Trust-building in pediatric hospital medicine discharge.

Recommendations for Minimum Residency Training Requirements in Pediatric Hospital Medicine.

How Should Pediatric Residents Prepare for a Career in Pediatric Hospital Medicine?

Training the Next Generation of Pediatrician-Advocates: A New Focus on the Inpatient Setting.

SECTION ON HOSPITAL MEDICINE LEADERSHIP AND STAFF

In 2018, pediatric hospitalists at several New England institutions established a regional pediatric hospital medicine conference to facilitate collaboration and communication of advances in the field of pediatric hospital medicine. Planning committee members were recruited from pediatric hospital medicine programs from all six New England states, including multiple community sites, to ensure adequate representation and breadth of impact. The first conference was held in person in June 2019 in Boston, Massachusetts, and contained a full day of original content, including several concurrent lectures and workshops, a keynote address, a poster session, and a clinicopathological conference sponsored by Massachusetts General Hospital. Supported by favorable feedback from >100 attendees of the first conference, the planning committee decided to establish the New England Pediatric Hospital Medicine (NEPHM) conference thereafter as an annual event. While we were planning the NEPHM 2020 conference, the novel coronavirus disease 2019 (COVID-19) became a global pandemic. After surveying members of the planning committee and the conference speakers, we elected to change the format of the conference to an entirely Web-based platform.Various forms of virtual delivery have been successfully used in health care1,2 and medical education.3 Although there is some precedent for online health care conferences,4 organizing an entirely virtual forum was a novel and unfamiliar process for the planning committee. We describe here our experience with this transition and the challenges and opportunities it presented, including feedback from participants and presenters.By early 2020, the planning committee had already completed the call for lecture and workshop proposals, and a final schedule for the in-person conference had been determined on the basis of a blinded peer review process. Once the format change was approved, the conference planners had just 2 months to prepare for transitioning to an online platform. All speakers were contacted to determine if they would be willing to convert their lectures or workshops to a virtual format. On the basis of their feedback, the planning committee decided to pursue a condensed 1-day online conference program, the format of which generally mirrored the structure of a typical in-person medical conference.One of our regional institutions with significant experience delivering online content, University of Massachusetts Memorial Children’s Medical Center, hosted the conference on their Zoom platform (Zoom Video Communications, Inc, San Jose, CA) and closely coordinated with their local information technology support. There were three separate Zoom rooms (A, B, and C), each independently moderated by a pediatric hospitalist, as well as a fourth room (Zoom room D) staffed by an administrator who helped with logistic questions and technical difficulties during the day. Zoom room A served as the venue for the large group plenary sessions, including the welcoming remarks, keynote address, and the COVID-19 discussion panel. The remainder of the activities were hosted in rooms B and C. Throughout the day, participants could maneuver between concurrent lectures in the three Zoom rooms. During lunch, the rooms were restructured as breakout networking sessions with focused discussions on three different topics: medical education, research and quality improvement initiatives, and pediatric hospitalist fellowships and board certification. All sessions were recorded and available to registrants online for later viewing, and presenters and participants provided their feedback via an online survey in the weeks after the conference. Registration fees were reduced to reflect the decreased costs of online content while still being able to offer continuing medical education credits.The innovative platform of a virtual conference provided several advantages over the traditional in-person setting with respect to cost, flexibility, inclusivity,5 and expanded reach. Without the typical costs associated with food and venue reservations, we were able to provide a 75% reduction in the registration fee. Participants could view the content from the comfort of their homes or offices without the inconveniences of traveling or parking. One participant viewed the conference from a “vacation home,” another did so from their primary home while “watching two kids,” and a different participant was able to listen to the audio during “commuting time.” The flexibility of an online platform also allowed for incorporation of new and timely content, such as a lecture on remote virtual medical education techniques and a COVID-19 discussion panel with several national experts. Participants could also choose to join select live sessions or view the entire day of content. Furthermore, we were able to broadcast the conference content to a much wider audience. The NEPHM 2019 conference was attended by 101 