Association of Subspecialty and Intensive Care Capabilities With Emergency Department Transfer

BACKGROUND: Pediatric emergency department (ED) transfers have increased even among hospitals with pediatric admitting capability. We sought to determine whether pediatric subspecialty capability or pediatric intensive care unit (PICU) capability was associated with ED transfers among hospitals with pediatric admitting capability. METHODS: This retrospective cross-sectional study included all pediatric ED visits from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database resulting in admission or transfer at hospitals with pediatric admitting capability. We compared EDs with and without pediatric subspecialty or PICU capabilities. Pediatric subspecialties included general surgery, orthopedic surgery, and neurology. Transfer rates were calculated as the number of patients transferred among those not discharged. We used logistic regression to evaluate the association of pediatric subspecialty and PICU capabilities with transfer. RESULTS: We analyzed 4 468 922 weighted ED visits. The transfer rate was 42.4% for EDs without pediatric subspecialty capability (adjusted odds ratio [aOR], 12.9; 95% CI, 8.5-19.6 compared with EDs with all 3 subspecialties), 12.8% for those with 1 subspecialty (aOR, 3.7; 95% CI, 2.4-5.6), 4.1% for those with 2 (aOR, 1.3; 95% CI, 0.9-2.1), and 2.6% for those with all 3. There was a 41.7% transfer rate for EDs without PICU capability (aOR, 1.6; 95% CI, 1.3-2.0) compared with 7.0% for those with PICU capability. CONCLUSION: Among hospitals with pediatric admitting capability, both the need for pediatric subspecialty care and intensive care were associated with increased transfers, and subspecialty capability had a larger association. Interventions to mitigate rising pediatric transfers may consider expanding subspecialty access.