California — Targeted Issue
Improving the Care of Acutely Ill and Injured Children in Rural Emergency Departments with Telemedicine
March 1, 2005 - Feb. 29, 2008

Details

Institution
Regents of University of California
Principal Investigator(s)
Grant Number
H34MC04367
Award Amount
$599977.00

Regions

HRSA Region

9

EMSC Region

PREP

HPP Region

9

NASEMSO Region

West

Contacts

Name Roles Agency Mailing Address Office Phone Email
James Marcin, MD, MPH
  • Principal Investigator
Regents of University of California

Disseminations

Title Published Author Abstract Publication PMID
Medication errors among acutely ill and injured children treated in rural emergency departments 2007 Marcin JP, Dharmar M, Cho Meyng, Seifert L, Cook JL, Cole SL, Romano PS Ann Emerg Med 17433496
Quality of care of children in the emergency department: association with hospital setting and physician training 2008 Dharmar M, Marcin JP, Romano PS, Andrada ER, Overly F, Valente JH, Harvey DJ, Cole SL, Kuppermann N J Pediatr. 18617191
A new implicit review instrument for measuring quality of care delivered to pediatric patients in the emergency department 2007 Dharmar M, Marcin JP, Kuppermann N, Andrada ER, Cole SL, Harvey DJ, Romano PS BMC Emerg Med 17714593
Impact of critical care telemedicine consultations on children in rural emergency departments 2013 Dharmar, M., P. S. Romano, N. Kuppermann, T. S. Nesbitt, S. L. Cole, E. R. Andrada, C. Vance, D. J. Harvey, J. P. Marcin 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; β=0.50 [95% CI, 0.17-0.84]), intermediate among patients receiving telephone consultation (n=63; β=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.
Critical Care Medicine 23921273
Telemedicine consultations and medication errors in rural emergency departments 2013 Dharmar, M., N. Kuppermann, P. S. Romano, N. H. Yang, T. S. Nesbitt, J. Phan, C. Nguyen, K. Parsapour, J. P. Marcin Objective: To compare the frequency of physician-related medication errors among seriously ill and injured children receiving telemedicine consultations, similar children receiving telephone consultations, and similar children receiving no consultations in rural emergency departments (EDs).

Methods: We conducted retrospective chart reviews on seriously ill and injured children presenting to 8 rural EDs with access to pediatric critical care physicians from an academic children's hospital. Physician-related ED medication errors were independently identified by 2 pediatric pharmacists by using a previously published instrument. The unit of analysis was medication administered. The association of telemedicine consultations with ED medication errors was modeled by using hierarchical logistic regression adjusting for covariates (age, risk of admission, year of consultation, and hospital) and clustering at the patient level.

Results: Among the 234 patients in the study, 73 received telemedicine consultations, 85 received telephone consultations, and 76 received no specialist consultations. Medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations (3.4% vs. 10.8% and 12.5%, respectively; P < .05). In hierarchical logistic regression analysis, medications for patients who received telemedicine consultations had a lower odds of physician-related errors than medications for patients who received telephone consultations (odds ratio: 0.19, P < .05) or no consultations (odds ratio: 0.13, P < .05).

Conclusions: Pediatric critical care telemedicine consultations were associated with a significantly reduced risk of physician-related ED medication errors among seriously ill and injured children in rural EDs.
Pediatrics 24276844
Economic Evaluation of Pediatric Telemedicine Consultations to Rural Emergency Departments 2015 Yang, N. H., M. Dharmar, B. K. Yoo, J. P. Leigh, N. Kuppermann, P. S. Romano, T. S. Nesbitt and J. P. Marcin Background: Comprehensive economic evaluations have not been conducted on telemedicine consultations to children in rural emergency departments (EDs).

Objective: We conducted an economic evaluation to estimate the cost, effectiveness, and return on investment (ROI) of telemedicine consultations provided to health care providers of acutely ill and injured children in rural EDs compared with telephone consultations from a health care payer prospective.

Methods: We built a decision model with parameters from primary programmatic data, national data, and the literature. We performed a base-case cost-effectiveness analysis (CEA), a probabilistic CEA with Monte Carlo simulation, and ROI estimation when CEA suggested cost-saving. The CEA was based on program effectiveness, derived from transfer decisions following telemedicine and telephone consultations.

Results: The average cost for a telemedicine consultation was $3641 per child/ED/year in 2013 US dollars. Telemedicine consultations resulted in 31% fewer patient transfers compared with telephone consultations and a cost reduction of $4662 per child/ED/year. Our probabilistic CEA demonstrated telemedicine consultations were less costly than telephone consultations in 57% of simulation iterations. The ROI was calculated to be 1.28 ($4662/$3641) from the base-case analysis and estimated to be 1.96 from the probabilistic analysis, suggesting a $1.96 return for each dollar invested in telemedicine. Treating 10 acutely ill and injured children at each rural ED with telemedicine resulted in an annual cost-savings of $46,620 per ED.

