Medical comanagement of surgical patients by pediatric hospital medicine providers has become increasingly common. Subjectively, the comanagement model is superior to more traditional consultative models because of the anticipatory preventive care and coordination hospitalists provide to patients and hospital colleagues. Although some studies have demonstrated the value of the comanagement model in adults and children, others have failed to do so. The coming years are both exciting and challenging for this emerging field as it attempts to sustain its early progress and define its future in pediatric hospital medicine.
Key points
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Surgical comanagement is one of several specialized niches emerging in pediatric hospital medicine.
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In a comanagement model, pediatric hospitalists and surgeons share responsibility and accountability for patient management and outcomes.
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Particular considerations are required in the establishment of surgical comanagement programs.
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Surgical hospitalists are poised to make contributions in the areas of clinical care, practice management, quality, education, and research.
Introduction
In the past decade, pediatric hospital medicine (PHM) has grown dramatically in breadth and in numbers. Simultaneously, as pediatric care has advanced, children who would not have survived infancy are growing into young adults with complex chronic diseases and are frequently hospitalized to address exacerbation of underlying disease processes and procedures to improve their quality of life. This article focuses on issues that arise in the comanagement of medically complex patients preoperatively and postoperatively with surgical colleagues.
In recent years, the comanagement of surgical patients has become prevalent among PHM programs, likely due to several factors. First, hospital medicine is becoming accepted as a subspecialty of pediatrics, and comanagement is one of several specialized niches in the practice of PHM. Second, hospitalized children are more complex medically. As pediatrics has become more specialized, so too have surgical specialties, such that training does not include as in-depth pediatric patient management as it may once have. Finally, comanagement in PHM is a natural evolution of comanagement in adult hospital medicine settings, which is a widespread practice model.
This relatively new role for PHM providers is an ideal fit within existing hospitalist practice models. PHM providers are typically involved directly in hospital safety and systems integration. They provide value to institutions in patient care coordination, excelling in the management of medically complex patients. These patients typically have multiple subspecialists involved in their care, as well as a battery of hospital-based ancillary staff. PHM providers communicate well with families, nurses, and surgical and medical providers, integrating all of the input into patient management plans that focus on the needs of the patient and family. In addition, in hospitals where sentinel events have occurred among surgical patients, PHM providers and comanagement have been identified as the solution.
As a relatively recent addition to the PHM provider repertoire, surgical comanagement suffers from a paucity of literature describing its benefits and limits. In this review, a summary of both the authors’ experiences and published data are provided to outline the current state of surgical comanagement and to create a framework for presenting challenges and issues within the field.
Introduction
In the past decade, pediatric hospital medicine (PHM) has grown dramatically in breadth and in numbers. Simultaneously, as pediatric care has advanced, children who would not have survived infancy are growing into young adults with complex chronic diseases and are frequently hospitalized to address exacerbation of underlying disease processes and procedures to improve their quality of life. This article focuses on issues that arise in the comanagement of medically complex patients preoperatively and postoperatively with surgical colleagues.
In recent years, the comanagement of surgical patients has become prevalent among PHM programs, likely due to several factors. First, hospital medicine is becoming accepted as a subspecialty of pediatrics, and comanagement is one of several specialized niches in the practice of PHM. Second, hospitalized children are more complex medically. As pediatrics has become more specialized, so too have surgical specialties, such that training does not include as in-depth pediatric patient management as it may once have. Finally, comanagement in PHM is a natural evolution of comanagement in adult hospital medicine settings, which is a widespread practice model.
This relatively new role for PHM providers is an ideal fit within existing hospitalist practice models. PHM providers are typically involved directly in hospital safety and systems integration. They provide value to institutions in patient care coordination, excelling in the management of medically complex patients. These patients typically have multiple subspecialists involved in their care, as well as a battery of hospital-based ancillary staff. PHM providers communicate well with families, nurses, and surgical and medical providers, integrating all of the input into patient management plans that focus on the needs of the patient and family. In addition, in hospitals where sentinel events have occurred among surgical patients, PHM providers and comanagement have been identified as the solution.
