Interhospital transfer of pediatric neurosurgical patients

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OBJECTIVE

The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients.

METHODS

All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%–30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score.

RESULTS

Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1–269 days). Median length of hospital stay was 2 days (range 1–269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home.

CONCLUSIONS

This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

ABBREVIATIONSICU = intensive care unit; PRISM = Pediatric Risk of Mortality.

Abstract

OBJECTIVE

The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients.

METHODS

All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%–30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score.

RESULTS

Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1–269 days). Median length of hospital stay was 2 days (range 1–269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home.

CONCLUSIONS

This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

Neurosurgical care may be a common reason for interhospital transfer.4,21,36,37 The impetus to transfer children for specialized pediatric services is no different.9,34 The primary indication for transfer is the need for urgent or emergency neurosurgical evaluation and intervention. Often, transferred patients have acute life-threatening conditions such as intracranial hemorrhage or hydrocephalus. Many hospitals lack full-time neurosurgical coverage,21,28 and the demand for interhospital transfer will increase as surgical subspecialists consolidate into larger regional pediatric surgical centers of excellence as designated by the American College of Surgeons.32

Previous studies9,34 of the transfer of critically ill children in the general pediatric patient population have demonstrated significant differences in patient characteristics, resource utilization, and outcomes across mortality risk-stratified groups. Costly length of intensive care unit (ICU) stay and incidence of invasive procedures were greater in the high-risk admissions, as compared with the low- and moderate-risk admissions. In addition, these same studies9,34 showed a higher mortality rate in the high-risk admissions, compared with low- and moderate-risk admissions.

To the best of our knowledge, the criteria for the transfer of pediatric neurosurgical patients, the resource utilization involved, and the characteristics of transferred patients have not been previously studied. Furthermore, there is a lack of data regarding outcomes for pediatric neurosurgical patients who undergo transfer. Our study aimed to examine the characteristics, resource utilization, and outcomes of transfer admissions to the pediatric neurosurgical service at a large tertiary/quaternary children's hospital.

Methods

Study Population

All consecutive prospectively documented requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital from October 1, 2013, to September 30, 2014, were retrospectively identified from a centralized transfer center database. Texas Children's Hospital is a 495-bed freestanding children's hospital, which attained Level I trauma designation in October 2010. The local Institutional Review Board approved this study with a waiver of informed consent.

Data Collection

Details of each patient transfer request were extracted from the transfer center database, including time of transfer request, duration of transit, time of arrival at our institution, reason for transfer, and reported diagnosis at the time of transfer request. The distance traveled for transfer was calculated using the shortest distance between the referring facility and our hospital on Google Maps. Electronic medical records of these patients were then reviewed for diagnostic, laboratory, physiological, and demographic information collected on all patients within 24 hours of admission. Therapeutic interventions, duration of use, and length of overall hospital stay and ICU stay were noted. Data on clinical outcomes were also collected at the time of discharge.

Pediatric Risk of Mortality

The Pediatric Risk of Mortality (PRISM) score was developed to assess pediatric ICU and surgical risk of mortality.25 Data for computation of the PRISM score were obtained within the first 24 hours of admission, and the PRISM score was calculated using the formula published by Pollack et al.28

Analysis of Resource Utilization

Resource utilization was assessed using information regarding receipt of neurosurgical procedures, length of stay in the ICU, and duration of hospital stay. Clinical outcomes were analyzed, including hospital and ICU length of stay and survival status at hospital discharge. For survivors, the discharge destination was determined, including home, rehabilitation, hospice, long-term skilled nursing facility, or transfer back to the referring hospital.

Data Analysis

Descriptive statistics, including means, standard deviations, standard errors, and confidence intervals, were computed as necessary. Bivariate analyses compared patient characteristics, resource utilization, and outcomes across predefined strata (low [< 5%], moderate [5%–30%], and high [> 30%]) of predicted probability of mortality using the PRISM algorithm.25 Bivariate comparisons of categorical and nonparametric continuous data across the 3 mortality risk strata were performed using the chi-square and Kruskal-Wallis tests, respectively. Analysis was performed using SPSS statistical package (version 21, IBM Corp.). All p values < 0.05 were considered significant.