Limitations: Telephone and telemedicine consultations were not randomly assigned, potentially resulting in biased results.

Conclusions: From a health care payer perspective, telemedicine consultations to health care providers of acutely ill and injured children presenting to rural EDs are cost-saving (base-case and more than half of Monte Carlo simulation iterations) or cost-effective compared with telephone consultations.
Medical Decision Making 25952744
Pediatric Critical Care Telemedicine Program: A Single Institution Review 2016 Hernandez, M., N. Hojman, C. Sadorra, M. Dharmar, T. S. Nesbitt, R. Litman and J. P. Marcin Background: Rural and community emergency departments (EDs) often receive and treat critically ill children despite limited access to pediatric expertise. Increasingly, pediatric critical care programs at children's hospitals are using telemedicine to provide consultations to these EDs with the goal of increasing the quality of care.

Materials and methods: We conducted a retrospective review of a pediatric critical care telemedicine program at a single university children's hospital. Between the years 2000 and 2014, we reviewed all telemedicine consultations provided to children in rural and community EDs, classified the visits using a comprehensive evidence-based set of chief complaints, and reported the consultations' impact on patient disposition. We also reviewed the total number of pediatric ED visits to calculate the relative frequency with which telemedicine consultations were provided.

Results: During the study period, there were 308 consultations provided to acutely ill and/or injured children for a variety of chief complaints, most commonly for respiratory illnesses, acute injury, and neurological conditions. Since inception, the number of consultations has been increasing, as has the number of participating EDs (n = 18). Telemedicine consultations were conducted on 8.6% of seriously ill children, the majority of which resulted in admission to the receiving hospital (n = 150, 49%), with a minority of patients requiring transport to the university children's hospital (n = 103, 33%).

Conclusions: This single institutional, university children's hospital-based review demonstrates that a pediatric critical care telemedicine program used to provide consultations to seriously ill children in rural and community EDs is feasible, sustainable, and used relatively infrequently, most typically for the sickest pediatric patients.
Telemed J E Health 26203917
Appropriateness of disposition following telemedicine consultations in rural emergency departments 2015 Yang, N. H., M. Dharmar, N. Kuppermann, P. S. Romano, T. S. Nesbitt, N. M. Hojman and J. P. Marcin Objectives: To compare the appropriateness of hospital admission in eight rural emergency departments among a cohort of acutely ill and injured children who receive telemedicine consultations from pediatric critical care physicians to a cohort of similar children who receive telephone consultations from the same group of physicians.

Design: Retrospective cohort study between January 2003 and May 2012.

Setting: Eight rural emergency departments in Northern California.

Patients: Acutely ill and injured children triaged to the highest-level triage category who received either telemedicine or telephone consultations.

Interventions: Telemedicine and telephone consultations.

Measurements and main results: We compared the overall and stratified observed-to-expected hospital admission ratios between telemedicine and telephone cohorts by calculating the risk of admission using the second generation of Pediatric Risk of Admission score and the Revised Pediatric Emergency Assessment Tool. A total of 138 charts were reviewed; 74 children received telemedicine consultations and 64 received telephone consultations. The telemedicine cohort had fewer hospital admissions compared with the telephone cohort (59.5% vs 87.5%; p < 0.05). Although the telemedicine cohort had lower observed-to-expected admission ratios than the telephone cohort, these differences were not statistically different (Pediatric Risk of Admission II, 2.36 vs 2.58; Revised Pediatric Emergency Assessment Tool, 2.34 vs 2.57). This result did not change when the cohorts were stratified into low (below median) and high (above median) risk of admission cohorts, using either Pediatric Risk of Admission II (low risk, 18.25 vs 22.81; high risk, 1.40 vs 1.54) or Revised Pediatric Emergency Assessment Tool (low risk, 5.35 vs 5.94; high risk, 1.51 vs 1.81).

Conclusions: Although the overall admission rate among patients receiving telemedicine consultations was lower than that among patients receiving telephone consultations, there were no statistically significant differences between the observed-to-expected admission ratios using Pediatric Risk of Admission II and Revised Pediatric Emergency Assessment Tool. Our findings may be reassuring in the context of previous research, suggesting that telemedicine specialty consultations can aid in the delivery of more appropriate, safer, and higher quality of care.
Pediatric Critical Care Medicine 25607743