Dana Aronson Schinasi

Objectives: Children are increasingly transferred from emergency departments (EDs) to children's hospitals for inpatient care. The existing literature on the use of direct admission (DA) specifically among pediatric patients transferred from referring EDs remains sparse. The objective of this study was to identify demographic, clinical, and contextual factors associated with the use of direct-to-inpatient versus ED-to-inpatient admission among patients transferred to children's hospitals from EDs. Methods: This was a retrospective chart review of nontrauma patients admitted to inpatient services at a single tertiary children's hospital after interfacility transfer from EDs between July 1, 2016, and June 30, 2017. Characteristics of the patient population and referring EDs were described; unadjusted associations between rates of DA and the demographic, clinical, and contextual variables of encounters were performed; and a logistic model quantified the relevant associations as odds ratios (ORs). Results: Of 2939 study encounters, 78% resulted in DA. Among White patients, private insurance was associated with decreased direct admission (OR, 0.5; 95% confidence interval [CI], 0.4–0.8). Younger patients and patients with respiratory diagnoses (OR, 3.9; 95% CI, 2.8–5.3) had increased likelihood of DA. Patients with gastrointestinal diagnoses had decreased likelihood of DA (OR, 0.6; 95% CI, 0.4–0.7). Conclusions: At a tertiary hospital with a high rate of DA among patients transferred from other EDs, we identified factors that were associated with the use of direct versus ED admission. Our results identify specific populations in which future work could inform admission processes for interfacility transfers.

Background: Procedural sedation (PS) is commonly performed in emergency departments (EDs) by nonanesthesiologists. Although adverse events (AEs) are rare, providers must possess the clinical skills to react in a timely manner. We previously described residents' experience and confidence in PS as part of a needs assessment. We found that their ability to perform important clinical tasks as a result of the usual training experience demonstrates educational needs. We developed an educational intervention to address the deficiencies uncovered during our needs assessment. Objective: To evaluate the effectiveness of an educational intervention on pediatric residents' clinical performance and confidence when faced with an AE during a simulated PS. Methods: This was a prospective observational cohort study of residents at a tertiary care children's hospital. All ED attending physicians and fellows were trained in uniform delivery of the educational intervention, which was delivered extemporaneously at the bedside (“Just-in-Time” [JIT]) to all residents performing PS on actual patients in the pediatric ED, over the course of 1 year. Subjects completed the following both before and after the educational intervention: a survey pertaining to confidence in PS, followed by a standardized, video-recorded simulated PS complicated by apnea and desaturation. Clinical performance was evaluated and assessed both in real time and by a video-rater blinded to participants' year of training. We summarized baseline resident characteristics, confidence questionnaire item rankings and success in both the preparation and AE tasks. We compared successful task completion and time to task completion before and after intervention. Results: Forty residents completed both the PRE and POST phases of the study. There was significant improvement in the proportion of residents who completed both preparation and AE tasks after the JIT training. Specifically, there was a significant improvement in the proportion of residents who performed positive-pressure ventilation to treat an apneic event associated with desaturation during the PS (P = 0.007). Residents' confidence scores also significantly improved after the training. Conclusion: A brief JIT training in the pediatric ED improves resident clinical performance and confidence when faced with an AE during a simulated PS. Future direction includes correlating this improved performance with patient outcomes in PS.

Introduction: Expansion of telemedicine enabled healthcare access during the COVID-19 pandemic. In response to in-person visit restrictions, our institution trained >1,000 clinicians in telemedicine. Little is known about telemedicine-naïve pediatric healthcare provider's perceptions as they adopted telemedicine practice.Methods: We conducted a cross-sectional survey of clinicians after expanding telemedicine practice at an independent children's hospital. The survey assessed experience with, concerns about, and intentions to continue telemedicine. Outpatient providers were included if they were first trained for telemedicine in response to COVID-19 and conducted at least one video visit, 3/21/2020–6/30/2020. Descriptive statistics were calculated; perceptions were compared across telemedicine activity level quartiles (based on proportions of visits delivered by video in June 2020) using Fisher's exact tests.Results: Of 609 survey responses, 305 (50.1%) met inclusion criteria, representing various roles and disciplines. Over half (54.1%) conducted >20 video visits 3/21/2020–6/30/2020. More than 75% of providers found telemedicine easy to learn. Providers with greater proportions of video visits in a typical week in June reported greater ease of incorporating telemedicine into clinical practice and greater intention to continue telemedicine practice in 6 months. Nearly all providers endorsed concerns. Patient care experiences reinforced technology-related concerns and alleviated liability and privacy concerns. Payer reimbursement was the leading influencer of anticipated future use of telemedicine.Discussion: Providers who conducted more telemedicine encounters reported greater ease of incorporating telemedicine into practice. Provider concerns were influenced by patient care experiences. Targeted training and quality improvement strategies are needed to sustain a robust post-pandemic telemedicine program.

Introduction: Formalized training in telemedicine addresses barriers to provider adoption and engagement and assures a level of competence for independent practice. We previously developed a blended-model training program, customizable according to role and specialty; this method of training was not feasible in the pandemic response. We describe the development and implementation of a multi- and interdisciplinary telemedicine provider training program enabling the rapid scaling of telemedicine at our institution.Methods: An existing curriculum was pared down to a 1-h session delivered synchronously, covering the foundational components of telemedicine practice. Supplemental materials were available for asynchronous learning via the hospital intranet. Completion of training was required of all clinicians who practice telemedicine.Results: We conducted 35 sessions for 1,070 providers over 12 weeks. Attendees included clinicians across numerous roles and specialties. Additional resources were created and available through the Telemedicine Virtual Handbook and housed in specific toolkits.Discussion: Telemedicine training is necessary for consistent, competent practice of telemedicine in pediatrics. We describe a training process that can be easily replicated and rapidly deployed to providers of telemedicine across roles and disciplines. Combining a mandatory and brief synchronous provider training session with a repository of online resources creates a foundation for consistent practice, while allowing for more individualized resources accessible on demand. Standardized telemedicine training followed by mechanisms for ongoing professional practice evaluation allow institutions to ensure consistent and competent practice of telemedicine. Further study is needed to determine the best modality for training, and optimal assessment tools according to professional role.