Pediatric Conditions Requiring Minimal Intervention or Observation After Interfacility Transfer

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Pediatric Conditions Requiring Minimal Intervention or Observation After Interfacility Transfer

Regionalization of pediatric acute care is increasing across the United States, with rates of interfacility transfer for general medical conditions in children similar to those of high-risk conditions in adults.1 The inability for children to receive definitive care (ie, care provided to conclusively manage a patient’s condition without requiring an interfacility transfer) within their local community has implications on public health as well as family function and financial burden.1,2 Previous studies demonstrated that 30% to 80% of interfacility transfers are potentially unnecessary,3-6 as indicated by a high proportion of short lengths of stay after transfer. While rapidity of discharge is an important factor in identifying potentially unnecessary transfers, many of these studies included diagnoses requiring specialized imaging or surgical interventions, which may not be available in referring institutions.

To highlight conditions that referring hospitals may prioritize for pediatric capacity building, we aimed to identify the most common medical diagnoses among pediatric transfer patients that did not require advanced evaluation or intervention and that had high rates of discharge within 1 day of interfacility transfer.

METHODS

We conducted a retrospective, cross-sectional, descriptive study using the Pediatric Health Information System (PHIS) database, which contains administrative data from 48 geographically diverse US children’s hospitals.

We included children <18 years old who were transferred to a participating PHIS hospital in 2019, including emergency department (ED), observation, and inpatient encounters. We identified patients through the source-of-admission code labeled as “transfer.” Diagnoses were identified through the International Classification of Diseases, Tenth Revision (ICD-10) codes using the Pediatric Clinical Classification System.7We excluded the following categories: mental or behavioral health diagnoses, maternal or labor diagnoses, primary newborn birth diagnoses, and transfers directly to an intensive care unit (ICU).

For each diagnosis, we determined the number of transfers and frequency of rapid discharge, defined as either discharge from the ED without admission or admission and discharge within 1 day from a general inpatient unit. As discharge times are not reliably available in PHIS, all patients discharged on the day of transfer or the following calendar day were identified as rapid discharge. Medical complexity was determined through applying the Pediatric Medical Complexity Algorithm (PMCA).8

To identify diagnoses seen with sufficient frequency to represent potentially useful areas for referring hospitals to target, we limited our analysis to diagnoses that had a minimum of 576 transfers per year, equivalent to at least 1 transfer for that diagnosis per month per PHIS hospital. We then categorized the frequency of interventions after transfer, including (1) no interventions received; (2) basic interventions only, defined as receiving any intravenous fluids, antimicrobials, antipyretics or analgesics, and/or basic imaging (ie, radiography and computed tomography [CT]); or (3) advanced interventions, including transfer to an ICU after initial presentation/management in the ED or inpatient ward, advanced imaging (eg, ultrasound, magnetic resonance [MR] imaging, MR angiography or venography, CT angiography), or any surgical intervention. A full categorization of basic and advanced interventions is available in Appendix Table 1.

For descriptive statistics, we calculated means for normally distributed variables, medians for continuous variables with nonnormal distributions, and percentages for binary variables. Comparisons were made using t-tests and chi-square tests.

This study was approved by the Seattle Children’s Institutional Review Board.

RESULTS

We identified 286,905 transfers into participating PHIS hospitals in 2019. Of these, 89,519 (31.2%) were excluded (Appendix Table 2), leaving 197,386 (68.6%) transfers. Patients discharged within 1 day were more likely to have public or unknown insurance (65.1% vs 61.5%, P < 0.01), to have no co-occurring chronic conditions (60.2% vs 28.5%, P < 0.01), and to reside within the Northeast (35.0% vs 11.0%, P < 0.01) (Appendix Table 3).

The most common medical diagnoses among these transfers included acute bronchiolitis (4.3% of all interfacility transfers, n = 8,425), chemotherapy (4.0%, n = 7,819), and asthma (3.3%, n = 6,430) (Appendix Table 4); 45.9% of bronchiolitis, 15.0% of chemotherapy, and 67.4% of asthma transfers were rapidly discharged.

The Table shows the medical conditions among transfers that most frequently experienced rapid discharge (primary surgical diagnoses are presented in Appendix Table 5).

Medical Diagnoses Most Commonly Discharged Rapidly After Interfacility Transfer
Within this cohort, patients transferred for cough were most likely to be rapidly discharged, with 98.5% (n = 611) discharged within 1 day of transfer. Among these, 66.5% (n = 412) received no interventions and 33.4% (n = 207) received only basic interventions. Only 1.3% (n = 8) required any advanced intervention. Similarly, 96.0% (n = 603) of patients with the diagnosis of chest pain were rapidly discharged, with 45.1% (n = 272) requiring no interventions, 48.3% (n = 291) receiving basic interventions, and 17.7% (n = 107) requiring advanced intervention. Patients with the diagnosis of febrile seizures, croup, and allergic reactions were rapidly discharged 91.8% (n = 584), 87.3% (n = 1,893) and 87.2% (n = 1,350) of the time, respectively, and more than 70% patients with these diagnoses underwent no intervention after transfer. In addition, while 92.0% (n = 3,392) of patients with abdominal pain diagnoses were discharged rapidly, 55.5% (n = 1,883) received advanced imaging (Appendix Table 6). Similarly, while 92.0% (n = 2,229) of patients with open wounds to the head, neck, and trunk were discharged rapidly, 17.3% (n = 419) of patients with these diagnoses required a surgical intervention after transfer (Appendix Table 6).