Results

Patient Transfer Requests

There were a total of 10,833 requests for transfer of pediatric patients during the study period. Requests for transfer to the pediatric neurosurgical service constituted 400 (3.7%) of the total requests. The majority of the transfers were via ground transport (85.8%; Table 1). Air transport (helicopter or airplane) was used in 14.2% of cases. Transfers from our affiliated West Campus, approximately 25 miles away, accounted for 17.5% of the transfers. Overall, there were 118 unique referring facilities for the study group. The median driving distance between the referring facility and our hospital was 37.7 miles (range 0.2–750 miles).

TABLE 1.

Patient demographics and transfer characteristics for patients transferred for pediatric neurosurgical evaluation

VariableNo. of Patients%
Age (yrs)
  <110426
  1–613433.5
  6–127919.8
  12–187919.8
  >1841
Sex
  Male22055
  Female18045
Mortality risk cohorts
  Low38696.5
  Moderate112.8
  High30.8
Method of transport
  Ambulance34085
  Private car30.8
  Helicopter5614
  Plane10.3
Transit time (mins)
  <6011528.7
  60–1207719.3
  120–1808020
  180–2405614
  >2407218

The overall median transit time (i.e., time interval between accepting the transfer and arrival of the transfer) was 125 minutes for pediatric neurosurgical transfers. However, the overall median time interval between receiving the transfer request and patient arrival was 139.5 minutes. This time interval includes the time required for the physician to review the transfer request and communicate acceptance to the referring facility. The majority of transfers (69.8%, Fig. 1 upper) were admitted to our facility after-hours (from 6 pm to 6 am), and nearly a third of the transfers were admitted on the weekend (32.3%, Fig. 1 lower).

FIG. 1.
FIG. 1.

Graphs of time of admission (upper) and day of admission (lower) for pediatric patients transferred for neurosurgical evaluation.

Patient Characteristics

Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk cohorts, respectively. The median patient age was 54 months (range 0.4–264 months), and 45% of the study population was female (Table 1). Demographic data were similar among the different mortality risk groups (Table 2). The most frequent diagnoses at the time of request for transfer were skull fracture (24.8%), subdural hematoma (8%), and head injury (5.8%). Traumatic brain injury, with or without intracranial hemorrhage, was the most common actual diagnosis for transferred patients (Fig. 2). Isolated skull fracture, noted in 84 patients (21%), was the most common single diagnosis at discharge. Incorrect diagnoses were noted in 35 patients. The most common transfer request with an incorrect diagnosis was spine fracture. Five patients were transferred with the diagnosis of spine fracture but had a negative clinical and radiographic workup at our facility.

TABLE 2.

Patient demographics, resource utilization, and outcomes based on predicted mortality risk calculated from the PRISM score

VariablePredicted Mortality Riskp Value
<5%5%–30%>30%
No. of patients386113
Median age (yrs)5.51.920.11
% females44.845.566.70.75
Median transit time (mins)1291311090.92
Median total transfer time (mins)1551441310.91
Neurosurgery (yes)71510.06
Median length of stay in hospital (days)85.520.001
Median length of ICU stay (days)25.520.12
Actual diagnosis
  VPS/HCP2200
  Tumor3000
  Traumatic brain injury21962
  Vascular1500
  Infection500
  Spinal4010
  Seizures/AMS/vomiting3500
  Other2041
Disposition
  Home34531
  CPS1830
  Rehabilitation facility1810
  Hospice300
  Transfer to another hospital020
  Death222

AMS = altered mental status; CPS = child protective services; VPS/HCP = ventriculoperitoneal shunt/hydrocephalus.

FIG. 2.
FIG. 2.

Bar graph showing actual diagnosis categories for 400 pediatric patients transferred for neurosurgical evaluation. HCP = hydrocephalus; VPS = ventriculoperitoneal shunt.

