Pediatric Emergency and Critical Care Physicians Provide Remote Consultations to Emergency Department Providers in Rural and Underserved Areas, Leading to Better Diagnosis and Treatment

Problem Addressed

Rural emergency departments (EDs) often lack the resources to adequately assess and optimally treat acutely ill and injured children.

• Ill-equipped rural facilities: Rural hospitals nationwide have a shortage of on-call pediatricians and pediatric specialists.² Like their peer institutions in other states, rural hospitals in California lack physicians with experience in pediatric emergency medicine and often do not have essential pediatric medical equipment.³  
• High incidence of medication errors: The rate of medication errors for hospitalized children is three times greater than for adults.⁴ One study in northern California found a high incidence of medication errors among children treated for acute illness and injury in rural EDs.⁵
• Greater risk: Children living in rural areas have higher mortality rates than do urban-dwelling children. In 1992, the incidence of fatal injuries among rural children was 44 percent higher than among urban children, while the death rate for children 1 to 14 years of age living in rural areas was 20 percent higher.⁶

Description of the Innovative Activity

• Standardized triage protocol and laminated reference cards: Critical care physicians train triage nurses on use of a new, standardized triage protocol. In addition, all eight participating EDs receive laminated reference cards that list physiologic and diagnostic criteria for each triage category included in the new protocol.
• Expert consultation through telemedicine: Expert consultations are available 24 hours a day, 7 days a week through interactive videoconferencing; remote sites can activate these sessions by paging pediatric critical care physicians at UC Davis Children’s Hospital Pediatric ED and intensive care unit (ICU), who then assist with history, examination, and interpretation of findings for category I and II (acutely ill or injured) pediatric cases. The consultation process is described below:
  • Initial assessment: A triage nurse assesses the pediatric patient using the standardized protocol described above. If the triage nurse determines a case to be category I or II, an ED physician at the remote hospital will assess the patient and decide whether a telemedicine consultation is appropriate.
  • Activating the consult: Once the ED physician determines a telemedicine consultation is necessary, the remote hospital ED obtains consent from the parent/guardian (if possible). The remote site then pages the on-duty UC Davis Children’s Hospital Pediatric ICU or ED physician and turns on the telemedicine unit. On-call pediatric critical care physicians also can connect through a home-based mobile telemedicine unit. The remote site is usually connected within 5 to 10 minutes.
  • Consultation: Once a connection has been established, the UC Davis pediatric emergency or critical care physician sees the examination room and everyone in it. The patient, parent or guardian, physician, nurse, and/or other parties can interact with the UC Davis physician in realtime. The UC Davis physician assists remotely during the physical examination and reviews radiographs and laboratory results.
• Monthly critical care training: UC Davis critical care pediatric physicians host monthly interactive lectures on a variety of topics related to pediatric critical care that are broadcast over secure internet connections to remote ED sites. The program encourages staff at the remote sites to identify specific areas of need so that training sessions can be tailored to address them. In theory, these sessions provide training that otherwise would not occur due to the prohibitive time and travel requirements for onsite training at UC Davis. However, most remote EDs have not been tuning into these monthly sessions, perhaps due to the stationary location of the telemedicine units (which may limit the ability of staff to use it) and/or to other competing obligations. Program leaders are investigating ways to increase attendance, including providing continuing medical education credits.

References/Related Articles

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Results

• Better diagnostic/treatment process and decisionmaking: The remote consultation program resulted in changes to diagnostic testing, treatment plans (including medication), and admission and method of transfer decisions. Specifically, survey results of consulting physicians suggest that telemedicine consultations at treatment sites were more likely than telephone consultations at control sites to result in: (1) additional diagnostic studies ordered (47.78 percent vs. 13.34 percent; p=0.01), and (2) changes to or addition of medications (55.23 percent vs 7.14 percent; p=0.01).
• Higher levels of parent satisfaction: The program resulted in higher levels of parent satisfaction with the treatment process. Results from a parent satisfaction survey yielded a mean score on a 7-point adjectival scale for the survey questions to be significantly higher with telemedicine (N=46) than telephone consultation (N=28) for courtesy of ED nurses (6.69 vs. 5.74, p<0.01), courtesy of ED physicians (6.60 vs. 5.74, p<0.01), knowledge and skill of the ED physician (6.44 vs. 5.56, p<0.01), explanation of what was done for a child (6.39 vs. 5.41, p<0.02), overall ED quality of care (6.41 vs. 5.63), and overall ED experience (6.37 vs. 5.33, p<0.01); except for the survey question “explanation of what was happening with child" (6.10 vs. 5.56), which was higher but not significant.
• Greater perceived value by physicians: Both the consulting and remote physicians believe that the program enhances the value of the consultation process. Specifically, consulting physicians at intervention and control sites used a 7-point scale to rank the degree to which the consultation assisted in the medical management of the patient; the mean score was 6.63 for telemedicine consultations compared to 5.0 for telephone consultations at control sites. In addition, referring physicians used a 7-point scale to rank their overall satisfaction with the consultation process; the mean score was 6.89 for telemedicine consultations, compared to 5.67 for telephone consultations.
• Further evaluation underway: An evaluation of data from all intervention sites using a pre- and post-implementation test design with matched comparison groups will assess the program’s impact on the following: quality of care, medication errors, rate of appropriate patient admissions and transfers, and parent/guardian satisfaction with the medical care provided.