DISCUSSION

We have identified medical conditions that not only had high rates of rapid discharge after transfer, but also received minimal intervention from the accepting institution. Although bronchiolitis and chemotherapy were the most common conditions for which patients were transferred, the range of severity varied widely, with more than 50% of bronchiolitis and 85% of chemotherapy transfers requiring hospitalization for longer than 1 day. Diagnoses such as chemotherapy, although common among transferred patients, likely represent conditions that may not be appropriate to care for in pediatric-limited settings, as they require subspecialized pediatric care. General conditions, however, such as cough, chest pain, allergic reactions, and febrile seizures may represent diagnoses for which it would be appropriate for general hospitals to develop infrastructure to provide definitive pediatric care given how infrequently specialized pediatric resources are needed in caring for these conditions.

Identifying conditions as potential targets to reduce the number of interfacility transfers requires balancing a hospital’s capacity (or lack thereof) for pediatric admissions, perceived risk of decompensation, referring provider discomfort, and parental preference.9-11 Although several studies have identified conditions associated with frequent transfer and rapid discharge,3-5 prior studies’ conclusions that 40% or more of interhospital transfers may be avoidable are potential over-estimates, representing conditions that may not be appropriate to care for in pediatric-limited settings given their need for advanced interventions. Our findings demonstrate that defining a cohort of conditions based on frequency of transfer, even when accounting for minimal intervention post transfer, may not adequately capture avoidable transfers. For example, abdominal pain was one of the conditions for which patients were most frequently transferred, with 92% of patients discharged rapidly. However, the most common surgical transfer was acute appendicitis with peritonitis. Many of these transfers may have been identified initially as “abdominal pain” at the referring institution, highlighting the role of diagnostic uncertainty in identifying preventable transfers. In addition, more than 56% of patients transferred for abdominal pain required advanced interventions, further illustrating the potential risk and uncertainty for referring hospitals that do not have the capacity for advanced imaging or surgical intervention.

The rapid upscale of telehealth may provide a unique opportunity to support the provision of pediatric care within local communities.12,13 As many general hospitals do not have ultrasound technicians trained for children available 24 hours per day, several conditions that fell into the advanced intervention category, like abdominal pain, were driven by the receipt of an ultrasound at the accepting hospital. Targeted work to expand ultrasound capabilities at referring hospitals may enable changing the categorization of an ultrasound to a basic intervention rather than an advanced intervention. Paired with telehealth, this might broaden the scope of potential diagnoses that could be triaged to stay within referring institutions.

Building infrastructure to prevent interfacility transfers may improve healthcare access for children in rural areas proportionately more than children in urban areas. Children in rural communities experience significantly higher rates of interfacility transfers than children in urban areas.14 This increases financial burden and causes additional distress and inconvenience for families.15 With constraints in staffing capacity, equipment, and finances, identifying a subset of medical conditions is a critical initial step to inform the design of targeted interventions to support pediatric healthcare delivery in local communities and avoid costly transfers, although it is not the wholesale solution. Additional utilization of tools such as informed shared decision-making resources and implementation of pediatric-specific protocols likely represent additional necessary steps.

Our study has several limitations. Because we used administrative data, there is a risk of misclassifying diagnoses. We attempted to mitigate this by using a standard ICD-10-based, pediatric-specific grouper. ICD-10 coding is also based upon discharge diagnoses, which inherently has retrospective bias that cannot capture the diagnostic uncertainty when making an initial decision for transfer. In addition, without a comparator group of patients who were not transferred, it remains unknown to what extent balancing factors informed the decision to transfer or whether these diagnoses represent conditions that the referring hospital encounters only a few times a year, or alternatively, that the percentage transferred represents a small fraction of the referring institution’s population with a given diagnosis.

CONCLUSION

Our exploration of pediatric interfacility transfers that experienced rapid discharge with minimal intervention provides a building block to support the provision of definitive pediatric care in non-pediatric hospitals and represents a step towards addressing limited access to care in general hospitals.

