P0289 - Duplicate Diagnostic Evaluations Among Interfacility Emergency Department Transfers

Background
Interfacility emergency department transfers of children can result in additional diagnostic evaluation. Testing after transfer may be unique or duplicate. Duplicate testing can expose children to pain, excess radiation, and higher costs. Little is known about duplicate testing in children who are transferred from a general ED to a tertiary pediatric ED.
Objectives
1) Identify characteristics of patients with duplicate testing
2) Compare patients with versus without duplicate testing
Methods
We performed a secondary analysis of a retrospective chart review, initially conducted to inform an ED telemedicine program. We included patients <21 years transferred from a general ED to a tertiary pediatric ED and discharged home between 7/1/16-6/30/17. Psychiatric and trauma activation cases were excluded. Discharge diagnosis was categorized by the PECARN Diagnosis Grouping System (DGS). Variables included imaging, EKG and labs including point-of-care (POC), blood, and urine studies. Descriptive statistics, chi-squared, Fisher’s exact, and Wilcoxon rank-sum testing were performed.
Results
Of the 454 patients transferred and discharged home, 291 (64%) received additional diagnostic evaluation in the tertiary pediatric ED and 163 (36%) received duplicate testing. Children who received duplicate testing were older (7.1 vs 5.0 yrs, p=0.024), were less likely to have a child abuse DGS (p<0.001), and were more likely to have a gastrointestinal (p<0.001), cardiovascular (p=0.046), or hematologic (p=0.014) DGS (Table 1). A smaller proportion were transferred from hospitals with pediatric inpatient units (70% vs 80%, p=0.019). No other differences were observed. Four classifications of duplicate testing emerged (Table 2): 1) incomplete or unsuccessful work-up at the referring center (n=69) (ex. equivocal ultrasound (US) of the appendix); 2) confirmatory testing (n=61); 3) results needing to be trended (n=16) (ex. foreign body ingestion); 4) previous results unavailable (n=17).
Children with GI and neuro DGSs commonly had duplicate labs and imaging (abdominal US and x-rays). Trended results often included abdomen and chest x-rays for foreign body ingestion. Unavailable results were most commonly observed for children with neuro DGSs who had imaging, labs, or EKGs at the referring center (Table 2).
Conclusions
Incomplete evaluation prior to transfer or confirmatory testing at the receiving ED were predominant reasons for duplicate testing among children transferred and discharged home. Telemedicine to guide diagnostic decision-making at referring EDs or to provide technical education on imaging studies may be a mechanism to decrease duplicate testing that stems from interfacility transfer. Further evaluation of local protocols may elucidate opportunities for reducing duplicate imaging.