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Context of the Innovation

Planning and Development Process

• Site recruitment: Program leaders initially recruited eight sites (two pilot sites plus six others), and then added two additional sites. All participating EDs are located in rural and/or underserved areas.
• Site preparation: Once sites agreed to participate, the program dispatched a technician to assess their technology needs and coordinate with internet technology specialists on location. A UC Davis pediatric critical care physician met with hospital administrators to answer any questions and make sure they understood the process and were still agreeable to program participation. This physician later returned to the remote ED, usually with a technician, for a kickoff meeting with ED physicians and personnel, typically held in conjunction with regularly scheduled staff meetings.
• Training: All triage nurses in participating hospitals received training on use of the standardized triage protocol and laminated reference cards. In addition, the program offered all personnel from the participating EDs formal telemedicine education through the UC Davis Telemedicine Learning Center. Sessions included a 1-day overview and a 3-day expansive course.

Resources Used and Skills Needed

• Staffing: Staffing for the program includes the following:
  • Pediatric emergency and/or critical care physicians: Currently, four pediatric emergency medicine and seven pediatric critical care physicians from UC Davis’ Children’s Hospital ICU volunteer their time to provide 24-hours-a-day, 7-days-a-week consultations to 10 rural and/or underserved hospital EDs. These physicians also conduct the initial and monthly training sessions, with assistance from a technician.  
  • Technical assistance staff: Technicians from the Center for Health and Technology are available around the clock to provide technical support and conduct weekly “test calls.” These weekly calls not only test the system, but also increase remote provider familiarity with the equipment and operating procedures. Tests are conducted at varying times and days of the week to accommodate all shifts. 
  • Telemedicine coordinators: A telemedicine coordinator oversees program operations, including hospital agreements, assignment of staff roles, equipment testing, provider training, quality assurance, and program evaluation. This person typically spends between 10 and 25 percent of his or her time in this role, depending on consultation volume.
• Equipment: All intervention and remote sites have pagers to contact experts at UC Davis. To provide confidential interactive audio and video capabilities, videoconferencing units are connected with fractionated T1 lines, triple Integrated Services Digital Network lines, or secure and encrypted high-speed internet connections.
• Costs: The cost of equipment at remote sites ranges from $15,000 to $25,000, depending on capital needs. Telecommunications costs range from $50 to $200 per month, depending on the type of connection used. Staff costs vary significantly depending on volume. The current cost of each consultation is negligible because most physicians volunteer their time. However, the program is working toward securing third-party insurance reimbursement of $250 per consultation. Because UC Davis sponsors the monthly pediatric critical care trainings, the program cost for these trainings is negligible, consisting only of the cost to set up a camera and telecommunication charges during the broadcast.

Funding Sources

Agency for Healthcare Research and Quality; Health Resources and Services Administration

Getting Started with This Innovation

• Secure buy-in and commitment from key stakeholders: Ensure the commitment of dedicated pediatric critical care physicians to provide as-needed consultations in addition to initial and monthly training. For their part, rural providers must be willing to seek and accept expert guidance from these physicians. Support from hospital administrators and a “champion” (e.g., the telemedicine coordinator at the remote site) is also essential. 
• Strike a balance between need and commitment when choosing sites: Remote sites must have both a need for the program (e.g., an adequate volume of cases to justify the investment, but not too much volume that adequate in-house expertise already exists) and strong desire among key staff to participate.

Sustaining This Innovation

• Actively pursue alternative funding sources: Because public funding can shift with new budget priorities, and grant funding is usually time-limited, active pursuit of alternative funding sources, including third-party reimbursement, is essential. Aside from the minimal costs associated with the monthly training, technical support, and communication lines, it may be possible to make this program essentially "self-sufficient" through third-party reimbursement for consultations. 
• Provide competent, responsive technical assistance: Remote sites needs ongoing guidance on efficient use of the technology and prompt resolution of any technical problems that arise. High-quality information technology and videoconferencing personnel are needed to establish, maintain, and troubleshoot telecommunications and equipment.