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References

1. França UL, McManus ML. Availability of definitive hospital care for children. JAMA Pediatr. 2017;171(9):e171096. https://doi.org/10.1001/jamapediatrics.2017.1096
2. Mumford V, Baysari MT, Kalinin D, et al. Measuring the financial and productivity burden of paediatric hospitalisation on the wider family network. J Paediatr Child Health. 2018;54(9):987-996. https://doi.org/10.1111/jpc.13923
3. Richard KR, Glisson KL, Shah N, et al. Predictors of potentially unnecessary transfers to pediatric emergency departments. Hosp Pediatr. 2020;10(5):424-429. https://doi.org/10.1542/hpeds.2019-0307
4. Gattu RK, Teshome G, Cai L, Wright C, Lichenstein R. Interhospital pediatric patient transfers-factors influencing rapid disposition after transfer. Pediatr Emerg Care. 2014;30(1):26-30. https://doi.org/10.1097/PEC.0000000000000061
5. Li J, Monuteaux MC, Bachur RG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics. 2012;130(1):83-92. https://doi.org/10.1542/peds.2011-1819
6. Rosenthal JL, Lieng MK, Marcin JP, Romano PS. Profiling pediatric potentially avoidable transfers using procedure and diagnosis codes. Pediatr Emerg Care. 2019 Mar 19;10.1097/PEC.0000000000001777. https://doi.org/10.1097/PEC.0000000000001777
7. Pediatric clinical classification system (PECCS) codes. Children’s Hospital Association. December 11, 2020. Accessed June 3, 2021. https://www.childrenshospitals.org/Research-and-Data/Pediatric-Data-and-Trends/2020/Pediatric-Clinical-Classification-System-PECCS
8. Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and validation of the pediatric medical complexity algorithm (PMCA) version 3.0. Acad Pediatr. 2018;18(5):577-580. https://doi.org/10.1016/j.acap.2018.02.010
9. Rosenthal JL, Okumura MJ, Hernandez L, Li ST, Rehm RS. Interfacility transfers to general pediatric floors: a qualitative study exploring the role of communication. Acad Pediatr. 2016;16(7):692-699. https://doi.org/10.1016/j.acap.2016.04.003
10. Rosenthal JL, Li ST, Hernandez L, Alvarez M, Rehm RS, Okumura MJ. Familial caregiver and physician perceptions of the family-physician interactions during interfacility transfers. Hosp Pediatr. 2017;7(6):344-351. https://doi.org/10.1542/hpeds.2017-0017
11. Peebles ER, Miller MR, Lynch TP, Tijssen JA. Factors associated with discharge home after transfer to a pediatric emergency department. Pediatr Emerg Care. 2018;34(9):650-655. https://doi.org/10.1097/PEC.0000000000001098
12. Labarbera JM, Ellenby MS, Bouressa P, Burrell J, Flori HR, Marcin JP. The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital. Telemed J E Health. 2013;19(10):760-766. https://doi.org/10.1089/tmj.2012.0303
13. Haynes SC, Dharmar M, Hill BC, et al. The impact of telemedicine on transfer rates of newborns at rural community hospitals. Acad Pediatr. 2020;20(5):636-641. https://doi.org/10.1016/j.acap.2020.02.013
14. Michelson KA, Hudgins JD, Lyons TW, Monuteaux MC, Bachur RG, Finkelstein JA. Trends in capability of hospitals to provide definitive acute care for children: 2008 to 2016. Pediatrics. 2020;145(1). https://doi.org/10.1542/peds.2019-2203
15. Mohr NM, Harland KK, Shane DM, Miller SL, Torner JC. Potentially avoidable pediatric interfacility transfer is a costly burden for rural families: a cohort study. Acad Emerg Med. 2016;23(8):885-894. https://doi.org/10.1111/acem.12972

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1Department of Pediatrics, University of Washington, Seattle, Washington; 2Seattle Children’s Research Institute, Seattle, Washington; 3Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; 4The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; 5Department of Health Services, University of Washington, Seattle, Washington.

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1Department of Pediatrics, University of Washington, Seattle, Washington; 2Seattle Children’s Research Institute, Seattle, Washington; 3Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; 4The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; 5Department of Health Services, University of Washington, Seattle, Washington.

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1Department of Pediatrics, University of Washington, Seattle, Washington; 2Seattle Children’s Research Institute, Seattle, Washington; 3Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; 4The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; 5Department of Health Services, University of Washington, Seattle, Washington.

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Related Articles

Regionalization of pediatric acute care is increasing across the United States, with rates of interfacility transfer for general medical conditions in children similar to those of high-risk conditions in adults.1 The inability for children to receive definitive care (ie, care provided to conclusively manage a patient’s condition without requiring an interfacility transfer) within their local community has implications on public health as well as family function and financial burden.1,2 Previous studies demonstrated that 30% to 80% of interfacility transfers are potentially unnecessary,3-6 as indicated by a high proportion of short lengths of stay after transfer. While rapidity of discharge is an important factor in identifying potentially unnecessary transfers, many of these studies included diagnoses requiring specialized imaging or surgical interventions, which may not be available in referring institutions.

To highlight conditions that referring hospitals may prioritize for pediatric capacity building, we aimed to identify the most common medical diagnoses among pediatric transfer patients that did not require advanced evaluation or intervention and that had high rates of discharge within 1 day of interfacility transfer.

METHODS

We conducted a retrospective, cross-sectional, descriptive study using the Pediatric Health Information System (PHIS) database, which contains administrative data from 48 geographically diverse US children’s hospitals.