Resource Utilization

One hundred three patients were admitted to the ICU after transfer, with a median of 3 days (range 1–269 days) spent in the ICU. The mean length of stay in the hospital was 2 days (range 1–269 days) for 400 patients. Ninety patients (22.5%) were discharged directly from the emergency room after transfer. Most of these discharges-on-transfer had a diagnosis of isolated skull fracture (53.3%). Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%). The types of surgical procedures performed are shown in Table 3.

TABLE 3.

Resource utilization and outcomes of care for 400 patients transferred for neurosurgical evaluation

VariableNo. of Patients%
Neurosurgical intervention
  Craniotomy for tumor246.0
  Craniotomy for hematoma*194.8
  Ventriculoperitoneal shunt insertion or revision123.0
  Spine surgery112.8
  Ventricular drain/tap71.8
  Others41.1
Median length of hospital stay in days (range)2 (1–269)
Median length of ICU stay in days (range)3 (1–269)
Disposition
  Home34987.3
  CPS215.3
  Rehabilitation facility194.8
  Hospice30.8
  Transfer to another hospital20.5
  Death61.5

Includes cranioplasty.

Includes vagus nerve stimulation (n = 2), transsphenoidal resection (n = 1), baclofen pump revision (n = 1).

Outcomes

Table 3 describes the discharge disposition for patients in this study. The majority of patients were discharged home (87.3%). Six patients (1.5%) died in the entire study population. Four patients deemed low- or moderate-risk at the time of transfer died for the following reasons: C1–2 dislocation with traumatic brain injury, cerebellar hemorrhage, hydrocephalus with sepsis, and brain tumor with hydrocephalus.

Discussion

In this first study to describe interhospital transfer of pediatric neurosurgical patients, reasons for transfer, hospital course, and discharge disposition have been described for a large tertiary/quaternary children's hospital over the course of 12 months. Pediatric neurosurgical transfers were relatively uncommon at our facility, comprising only 3.7% of all transfer requests. Nonetheless, the absence of neurosurgical coverage is a common indication for inter-hospital transfer.21 Many outlying community hospitals do not have pediatric neurosurgeons on staff, whereas others do not provide full-time pediatric neurosurgical coverage. The American College of Surgeons has recognized that higher-volume pediatric surgical centers may achieve better outcomes.32 Furthermore, other data indicate that high-volume centers may achieve better outcomes for certain neurosurgical conditions,13 which has further stimulated regionalization of care and the trend toward transfer of patients to specialized centers.6,14,22,24 The management of some pediatric neurosurgical conditions requires dedicated teams, such as neurointensivists, that may not be available at other facilities; in the adult neurosurgical patient population, this has been shown to improve outcomes.2,13 Patients or family members may request transfers on the basis of outside recommendations or the reputation of a particular center.21 Unfortunately, there are other reasons for transfer, such as concerns over professional liability or a patient's insurance status. On the basis of recent trends in the delivery of health care sparked by national health care reform, including hospital system consolidation, subspecialization, and regionalization,5 we expect that interhospital transfers in pediatric neurosurgery will become increasingly more common.

Opportunities for Quality Improvement

Telemedicine—and in particular teleradiology—technology has existed for quite a long period of time.8 However, its implementation in the interhospital transfer process has not been consistently applied. Prior research has shown that teleradiology increased the intervention rate in transferred patients, decreased transfer time, reduced unnecessary transfers, and even reduced the number of adverse events during transfer itself.1 Specifically, patients with isolated skull fractures, and those with isolated neck pain without evidence of fractures on CT imaging, may be examined remotely by the neurosurgeon using an audio-video interface. Isolated skull fractures without evidence of intracranial hemorrhage, which composed the majority of patients discharged from our emergency room soon after transfer (53.3%), is a relatively benign diagnosis given the low likelihood for neurological deterioration or intervention.3,29,30 The presence of neck pain without neurological deficits and a normal CT scan of the neck, in an older child, is another condition in which a clinical decision rule1 for transfer should be used. The neurosurgeon would be more confident of the patient's clinical examination and could potentially avoid transferring those patients who would be discharged home from the emergency room after transfer. In the present study, although we could review radiological images from our affiliate hospital (17.5% of transfers), we could not clinically evaluate the patient, and this limited our ability to reduce unnecessary transfers. In addition to the introduction of telemedicine, the implementation of frequent educational workshops on common neurosurgical conditions for emergency room teams, as well as general pediatricians at major community hospitals, is needed. The creation and distribution of well-defined clinical protocols for common neurosurgical cases among our referring centers is essential to change transfer practices.