registrants, 96% of whom were from the six New England states. In contrast, the NEPHM 2020 virtual conference had 155 registrants, and less than half (44%) were from the New England region, with broad representation from a total of 32 states across the United States. The majority of participants indicated that the NEPHM 2020 conference was the first virtual academic medical conference they had ever attended, and 99% of attendees found the online platform to be effective in delivering the conference content.Despite these advantages, hosting the conference virtually presented some unique challenges. The original in-person conference included eight didactic lectures and eight workshops. Six of the original workshops were postponed because the presenters felt audience participation would be limited in the virtual setting. Two of the original lectures were also postponed, and two lecture topics were changed. Several presenters felt the online structure would “hinder the ability to engage participants” and make it “challenging to do an interactive session,” such as a debate between two pediatric infectious disease hospitalists. The lectures and workshops eventually presented were converted to a virtual format, and the two workshops had to “cut back on some interactive portions.” For instance, a workshop discussing ethical dilemmas was ultimately presented as a didactic lecture, and the presenters solicited comments from the larger group in the chat box rather than breaking out into small group discussions as originally intended. Because of limited planning time, we also had to postpone the poster session and the clinicopathological conference until next year’s conference.Furthermore, video conferences lack the face-to-face networking interactions and casual conversations that provide personal satisfaction among conference participants. These serendipitous encounters often encourage future collaboration.6,7 One participant noted that they missed conversing “one-on-one during breaks as you would in a live conference.” Presenters also found participants harder to engage and, as one presenter stated, “not as talkative as they may have been in person.” Attendees were reluctant to turn on their video cameras or unmute themselves to ask questions or participate in discussions. This made the lunch networking sessions particularly challenging and sometimes minimally interactive. Both presenters and attendees noted that participation would be improved if groups were kept small and participants were required to be visible on camera. Some presenters used virtual avenues to improve participation, such as the thumbs up button to show support or the chat box to solicit questions. One speaker used an audience response system with multiple choice questions to facilitate the discussion of infectious disease cases, and another used virtual breakout rooms to discuss the management of challenging clinical scenarios in small groups. Although hardly a substitute for the physical presence of an in-person conference, expanded use of these digital modalities could help improve the interactive component of virtual meetings.Although all conferences require technical expertise and troubleshooting, the success of our virtual conference required intensive preparation, including the testing of speakers’ Internet connections, practice runs of all presentations, and redundant sources of remote technical support during the live conference. Fortunately, we did not experience significant technical difficulties, and our extensive preparations ensured a problem-free conference day.Despite our relative inexperience with virtual technology in this setting and an abbreviated planning time, we were able to complete a well-received conference, which conveniently delivered pediatric hospital medicine–related educational content to a broader audience with basic information technology support and nominal registration fees. Additional planning time and increased familiarity with virtual conference tools will address many of the limitations we encountered.After attending the NEPHM 2020 conference, 30% of our registrants preferred an all-virtual future conference and 52% would opt for a hybrid conference with the option to attend in person or participate virtually. Regardless of the length of the pandemic, we now see virtual platforms, at least in part, as the way of the future for continuing medical education activities. Further experience using technology to encourage audience interaction should broaden the scope of presentations going forward.We greatly appreciate the contributions of the members of the NEPHM 2020 Conference Planning Committee, including Abigail Adler, MD, The University of Vermont Children’s Hospital; Amanda Begley, MD, Connecticut Children’s Medical Center; Jamie Fey, MD, The Barbara Bush Children’s Hospital at Maine Medical Center; Lindsay Fox, MD, Tufts Children’s Hospital; Ilyssa Greenberg, DO, Baystate Children’s Hospital; Samantha House, DO, MPH, Children’s Hospital at Dartmouth-Hitchcock Medical Center; Elizabeth Hutton, MD, Boston Medical Center; Matthew Lorenz, MD, Hasbro Children’s Hospital; Allison Mariani, MD, Newton-Wellesley Hospital, Massachusetts General Hospital for Children, and St Elizabeth’s Medical Center; and Patricia Stoeck, MD, Boston Children’s Hospital.

