Pediatric emergency and trauma care is not readily available across a sizable chunk of the US, particularly in rural areas. Couple this with the fact that many rural emergency providers are not necessarily trained in emergency medicine and may have little recent pediatric training fosters the common practice of transferring these injured children to a higher level of care.

And unfortunately, many of these transferred children have relatively simple issues that really don’t actually need a transfer. Some studies have reported that up to 40% of children sent to tertiary pediatric centers are sent home in less than 24 hours.

Most research in this area focuses on single medical center experiences. An article currently in press looks at the experience of the entire state of Iowa over a 10 year period. The authors looked at all claims data for children between ages 8 days and 18 years. Children who were transferred were compared to those who were not.

Here are the factoids:

• 2 million cases were included in the study, and only 1% were transferred (21,319)
• Children in rural areas were transferred 3x more often than those in urban areas
• Only 63% were transferred to a designated children’s hospital, and 45% were sent to an ED rather than direct transfer to an inpatient bed
• 39% were potentially avoidable transfers, meaning that they were discharged from the receiving ED or the hospital within 24 hours of admission
• Two of the top 5 reasons for transfer were trauma related: fracture, and TBI without blood in the head.
• The cost for potentially avoidable transfers in the top 5 categories was $2 million dollars (!)

Bottom line: This is a very comprehensive study that shows the magnitude and cost consequences of potentially inappropriate pediatric transfers. It was not designed to figure out what to do about it, but it provides some insight for the problem solvers out there. Since we know the top 5 transfer diagnoses (seizure, fracture, TBI without bleeding, respiratory infection, and asthma), we can start to work on systems to provide education to rural providers on these topics, as well as real-time interaction to help them determine the 60% that really do need a higher level of care. Telemedicine will eventually be a big part of this, but most areas around the country are still struggling to figure out the details. Stay tuned!

Reference: Potentially Avoidable Pediatric Interfacility Transfer is a Costly Burden for Rural Families: A Cohort Study. Acad Emerg Med 28 March 2016, in press.