CHAPTER 19

Pediatric Hospital Medicine

Melanie Rudnick, MD, FAAP, and Grant P. Christman, MD, FAAP

Introduction

Every primary care physician (PCP) must periodically make the decision to hospitalize a patient who can no longer be cared for effectively in the outpatient setting. In 2015, 2.1% of all children and teenagers younger than 18 years, or more than 1.5 million patients, required hospitalization.

Common reasons for hospitalization include need for close monitoring due to existing or expected clinical compromise, initiation of an intensive diagnostic workup, expected need for surgical procedures, and administration of treatments that are complex and technology intensive or have a high adverse effect profile.

In the traditional model of providing hospital care, the PCP admits the patient to the hospital and continues to personally direct the patient’s care, examining the patient while on rounds in the hospital daily; writing all orders for diagnostic studies, medications, and other care; and consulting directly with subspecialists as needed. Due to economic and structural pressures from a changing health care system, a second model has emerged in which, once the PCP admits the patient to the hospital, further care is coordinated by a pediatrician specializing in inpatient medicine: a hospitalist.

The term hospitalist was first coined by Wachter and Goldman in 1996. Although hospitalists existed prior to that time, the prevalence of hospitalists has increased significantly in the decades since. The Society of Hospital Medicine defines the scope of the hospitalist’s work to include the clinical care of acutely ill, hospitalized patients; education, research, and leadership in the field of hospital medicine; and working to enhance the performance of hospitals and health care systems.

While hospitalists are unable to provide the uninterrupted continuity of care that PCPs provide in the traditional model, hospitalist systems offer a different advantage: the extended physical presence of a physician in the hospital who is responsible for the patient’s care—as much as 24 hours a day, 7 days a week in some systems—which is impossible to sustain for a PCP with a busy outpatient practice.

Inpatient Pediatric Care

Every patient presenting for admission to the hospital requires a thorough initial evaluation (history and physical examination) following a direct verbal handoff from the health professional requesting the patient be admitted. If admission is requested by someone other than the PCP (eg, emergency physician, surgeon following a surgical procedure), the hospitalist should consider contacting the PCP to establish a relationship, gather more information about the presenting symptom, and learn more about the patient’s established medical problems and routine care. Primary care physicians may not always be available, and, as such, it is helpful if patients have been thoroughly educated on their medical conditions and carry a list of their medications and allergies with them.

Inpatient pediatric care should be patient and family centered, which has been defined by the American Academy of Pediatrics as “health care that is grounded in a mutually beneficial partnership among patients, families, and providers that recognizes the importance of the family in the patient’s life.” In the hospital setting, this may take the form of multidisciplinary family-centered rounds, a system in which doctors, nurses, and other allied health professionals make rounds together on hospitalized patients with their families at the bedside. During rounds, health professionals educate patients and families, hear their preferences, and include them in the medical decision making process. Some families may prefer not to participate in rounds, and this preference should be respected as well. If there is a language barrier, in-person, video, or telephonic interpreters should be used to facilitate making rounds, in accordance with the principle of equitability of care. A child life specialist may be consulted to help the patient cope with the hospitalization, including daily rounds and anxiety-provoking or painful procedures, by clarifying what is discussed in terms the child can understand and helping the child process or be distracted from these events through various types of creative play.

Patient- and family-centered care is complemented by the application of evidence-based medicine principles to medical decision-making. Questions of diagnosis, prognosis, treatment, or avoidance of harm should be clearly defined to facilitate an effective review of the medical literature. One way of developing a focused clinical question is through the PICO process, wherein the physician identifies the applicable patient population, the intervention (ie, treatment, diagnostic test, or prognostic factor), the comparison (ie, control or placebo group), and the outcome (ie, diagnosis, prognosis, or harm to the patient). For example, in formulating a diagnostic workup for a 5-year-old patient presenting with an asthma exacerbation, the physician might ask whether school-age children with asthma (P) who undergo chest radiography (I) have a shorter length of hospital stay (O) than children who undergo no imaging (C).

Advances in technology have made it possible to consult medical evidence at the point of care—even in the patient’s room during bedside rounds—with the use of laptops, tablets, and in-room computers. When searching through primary research studies, such as randomized controlled trials, to answer a clinical question, the physician must determine whether the results are valid and generalizable to the patient under consideration. It may be more efficient and just as legitimate to use a summary of the evidence, such as a systematic review, which may be available through an established medical journal or a web-based service. Having the PCP as an ally during the hospital stay may give the hospitalist more insight into how applicable a certain study is to the patient for whom the hospitalist is caring.

Hospitalists should also make use of clinical practice guidelines as a way of providing standardized and evidence-based care. The Health and Medicine Division of the National Academies (formerly known as the Institute of Medicine) defines clinical practice guidelines as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” In applying clinical practice guidelines, hospitalists should consider factors specific to the individual patient, such as comorbid conditions, limited availability of services in specific hospital settings, and patient values and preferences, that may warrant deviating from aspects of care recommended by the guidelines. Many of the guidelines used by hospitalists include discharge criteria, which are often dependent on availability of outpatient follow-up. This is yet another example of importance of communication with PCPs throughout patient hospitalization.