Pediatric hospital discharge processes across the United States are rife with inadequacies. More than 5.8 million US pediatric hospital discharges are completed yearly,1 and many children and their families experience problematic discharge processes. Deficiencies in discharge processes include detrimental variations in care2,3; miscommunication among care team members, including families and outpatient pediatricians2,4; fragmented care transitions5–7; and non–patient-centered discharge communication.8 These system failures are associated with more errors,6,9,10 hospitalization beyond medical necessity,3 increased health care costs,3 increased readmissions,11,12 increased wait times,13 and decreased patient satisfaction.14,15 In an effort to address these challenges on a national scale, The Joint Commission, the Centers for Medicare & Medicaid Services, and other national organizations have encouraged legislation to improve hospital discharge quality.16–19Before we can begin to improve hospital discharges, we must first start with a standard definition. Several authors have attempted to define hospital discharge. In this article, we present 2 interpretations that we believe bring an inclusive, macrolevel perspective, thereby supporting broader and more thorough improvement. Waring et al20 defined discharge as “the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community or domestic environments. Reflecting this, hospital discharge is not an end point, but rather one of multiple transitions within the patient’s care journey.” Berry et al21 added, “rather than existing simply as a transient clinical event that occurs as the child and family leave the hospital, the pediatric discharge process is best conceptualized…as a set of care processes to be executed throughout the child’s full hospital course.” We use these definitions to guide the present discussion of high-quality discharge processes. These definitions establish the understanding that discharge has extensive impacts throughout the care continuum and allow for a comprehensive application of quality definitions.Health care experts have devised a variety of interventions to address the gaps in discharge process quality, many of which are described here, but no single strategy exists that wholly optimizes discharge. A more comprehensive approach to discharge process improvement will require elements of various strategies to be used together. In 2001, the Institute of Medicine (now the National Academy of Medicine [NAM]) Committee on the Quality of Health Care in America released Crossing the Quality Chasm, a report addressing the array of health care quality problems evident in modern American medicine.22 The committee declared that health care should be safe, efficient, effective, timely, patient centered, and equitable (Table 1). The quality domain framework constructed by NAM has been used to inform nearly 2 decades of improvement efforts but has not previously been applied holistically to discharge processes. In the current article, we present an inpatient-focused framework to define high-quality discharge processes using the NAM quality domains, explain how discharge processes connect to the system-wide delivery of high-quality care, and synthesize solutions relevant to the individual NAM domains. We also present our concept of “the discharge bridge,” describing how discharge processes holistically connect hospital care with all other modes of care delivery and how the adherence to high-quality discharge practices can carry patients across this bridge.Safe discharge processes may prevent errors of omission and commission during care transitions.22 Errors are common during and after hospital discharge, and they are often preventable.5 Checklists are a successful component of patient safety, with broad applications across health care for avoiding errors, and are used as a standardized approach to safety on the basis of foundational principles in human factors engineering.23,24 Incomplete discharge processes can significantly increase the risk of postdischarge adverse events; thus, the discharge process is an ideal candidate for improvement with checklists.5Discharge checklists are associated with fewer unmet needs after discharge, and published checklists were created using expert consensus and evidence-based practices associated with improvements in outcomes.25,26 Soong et al26 proposed a checklist of safe discharge practices for adult hospital patients that included 7 categories with guidance on when particular tasks should occur. Although this list was made with adult patients in mind, it could be modified for local pediatric needs. Additionally, the Society of Hospital Medicine adapted Project BOOST (Better Outcomes by Optimizing Safe Transitions) for the pediatric population and renamed it Pedi-BOOST. The authors provided a series of checklists, including general assessments of socioeconomic, behavioral, cultural, linguistic, and educational barriers to safe discharge; risk assessments of medical and holistic complexity; and recommendations regarding responses to barriers and systems to delineate task responsibility.27 Checklists similar to those of Soong et al and Pedi-BOOST can be used to deliver care to individual patients and to inform system-wide policies on hospital best practices. These checklists can be incorporated into the electronic health record (EHR) to improve reliability and expanded as needed. Any such improvement must be designed with human factors engineering principles in mind to effectively balance potential benefits with potential drawbacks, such as unnecessary detail or time burdens.Although the checklist itself is valuable, it has limitations, and a multidisciplinary approach to the exploration of local barriers likely contributes to successful implementation. Checklists are a safety net in the discharge process and do not intrinsically lead to the growth of systems required to track or prevent safety events. They should not be considered comprehensive or as a replacement for clinical judgment, especially in the case of patients with medical complexity.28 In their landmark study on surgical safety checklists, Haynes et al24 noted that the implementation of checklists often requires significant systems changes and that their success is not exclusively due to the avoidance of omission errors alone. The checklist itself will not improve care; it is a tool that invites the discovery of barriers to safety while supporting adherence to safety principles and procedures going