We included children <18 years old who were transferred to a participating PHIS hospital in 2019, including emergency department (ED), observation, and inpatient encounters. We identified patients through the source-of-admission code labeled as “transfer.” Diagnoses were identified through the International Classification of Diseases, Tenth Revision (ICD-10) codes using the Pediatric Clinical Classification System.7We excluded the following categories: mental or behavioral health diagnoses, maternal or labor diagnoses, primary newborn birth diagnoses, and transfers directly to an intensive care unit (ICU).

For each diagnosis, we determined the number of transfers and frequency of rapid discharge, defined as either discharge from the ED without admission or admission and discharge within 1 day from a general inpatient unit. As discharge times are not reliably available in PHIS, all patients discharged on the day of transfer or the following calendar day were identified as rapid discharge. Medical complexity was determined through applying the Pediatric Medical Complexity Algorithm (PMCA).8

To identify diagnoses seen with sufficient frequency to represent potentially useful areas for referring hospitals to target, we limited our analysis to diagnoses that had a minimum of 576 transfers per year, equivalent to at least 1 transfer for that diagnosis per month per PHIS hospital. We then categorized the frequency of interventions after transfer, including (1) no interventions received; (2) basic interventions only, defined as receiving any intravenous fluids, antimicrobials, antipyretics or analgesics, and/or basic imaging (ie, radiography and computed tomography [CT]); or (3) advanced interventions, including transfer to an ICU after initial presentation/management in the ED or inpatient ward, advanced imaging (eg, ultrasound, magnetic resonance [MR] imaging, MR angiography or venography, CT angiography), or any surgical intervention. A full categorization of basic and advanced interventions is available in Appendix Table 1.

For descriptive statistics, we calculated means for normally distributed variables, medians for continuous variables with nonnormal distributions, and percentages for binary variables. Comparisons were made using t-tests and chi-square tests.

This study was approved by the Seattle Children’s Institutional Review Board.

RESULTS

We identified 286,905 transfers into participating PHIS hospitals in 2019. Of these, 89,519 (31.2%) were excluded (Appendix Table 2), leaving 197,386 (68.6%) transfers. Patients discharged within 1 day were more likely to have public or unknown insurance (65.1% vs 61.5%, P < 0.01), to have no co-occurring chronic conditions (60.2% vs 28.5%, P < 0.01), and to reside within the Northeast (35.0% vs 11.0%, P < 0.01) (Appendix Table 3).

The most common medical diagnoses among these transfers included acute bronchiolitis (4.3% of all interfacility transfers, n = 8,425), chemotherapy (4.0%, n = 7,819), and asthma (3.3%, n = 6,430) (Appendix Table 4); 45.9% of bronchiolitis, 15.0% of chemotherapy, and 67.4% of asthma transfers were rapidly discharged.

The Table shows the medical conditions among transfers that most frequently experienced rapid discharge (primary surgical diagnoses are presented in Appendix Table 5).

Medical Diagnoses Most Commonly Discharged Rapidly After Interfacility Transfer
Within this cohort, patients transferred for cough were most likely to be rapidly discharged, with 98.5% (n = 611) discharged within 1 day of transfer. Among these, 66.5% (n = 412) received no interventions and 33.4% (n = 207) received only basic interventions. Only 1.3% (n = 8) required any advanced intervention. Similarly, 96.0% (n = 603) of patients with the diagnosis of chest pain were rapidly discharged, with 45.1% (n = 272) requiring no interventions, 48.3% (n = 291) receiving basic interventions, and 17.7% (n = 107) requiring advanced intervention. Patients with the diagnosis of febrile seizures, croup, and allergic reactions were rapidly discharged 91.8% (n = 584), 87.3% (n = 1,893) and 87.2% (n = 1,350) of the time, respectively, and more than 70% patients with these diagnoses underwent no intervention after transfer. In addition, while 92.0% (n = 3,392) of patients with abdominal pain diagnoses were discharged rapidly, 55.5% (n = 1,883) received advanced imaging (Appendix Table 6). Similarly, while 92.0% (n = 2,229) of patients with open wounds to the head, neck, and trunk were discharged rapidly, 17.3% (n = 419) of patients with these diagnoses required a surgical intervention after transfer (Appendix Table 6).

DISCUSSION

We have identified medical conditions that not only had high rates of rapid discharge after transfer, but also received minimal intervention from the accepting institution. Although bronchiolitis and chemotherapy were the most common conditions for which patients were transferred, the range of severity varied widely, with more than 50% of bronchiolitis and 85% of chemotherapy transfers requiring hospitalization for longer than 1 day. Diagnoses such as chemotherapy, although common among transferred patients, likely represent conditions that may not be appropriate to care for in pediatric-limited settings, as they require subspecialized pediatric care. General conditions, however, such as cough, chest pain, allergic reactions, and febrile seizures may represent diagnoses for which it would be appropriate for general hospitals to develop infrastructure to provide definitive pediatric care given how infrequently specialized pediatric resources are needed in caring for these conditions.

