Pediatric hospitals are not appropriate for adult admissions

Abstract

The transition literature raises the issue of the importance that youth with special health care needs/disabilities be transferred to adult health care settings. However, this ideal is a difficult reality to achieve. Experts have identified a number of barriers that prevent the expected transfer to adult health settings that include lack of providers with necessary expertise to provide care to adults with childhood acquired illnesses, lack of adequate reimbursement, reluctance by adult providers to serve special needs populations, and time constraints (Geenen et al., 2003Geenen S.J. Powers L.E. Sells W. Understanding the role of health care providers during the transition of adolescents with disabilities and special health care needs.Journal of Adolescent Health. 2003; 32: 225-233Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, McDonagh et al., 2000McDonagh J.E. Southwood T.R. Ryder C.A. Bridging the gap in rheumatology.Annals of the Rheumatic Diseases. 2000; 59: 86-93Crossref PubMed Scopus (16) Google Scholar, Patterson and Lanier, 1999Patterson D. Lanier C. Adolescent health transitions Focus group study of teens and young adults with special health care needs.Family and Community Health. 1999; 22: 43-58Crossref Scopus (55) Google Scholar, Scal, 2002Scal P. Transition for youth with chronic conditions primary care physicians’ approaches.Pediatrics. 2002; 110: 1315-1321PubMed Google Scholar). Other issues identified include family and consumer reluctance to leave pediatric specialist and lack of insurance coverage (Betz and Redcay, 2002Betz C.L. Redcay G. Lessons learned from providing transition services to adolescents with special health care needs.Issues in Comprehensive Pediatric Nursing. 2002; 25: 129-149Crossref PubMed Scopus (32) Google Scholar, Hauser, 1999Hauser E.D.L. Transitioning adolescents with sickle cell disease to adult-centered care.Pediatric Nursing. 1999; 25 (496–497.): 479-488PubMed Google Scholar, Telfair et al., 1994Telfair J. Myers J. Drezner S. Transfer as a component of the transition of adolescents with sickle cell disease to adult care. Adolescent, adult, and parent perspectives.Journal of Adolescent Health. 1994; 15: 558-565Abstract Full Text PDF PubMed Scopus (91) Google Scholar). Although the limitations of providing services to adults with childhood acquired chronic illnesses in pediatric settings have been acknowledged, there has been limited discussion about the very real problems of providing care to adults in pediatric settings. It is worthwhile to examine the problems and pitfalls of providing care to adults in pediatric settings that conflict with the established principles of care that have distinguished the scope of practice for populations of adults in contrast to those for children. To begin with, interdisciplinary pediatric health care providers, including pediatric nurses, do not have the needed training or clinical experience to provide comprehensive care to adults with childhood acquired chronic illnesses. Pediatric nurses have specialized expertise to provide nursing care to children and their families. However, this expertise does not extend to providing nursing care to adults with chronic conditions who continue to receive care in pediatric hospitals. Pediatric nurses are experts in developing and implementing plans of nursing care for children with chronic conditions, but not for adults with childhood acquired chronic illnesses. Quite simply, it is erroneous to consider adults as grown children, as their physiology is vastly different from children. The adult norms are different from children, ranging from vital signs and laboratory values to physiologic responses to illness. The variations in adult disease symptomology have been and are widely acknowledged as so very different from children, that systems of health care for children and adults have been organized as separate systems to respond optimally to the needs of each population. Health care professionals are trained very differently depending on their chosen area of specialty and age groups. Specialty practice for adults and children requires two very different approaches to training, each with their own unique didactic content and clinical practicums. For example, it would be highly problematic for a nurse with medical surgical expertise to rotate to a pediatric unit and provide care to acutely ill children without adequate didactic and clinical training. A closer examination of the consequences of hospitalizing an adult in a pediatric facility reveals a number of logistical problems and thorny issues. For starters, a pediatric hospital setting is decorated in a juvenile fashion to create a developmentally appealing environment. Cartoon figures, toys and bold, bright colors typify the hospital surroundings, certainly not an environment entirely suitable for a hospitalized adult. The furnishings, fixtures, toilets, sinks, baths and showers are sized for children. The usual supplies taken for granted for children’s use such as bedpans, emesis basins, and toothbrushes may not be available or be of appropriate size for adults. Most pediatric rooms do not have showers, thereby lessening the privacy of adults for bathing. The nightgowns are sized and designed for children bodies. In some pediatric units, there are no call buttons enabling adults to indicate their needs for assistance. Adults needing assistance with ambulation may require walkers, harnesses that are not usually found in pediatric facilities. There are limited quantities of supplies and available equipment sized for adults. Meals, both in portion and selection, are geared to the preferences of children. All forms of media such as the televisions, computer stations, video and DVD players contain content that is developmentally appropriate for children and not for adults. Adults require doses of medications vastly different than children. Reliance on physicians and nurses who are long accustomed to prescribing and administering pediatric doses creates the potential risk of not administering right doses because of lack of experience/familiarization in providing medications to adults. Adults require other forms of comfort and intervention that are not readily accessible in pediatric facilities. Sources of comfort include access to other adults with whom to share concerns, access to social workers and psychologists with expertise in issues of concern with adults. Pediatric nurses are accustomed to interacting with children that require different styles of communication in contrast to adults. The consequences of inexperience in working with adults can result in inadequate responses to patients needs. For example, pediatric nurses may be less familiar with adult symptoms of pain. Adults may be less demonstrative of their pain needs than children resulting in insufficient pain relief measures. Another challenge in caring for adults in pediatric facilities are the problems associated with care coordination. Generally, pediatric providers are not knowledgeable of adult resources available for adults following hospitalization such as physical therapists, home care, insurance programs, and other health care resources. All patient literature and hospital forms are written for the pediatric audience-children and their families. Patient education literature is written at grade levels appropriate to children and/or the needs of parents and/or primary caregivers and with juvenile themes and format style. The issue of adult care provided in pediatric settings warrants attention. Addressing this problem effectively begins with identifying the scope of the problem. Further investigation is needed to 1) identify the extent of the number of adults now provided care in pediatric facilities; 2) learn directly from consumers about their experiences, both positive and negative; 3) identify successful models that have addressed the issue of transferring adults to pediatric facilities and, most importantly, 4) develop and implement cost effective service models. Sustaining care to adults with childhood-acquired conditions in the pediatric health care system is a flawed service model. Adults with acquired childhood conditions are not provided the level of comprehensive care that they require, as there are obvious gaps in services. Quite simply, there are good reasons why adults stop going to pediatricians, so why would we expect any less for this population of adults who have special health care needs?