The approach to the hospitalized child and family has changed dramatically over the last decade. Physicians are rarely the sole decision makers when children are hospitalized. Patients and families expect to be actively involved in medical decision-making, and this expectation is strongly supported by leaders in health care and government.
In 2001 the Institute of Medicine published a report outlining the six aims of a transformed health care delivery system in the United States. The report stated a health care system should be timely, effective, efficient, patient-centered, equitable, and safe. Inpatient care should be focused on achieving these aims. In recent years, healthcare reform in the United States has focused on cost-effective care and better patient outcomes. As many innovative models of healthcare emerge, new emphasis is on encouraging physicians, hospitals, and other healthcare providers to work more closely as a team and to better coordinate patient care through team-based approaches, therefore giving a greater role to patients in healthcare decision-making.
Team-based care may help achieve improvement in health care at a reasonable cost. The health care teams may vary depending on setting (home, office, hospital), disease type (chronic care coordination vs. acute care or well checks), or personnel (care coordination, social worker, home health in a complex care setting vs. nursing, respiratory therapists, pharmacy in asthma centers). Healthcare teams may be large or small depending on the model of care provided.
In high-functioning healthcare teams, patients are members of the team; they are the reason healthcare teams exist. “Nothing about me without me” conveys the powerful message of patients’ active involvement in care decisions. This involves integrating patients, family, physicians, and other providers in healthcare teams.
Hospitalists play a crucial role in managing healthcare teams in the inpatient setting. They can incorporate the principles and values of family- and patient-centered care to improve quality as defined by outcomes, safety, and patient experience.
A hospitalized child requires timely access to clinical services without delays attributable to system design. Variations in clinical care are frequently attributed to failures in clinical care. Systems that are well designed to ensure necessary levels of clinical reliability decrease variation and improve outcomes. Clinical care should be evidence based, and the implementation of evidence-based clinical guidelines decreases unnecessary variation in care and improves clinical outcomes. When there are no available guidelines, the original medical literature can be accessed and evaluated using generally accepted methods of critical appraisal. Equitable care must be available for all hospitalized children without regard to race, national origin, religious or cultural background, gender, or insurance status. Hospital systems must be designed to ensure patient safety and to dramatically decrease preventable sources of error. The use of computerized technologies, such as electronic medical records, computerized order entry systems, and automated safety triggers can increase the reliability of hospital systems.
For successful transitions to occur, hospital cultures need to change from physician-centered to patient- and family-centered. Dimensions of care that patients and families value, including respect for preferences, involvement in decision making, access to care, coordination of care, information and education, physical comfort, emotional support, involvement of family and friends, and continuity in the transition from inpatient to outpatient or medical home setting should be the center of focus.
Hospitalization is a stressful event for both the child and family. Children and families may experience feelings ranging from fear of the unknown to complete loss of control. These feelings complicate the clinical situation and detract from development of a healing environment. Physician and other healthcare professionals should address these stresses directly and provide an environment designed to preserve patient and family control. Whenever possible, the child and family should be prepared for the hospitalization; this allows them to be educated about the proposed care and can help clarify the expectations of the family and physicians.
Such preparations also provide opportunity to initiate clear and open communication between physicians and prepare for safe handoffs of care and discharge planning. If possible, before a planned hospitalization, the child and family should be given an opportunity to tour the facility and meet the staff who will provide care. An active child life service can facilitate the pre-hospital activity. When hospitalization occurs urgently or emergently, the child life programs can provide support for children and families at the point of contact.
