The Case

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue. A nasal swab for SARS-CoV-2 and influenza was negative, lung sounds were clear, and the family was counseled regarding viral illnesses and warning signs. The following day, she had periods of active play, but by that evening, her temperature had increased to 102.8^o F, with little response to acetaminophen and ibuprofen. The following morning, her breathing was labored and rapid at 50-60 breaths a minute. The patient was taken to a community hospital-based urgent care clinic and then referred to the Emergency Department (ED).

At the hospital, testing for SARS-CoV-2, influenza, and respiratory syncytial virus (RSV) was negative, and a chest radiograph was normal. Albuterol was administered via mask, and a nasal cannula was prescribed with high-flow oxygen. Miscommunication amongst team members led to a delay in the administration of high-flow oxygen. The patient’s parents were told that this was the “top” of the clinical care that could be provided at this hospital, which does not have a pediatric intensive care unit (PICU), and that transport to a children’s hospital might be necessary. 

After 7 hours in the community hospital, the patient was tachypneic at 60-80 breaths per minute, hypoxic with oxygen saturation in the high 80% range, grunting while breathing, anorexic, and lethargic. Her parents demanded transfer to a specialty hospital, but there was a shift change and the new emergency physician on duty needed to round on multiple sick children. During this waiting time, the pulse oximeter alert went off frequently and nurses were continually in and out of the room to check the patient. The ED physician on duty said that transition to a tertiary care hospital could occur “if wanted” by the parents. The parents insisted on a care transition, whereupon the ED physician called the tertiary center and was told by the on-call pediatric intensivist to administer prednisone, increase her oxygen flow, and administer more albuterol before transfer. Given the patient’s vital signs, she was deemed ineligible for ground transfer. The flight crew arrived and immediately increased the patient’s oxygen flow rate, administered an intravenous steroid, and initiated transport.

After arrival at the tertiary care hospital, the patient was admitted to the PICU on higher-flow oxygen, ceftriaxone was started for bilateral ear infections, and intravenous fluids, ibuprofen, and acetaminophen were administered for comfort. She was diagnosed with adenovirus after developing conjunctivitis and bronchiolitis. After 3 days of continuous monitoring and treatment in the PICU, the patient was alert, responsive, and hungry. She was taken off supplemental oxygen after about 24 more hours, transferred to a regular pediatric bed, and then discharged to outpatient follow-up care.

The Commentary

The hospital-to-hospital transfer of a pediatric patient is a transition of care that places both the patient and their family at risk of harm. Interfacility transfers inherently include a handoff of care among healthcare providers who are physically located in different facilities. Transfers additionally involve a physical transport of the patient. Effective communication and engagement among providers, patients, and families is imperative to reducing preventable harm during this high-risk health care delivery process.

The child and parents described in this case experienced preventable harms due to poor provider-provider communication, provider-family communication, and family engagement. This young child presented with respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital. Bronchiolitis can be a dynamic illness that can cause rapid clinical deterioration, and thus the clinical trajectory of this child might have been unavoidable. However, the miscommunication and ensuing care delays, need for air transport, and parental stress could have likely been avoided with better communication and engagement among the emergency department (ED) providers, children’s hospital pediatric intensivist, transport team, and parents. Adherence to transfer protocols and standard communication tools are strategies that can promote higher quality of care during pediatric transfers, enhance family- and patient-centered care, and improve clinical outcomes.

Hospital-to-Hospital Transfers for Children are Relatively Common and Present a Risk to Patient Safety

Children often present to local EDs but require transfer to a tertiary care hospital for definitive care, given the unavoidable regionalization of pediatric specialty care. The young child in this case required high-flow oxygen support for her respiratory failure. As the initial treating physician explained to the parents, their local ED lacked the resources necessary to provide the level of care this child required. Specifically, the local facility did not have a pediatric intensive care unit. This limitation is very common, because pediatric intensive care units are concentrated in mostly urban areas at large teaching hospitals.¹ However, even non-critically ill children requiring hospitalization often require transfer. Most ED providers cannot admit children to their local hospital facility due to lack of comprehensive pediatric resources, sub-specialty expertise, or even pediatric admitting privileges.^2,3 Consequently, nearly 350,000 children are transferred between facilities each year, and the number of pediatric interfacility transfers is rising over time.^4,5

Despite the rising frequency of pediatric interfacility transfers, the transfer process continues to involve significant burdens and safety risks to patients and their families. Previously demonstrated safety risks associated with interfacility transfer include communication deficits, clinical deterioration, and inadequate monitoring.⁶ In this present case, the child remained in the local ED for seven hours while clinically worsening and requiring increasing respiratory support. The parents were initially told of the possible need for transfer to a children’s hospital; however, the transfer process was not initiated until the parents demanded that their child be transferred. This delay in transfer, and thus delay in care, could have been mitigated with earlier initiation of the transfer process. Earlier initiation could have potentially prevented the child’s worsening respiratory failure, the need for air transport, and the parents’ poor experience, stress, and distrust.

