How a telehealth model could curb pediatric ED transfers
A telehealth model for pediatric orthopedic care could reduce unnecessary ED transfers, saving costs and improving patient experience by remotely triaging patients before transfers.
When a child or adolescent breaks their arm, parents usually rush them to their local urgent care or closest emergency department. However, these settings cannot always provide the specialized orthopedic care pediatric patients need, so they are shuttled to one or more other facilities. These ED transfers result in unnecessary, inefficient and costly care, fostering patient dissatisfaction and provider frustration.
One such incident inspired a team of researchers from Nemours/Alfred I. duPont Hospital for Children, Thomas Jefferson University and the Hospital for Special Surgery to study whether a telehealth triage approach could reduce pediatric ED transfers related to orthopedic care.
Alfred Atanda, M.D., director of the sports medicine program, pediatric orthopedic surgeon and sports medicine specialist at Nemours, described the incident in an interview.
"There was a kid, 15, played football, broke his elbow," he said. "He, of course, panicked, was taken off the field. He went to a local urgent care. At that urgent care, for whatever reason, they didn't take [him]…. Then, they sent him to another urgent care. So, he goes there, he gets X-rays, and they're like, 'Yeah, you have a medial condyle fracture.' So, of course, he goes to his local emergency room, and of course, they don't have pediatric orthopedic surgeons on staff there. So they see him -- mind you, he's already in a splint, he's already had X-rays -- and they see him, and they're like, 'You have to go to Nemours. It's urgent.'"
The adolescent was rushed over to Nemours in an ambulance, only for the Nemours team to confirm that he had had a fracture, but it was not an emergency.
"So, we just sent him home, and we said, 'Okay, well, we'll fix it as an outpatient,'" Atanda said. "So, as you can imagine, he's been to four healthcare facilities, [spent] 12 hours in the lab. He's checking into each place, getting his vitals checked the whole time. His arm is hurting, he's in pain, he doesn't know what's going on."
This incident led Atanda and the research team to develop and assess a theoretical telehealth model that could have connected the patient with specialty care far sooner, avoiding extensive travel and other burdens for the patient.
What would the peer-to-peer telehealth model look like?
For a worried parent, your kid's in pain; their arm is swollen, you're getting bounced around from institution to institution. All the while, you're being told things that usually just make you anxious. But imagine if I can talk to you initially and soothe that anxiety -- help reassure patients.
Alfred Atanda, M.D.,Director of the sports medicine program and pediatric orthopedic surgeon, Nemours/Alfred I. duPont Hospital for Children
This led Atanda and his fellow researchers to develop a theoretical peer-to-peer telehealth intervention to virtually triage patients before they arrive at the ED. Under the model, the ED physicians caring for a pediatric patient with an acute musculoskeletal injury could consult with a pediatric orthopedic surgeon via telehealth, resulting in an informed treatment plan for the patient.
"I would envision myself sitting at my desk with two, three, four computer monitors being able to tap and interface with multiple urgent cares and emergency rooms here in the Delaware Valley," Atanda said. "And then when the patients are there, the physicians can reach out to me."
In this virtual care scenario, Atanda would be able to examine the patient's X-rays and other lab tests or imaging, as well as conduct physical exams with the help of the on-site emergency care physicians. Atanda and the emergency care physician would then decide whether the patient needed a splint, surgery or another treatment and how soon the treatment would need to be administered.
Thus, the model primarily aims to curb ED transfers by beaming pediatric orthopedic specialists like Atanda into EDs that don't have those specialists on staff.
"Basically, when anybody calls or wants to be transported or even wants an appointment if they've already had imaging and been seen and evaluated, how do we create an infrastructure so that we can evaluate all that stuff [virtually]?" Atanda said. "So, we can see, do they need to come? And if they need to come, when do they need to come? Is it an emergency? Can they come in a week? Are they going to drive in their own car? Are they going to come in an ambulance?"
Enhancing pediatric orthopedic care in ERs with telehealth
Implementing a peer-to-peer telehealth model boasts numerous benefits for the healthcare system and the patients. These include reducing healthcare costs by curbing unnecessary service utilization and improving the patient experience.
The model's potential cost-savings are evident from the findings of a study published by Atanda and his fellow researchers in the Journal of the American Academy of Orthopaedic Surgeons.
For the study, the researchers performed a retrospective modeling analysis using data from 350 pediatric orthopedic trauma patients transferred to two in-network hospitals from outside facilities. They developed a decision tree to evaluate the expected costs of two triaging strategies: one in which every patient was transferred and one in which patients underwent virtual triage via telehealth first.
The researchers found that the telehealth triage strategy was cheaper than the transfer-all strategy. After accounting for all modeled costs, the transfer-all strategy costs $6,610 per patient, whereas the telehealth strategy costs $4,858.
Further, the study shows that the cost savings resulting from fewer unnecessary transfers are almost always greater than the additional cost of conducting peer-to-peer telehealth consultations.
"We found initial provider-to-provider e-consultations to be more cost-effective than reflexive ambulance transfer in almost all situations," the researchers concluded. "Only at the extremes of high telehealth encounter cost and high proportion of appropriate patient transfers would such a system fail to be cost saving."
These cost savings not only benefit the healthcare system but also financially benefit patients, their families and other healthcare industry stakeholders.
Atanda noted that the mother of the 15-year-old in the anecdote he had shared was frustrated with the multiple transfers and did not want to pay ED and ambulance bills. Her frustration was part of why Atanda and his researchers focused on the potential cost savings of a telehealth-based triage model.
"The biggest, biggest thing is that there are people on the other end of these, kind of, inefficient, chaotic navigation stories," he said.
The potential cost savings would also benefit healthcare payers trying to reign in healthcare costs.
Then, there is the emotional component. Atanda highlighted how the telehealth triage model could help alleviate emotional and mental distress for pediatric patients and their parents seeking urgent orthopedic care.
"For a worried parent, your kid's in pain; their arm is swollen, you're getting bounced around from institution to institution," he said. "All the while, you're being told things that usually just make you anxious. But imagine if I can talk to you initially and soothe that anxiety -- help reassure patients."
In addition to lowering costs and improving the patient and family experience, the model frees up emergency room beds, alleviating capacity challenges in the ED. Reducing ED transfers means that clinicians in multiple emergency care locations won't see the same patient, increasing ED capacity and allowing physicians to focus on other patients requiring emergency care, Atanda said.
Of course, implementing and operating the telehealth model would involve overcoming several hurdles, including reimbursement, workflow and liability issues.
"If I'm talking to doctors at other hospitals, do I have to be credentialed at that hospital?" Atanda elaborated. "I mean, it just creates a lot of questions so that people are not willing to overcome that inertia. It's just easier to say, 'Oh, just ship them here, and we'll deal with it.' That's just easier, the path of least resistance."
Still, Nemours plans to tackle these hurdles and operationalize the model after it has completed other pilot programs that aim to ease the patient care journey through virtual care tools. The telehealth triage model in the ED is a much larger project, requiring more resources, but Atanda hopes that as smaller digitization projects are launched, the hospital can iron out the technology and workflow kinks that will support the implementation of larger efforts.
Though not yet in practice, the study findings bode well for further telehealth triage models in EDs and other initiatives that aim to ease healthcare access and patient experience.
"I think that the paper demonstrates that there's a dawn of a new day that could be here," Atanda said. "Where the focus isn't just seeing patients that are in front of you but putting some emphasis on helping to navigate patients into and through a healthcare ecosystem -- shepherding them, guiding them, managing expectations."
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.
