Limitations
ADVERSE EVENTS
Our study has limitations. As a pragmatic trial, we could not force physicians to use or not use telemedicine or telephone as assigned. We anticipated a high rate of telephone use when encounters were allocated to the telemedicine arm. For these reasons, we used an unbalanced design and conducted an intention-to-treat analysis. In fact, 42.5% of patient encounters allocated to telemedicine actually used telemedicine for the consultation. Patients with consultations that occurred over the telephone when allocated to telemedicine had slightly different chief signs and symptoms and were more likely to have arrived by emergency medical services; however, there did not appear to be clinically significant differences in patient demographic characteristics, patient conditions, or severities of illness for encounters that resulted in protocol deviations. Furthermore, clinical experience suggests that telemedicine and the associated video experience may not necessarily assist in the care or triage decisions in all cases and that consulting physicians may have opted to not use telemedicine when a physical examination was not considered to be helpful in informing their decision-making. Also, because telemedicine consultations generally take longer than telephone consultations, this may have contributed to decisions on which consultation modality was ultimately used. Another limitation was that we did not determine the appropriateness of the transfer or nontransfer by assessing outcomes. While a greater proportion of children in the telephone arm were discharged home following an interfacility transport, suggesting overtriage, it is possible that avoided transfers were inappropriate, particularly in the telemedicine arm. We did not collect outcomes for patients who were discharged from the presenting ED or hospital, and it is therefore possible that some of these children may have had adverse events from not being transferred. However, we believe this is unlikely; no child who was discharged from a participating ED returned to the ED for an issue related to the injury or was admitted or transferred to the UCDCH following a telemedicine or telephone consultation. In addition, this is a study of a telemedicine program that has been in existence for many years and therefore the implementation, use, and impact of other pediatric telemedicine programs may not result in similar findings.