社区急诊就诊中的儿科创伤远程医疗会诊与家长照护体验：一项阶梯楔形整群随机临床试验。
完整摘要 · 中文译文
重要性：在非儿科创伤中心的急诊科（ED）接受治疗的急性损伤儿童的电话会诊，通常缺乏与家长的直接沟通和知情决策。利用远程医疗促进实时专家会诊及家长与儿科创伤专家的沟通尚未得到充分探索，可能改善家庭体验并支持临床决策。 目的：探讨远程医疗对非儿科创伤中心急诊科就诊的急性损伤儿童的家长照护体验、家长痛苦及转运频率的影响。 设计、设置和参与者：本阶梯楔形整群随机临床试验于2020年11月30日至2022年11月27日期间招募患者。参与者包括因急性躯体创伤就诊于北加利福尼亚州10家非儿科创伤中心之一的18岁以下儿童的家属。分析于2023年6月至2026年3月期间进行。 干预措施：急诊科被随机分配为在与儿科创伤医师会诊时采用标准电话会诊后使用远程医疗，或采用标准照护（仅电话会诊）。 主要结局和指标：主要结局为家长照护体验和家长痛苦，于儿童受伤后3天或更长时间测量。照护体验采用急诊科医疗提供者与系统消费者评估（CAHPS）问题进行测量。痛苦采用状态-特质焦虑量表Y型问卷进行测量。改良意向性治疗分析 进行了分析以评估结局。 结果：本研究纳入595例急性躯体创伤儿童，平均（标准差）年龄为7.6（5.1）岁，其中369例（62.0%）被分配至远程医疗组，226例（38.0%）被分配至标准照护组。损伤后3天家长照护体验的汇总评分在两组间相似（校正平均差[AMD]，0.041 [95% CI，-0.008至0.090；P = .10]），家长痛苦汇总评分亦相似（AMD，-0.031 [95% CI，-0.297至0.235；P = .82]）。分配至远程医疗组的患者转院的校正比值比为0.59（95% CI，0.16至2.16；P = .43）。亚量表分析发现，分配至远程医疗组的患者家长对急诊科出院和/或转院体验的评分显著更高（AMD，0.104 [95% CI，0.023至0.186；P = .01]）。 结论与意义：在这项随机临床试验中，就家长照护体验、痛苦和转院率而言，远程医疗会诊与标准照护相比无统计学显著差异。亚量表分析提示，远程医疗会诊可能在家长对急诊科出院和院际转院相关体验方面具有潜在改善作用，突出了在照护过渡期间沟通和准备方面的潜在获益。 试验注册：ClinicalTrials.gov标识符：NCT04469036。
完整摘要 · 英文原文
IMPORTANCE: Telephone consultations for acutely injured children receiving care in emergency departments (EDs) in nonpediatric trauma centers frequently exclude direct communication and informed decision-making with parents. The use of telemedicine to facilitate real-time expert consultation and parental communication with pediatric trauma specialists is underexplored and may improve family experience and support clinical decision-making. OBJECTIVE: To examine the impact of telemedicine on parent experience of care, parent distress, and transfer frequency for acutely injured children presenting to EDs in nonpediatric trauma centers. DESIGN, SETTING, AND PARTICIPANTS: This stepped-wedge cluster-randomized clinical trial recruited patients between November 30, 2020, and November 27, 2022. Participants included families of children younger than 18 years with acute physical trauma presenting to 1 of 10 nonpediatric trauma centers in northern California. Analyses were conducted between June 2023 and March 2026. INTERVENTIONS: EDs were randomized to use telemedicine following a standard telephone consultation or the standard of care (telephone consultation only) when consulting with pediatric trauma physicians. MAIN OUTCOMES AND MEASURES: Primary outcomes were parent experience of care and parent distress measured 3 days or more following the child's injury. Experience of care was measured using ED Consumer Assessment of Healthcare Providers and Systems (CAHPS) questions. Distress was measured using the State-Trait Anxiety Inventory Form Y survey. Modified intention-to-treat analyses were performed to evaluate outcomes. RESULTS: The study included 595 children with acute physical trauma with a mean (SD) age of 7.6 (5.1) years, of whom 369 (62.0%) were assigned to telemedicine and 226 (38.0%) to standard of care. Summary scores for parent experience of care 3 days post injury were similar between cohorts (adjusted mean difference [AMD], 0.041 [95% CI, -0.008 to 0.090; P = .10]), as were parent distress summary scores (AMD, -0.031 [95% CI, -0.297 to 0.235; P = .82]). The adjusted odds ratio for transfer of patients assigned to telemedicine was 0.59 (95% CI, 0.16 to 2.16; P = .43). Subscale analyses found significantly higher parental ED discharge and/or transfer experience ratings for patients assigned to telemedicine (AMD, 0.104 [95% CI, 0.023 to 0.186; P = .01]). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, telemedicine consultations did not differ statistically significantly from standard care with respect to parent experience of care, distress, and transfer rates. Subscale analyses suggested a potential improvement with telemedicine consultations in parent experience related to ED discharge and interfacility transfers, highlighting a potential benefit in communication and preparation during care transitions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04469036.