This study also highlighted the large number of patients arriving after-hours or on the weekends. A proportion of these transfers may be attributed to working parents unable to take their children to the hospital during regular working hours on weekdays. However, delays in establishing a diagnosis and initiating a transfer request at the referring facility also contribute to these patterns. The potential impact of transfer delays is underscored by several studies reporting that pediatric patients who undergo surgery at night or on the weekend have higher complications rates,3,7,10–12,15–20,23,26,29,31,33,35,38,39 including an analysis of our own practice patterns in pediatric neurosurgery.30 Our results indicate the need for early transfer requests to reduce delays in care and after-hour transfers.

PRISM in Pediatric Neurosurgery

We stratified our study population into groups of predicted mortality based on PRISM score. These scores and their associated strata of risk were not associated with a shorter or longer transit time, expedited or prolonged ICU stay, or absence or need for neurosurgical intervention. Hence, the PRISM score may not be as valuable for pediatric neurosurgical patients undergoing interhospital transfer as it is for children cared for by other pediatric subspecialists. The use of the updated PRISM III score, which has revised the list of variables and ranges, may have improved the mortality prediction in our patient population.27 However, many of the neurosurgical patients did not have significant systemic physiological derangements at the time of transfer. These measures of systemic physiological variables, such as blood pressure, heart rate, respiratory rate, partial pressure of oxygen, and partial pressure of carbon dioxide, prothrombin time/partial thromboplastin time, total bilirubin, and serum electrolytes, are required by the PRISM formula.

Limitations of the Study

Certain limitations of this study need to be highlighted. Our study involved only 1 academic children's medical center; therefore, the results may not be generalizable to other children's hospitals in the US. Moreover, the case mix of patients and illness severity noted in our study population may not reflect those at other children's hospitals. Neurosurgery does not exist in isolation, and children with multisystem injury, who often require neurosurgical evaluation in addition to input from other services, will need to be transferred to a higher level of care. Many of these patients are brought directly to our facility by emergency services, and this may be the reason why the high mortality risk group was particularly small in our study.

In addition, we were unable to show that resource utilization varied according to the severity of illness of the patients. That is, greater risk of mortality was associated with higher utilization of resources. Unfortunately, only 3 high-risk patients were included in our study cohort, which limits meaningful comparisons between low-, moderate-, and high-risk groups. However, our methodological approach of describing the study cohort across strata of predicted mortality risk could be easily applied to other children's hospitals in the setting of future multicenter collaborations.

Conclusions

An appropriate and timely transfer process may improve care and safety for pediatric neurosurgical patients. This study serves as a first step in the identification and characterization of pediatric neurosurgical patients at the time of interhospital transfer. Future larger multiinstitutional studies based on our present work may demonstrate that resource consumption needs vary from primarily rehabilitative for lower-risk admissions, to aggressive surgical interventions for high-risk admissions. Multiple aspects of the transfer process of pediatric neurosurgical patients may be improved upon.