Identifying conditions as potential targets to reduce the number of interfacility transfers requires balancing a hospital’s capacity (or lack thereof) for pediatric admissions, perceived risk of decompensation, referring provider discomfort, and parental preference.9-11 Although several studies have identified conditions associated with frequent transfer and rapid discharge,3-5 prior studies’ conclusions that 40% or more of interhospital transfers may be avoidable are potential over-estimates, representing conditions that may not be appropriate to care for in pediatric-limited settings given their need for advanced interventions. Our findings demonstrate that defining a cohort of conditions based on frequency of transfer, even when accounting for minimal intervention post transfer, may not adequately capture avoidable transfers. For example, abdominal pain was one of the conditions for which patients were most frequently transferred, with 92% of patients discharged rapidly. However, the most common surgical transfer was acute appendicitis with peritonitis. Many of these transfers may have been identified initially as “abdominal pain” at the referring institution, highlighting the role of diagnostic uncertainty in identifying preventable transfers. In addition, more than 56% of patients transferred for abdominal pain required advanced interventions, further illustrating the potential risk and uncertainty for referring hospitals that do not have the capacity for advanced imaging or surgical intervention.

The rapid upscale of telehealth may provide a unique opportunity to support the provision of pediatric care within local communities.12,13 As many general hospitals do not have ultrasound technicians trained for children available 24 hours per day, several conditions that fell into the advanced intervention category, like abdominal pain, were driven by the receipt of an ultrasound at the accepting hospital. Targeted work to expand ultrasound capabilities at referring hospitals may enable changing the categorization of an ultrasound to a basic intervention rather than an advanced intervention. Paired with telehealth, this might broaden the scope of potential diagnoses that could be triaged to stay within referring institutions.

Building infrastructure to prevent interfacility transfers may improve healthcare access for children in rural areas proportionately more than children in urban areas. Children in rural communities experience significantly higher rates of interfacility transfers than children in urban areas.14 This increases financial burden and causes additional distress and inconvenience for families.15 With constraints in staffing capacity, equipment, and finances, identifying a subset of medical conditions is a critical initial step to inform the design of targeted interventions to support pediatric healthcare delivery in local communities and avoid costly transfers, although it is not the wholesale solution. Additional utilization of tools such as informed shared decision-making resources and implementation of pediatric-specific protocols likely represent additional necessary steps.

Our study has several limitations. Because we used administrative data, there is a risk of misclassifying diagnoses. We attempted to mitigate this by using a standard ICD-10-based, pediatric-specific grouper. ICD-10 coding is also based upon discharge diagnoses, which inherently has retrospective bias that cannot capture the diagnostic uncertainty when making an initial decision for transfer. In addition, without a comparator group of patients who were not transferred, it remains unknown to what extent balancing factors informed the decision to transfer or whether these diagnoses represent conditions that the referring hospital encounters only a few times a year, or alternatively, that the percentage transferred represents a small fraction of the referring institution’s population with a given diagnosis.

CONCLUSION

Our exploration of pediatric interfacility transfers that experienced rapid discharge with minimal intervention provides a building block to support the provision of definitive pediatric care in non-pediatric hospitals and represents a step towards addressing limited access to care in general hospitals.

Regionalization of pediatric acute care is increasing across the United States, with rates of interfacility transfer for general medical conditions in children similar to those of high-risk conditions in adults.1 The inability for children to receive definitive care (ie, care provided to conclusively manage a patient’s condition without requiring an interfacility transfer) within their local community has implications on public health as well as family function and financial burden.1,2 Previous studies demonstrated that 30% to 80% of interfacility transfers are potentially unnecessary,3-6 as indicated by a high proportion of short lengths of stay after transfer. While rapidity of discharge is an important factor in identifying potentially unnecessary transfers, many of these studies included diagnoses requiring specialized imaging or surgical interventions, which may not be available in referring institutions.

To highlight conditions that referring hospitals may prioritize for pediatric capacity building, we aimed to identify the most common medical diagnoses among pediatric transfer patients that did not require advanced evaluation or intervention and that had high rates of discharge within 1 day of interfacility transfer.

METHODS

We conducted a retrospective, cross-sectional, descriptive study using the Pediatric Health Information System (PHIS) database, which contains administrative data from 48 geographically diverse US children’s hospitals.

We included children <18 years old who were transferred to a participating PHIS hospital in 2019, including emergency department (ED), observation, and inpatient encounters. We identified patients through the source-of-admission code labeled as “transfer.” Diagnoses were identified through the International Classification of Diseases, Tenth Revision (ICD-10) codes using the Pediatric Clinical Classification System.7We excluded the following categories: mental or behavioral health diagnoses, maternal or labor diagnoses, primary newborn birth diagnoses, and transfers directly to an intensive care unit (ICU).

For each diagnosis, we determined the number of transfers and frequency of rapid discharge, defined as either discharge from the ED without admission or admission and discharge within 1 day from a general inpatient unit. As discharge times are not reliably available in PHIS, all patients discharged on the day of transfer or the following calendar day were identified as rapid discharge. Medical complexity was determined through applying the Pediatric Medical Complexity Algorithm (PMCA).8

To identify diagnoses seen with sufficient frequency to represent potentially useful areas for referring hospitals to target, we limited our analysis to diagnoses that had a minimum of 576 transfers per year, equivalent to at least 1 transfer for that diagnosis per month per PHIS hospital. We then categorized the frequency of interventions after transfer, including (1) no interventions received; (2) basic interventions only, defined as receiving any intravenous fluids, antimicrobials, antipyretics or analgesics, and/or basic imaging (ie, radiography and computed tomography [CT]); or (3) advanced interventions, including transfer to an ICU after initial presentation/management in the ED or inpatient ward, advanced imaging (eg, ultrasound, magnetic resonance [MR] imaging, MR angiography or venography, CT angiography), or any surgical intervention. A full categorization of basic and advanced interventions is available in Appendix Table 1.

