PROPOSAL TITLE: Improving pediatric emergency care access with an integrated telemedicine solution
PROJECT LEAD(S): Daftary, Rajesh; Baker, Peter (Chris); Whitelaw, Kevin
EXECUTIVE SPONSOR(S): Grupp-Phelan, Jacqueline; Colorado, Yahaira

ABSTRACT: We propose a pilot telemedicine program that will facilitate real-time support of referring facilities seeking to care for, consult on, or transfer pediatric patients needing pediatric emergency care.  Requested funding will enable the staffing of a telemedicine shift that will also be able to serve real-time surge needs and reduce the number of emergency department patients left without being seen.  A dedicated, staffed position that is simultaneously supporting both UCSF BCH sites (Oakland, San Francisco) can help improve emergency department (ED) efficiency, reduce error, and improve perception of care for patients already in either ED.

TEAM: Pediatric emergency medicine faculty, UCSF Telehealth

PROBLEM

UCSF Benioff Children’s Hospitals (BCH) are quaternary care centers that provide comprehensive pediatric emergency and critical care support to community hospitals.  Children at outlying hospitals who need care beyond local capability are transferred to either children’s hospital for further care.  These transfers account for about 5% of overall ED volumes.  Data between 2020-2023 suggest that some portion of these transfers need only a physician assessment and can be discharged home afterwards.  At our children’s hospitals, 23-33% of patients transferred from community hospitals are discharged after ED evaluation and do not require admission.  Between 7-9% of patients transferred by flight (fixed-wing or rotor) are discharged after ED evaluation.  This data suggests that assessment by a pediatric emergency medicine (PEM) physician may be all that is needed to provide comprehensive care to a patient.  National evidence replicates these findings and suggest that up to 25% of patients who are referred from community hospitals to a pediatric emergency department are discharged without any additional testing.  There is an opportunity to reduce unnecessary transfers.

Some facilities, after discussion with a PEM physician, determine that a patient does not need to be transferred.  Access Center data indicates that at least fifty calls per month are from EDs requesting advice without transfer; these calls are beneficial by supporting local medical decision making and allowing for a patient to be cared for without costly transfer.  However, these calls are currently an uncompensated service our EDs provide.  PEM physicians answering these calls during clinical shifts experience interruptions in care for patients in the department, reduced efficiency, and challenges in providing timely support to hospitals requesting clinical support.

Inefficiencies delay care for children needing assessment, testing, and treatment in the ED.  Further, the pediatric EDs have been impacted by difficult to anticipate surges in patient volumes, especially during the 2022-2023 respiratory season.  It has been challenging to rapidly upstaff when needed, and prolonged wait times, especially for low acuity patients has resulted in highrates of patients left without being seen (LWBS) (8.7% of patients in the BCH Oakland ED, 3.5% in the BCH San Francisco ED [2022]). Nationally, most EDs aim for a LWBS between 1% to 2% or less.  High ED volumes also limit our ability to accept patients who need our care.  During the winter respiratory surge, there were several times when patients on high levels of respiratory support could not be accepted due to lack of capacity.  High rates of LWBS and turning away transfers reflect a failure of our pediatric EDs in their mission to provide care, especially to those most vulnerable.  It also reflects a failed opportunity for UCSF to establish itself as the preferred destination for children needing care in our region any beyond.

TARGETS

We aim to pilot a telemedicine intervention that, during staffed hours, will:

1)    Provide a real-time platform supporting clinicians without access to in-house pediatric specialty and subspecialty care

• Convert at least 10%emergency department referral calls to video

2)    Better differentiate which patients need transfer to a specialty hospital versus who can be treated in-place

• Reduce current rate of transfers resulting in discharges by 10%

3)     Reduce interruptions to clinical care:

• Offload 100% of incoming access center calls to telemedicine clinician instead of PEM physicians providing bedside care

4)    Assess feasibility of a telemedicine provider in triage during high volume hours

• Provide four hours of coverage per week during peak volume times

5)    Improve patient satisfaction by improving efficiency and reducing prolonged wait times in the emergency department

GAPS

Telemedicine has already been implemented in a patient-facing offering for many primary care pediatric clinics.  Additionally, telemedicine is utilized by adult neurology to provide consultation to critical-access and community hospitals.  Nationally there is a growing number of PEM programs that offer ED-to-ED telemedicine services, but none currently exist in the Bay Area.  Implementation has been hindered by lack of investment.  Without funding to provide clinical coverage for a telemedicine role, it has been difficult to test feasibility of a telemedicine offering, distribute dedicated telemedicine devices to community partners, or present a reliable alternative to our current workflow of clinical support by telephone only – often resulting in delays in care and overuse of transfers.

