Are smaller emergency departments increasingly less able to handle children? The problem of lateral transfer
There are about 27 million visits by children to America’s emergency departments each year. About a quarter of those are to rural EDs or ones at some distance from a dedicated children’s facility, such as a children’s hospital. Over the last decade or so it’s become clear that, for critically ill children, early transfer to an advanced pediatric facility improves outcomes. The children do better if they can be transferred early in their care to a pediatric intensive care unit. This has prompted attempts to regionalize pediatric critical care, and pediatric transport, in some formal way. That’s all reasonable and good.
What has also happened, though, is an increasing tendency to transfer children from one emergency department to another, from a facility not dedicated to pediatric care to one that is. And this may not be best for children and their families; transfer adds risk and cost, especially if it is unnecessary. What may be happening is an unwillingness of general purpose EDs to provide even fairly ordinary pediatric care.
A recent article in Pediatrics, the journal of the American Academy of Pediatrics, examined this group of children — those not critically ill but who were transferred to a pediatric emergency department for care. The authors premise is that, if a significant number of those children were discharged home from the receiving emergency department, they most likely could have been handled appropriately at the ED that sent them. There should be some caveats with that assumption, though. One is that sometimes the availability of a pediatric subspecialist, for example a pediatric cardiologist to evaluate a child with a possible heart problem, allows a dedicated pediatric ED to send home children because they have the expertise to make that decision. But I have certainly seen children flown in by helicopter from another hospital and then get sent home. They didn’t need the expensive (and sometimes dangerous) helicopter ride.
The authors of the article looked at the records for 42 pediatric hospitals to identify such interfacility ED to ED transfers. There were about 25,000 of them, a pretty large group. It turned out that a full quarter of these children were sent home from the pediatric ED. Another 17% were admitted to the hospital for less than 24 hours.
The authors’ conclusions are judiciously phrased:
A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.
What can be done about this? One solution is to continue to regionalize pediatric care. This allows doctors in a nonpediatric ED to have easy access to pediatric specialists by phone at least, or even better by telemedicine links. This allows remote consultation with an expert. A lot of this already happens — I get many such calls — but formalizing these interfacility relationships does improve care. Transport mishaps are uncommon, but they do occur. It would be terrible for a child to suffer injury or death from a transport that did not need to happen.