For descriptive statistics, we calculated means for normally distributed variables, medians for continuous variables with nonnormal distributions, and percentages for binary variables. Comparisons were made using t-tests and chi-square tests.

This study was approved by the Seattle Children’s Institutional Review Board.

RESULTS

We identified 286,905 transfers into participating PHIS hospitals in 2019. Of these, 89,519 (31.2%) were excluded (Appendix Table 2), leaving 197,386 (68.6%) transfers. Patients discharged within 1 day were more likely to have public or unknown insurance (65.1% vs 61.5%, P < 0.01), to have no co-occurring chronic conditions (60.2% vs 28.5%, P < 0.01), and to reside within the Northeast (35.0% vs 11.0%, P < 0.01) (Appendix Table 3).

The most common medical diagnoses among these transfers included acute bronchiolitis (4.3% of all interfacility transfers, n = 8,425), chemotherapy (4.0%, n = 7,819), and asthma (3.3%, n = 6,430) (Appendix Table 4); 45.9% of bronchiolitis, 15.0% of chemotherapy, and 67.4% of asthma transfers were rapidly discharged.

The Table shows the medical conditions among transfers that most frequently experienced rapid discharge (primary surgical diagnoses are presented in Appendix Table 5).

Medical Diagnoses Most Commonly Discharged Rapidly After Interfacility Transfer
Within this cohort, patients transferred for cough were most likely to be rapidly discharged, with 98.5% (n = 611) discharged within 1 day of transfer. Among these, 66.5% (n = 412) received no interventions and 33.4% (n = 207) received only basic interventions. Only 1.3% (n = 8) required any advanced intervention. Similarly, 96.0% (n = 603) of patients with the diagnosis of chest pain were rapidly discharged, with 45.1% (n = 272) requiring no interventions, 48.3% (n = 291) receiving basic interventions, and 17.7% (n = 107) requiring advanced intervention. Patients with the diagnosis of febrile seizures, croup, and allergic reactions were rapidly discharged 91.8% (n = 584), 87.3% (n = 1,893) and 87.2% (n = 1,350) of the time, respectively, and more than 70% patients with these diagnoses underwent no intervention after transfer. In addition, while 92.0% (n = 3,392) of patients with abdominal pain diagnoses were discharged rapidly, 55.5% (n = 1,883) received advanced imaging (Appendix Table 6). Similarly, while 92.0% (n = 2,229) of patients with open wounds to the head, neck, and trunk were discharged rapidly, 17.3% (n = 419) of patients with these diagnoses required a surgical intervention after transfer (Appendix Table 6).

DISCUSSION

We have identified medical conditions that not only had high rates of rapid discharge after transfer, but also received minimal intervention from the accepting institution. Although bronchiolitis and chemotherapy were the most common conditions for which patients were transferred, the range of severity varied widely, with more than 50% of bronchiolitis and 85% of chemotherapy transfers requiring hospitalization for longer than 1 day. Diagnoses such as chemotherapy, although common among transferred patients, likely represent conditions that may not be appropriate to care for in pediatric-limited settings, as they require subspecialized pediatric care. General conditions, however, such as cough, chest pain, allergic reactions, and febrile seizures may represent diagnoses for which it would be appropriate for general hospitals to develop infrastructure to provide definitive pediatric care given how infrequently specialized pediatric resources are needed in caring for these conditions.

Identifying conditions as potential targets to reduce the number of interfacility transfers requires balancing a hospital’s capacity (or lack thereof) for pediatric admissions, perceived risk of decompensation, referring provider discomfort, and parental preference.9-11 Although several studies have identified conditions associated with frequent transfer and rapid discharge,3-5 prior studies’ conclusions that 40% or more of interhospital transfers may be avoidable are potential over-estimates, representing conditions that may not be appropriate to care for in pediatric-limited settings given their need for advanced interventions. Our findings demonstrate that defining a cohort of conditions based on frequency of transfer, even when accounting for minimal intervention post transfer, may not adequately capture avoidable transfers. For example, abdominal pain was one of the conditions for which patients were most frequently transferred, with 92% of patients discharged rapidly. However, the most common surgical transfer was acute appendicitis with peritonitis. Many of these transfers may have been identified initially as “abdominal pain” at the referring institution, highlighting the role of diagnostic uncertainty in identifying preventable transfers. In addition, more than 56% of patients transferred for abdominal pain required advanced interventions, further illustrating the potential risk and uncertainty for referring hospitals that do not have the capacity for advanced imaging or surgical intervention.

