who present with syncope. A thorough personal and family history should be documented, with particular attention to prior syncopal episodes, congenital deafness, and unexplained sudden death. Syncope that is either recurrent or induced by exercise or stress is concerning and also should be noted. An electrocardiogram with manual calculation of the QT interval should be performed on all patients with a suggestive history. Furthermore, the diagnosis of LQTS warrants evaluation of all other family members. With recognition and appropriate treatment of affected patients, the potentially fatal consequences of LQTS may be prevented.