INTERVENTION

As a pilot study, we will engage the top 10 community hospitals responsible for ED-to-ED referrals for each site (Oakland and San Francisco).  Partner hospitals will be briefed on the capability of the PEM telemedicine service and be asked to complete a needs assessment survey.  UCSF PEM faculty, nursing, and staff will also complete a feasibility assessment survey.  These data will identify opportunities and barriers to implementation.

During the implementation phase, PEM physicians will staff a daily telemedicine shift and provide at least five days of coverage per week.  They will be compensated based on a set base rate with additional payment for calls that exceed a minimum number.  During these shifts, the PEM telemedicine physician will be the point of contact for all incoming calls from the Access Center.  During intake, if it is deemed that a video consultation would be beneficial, callers will be prompted to join a predesignated video conference channel (Zoom).  When calls are not being answered, the PEM telemedicine physician will staff a video conference channel that is linked to triage rooms at both pediatric EDs.  In this role, they will assist nursing with initial management decisions, including diagnostic testing, thereby reduce delays for patients needing such testing.

During this pilot phase, we aim to understand the feasibility of implementation of this service line, with a particular interest in staffing needs, community partner barriers to engagement, and impact to care provided to patients.  We will also use this information to develop a financial model that covers the operational costs of a permanent program.  Major barriers to implementation may be consistent staffing of telemedicine shifts, utilization of the service by community EDs, integration in the Access Center workflows, and duplication of efforts between nursing and physicians in triage.  Careful prework in the form of planned feasibility and implementation surveys can help reduce these barriers.

We do not anticipate adverse outcomes from this intervention.  A telemedicine service line is an added functionality to the care and support we already provide.  Community EDs who are not able to provide comprehensive care with telemedicine support will still be able to transfer patients to our pediatric EDs.  Telemedicine consultations usually lengthen time of interaction by five to ten minutes compared to phone consultation only and should not pose significant delay for patients needing transfer.  Patients already in the pediatric ED who are assessed in triage by telemedicine may experience higher rates of diagnostic testing by a physician who is not physically present to perform an evaluation, however any test ordered can be cancelled by the ED care team.

PROPOSED EHR MODIFICATIONS

We can adapt the current APeX build to allow registration of patients and documentation of consultative services offered via telemedicine.  No additional build will be required for this role.

COST

Savings calculation: During high-volume shifts, PEM physicians anecdotally report 10-20% of their clinical time is spent answering transfer telephone calls and providing advice.  By offloading this responsibility to a dedicated telemedicine physician, we can increase efficiency and improve patient throughput.  Further, patients who are transferred and discharged after evaluation in the emergency department slow overall throughput in the department and limit the number of patients that can be accepted who would ultimately need admission.  Finally, decreased efficiency in the ED results in longer wait times, which is correlated with increased LWBS.  Each LWBS results in lost revenue for the emergency department (facility and provider fees).  

Depending on the model of staffing needed to incentivize coverage, cost to staff one telemedicine shift per day will range from $600-$1200 ($600 minimum payment with four-hour provider in triage coverage, with an additional $100 per call received).

Other costs are likely to be derived from device procurement and distribution.  These devices will likely be one-time purchases but may require maintenance or replacement as they reach the end of their serviceable life span.  Devices would include a tablet or laptop computer for each partner site.

SUSTAINABILITY

Ultimately, if the model proves feasible, we can implement a billing system that charges consulting hospitals a flat fee charged to the facility ($300 per call).  These fees can help offset the operational expense of staffing telemedicine shifts.  This billing system has already proven effective at other institutions (Lurie Children’s Hospital of Chicago).

 Process owners will be project leads within the UCSF Division of Pediatric Emergency Medicine.

BUDGET

Staffing: $40,000 – provides 33-60 staffed days depending on call volumes.  It would be necessary to have at least eight weeks of funding support to allow sufficient time for community partner engagement.

Device procurement and distribution, support from UCSF Office of Telehealth: $10,000 – These funds can be reallocated to staffing costs if community partners are willing to use HIPAA complaint devices already on site (laptops, tablets, smartphones) and link to a pre-established Zoom channel managed by the department.