Pediatric hospitalists are increasingly common in community hospitals and are playing increasingly important roles. Scope of practice and staffing models vary significantly by program. Unique aspects of small pediatric hospital medicine programs in hospitals with limited pediatric subspecialty and surgical support are discussed, including clinical and logistic considerations, training needs, and advocacy roles.
Key points
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Pediatric hospital medicine (PHM) programs are now commonplace in community hospitals with medium-sized to large pediatric inpatient services and vary significantly based on local needs and resources.
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Clinical capabilities of Community Hospital Pediatric Hospital Medicine (CHPHM) programs depend on the hospitalists’ skill sets, nursing expertise, subspecialist and surgeon availability, and proximity to neonatal and pediatric critical care services.
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CHPHM programs create value by increasing quality, satisfaction, and efficiency while reducing costs, but are not financially self-supporting based on professional fee revenues.
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Training needs for community hospitalists reflect the diversity of clinical practice with an emphasis on procedural competency.
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CHPHM programs have a responsibility to advocate for children’s interests throughout the hospital through participation on key committees and nurturing of key liaison relationships.
Background
Terminology and Overview
This article uses the term pediatric hospitalists in community hospitals or the shorter term community hospitalists to identify pediatricians who practice the discipline of PHM in general, nonuniversity, nonchildren’s hospitals. Community Hospital Pediatric Hospital Medicine programs are referred to as CHPHM programs. Although other entities, most notably the Medical Group Management Association, may use the terms community and academic to distinguish between different management models for compensation and productivity surveys, this article explicitly avoids the term academic hospitalists in favor of pediatric hospitalists in university or children’s hospitals. This language has been carefully chosen to avoid the implication that PHM programs in community hospitals are necessarily nonacademic. In addition, this article focuses on community hospitals with limited pediatric resources and the challenges community hospitalists face caring for children without the infrastructure and support of a tertiary care referral center or a complete pediatric department, regardless of whether that department is housed in a larger community hospital, a children’s hospital within a hospital, or a free-standing children’s hospital.
Growth of CHPHM Programs
Tracking the number of pediatric hospitalists currently practicing in community hospitals is problematic. The Kid’s Inpatient Database uses descriptors of children’s versus nonchildren’s hospitals, and separately classifies hospitals by size (small, medium, or large). There is no comprehensive national database of community hospitals with pediatric services. Similarly, pediatric hospitalists lack a unique subspecialty identifier (such as subboard certification or eligibility), and all hospitalist data are self-reported. Estimates of the growth of pediatric hospitalists in community hospitals are largely extrapolated from growth of the PHM community in general and by anecdotal observations of leaders in the field. Overall, the author believes that CHPHM programs have grown in frequency similar to the growth of adult hospital medicine programs in general and PHM programs at children’s and university hospitals, but firm data are lacking. The key distinguishing feature between adult and pediatric hospital medicine programs in community hospitals is that every adult hospital is large enough to support a hospitalist; this is not the case in pediatrics. In rural community hospitals with small inpatient pediatric services, office-based general pediatricians still cover the hospital on-call, attend deliveries, consult in the emergency department (ED), and manage their own inpatients without benefit of hospitalists.
The most recent American Academy of Pediatrics (AAP) Section on Hospital Medicine (SOHM) survey indicates that 31% of respondents work in community hospitals (17% in hospitals with limited or no pediatric subspecialty and surgical services, 8% in community hospitals with significant services, and 6% in hospitals with nearly complete pediatric services). The increasing importance of pediatric hospitalists in community hospitals is recognized by the creation of (1) a community hospitalist subcommittee within the AAP SOHM beginning in about 2010, (2) a specific community hospitalist track at the annual PHM 20XX meeting beginning 2013, and (3) dedicated community hospitalist seats on both the AAP SOHM Executive Committee and the Joint Council of Pediatric Hospital Medicine also in 2013.
Variability of CHPHM Programs
CHPHM programs vary widely in terms of size, scope of practice, available resources, coverage models, and nonclinical duties, including teaching of house staff and medical students, as well as other learners. All programs share a common focus of care of the hospitalized child on the general pediatric ward, but from there it varies greatly. Table 1 lists different potential responsibilities for pediatric hospitalists in community hospitals. The ability of the community hospitalists to multitask across settings and services adds value to the local pediatric services. CHPHM programs are often established to enable smaller hospitals to continue to provide local pediatric inpatient care in the face of trends to hospitalize children at children’s hospitals and larger community hospitals. CHPHM programs are not profitable in and of themselves. They are mission driven, not margin driven. The individuals working in these settings need to be comfortable functioning independently, triaging simultaneous clinical demands, and working in different parts of the hospital. It is a source of both frustration and satisfaction, and makes practice in smaller community hospitals unique compared with the narrower range (but admittedly higher acuity) of practice in larger community hospitals, university hospitals, and children’s hospitals.