The rapid upscale of telehealth may provide a unique opportunity to support the provision of pediatric care within local communities.12,13 As many general hospitals do not have ultrasound technicians trained for children available 24 hours per day, several conditions that fell into the advanced intervention category, like abdominal pain, were driven by the receipt of an ultrasound at the accepting hospital. Targeted work to expand ultrasound capabilities at referring hospitals may enable changing the categorization of an ultrasound to a basic intervention rather than an advanced intervention. Paired with telehealth, this might broaden the scope of potential diagnoses that could be triaged to stay within referring institutions.

Building infrastructure to prevent interfacility transfers may improve healthcare access for children in rural areas proportionately more than children in urban areas. Children in rural communities experience significantly higher rates of interfacility transfers than children in urban areas.14 This increases financial burden and causes additional distress and inconvenience for families.15 With constraints in staffing capacity, equipment, and finances, identifying a subset of medical conditions is a critical initial step to inform the design of targeted interventions to support pediatric healthcare delivery in local communities and avoid costly transfers, although it is not the wholesale solution. Additional utilization of tools such as informed shared decision-making resources and implementation of pediatric-specific protocols likely represent additional necessary steps.

Our study has several limitations. Because we used administrative data, there is a risk of misclassifying diagnoses. We attempted to mitigate this by using a standard ICD-10-based, pediatric-specific grouper. ICD-10 coding is also based upon discharge diagnoses, which inherently has retrospective bias that cannot capture the diagnostic uncertainty when making an initial decision for transfer. In addition, without a comparator group of patients who were not transferred, it remains unknown to what extent balancing factors informed the decision to transfer or whether these diagnoses represent conditions that the referring hospital encounters only a few times a year, or alternatively, that the percentage transferred represents a small fraction of the referring institution’s population with a given diagnosis.

CONCLUSION

Our exploration of pediatric interfacility transfers that experienced rapid discharge with minimal intervention provides a building block to support the provision of definitive pediatric care in non-pediatric hospitals and represents a step towards addressing limited access to care in general hospitals.

References

1. França UL, McManus ML. Availability of definitive hospital care for children. JAMA Pediatr. 2017;171(9):e171096. https://doi.org/10.1001/jamapediatrics.2017.1096
2. Mumford V, Baysari MT, Kalinin D, et al. Measuring the financial and productivity burden of paediatric hospitalisation on the wider family network. J Paediatr Child Health. 2018;54(9):987-996. https://doi.org/10.1111/jpc.13923
3. Richard KR, Glisson KL, Shah N, et al. Predictors of potentially unnecessary transfers to pediatric emergency departments. Hosp Pediatr. 2020;10(5):424-429. https://doi.org/10.1542/hpeds.2019-0307
4. Gattu RK, Teshome G, Cai L, Wright C, Lichenstein R. Interhospital pediatric patient transfers-factors influencing rapid disposition after transfer. Pediatr Emerg Care. 2014;30(1):26-30. https://doi.org/10.1097/PEC.0000000000000061
5. Li J, Monuteaux MC, Bachur RG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics. 2012;130(1):83-92. https://doi.org/10.1542/peds.2011-1819
6. Rosenthal JL, Lieng MK, Marcin JP, Romano PS. Profiling pediatric potentially avoidable transfers using procedure and diagnosis codes. Pediatr Emerg Care. 2019 Mar 19;10.1097/PEC.0000000000001777. https://doi.org/10.1097/PEC.0000000000001777
7. Pediatric clinical classification system (PECCS) codes. Children’s Hospital Association. December 11, 2020. Accessed June 3, 2021. https://www.childrenshospitals.org/Research-and-Data/Pediatric-Data-and-Trends/2020/Pediatric-Clinical-Classification-System-PECCS
8. Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and validation of the pediatric medical complexity algorithm (PMCA) version 3.0. Acad Pediatr. 2018;18(5):577-580. https://doi.org/10.1016/j.acap.2018.02.010
9. Rosenthal JL, Okumura MJ, Hernandez L, Li ST, Rehm RS. Interfacility transfers to general pediatric floors: a qualitative study exploring the role of communication. Acad Pediatr. 2016;16(7):692-699. https://doi.org/10.1016/j.acap.2016.04.003
10. Rosenthal JL, Li ST, Hernandez L, Alvarez M, Rehm RS, Okumura MJ. Familial caregiver and physician perceptions of the family-physician interactions during interfacility transfers. Hosp Pediatr. 2017;7(6):344-351. https://doi.org/10.1542/hpeds.2017-0017
11. Peebles ER, Miller MR, Lynch TP, Tijssen JA. Factors associated with discharge home after transfer to a pediatric emergency department. Pediatr Emerg Care. 2018;34(9):650-655. https://doi.org/10.1097/PEC.0000000000001098
12. Labarbera JM, Ellenby MS, Bouressa P, Burrell J, Flori HR, Marcin JP. The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital. Telemed J E Health. 2013;19(10):760-766. https://doi.org/10.1089/tmj.2012.0303
13. Haynes SC, Dharmar M, Hill BC, et al. The impact of telemedicine on transfer rates of newborns at rural community hospitals. Acad Pediatr. 2020;20(5):636-641. https://doi.org/10.1016/j.acap.2020.02.013
14. Michelson KA, Hudgins JD, Lyons TW, Monuteaux MC, Bachur RG, Finkelstein JA. Trends in capability of hospitals to provide definitive acute care for children: 2008 to 2016. Pediatrics. 2020;145(1). https://doi.org/10.1542/peds.2019-2203
15. Mohr NM, Harland KK, Shane DM, Miller SL, Torner JC. Potentially avoidable pediatric interfacility transfer is a costly burden for rural families: a cohort study. Acad Emerg Med. 2016;23(8):885-894. https://doi.org/10.1111/acem.12972

