Characteristics and predictors of high acuity pediatric patients presenting to a regional community healthcare system who require transfer to a tertiary pediatric center.

Main Article Content

Rahim Valani, MD, FRCP, MBA, LLM Maroof Khalid, MD Hannah Snyder, MD Tanmay Sharma, MSc Suneel Upadhye, MD, FRCP, MSc Shira Brown, MD, CCFP-EM, MBA


Purpose: To identify the characteristics at triage of high acuity pediatric patients who presented to community emergency departments and determine predictors for those who require transfer to a tertiary care pediatric center.

Patients and methods: We conducted a retrospective study of all pediatric Canadian Triage and Acuity Scale (CTAS) I patients presenting to five semirural hospital sites from January to December 2018. Univariate tests were used to identify significant predictors for transfer based on age, gender, Pediatric Early Warning Score (PEWS) score and presenting complaint. A multivariate model was developed based on backward selection from the significant factors from the univariate analysis to identify predictors for transfer.

Results: There were 1,137 subjects with an average age of 5.08 years (SD: 5.03) of whom, 559 (49.2%) were males. Sixty patients (5.3%) were transferred to a tertiary care center (60.9% <4 years). A PEWS score ≥3 (OR 3.005, 95% CI 1.623–5,563), presenting with trauma (OR 6.617, 95% CI 2.820–15-531), mental health issues (OR 5.131, 95% CI 1.444–18.232), or neurological issue (OR 3.057, 95% CI 1.355–6.896) were associated with transfer. Patients with fever (OR 0.113, 95% CI 0.031–0.407) and respiratory symptoms (OR 0.345, 95% CI 0.142–0.840) were less likely to be transferred.

Conclusion: Predictors of transfer from a community hospital to a pediatric tertiary care center were a PEWS score ≥3, trauma patients, those presenting with mental health issues, and patients with neurological symptoms. Early recognition can facilitate quicker transfer of these high acuity patients requiring tertiary care management.

Keywords: pediatric, transfer, high acuity

Keywords: pediatric, transfer, high acuity

Article Details

How to Cite
VALANI, Rahim et al. Characteristics and predictors of high acuity pediatric patients presenting to a regional community healthcare system who require transfer to a tertiary pediatric center.. Medical Research Archives, [S.l.], v. 10, n. 11, nov. 2022. ISSN 2375-1924. Available at: <>. Date accessed: 17 june 2024. doi:
Research Articles


1. Canadian Institute for Health Information. Almost 12,000 Canadian children and youth readmitted to hospital last year. 2019; Accessed 2021, September.
2. Auerbach M, Brown L, Whitfill T, et al. Adherence to Pediatric Cardiac Arrest Guidelines Across a Spectrum of Fifty Emergency Departments: A Prospective, In Situ, Simulation-based Study. Acad Emerg Med. 2018;25(12):1396-1408.
3. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015: Statistical Brief #242. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006.
4. Bourgeois FT, Shannon MW. Emergency care for children in pediatric and general emergency departments. Pediatr Emerg Care. 2007;23(2):94-102.
5. McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R. Critical pediatric equipment availability in Canadian hospital emergency departments. Ann Emerg Med. 2001;37(4):371-376.
6. Stys D, Landry K, Mitra T, Grant V. A provincial assessment of readiness for paediatric emergencies: What are the existing resource gaps in Alberta? Paediatr Child Health. 2020;25(8):498-504.
7. Jain PN, Choi J, Katyal C. Pediatric Care in the Nonpediatric Emergency Department: Provider Perspectives. Hosp Pediatr. 2019;9(3):216-219.
8. Peebles ER, Miller MR, Lynch TP, Tijssen JA. Factors Associated With Discharge Home After Transfer to a Pediatric Emergency Department. Pediatr Emerg Care. 2018;34(9):650-655.
9. Fuchs S YL. APLS: The pediatric emergency medicine resource. Burlington, MA: Jones & Bartlett Learning; 2012.
10. Bullard MJ, Musgrave E, Warren D, et al. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines 2016. Cjem. 2017;19(S2):S18-s27.
11. Warren DW, Jarvis A, LeBlanc L, Gravel J. Revisions to the Canadian Triage and Acuity Scale Paediatric Guidelines (PaedCTAS). Canadian Journal of Emergency Medicine. 2008;10(3):224-232.
12. Chapman SM, Maconochie IK. Early warning scores in paediatrics: an overview. Arch Dis Child. 2019;104(4):395-399.
13. Ames SG DB, Marin JR, L. Fink EL, Olson LM, Gausche-Hill M, Kahn JM,. Emergency Department Pediatric Readiness and Mortality in Critically Ill Children. [published in erratum in: Pedistrics 2020;145(5):e20200542]. Pediatrics. 2019;144(3):e20190568.
14. Alam N, Hobbelink EL, van Tienhoven AJ, van de Ven PM, Jansma EP, Nanayakkara PW. The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation. 2014;85(5):587-594.
15. Lillitos PJ, Hadley G, Maconochie I. Can paediatric early warning scores (PEWS) be used to guide the need for hospital admission and predict significant illness in children presenting to the emergency department? An assessment of PEWS diagnostic accuracy using sensitivity and specificity. Emerg Med J. 2016;33(5):329-337.
16. Doan Q, Wong H, Meckler G, et al. The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study. CMAJ. 2019;191(23):E627-E635.
17. Auerbach M, Whitfill T, Gawel M, et al. Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments. JAMA Pediatr. 2016;170(10):987-994.
18. Rosenthal JL, Hilton JF, Teufel RJ, 2nd, Romano PS, Kaiser SV, Okumura MJ. Profiling Interfacility Transfers for Hospitalized Pediatric Patients. Hosp Pediatr. 2016;6(6):345-353.
19. Leroux Y, Cook J, Goldstein J, et al. Pediatric Secondary Transfer Percentages: A Retrospective Observational Study. Cureus. 2020;12(1):e6766.
20. Moylan A, Maconochie I. Demand, overcrowding and the pediatric emergency department. CMAJ. 2019;191(23):E625-e626.
21. Murray JS, Williams LA, Pignataro S, Volpe D. An Integrative Review of Pediatric Early Warning System Scores. Pediatr Nurs. 2015;41(4):165-174.
22. Edwards ED, Powell CV, Mason BW, Oliver A. Prospective cohort study to test the predictability of the Cardiff and Vale paediatric early warning system. Arch Dis Child. 2009;94(8):602-606.
23. Edwards ED, Mason BW, Oliver A, Powell CV. Cohort study to test the predictability of the Melbourne criteria for activation of the medical emergency team. Arch Dis Child. 2011;96(2):174-179.
24. Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care. 2006;21(3):271-278.
25. McElroy T, Swartz EN, Hassani K, et al. Implementation study of a 5-component pediatric early warning system (PEWS) in an emergency department in British Columbia, Canada, to inform provincial scale up. BMC Emerg Med. 2019;19(1):74.
26. Cioffredi LA, Jhaveri R. Evaluation and Management of Febrile Children: A Review. JAMA Pediatr. 2016;170(8):794-800.
27. Wing R, Dor MR, McQuilkin PA. Fever in the pediatric patient. Emerg Med Clin North Am. 2013;31(4):1073-1096.