| Area | Comments |
|---|---|
| General pediatric ward | Core activity |
| Well-baby nursery | Frequent activity, particularly for unassigned newborns |
| Labor and delivery | Newborn resuscitation skills are key |
| Step-down unit/intermediate care | Often intermediate level of care within a general pediatric unit |
| Neonatal intensive care unit | Typically for after-hours coverage only |
| Pediatric intensive care unit | Only in larger community hospitals, after-hours coverage only |
| Emergency department | As consultant or potentially as primary provider |
| Other | Sedation, consultant for diagnostic dilemmas, occasional outpatient follow-up |
Background
Terminology and Overview
This article uses the term pediatric hospitalists in community hospitals or the shorter term community hospitalists to identify pediatricians who practice the discipline of PHM in general, nonuniversity, nonchildren’s hospitals. Community Hospital Pediatric Hospital Medicine programs are referred to as CHPHM programs. Although other entities, most notably the Medical Group Management Association, may use the terms community and academic to distinguish between different management models for compensation and productivity surveys, this article explicitly avoids the term academic hospitalists in favor of pediatric hospitalists in university or children’s hospitals. This language has been carefully chosen to avoid the implication that PHM programs in community hospitals are necessarily nonacademic. In addition, this article focuses on community hospitals with limited pediatric resources and the challenges community hospitalists face caring for children without the infrastructure and support of a tertiary care referral center or a complete pediatric department, regardless of whether that department is housed in a larger community hospital, a children’s hospital within a hospital, or a free-standing children’s hospital.
Growth of CHPHM Programs
Tracking the number of pediatric hospitalists currently practicing in community hospitals is problematic. The Kid’s Inpatient Database uses descriptors of children’s versus nonchildren’s hospitals, and separately classifies hospitals by size (small, medium, or large). There is no comprehensive national database of community hospitals with pediatric services. Similarly, pediatric hospitalists lack a unique subspecialty identifier (such as subboard certification or eligibility), and all hospitalist data are self-reported. Estimates of the growth of pediatric hospitalists in community hospitals are largely extrapolated from growth of the PHM community in general and by anecdotal observations of leaders in the field. Overall, the author believes that CHPHM programs have grown in frequency similar to the growth of adult hospital medicine programs in general and PHM programs at children’s and university hospitals, but firm data are lacking. The key distinguishing feature between adult and pediatric hospital medicine programs in community hospitals is that every adult hospital is large enough to support a hospitalist; this is not the case in pediatrics. In rural community hospitals with small inpatient pediatric services, office-based general pediatricians still cover the hospital on-call, attend deliveries, consult in the emergency department (ED), and manage their own inpatients without benefit of hospitalists.
The most recent American Academy of Pediatrics (AAP) Section on Hospital Medicine (SOHM) survey indicates that 31% of respondents work in community hospitals (17% in hospitals with limited or no pediatric subspecialty and surgical services, 8% in community hospitals with significant services, and 6% in hospitals with nearly complete pediatric services). The increasing importance of pediatric hospitalists in community hospitals is recognized by the creation of (1) a community hospitalist subcommittee within the AAP SOHM beginning in about 2010, (2) a specific community hospitalist track at the annual PHM 20XX meeting beginning 2013, and (3) dedicated community hospitalist seats on both the AAP SOHM Executive Committee and the Joint Council of Pediatric Hospital Medicine also in 2013.
Variability of CHPHM Programs
CHPHM programs vary widely in terms of size, scope of practice, available resources, coverage models, and nonclinical duties, including teaching of house staff and medical students, as well as other learners. All programs share a common focus of care of the hospitalized child on the general pediatric ward, but from there it varies greatly. Table 1 lists different potential responsibilities for pediatric hospitalists in community hospitals. The ability of the community hospitalists to multitask across settings and services adds value to the local pediatric services. CHPHM programs are often established to enable smaller hospitals to continue to provide local pediatric inpatient care in the face of trends to hospitalize children at children’s hospitals and larger community hospitals. CHPHM programs are not profitable in and of themselves. They are mission driven, not margin driven. The individuals working in these settings need to be comfortable functioning independently, triaging simultaneous clinical demands, and working in different parts of the hospital. It is a source of both frustration and satisfaction, and makes practice in smaller community hospitals unique compared with the narrower range (but admittedly higher acuity) of practice in larger community hospitals, university hospitals, and children’s hospitals.