Potential barriers to initiating the transfer process included multiple contributing factors. First, the initial treating physician recognized that high-flow oxygen delivery was beyond the level of care that could be provided at the local facility but did not contact the children’s hospital to begin the transfer. While it is reasonable to trial respiratory support while monitoring for clinical improvement, this child did not improve but rather worsened. Second, the shift change introduced a new treating physician who did not recognize the necessity of transfer; this physician communicated that the child could transfer “if wanted” by the parents. It is possible that the handoff communication between these physicians did not adequately include the need for transfer should the child continue to require high-flow oxygen. Potentially, this second physician did not know that high-flow oxygen required a pediatric intensive care unit. Alternatively, this second physician did not recognize the illness severity of this child and the need for escalating respiratory support. 

Protocols to Govern the Transfer Process

A 2009 joint policy statement of best practices endorsed by multiple professional organizations requires EDs to have written transfer procedures. Components of these transfer procedures include having a defined process for initiating a transfer as well as plans to ensure timely transport.⁷ However, a survey of ED nurse managers found that only 50% of EDs self-reported having transfer guidelines meeting the criteria in the joint policy statement.⁸ Furthermore, medium and low patient volume EDs were less likely to have written transfer guidelines than high-volume EDs. Yet, low-volume EDs would likely benefit most from having protocols to guide the pediatric transfer process. An updated revision of the joint policy statement was published in 2018.⁹ Updates to the transfer procedure requirements included integrating telehealth processes.

Regarding the present case of a child with respiratory failure, written transfer protocols outlining how to initiate a transfer might or might not have prevented the poor outcomes. Nevertheless, protocols supporting early outreach to the specialty hospital to engage the pediatric intensivist and initiate the transfer process would probably have been beneficial, especially since discharge from the ED is extremely rare once a patient is initiated on high flow oxygen.¹⁰ Similarly, protocols supporting the use of telehealth to obtain a consultation with the pediatric intensivist could have assisted with this child’s clinical management. Use of telehealth could have also provided additional opportunities to strengthen communication and engagement with the family. A telehealth connection to bring the pediatric intensivist and transport team to the child’s bedside could change the communication paradigm so that the ED providers, pediatric intensivist, transport team, patient, and parents can engage in a virtual face-to-face conversation.

In addition to protocols governing the transfer process, disease-specific protocols targeting some of the most common pediatric diagnoses may be helpful in standardizing pediatric care at referring hospitals and ensuring appropriate treatment. For example, for the patient described in this case, a protocol describing standard treatment for bronchiolitis, scenarios requiring escalation of treatment, and indications for transfer could have been helpful in expediting her care. The American Academy of Pediatrics has published an evidence-based clinical practice guideline addressing routine bronchiolitis management.¹¹ In addition, several centers have recently implemented practice guidelines specifically addressing high flow oxygen use in bronchiolitis, including initiation criteria, flow rates, and weaning protocols.^12-15 Such protocols could easily be adapted for use in community settings and could be integrated with the transfer guidelines described above.

Structured Tools are Needed to Mitigate Communication Errors

Strengthened communication between the treating physicians at shift change might have prevented the care delays and resulting need for air transport and poor parent experience. Miscommunication between providers during patient handoffs is a contributing cause for approximately 80% of serious medical errors.¹⁶ Standardized handoff processes can effectively decrease adverse events and medical errors.^17,18 I-PASS, for example, is a widely adopted program that includes a standardized handoff mnemonic. I-PASS was originally designed to train pediatric residents to improve patient handoffs in pediatric inpatient units. The use of I-PASS for patient handoffs during inpatient pediatric shift changes was found to decrease preventable medical errors by 30%.^17,18 Over the last decade, I-PASS has been successfully implemented across a variety of disciplines and types of handoffs in both community and teaching settings.¹⁹ Use of a structured handoff tool in the present case could have prevented the miscommunications that occurred among the ED providers. 

