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Alice,

There is no question that you did what was most appropriate for all parties potentially effected by the decision. The way this is handled with the refering facility is the key. Too often there is not enough thought, consideration and honest analysis given to these type of scenarios. The "least path of resistance" is always to say, " Sure, transfer" to CCCH or whatever tertiary center and this is not the best decision for many of the reasons you outlined. If there is no benefit to the patient, then why transfer.
Over the past two decades the chronically ill pediatric population has significantly increased which has put this issue in the forefront.
We all need to better appreciate the incredible resources involved transfering such patients, not to mention the impact on the families.
We do have a professional responsibility to educate our outlying ED facilities and to support them as local triage centers so that we can make the best decisions for the patients and their families in like scenarios.
Our Pediatric Transport Outreach Program here at CCCH does just that and over years has had an impact. Trust between the tertiary center and the local/regional ED's is paramount.
I sleep better when I make decisions that I am confident are in the best interest of the patient and family.

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