| Area | Comments |
|---|---|
| General pediatric ward | Core activity |
| Well-baby nursery | Frequent activity, particularly for unassigned newborns |
| Labor and delivery | Newborn resuscitation skills are key |
| Step-down unit/intermediate care | Often intermediate level of care within a general pediatric unit |
| Neonatal intensive care unit | Typically for after-hours coverage only |
| Pediatric intensive care unit | Only in larger community hospitals, after-hours coverage only |
| Emergency department | As consultant or potentially as primary provider |
| Other | Sedation, consultant for diagnostic dilemmas, occasional outpatient follow-up |
Clinical issues
Unique Aspects of Small Community Hospital Programs
CHPHM programs demonstrate significant more variability than the traditional resident teaching service at children’s and university hospitals. Larger community hospitals with larger volumes may have multiple hospitalists assigned to the inpatient unit at a time or may have one hospitalist assigned to the inpatient unit and another to the ED/urgent care or well-baby nursery (WBN). In smaller community hospitals, a single hospitalist may be simultaneously responsible for the general pediatric ward, the WBN, and ED consultations. Maryland hospital regulations permit shared ED and inpatient pediatric units. These units are designed to accommodate both short- and long-term ED visits/observation stays, as well as short inpatient stays. Nurses and physicians working in these units must be skilled and comfortable managing both patient populations. The flexible staffing and common physical space create efficiencies and economic savings more than what separate inpatient and outpatient (ie, ED) units would offer and allow these community programs to continue to provide low-acuity inpatient pediatric services instead of automatically transferring out any child who requires hospitalization.
For CHPHM programs in which a single pediatrician covers the entire hospital, flexibility is required to manage simultaneous demands. This situation requires the aptitude and ability to triage requests effectively and the flexibility for other team members to expand their practice beyond their usual role. For example, when a hospitalist is attending a delivery for fetal distress, most other responsibilities have to wait. But if there is a child acutely decompensating in the ED while the hospitalist is attending an elective C-section, perhaps the ED physician can manage the child in the ED until the pediatrician arrives or an appropriately trained nurse can recover the newborn and the hospitalist can leave the delivery room (DR). On-call backup from home in the form of another hospitalist, a neonatologist, or a community pediatrician may also be part of contingency planning.
Subspecialty and Surgical Resources
Hospitalist staffing considerations have less impact on patient selection for community hospitals than does the availability of pediatric subspecialty and/or surgical resources. Community hospitals should develop admission, discharge, and transfer (ADT) criteria collaboratively and proactively with PHM program leadership, surgical and subspecialty representatives, and nursing leadership to address likely scenarios. For example, should the community hospital perform a barium enema to attempt to diagnose and reduce on intussusception, or should such patients be referred to a tertiary care center where an air contrast enema could be performed? Without a pediatric surgeon, what is the lower age limit for appendectomies by a general adult surgeon? Similar questions can be asked of medical subspecialists. When pediatric subspecialty and surgical expertise is readily available at a nearby hospital, local standards of care typically direct most subspecialty care to tertiary care centers. In more rural settings where pediatric expertise is several hours away, adult trained physicians may of necessity be more comfortable and experienced caring for younger children. The availability of pediatric hospitalists to comanage the general medical care of pediatric patients contributes additional comfort for adult providers. Telemedicine can further augment the ability of rural community hospitals to deliver more expert pediatric inpatient care.
Patient Acuity and Intermediate Care
Acuity is the other main concern driving patient selection. For hospitals without a pediatric intensive care unit (PICU), patient admission to a community hospital may depend on the ability of the hospital to provide intermediate level care. Intermediate level care is most appropriate for patients in whom there is potential for deterioration, but the likelihood is low. It includes cardiorespiratory monitoring and intermediate nursing staffing ratios. The definition refers to a level of care and not a geographically defined unit such as a step-down unit. Intermediate level care may be provided on a general pediatric ward or in a PICU. Criteria for intermediate care should be determined in advance of admission by program leadership including nursing and not on the fly, after-hours, by junior personnel.
Intermediate level care is certainly appropriate for hospitalists to initiate in the ED. These patients may be quickly transferred to a tertiary care hospital with a PICU if their status does not rapidly improve and the referral hospital is nearby. Alternatively, in more rural settings where transfer to referral centers involves greater distances, hospitalists may choose to provide intermediate level care on the ward for a longer period before transferring patients, as long as the child’s initial status meets predefined physiologic parameters, the patient’s status does not worsen, and the duration of intermediate care therapy does not exceed predefined limits. Sample criteria frameworks are highlighted in Table 2 .
