Methods
We conducted a pragmatic, cluster-randomized, crossover trial to evaluate the impact of telemedicine consultations on risk-adjusted transfer rates among children presenting to rural and community EDs in northern California. The primary end point for the trial was whether a patient was transferred to the University of California Davis Children’s Hospital (UCDCH) following a pediatric critical care consultation. Pediatric critical care physicians at the UCDCH are available 24 hours daily to provide emergency and critical care telephone and telemedicine consultations to clinicians caring for children receiving care in referring EDs, for both patient management and to facilitate interfacility transfers if indicated. From the more than 30 hospital EDs in the UCDCH catchment area with telemedicine capabilities, we selected 16 EDs to ensure a diverse sample of critical access hospitals (n = 6) including those located in Health Resources and Services Administration–designated rural geographic areas (n = 12). One of the participating hospitals closed early in the trial after conducting only 4 consultations (2 telemedicine and 2 telephone) and because medical records were not available, these patients were not included in the analyses (