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    Anderson RCScaife ERFenton SJKan PHansen KWBrockmeyer DL: Cervical spine clearance after trauma in children. J Neurosurg 105:5 Suppl3613642006

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    Arias YTaylor DSMarcin JP: Association between evening admissions and higher mortality rates in the pediatric intensive care unit. Pediatrics 113:e530e5342004

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    Arrey ENKerr MLFletcher SCox CS JrSandberg DI: Linear nondisplaced skull fractures in children: who should be observed or admitted?. J Neurosurg Pediatr 16:7037082015

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    Babu MANahed BVDemoya MACurry WT: Is trauma transfer influenced by factors other than medical need? An examination of insurance status and transfer in patients with mild head injury. Neurosurgery 69:6596672011

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    Barnett MJKaboli PJSirio CARosenthal GE: Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care 40:5305392002

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    Bershad EMFeen ESHernandez OHSuri MFSuarez JI: Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care 9:2872922008

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    Buckley DBulger D: Trends and weekly and seasonal cycles in the rate of errors in the clinical management of hospitalized patients. Chronobiol Int 29:9479542012

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    Burke BL JrHall RW: Telemedicine: pediatric applications. Pediatrics 136:e293e3082015

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    Byrne RWBagan BTSlavin KVCurry DKoski TROrigitano TC: Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study. Neurosurgery 62:7097162008

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    Chang GMTung YC: Factors associated with pneumonia outcomes: a nationwide population-based study over the 1997–2008 period. J Gen Intern Med 27:5275332012

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    Concha OPGallego BHillman KDelaney GPCoiera E: Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study. BMJ Qual Saf 23:2152222014

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    Cram PHillis SLBarnett MRosenthal GE: Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med 117:1511572004

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    Cross DT IIITirschwell DLClark MATuden DDerdeyn CPMoran CJ: Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states. J Neurosurg 99:8108172003

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    Cutler DMScott Morton F: Hospitals, market share, and consolidation. JAMA 310:196419702013

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    Desai VGonda DRyan SLBriceño VLam SKLuerssen TG: The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients. J Neurosurg Pediatr 16:7267312015

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    Fendler WBaranowska-Jazwiecka AHogendorf AWalenciak LSzadkowska APiotrowski A: Weekend matters: Friday and Saturday admissions are associated with prolonged hospitalization of children. Clin Pediatr (Phila) 52:8758782013

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    Freemantle NRichardson MWood JRay DKhosla SShahian D: Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 105:74842012

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    Goh KYLam CKPoon WS: The impact of teleradiology on the inter-hospital transfer of neurosurgical patients. Br J Neurosurg 11:52561997

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    Goldstein SDPapandria DJAboagye JSalazar JHVan Arendonk KAl-Omar K: The “weekend effect” in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend. J Pediatr Surg 49:108710912014

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    Hixson EDDavis SMorris SHarrison AM: Do weekends or evenings matter in a pediatric intensive care unit?. Pediatr Crit Care Med 6:5235302005

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    Holland CMMcClure EWHoward BMSamuels OBBarrow DL: Interhospital transfer of neurosurgical patients to a high-volume tertiary care center: opportunities for improvement. Neurosurgery 77:2002072015

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    Johnston SC: Effect of endovascular services and hospital volume on cerebral aneurysm treatment outcomes. Stroke 31:1111172000

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    Laupland KBShahpori RKirkpatrick AWStelfox HT: Hospital mortality among adults admitted to and discharged from intensive care on weekends and evenings. J Crit Care 23:3173242008

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    Lawton MTDu R: Effect of the neurosurgeon's surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery 57:9152005

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Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Jea, Hansen, Briceño, Moreno, Ryan. Acquisition of data: Vedantam, Hansen, Briceño, Moreno, Ryan. Analysis and interpretation of data: Vedantam, Hansen, Briceño, Moreno, Ryan. Drafting the article: all authors. Critically revising the article: Jea, Hansen, Briceño, Moreno, Ryan. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Jea. Study supervision: Jea.

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Article Information

INCLUDE WHEN CITING Published online July 22, 2016; DOI: 10.3171/2016.5.PEDS16155.

Correspondence Andrew Jea, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202. email: ajea@goodmancampbell.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graphs of time of admission (upper) and day of admission (lower) for pediatric patients transferred for neurosurgical evaluation.