forward. This exploration of barriers can inform the creation of new processes, show areas of weakness in current processes, and encourage process standardization. This exploration may be particularly effective for patients with medical complexity for whom polypharmacy and medication reconciliation are essential during transitions of care.29Efficient discharge processes avoid the unnecessary use of limited resources across the spectrum of care.22 Srivastava et al3 found that unnecessary delays in hospital discharge make up 8.9% of total hospital costs and 9% of pediatric hospital days. Initiation of discharge planning on admission can shorten length of stay (LOS) and thus improve efficiency.14 Although early initiation of discharge planning can be implemented in a variety of ways, we will discuss the roles of clinical pathways, discharge criteria, and collaboration with case managers.In the context of improving discharge processes, both clinical pathways and discharge criteria can support efficient discharge planning. Ideally, this planning begins immediately after admission with a focus on what must be achieved to facilitate discharge and to identify barriers and necessary steps along the way. Clinical pathways have a decades-long history of reducing variability in care and LOS, leading to more streamlined and efficient care.30,31 More recently, objective, patient-specific criteria describing medical readiness for discharge, with a supportive EHR infrastructure, have been built upon this work by using diagnosis-specific medical benchmarks to indicate discharge readiness.2,32 When discharge criteria are combined with classic clinical pathways, the care team, patients, and families gain a high-level understanding of hospital trajectory, which allows them to anticipate hospital courses and supports the reduction of unnecessary practice variation and LOS.Researchers have found that early use of multidisciplinary rounds with case managers to address postdischarge needs can shorten overall LOS.33 Additionally, they have shown that starting individualized discharge planning by investigating specific patient needs on admission can reduce overall LOS.14 If barriers to discharge, such as delayed arrangement of medical equipment, home nursing, or medications, are addressed early in an admission, patients may not need to wait for these issues to be resolved once they are medically ready for discharge.Although initiating early discharge planning can reduce practice variation and LOS, an additional benefit is that the entire care team is encouraged to focus on discharge and its barriers throughout the admission. By focusing on discharge, care teams can establish shared expectations with families for discharge goals.21,26 Because family expectations are an often-cited reason for delay, engagement with families early in the admission is important for creating a shared outlook on discharge trajectory.34,35 When discharge planning is well executed and the discharge itself is efficient, patients do not experience diminished quality or safety of care.36Effective discharge processes support the continuation of recommended care after discharge.22 The American Academy of Pediatrics published guidelines on the notification of primary care physicians (PCPs) regarding their patients’ status upon hospital discharge to facilitate effective handoffs and care transitions.37 Despite these guidelines, verbal communication between clinicians and PCPs is infrequent,7,38 the availability of discharge summaries is low,7 and the quality of discharge summaries and handoffs varies.39 Additionally, the majority of adult patients cannot recall what medications they are on, what their medications are for, the side effects associated with their medications, or their own diagnoses.10 Thus, it is unsurprising that significant portions of patients experience medical errors because of discontinuity from inpatient to outpatient settings6 and that the availability of discharge summaries at outpatient follow-up visits is associated with lower rates of readmission.40 Patients, their families, and their PCPs must understand hospital management decisions and postdischarge responsibilities to obtain the best possible outcomes after discharge.Families often describe the difficulty of processing new information during the hospital-to-home transition, emphasizing the need to improve communication methods with patients and families when building effective discharge processes.41 The teach-back method of communication is a useful tool for improving the quality of discharge education with a focus on closing the loop between clinicians and patients to increase patients’ understanding of the disease information communicated to them. Teach-back communication occurs when clinicians ask patients to repeat back key aspects of their care (eg, “Can you tell me how you will take these medications?”) to ensure understanding.11 Teach-back communication is used to explore and confirm a person’s understanding, not to test knowledge, and to provide personalized education without under- or overexplaining topics.11 This method is associated with improvements in medication adherence, patient self-management, and lower rates of readmission and can be used to teach families about diagnoses, appointments, and medications.11,12,18Clinicians must also improve their communication processes with PCPs by focusing on the content, method, and timeliness of information delivery. Tension between the priorities of PCPs and hospitalists is driven in part by a lack of standardization of the method of and indications for communication, and PCPs have emphasized the importance of accurate and timely discharge communication from clinicians in delivering high-quality patient care.39,42 Several research groups across the country have succeeded in improving discharge communication through quality improvement (QI) methods with multidisciplinary collaboration and process standardization.38,43,44 Common individual-level key drivers that contributed to communication improvement among these groups included timely and individualized feedback for hospital-based clinicians, financial incentives, support from leadership and their multidisciplinary team, and stakeholder buy-in. Common system-level key drivers that contributed to communication improvement among these groups were process automation with EHR integration, communication process standardization, assignment of discharge communication responsibility, and data transparency. Although 1 group used a national, multidisciplinary