The association between PICU to ed telemedicine consultations on changes in severity of illness

ABSTRACT

INTRODUCTION: Children and adolescents transferring from emergency departments (EDs) with video telemedicine programs have been associated with lower severity of illness (SOI) on admission to Pediatric Intensive Care Units (PICUs) compared to patients transferred from EDs without telemedicine programs. Very little is known about the relationship between telemedicine use and SOI in the ED. We hypothesize telemedicine will be used on patients with higher SOI in comparison to telephone consultations. METHODS: A prospective crossover-cluster randomized controlled trial was conducted to compare telemedicine and telephone consultations conducted on critically ill children. Patients age 0-14 from 15 participating EDs with established telemedicine programs were included if they were transferred to the regional PICU. Patients were randomized to either telemedicine or telephone consultation based on four 6-month blocks. Data was analyzed using 'intention to treat' analysis, as well as 'as treated' and 'per protocol'. RePEAT (Revised Pediatric Emergency Assessment Tool) and PRISA (Pediatric Risk of Admission) scores were used to estimate SOI in the ED and Pediatric Index of Mortality (PIM) was used to assess SOI at the time of PICU admission. RESULTS: This study enrolled 696 patients, 373 were admitted to the PICU. Telemedicine and telephone cohorts were comparable by sex, age and race/ethnicity. PIM-2/3 scores (median -4.97 telemed, -5.1 telephone, p = 0.95) and mean RePEAT scores (1.67 telemed, 1.71 telephone, p=0.61) were not statistically significant between the groups whether using the intention to treat or as treated analysis. PRISA scores were similar in the intention to treat analysis, (19.5 telemed, 21.7 telephone, p=0.15) but were significantly higher in the telemedicine cohort (mean=22, SD=13.09) than in the telephone cohort (mean=19, SD=12.82), p= 0.039) in the as treated analysis. CONCLUSIONS: Despite randomization of telemedicine and telephone consultations among patients presenting to 15 EDs as part of a multi-institutional trial, physicians did not adhere to telephone consultations when patients had higher SOI and instead preferentially used telemedicine. More data is needed to understand the effect of telemedicine consultation on transfer rates, SOI, and optimal application in the post-COVID era.