References

1. França UL, McManus ML. Availability of definitive hospital care for children. JAMA Pediatr. 2017;171(9):e171096. https://doi.org/10.1001/jamapediatrics.2017.1096
2. Mumford V, Baysari MT, Kalinin D, et al. Measuring the financial and productivity burden of paediatric hospitalisation on the wider family network. J Paediatr Child Health. 2018;54(9):987-996. https://doi.org/10.1111/jpc.13923
3. Richard KR, Glisson KL, Shah N, et al. Predictors of potentially unnecessary transfers to pediatric emergency departments. Hosp Pediatr. 2020;10(5):424-429. https://doi.org/10.1542/hpeds.2019-0307
4. Gattu RK, Teshome G, Cai L, Wright C, Lichenstein R. Interhospital pediatric patient transfers-factors influencing rapid disposition after transfer. Pediatr Emerg Care. 2014;30(1):26-30. https://doi.org/10.1097/PEC.0000000000000061
5. Li J, Monuteaux MC, Bachur RG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics. 2012;130(1):83-92. https://doi.org/10.1542/peds.2011-1819
6. Rosenthal JL, Lieng MK, Marcin JP, Romano PS. Profiling pediatric potentially avoidable transfers using procedure and diagnosis codes. Pediatr Emerg Care. 2019 Mar 19;10.1097/PEC.0000000000001777. https://doi.org/10.1097/PEC.0000000000001777
7. Pediatric clinical classification system (PECCS) codes. Children’s Hospital Association. December 11, 2020. Accessed June 3, 2021. https://www.childrenshospitals.org/Research-and-Data/Pediatric-Data-and-Trends/2020/Pediatric-Clinical-Classification-System-PECCS
8. Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and validation of the pediatric medical complexity algorithm (PMCA) version 3.0. Acad Pediatr. 2018;18(5):577-580. https://doi.org/10.1016/j.acap.2018.02.010
9. Rosenthal JL, Okumura MJ, Hernandez L, Li ST, Rehm RS. Interfacility transfers to general pediatric floors: a qualitative study exploring the role of communication. Acad Pediatr. 2016;16(7):692-699. https://doi.org/10.1016/j.acap.2016.04.003
10. Rosenthal JL, Li ST, Hernandez L, Alvarez M, Rehm RS, Okumura MJ. Familial caregiver and physician perceptions of the family-physician interactions during interfacility transfers. Hosp Pediatr. 2017;7(6):344-351. https://doi.org/10.1542/hpeds.2017-0017
11. Peebles ER, Miller MR, Lynch TP, Tijssen JA. Factors associated with discharge home after transfer to a pediatric emergency department. Pediatr Emerg Care. 2018;34(9):650-655. https://doi.org/10.1097/PEC.0000000000001098
12. Labarbera JM, Ellenby MS, Bouressa P, Burrell J, Flori HR, Marcin JP. The impact of telemedicine intensivist support and a pediatric hospitalist program on a community hospital. Telemed J E Health. 2013;19(10):760-766. https://doi.org/10.1089/tmj.2012.0303
13. Haynes SC, Dharmar M, Hill BC, et al. The impact of telemedicine on transfer rates of newborns at rural community hospitals. Acad Pediatr. 2020;20(5):636-641. https://doi.org/10.1016/j.acap.2020.02.013
14. Michelson KA, Hudgins JD, Lyons TW, Monuteaux MC, Bachur RG, Finkelstein JA. Trends in capability of hospitals to provide definitive acute care for children: 2008 to 2016. Pediatrics. 2020;145(1). https://doi.org/10.1542/peds.2019-2203
15. Mohr NM, Harland KK, Shane DM, Miller SL, Torner JC. Potentially avoidable pediatric interfacility transfer is a costly burden for rural families: a cohort study. Acad Emerg Med. 2016;23(8):885-894. https://doi.org/10.1111/acem.12972

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Journal of Hospital Medicine 16(7)
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Journal of Hospital Medicine 16(7)
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412-415. Published Online First June 16, 2021
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412-415. Published Online First June 16, 2021
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Pediatric Conditions Requiring Minimal Intervention or Observation After Interfacility Transfer
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Pediatric Conditions Requiring Minimal Intervention or Observation After Interfacility Transfer
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Corrie McDaniel, DO; Email: Corrie.mcdaniel@seattlechildrens.org; Telephone: 206-818-9821; Twitter: @Corrie.Erin.
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