As a relatively recent addition to the PHM provider repertoire, surgical comanagement suffers from a paucity of literature describing its benefits and limits. In this review, a summary of both the authors’ experiences and published data are provided to outline the current state of surgical comanagement and to create a framework for presenting challenges and issues within the field.
What is comanagement and why is it increasingly common?
Traditional models of medical care for surgical patients involve consultation of medical providers if and when a need arises. Although this model may work in some situations, it is not optimal, because it can lead to missed diagnoses and poor quality care. In essence, by waiting for something to happen, an opportunity may have been missed to prevent patient harm. The solution to this issue is to bring medical providers into the care team early in the process, before any harm occurs. For example, in a child with a seizure disorder, it would be better for a medical provider to manage antiepileptic medications to prevent a seizure rather than consult someone after a seizure has occurred. The model that has emerged to provide medical care for surgical patients is one of comanagement between surgical and PHM providers.
According to the Society of Hospital Medicine (SHM), surgical comanagement is the “shared responsibility, authority, and accountability for the care of a hospitalized patient…[where] the patient’s surgeon manages the surgery related treatments and a hospitalist manages the patient’s medical conditions.” In theory, comanaging pediatricians promote valuable assets to institutions. These assets may include safety, by anticipating complications and preventing poor patient outcomes, availability for families and nurses by being present on the medical units, and resource allocation by allowing surgical colleagues to spend more time operating than managing admitted patients.
In reality, the benefit provided by pediatric hospitalist comanagement likely differs between targeted populations and routine use. Among pediatric patients receiving comanagement before and following surgery for neuromuscular scoliosis, length of stay was decreased in one study and unchanged in another. Among adult populations receiving comanagement before and following knee or hip replacement surgery, results also varied, with some studies showing decreased length of stay, complication rates, and mortality among comanaged patients, but others showing no such benefit. One study reported a subjective benefit to hospitalist comanagement of surgical patients, where nurses and surgeons both reported preferring the comanagement model for its delivery of prompt coordinated care. However, the same study failed to show a decrease in cost or mortality for co-managed patients. Finally, there is no evidence that surgeons’ time in the operating room increased in the context of comanagement.
Current state of comanagement in PHM
According to a recent informal survey of PHM providers conducted on the American Academy of Pediatrics Section on Hospital Medicine Listserve©, surgical comanagement represents a portion and not the whole of time spent in care of hospitalized patients (J. Schaffzin, unpublished data, 2013). Approximately one-third of respondents reported spending between 20% and 39%, and nearly half reported spending less than 20% of their clinical time in postoperative care ( Fig. 1 ). PHM providers who care for surgical patients do so mostly through consultation, with 92% of respondents reporting working in a consultative model, whereas 65% reported working in a comanagement model ( Fig. 2 ). In addition, PHM providers do not work alone in providing medical care to surgical patients. At free-standing hospitals and hospitals-within-hospitals, PHM providers most often collaborate with surgical residents and midlevel providers (eg, nurse practitioners) in addition to the attending surgeons, to provide care to surgical patients.
Establishing a surgical comanagement program
Although comanagement models provide what is thought to be quality medical care to surgical patients, comanagement may not be appropriate in all clinical settings. PHM providers may think they mediate well between different providers, but it is possible that in the instance of disagreement between medical and surgical providers, the family is left in the middle. In addition, when attending physicians take over care and work directly with each other, there is a potential for education of residents, particularly surgical residents, to suffer. It may be detrimental to withhold the experience of providing basic medical care to postoperative pediatric patients to future surgery attendings, because comanagement models may not be available in their future practices. On the other hand, exposure to hospitalists may enhance surgical residents’ learning, given the prominent role hospitalists play in resident education.
The American Medical Association, SHM, and the literature provide guidance for aspects desirable to include in comanagement models. There are 5 aspects to consider. The first is equity, whereby all stakeholders have a similar investment in and accountability for patient outcomes, and all share the responsibility of patient management. Second, each stakeholder has clearly defined and mutually agreed-on roles, ideally in the form of a comanagement agreement ( Table 1 ). Third, an equal exchange of information, education, and ideas among all providers is critical. Fourth, adequate staffing of PHM providers is necessary to ensure adequate coverage is provided for the patient volume seen. Finally, constant and open communication is required to develop and maintain the relationship between comanaging providers.