  • View in gallery

    Bar graph showing actual diagnosis categories for 400 pediatric patients transferred for neurosurgical evaluation. HCP = hydrocephalus; VPS = ventriculoperitoneal shunt.

References

1

Anderson RCScaife ERFenton SJKan PHansen KWBrockmeyer DL: Cervical spine clearance after trauma in children. J Neurosurg 105:5 Suppl3613642006

2

Arias YTaylor DSMarcin JP: Association between evening admissions and higher mortality rates in the pediatric intensive care unit. Pediatrics 113:e530e5342004

3

Arrey ENKerr MLFletcher SCox CS JrSandberg DI: Linear nondisplaced skull fractures in children: who should be observed or admitted?. J Neurosurg Pediatr 16:7037082015

4

Babu MANahed BVDemoya MACurry WT: Is trauma transfer influenced by factors other than medical need? An examination of insurance status and transfer in patients with mild head injury. Neurosurgery 69:6596672011

5

Barnett MJKaboli PJSirio CARosenthal GE: Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care 40:5305392002

6

Bershad EMFeen ESHernandez OHSuri MFSuarez JI: Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care 9:2872922008

7

Buckley DBulger D: Trends and weekly and seasonal cycles in the rate of errors in the clinical management of hospitalized patients. Chronobiol Int 29:9479542012

8

Burke BL JrHall RW: Telemedicine: pediatric applications. Pediatrics 136:e293e3082015

9

Byrne RWBagan BTSlavin KVCurry DKoski TROrigitano TC: Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study. Neurosurgery 62:7097162008

10

Chang GMTung YC: Factors associated with pneumonia outcomes: a nationwide population-based study over the 1997–2008 period. J Gen Intern Med 27:5275332012

11

Concha OPGallego BHillman KDelaney GPCoiera E: Do variations in hospital mortality patterns after weekend admission reflect reduced quality of care or different patient cohorts? A population-based study. BMJ Qual Saf 23:2152222014

12

Cram PHillis SLBarnett MRosenthal GE: Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med 117:1511572004

13

Cross DT IIITirschwell DLClark MATuden DDerdeyn CPMoran CJ: Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states. J Neurosurg 99:8108172003

14

Cutler DMScott Morton F: Hospitals, market share, and consolidation. JAMA 310:196419702013

15

Desai VGonda DRyan SLBriceño VLam SKLuerssen TG: The effect of weekend and after-hours surgery on morbidity and mortality rates in pediatric neurosurgery patients. J Neurosurg Pediatr 16:7267312015

16

Fendler WBaranowska-Jazwiecka AHogendorf AWalenciak LSzadkowska APiotrowski A: Weekend matters: Friday and Saturday admissions are associated with prolonged hospitalization of children. Clin Pediatr (Phila) 52:8758782013

17

Freemantle NRichardson MWood JRay DKhosla SShahian D: Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 105:74842012

18

Goh KYLam CKPoon WS: The impact of teleradiology on the inter-hospital transfer of neurosurgical patients. Br J Neurosurg 11:52561997

19

Goldstein SDPapandria DJAboagye JSalazar JHVan Arendonk KAl-Omar K: The “weekend effect” in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend. J Pediatr Surg 49:108710912014

20

Hixson EDDavis SMorris SHarrison AM: Do weekends or evenings matter in a pediatric intensive care unit?. Pediatr Crit Care Med 6:5235302005

21

Holland CMMcClure EWHoward BMSamuels OBBarrow DL: Interhospital transfer of neurosurgical patients to a high-volume tertiary care center: opportunities for improvement. Neurosurgery 77:2002072015

22

Johnston SC: Effect of endovascular services and hospital volume on cerebral aneurysm treatment outcomes. Stroke 31:1111172000

23

Laupland KBShahpori RKirkpatrick AWStelfox HT: Hospital mortality among adults admitted to and discharged from intensive care on weekends and evenings. J Crit Care 23:3173242008

24

Lawton MTDu R: Effect of the neurosurgeon's surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery 57:9152005

25

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