In addition to providing routine inpatient care, some hospitalists also provide specialized care, such as procedural sedation, palliative care consultations, and surgical or medical comanagement. Hospitalists often play a role in accepting patients for admission to the inpatient service, facilitating hospital-to- hospital transfers, and providing physician-assisted transport. They may also be tasked with determining the appropriate mode and level of transport.

Due to medical and technological advances leading to improved survival rates, hospitalists are increasingly caring for the growing population of children with complex medical needs. Providing quality care to these children is challenging due to their dependence on medical technologies and multiple medications, the paucity of applicable clinical evidence to support management strategies, and the need for time-intensive and complex care coordination. Depending on the resources available to the family and the PCP’s familiarity with the patient (which may be limited if the patient has had frequent or prolonged hospital stays), transitioning the patient to the outpatient medical home may be particularly challenging. Specific efforts should be made to ensure a quality handoff so that there are no lapses in care and the PCP fully understands any adjustments made to the care plan during hospitalization.

Patient Safety and Quality Improvement

While it is important for individual physicians to engage in clinical practice that is family centered and evidence based, the next step is to ensure that quality care is being systematically delivered at the hospital level, and where it is not, that quality improvement (QI) programs are initiated. In its 2001 report, Crossing the Quality Chasm, the Institute of Medicine defined quality health care as having 6 characteristics: safe, effective, efficient, patient centered, timely, and equitable. Opportunities to improve the quality of care delivered by the hospital may be suggested by issues faced in individual patient encounters, quality metrics tracked by hospital administration (eg, length of stay, readmissions), or feedback from patients, their families, and their PCPs.

One model for the creation of QI projects is the Plan-Do-Study-Act cycle. In the Plan phase, the hospitalist identifies a problem or aim, defines a change that could be made to address the problem, and determines how the effectiveness of the change will be measured. It is usually necessary to form a team of like-minded physicians, administrators, nurses, and other allied health professionals early in the planning process. In the Do phase, the change is implemented, and data are collected about its effectiveness. These data may include process measures (ie, how consistently the change is implemented) and outcome measures (ie, the effect of the change on the patient population, hospital system, costs). In the Study phase, data are analyzed, and successes and failures of the program are identified. Finally, in the Act phase, the team determines whether the change should be continued and adopted more widely in the hospital, modified in some way, or discarded altogether. Depending on the project, additional Plan-Do-Study-Act cycles may be needed to maximize the breadth and depth of the effect. Successes should be shared publicly with the hospital community to promote support for further QI efforts.

Physicians should also promote a culture of safety in the hospital, meaning that the hospital’s processes and workforce are dedicated to the promotion of patient safety. Adverse events, a term encompassing all injuries caused by medical management, are common and are often caused by preventable medical errors, especially medication errors (eg, incorrect dosing, administering medications to the wrong patient). Common initiatives to improve patient safety include use of electronic health records and computerized order entry, review of orders by multiple health professionals, promotion of sterile technique and handwashing, work-hour limitations to prevent fatigue, and having time-outs before procedures to verify the patient’s identity and the site of the procedure. Hospitals should hold regular morbidity and mortality conferences to review cases in which adverse events occur. These conferences should be confidential and focus not on blaming individual health professionals but on identifying systemic failures that may be corrected to prevent future adverse events. When adverse events occur, patients and their families should be informed in a timely fashion, according to procedures established by the hospital.

Transitions of Care

Inpatient systems in which hospitalists work in shifts typically have physician-to-physician handoffs of patient care responsibility at least once every 24 hours. Resident work hours in teaching hospitals have been limited to promote patient safety, but this also results in more frequent patient handoffs. If there is inadequate communication, handoffs may increase risk for medical errors and adverse events. Safe handoffs may be promoted by written handoff notes and strategies for effective verbal handoffs. One such strategy uses the I-PASS mnemonic, with the letters standing for a 5-step process in verbal handoffs (Box 19.1).

The discharge process should begin as soon as the patient is hospitalized. Goals of the hospitalization, discharge criteria, potential barriers to discharge, and an anticipated date of discharge should be identified in concert with the patient and family and reviewed during daily rounds. The hospitalist should formulate the discharge plan together with the other health care and allied health professionals involved in the care of the patient, including subspecialists, nurses, social workers, and discharge planners. For patients with complex needs, issues to address may include procurement of durable medical equipment, insurance coverage for medications, scheduling of follow-up appointments, and provision of other services, such as in-home nursing. The use of written or computerized discharge checklists may help ensure that no element is delayed long enough to prolong the hospital stay or forgotten altogether.

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