Although the recognized communication deficits in this case occurred among ED providers, miscommunications frequently occur during interfacility transfers. Research on pediatric interfacility transfers has suggested that verbal and written communication is often incomplete and that handoff deficits are associated with more reported errors in care.^20,21 Structured tools to facilitate effective patient care handoffs are particularly important during interfacility transfers, as these patient handoffs involve information transmission across different facilities. This physical separation imposes additional barriers to communication, such as healthcare providers who likely do not know one another and electronic health record systems that may not integrate. Structured tools have been developed for pediatric interfacility transfer handoffs;²² widespread use of such tools could have substantial benefits for patient safety.

Use of Telehealth to Increase Access to Pediatric Specialty Care

Upon contacting the children’s hospital to request the child’s transfer, the on-call pediatric intensivist recommended additional management measures to support the child’s respiratory failure. Subsequently, the transport team arrived and immediately increased the patient’s oxygen flow rate and administered an intravenous steroid. It is possible that the child acutely worsened while waiting for the transport team to arrive. Had the pediatric intensivist used telehealth to virtually examine the child, the intensivist might have gained better understanding of the child’s clinical needs and provided earlier recommendations to increase her respiratory support.

The use of telehealth to increase access to pediatric specialty care is particularly useful for critically ill children who present to EDs lacking such resources.²³ In this case, telehealth could have helped improve care delivery for a child whose illness severity was underestimated and whose clinical needs were being under-triaged. Telehealth also has potential use for situations when children are over-triaged. Although many interfacility transfers are necessary, some are not. Upwards of 39% of pediatric transfers are potentially avoidable.^24-30 The rates of pediatric transfers for common conditions have risen over time,^4,5 possibly contributing to a growing problem of over-triage. ED visits that result in unnecessary interfacility transfers not only consume critical resources such as hospital beds in tertiary care centers, but they also impose financial and emotional burdens on the patient and family. Even among necessary transfers, additional preventable harm can occur when the post-transfer level of care is either under- or over-triaged.³¹ Studies suggest telehealth use can safely reduce rates of triage to pediatric intensive care units by 34%³¹ and safely reduce transfer rates by up to 50%.^32-34

Family Engagement Throughout the Process is Essential

Communication challenges during interfacility transfers exist not only among healthcare providers, but also between providers and their patients and patients’ families. Family members report experiences of poor information sharing and little shared decision-making during pediatric interfacility transfers.^35,36 Suboptimal communication can worsen families’ stress during this acute event and hinder families’ trust in their child’s providers.³⁵ Parent stress leads to child distress,^37-39 and parent distress and distrust may accumulate to negatively affect the child’s medical care and well-being both during and after the hospitalization.⁴⁰

Effective communication is one of the key attributes of delivering patient- and family-centered care. Other key attributes include collaboration, empowerment, respect, individualized care, and support.^41,42 Had the ED providers for this patient better engaged her parents through these family-centered care attributes, the outcomes of this case could have been different. Research supports that family-centered care is associated with improved care quality, trust, parent satisfaction, parent anxiety, and lower costs.^42-44

Barriers to delivering family-centered care include family and provider stress, competing demands, and organizational limitations.^45,46 The ED environment exacerbates these challenges. Furthermore, providers and parents have described pediatric interfacility transfers as a time fraught with poor family-centered care experiences; yet transfers are a time when parent engagement is particularly important.³⁵ Providers need to prioritize the engagement of families in the ED, especially for parents of children likely to require interfacility transfers. Better family engagement could have made a significant difference for the child and parents in this case.

Take Home Points

• The pediatric interfacility transfer process presents a potential risk to patient safety and family experience.
• Management of critically ill children with common conditions, such as bronchiolitis, and pediatric interfacility transfers to provide higher-level care for these children, are both facilitated by disease-specific, evidence-based protocols incorporating standardized transfer guidelines and processes.
• Telehealth and structured communication tools may be leveraged to improve communication among all members of the healthcare team involved in pediatric transfers.
• Family engagement is key to designing a family-centered transfer experience.

Jennifer Rosenthal, MD, MAS
Associate Professor
Department of Pediatrics 
Division of Pediatric Hospital Medicine
UC Davis Health
rosenthal@ucdavis.edu

Michelle Hamline, MD, PhD, MAS
Assistant Professor
Department of Pediatrics 
Division of Pediatric Hospital Medicine
Associate Director, Department of Pediatrics Quality and Safety
UC Davis Health
mhamline@ucdavis.edu

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