QI collaborative with local champions, the others reported benefits from instituting local QI projects.44 Future researchers might explore various communication approaches, including direct PCP discussion, EHR messaging, and virtual conferencing. By partnering with both families and their PCPs to teach how to best manage the child’s health after discharge, we create greater opportunities to ensure successful completion of treatment plans.Timely discharge processes prevent delays in care delivery, allowing more patients to receive the care they need quickly.22 Sluggish discharge processes have downstream effects throughout the hospital system, reducing hospital capacity and increasing wait times for patients in the hospital and those awaiting transfer from outside hospitals.13,15,45–47 Late afternoon discharge of patients who were medically ready for discharge in the morning creates bottlenecks early in the day for patients in the emergency department and the postanesthesia care unit, for those awaiting transfer from outside hospitals,13,15,45–47 and for those who need admission early in the day.48 The discovery of barriers to morning discharge, sometimes driven by the implementation of time-of-day discharge goals, is fundamental to shifting the traditional late-afternoon discharge to a morning discharge for patients who are medically ready and can reduce ambulance diversion, emergency department wait times and boarding, and postanesthesia care unit wait times. Time-of-day discharge goals are associated with increased hospital capacity and reduced LOS.13,15,45,47,49,50The focus of improvement efforts should be on patients who could have been discharged earlier in the day but stayed for nonclinical reasons.47,51 If organizations choose to implement time-of-day discharge goals, the pursuit must be balanced with the understanding that there are clinical cases where it is inappropriate to discharge patients in the morning, that medical readiness is always required, and that evening discharges are sometimes examples of timely care. Pediatric clinicians are well acquainted with scenarios where a patient is not ready for discharge until evening, such as infants admitted with fever awaiting negative culture results or slowly improving oral intake in a patient with dehydration. These patients are not the focus of time-of-day discharge initiatives, and improvement efforts should instead concentrate on ways to facilitate early morning discharges in appropriate patients, not simply to set a deadline. Any incentivization of clinicians to discharge patients early in the morning must not inadvertently encourage clinicians to keep patients hospitalized for another night to satisfy the early discharge metric. Improvement efforts should instead be aimed at eliminating barriers to discharging patients as soon as they are medically ready.The successful exploration of barriers to timely morning discharge depends on barrier assessments and multidisciplinary stakeholder involvement. Time-of-day discharge or discharge when medically ready goals are not inherently valuable in themselves; value comes from the associated investigation into barriers and implementation of workflow changes that come while instituting the goal. Because every hospital system is unique, timely discharge implementation must begin with investigation of the barriers to achieving this goal. Such an investigation can be done informally, using guidance based on stakeholder experience,52 or formally, using Lean health care management,47,50 process mapping, and Ishikawa (fishbone) diagrams.34 Multidisciplinary communication is a frequent reason for discharge delay,34,35,53 and successful interventions typically have a component that focuses on care team member communication.47,50,51,54 Researchers have found particular success with standardized multidisciplinary huddles throughout the day with physicians, nurses, social workers, and case managers collaborating to identify potential early discharge patients. Afternoon huddles build a unified view of the clinical status of the patient and promote early recognition of the action items needed to facilitate early discharge on the next day.47,50,51,54Other significant barriers to timely discharge include delayed discharge order entry and an unplanned approach to the order that patients are seen on rounds.47,50,51,55 Groups that rounded on early discharge patients first and encouraged discharge order entry during rounds showed improvement in early discharge rates.47,50,51,55 Overnight teams may be able to facilitate early discharge by beginning discharge preparation during their shift. These workflow changes can be encouraged at an institutional level through provider education, feedback, and incentivization.Patient-centered discharge processes support the provision of empathetic, individualized, trauma-informed care.22 Patients and their caregivers often describe hospitalization as “a fog,” where the emotional toll of hospitalization and the communication practices of clinicians lead to difficulty with processing information.41 In discussing care transitions, when clinicians do not use compassionate and empathic language, anticipate home needs, or plan for discharge collaboratively, caregivers felt that their care was unsafe and that they were deserted by the health care system.56 In 1993, Gerteis et al57 outlined several dimensions of patient-centered care that were then adapted by NAM in Crossing the Quality Chasm.22 These dimensions include information sharing, communication between patient and clinician, and patient education, as well as respect for patients’ values, preferences, and expressed needs. At the core of patient centeredness is the clinician’s responsiveness to the patient’s individual personhood and the patient’s understanding that the health care team cares for him or her as a person.56To provide patient-centered discharge care, clinicians must engage patients and their families in the discharge planning process with compassion and empathy. The end of the inpatient hospitalization concludes an intense and sometimes emotionally traumatic experience, and particular attention should be paid to addressing this emotionally traumatic experience, and particular attention should be paid to addressing this trauma throughout the hospital course.. Marsac et al58 discussed a variety of tools to support pediatric health systems in providing trauma-informed care. At the core of trauma-informed care is the acknowledgement of the presence of emotional trauma in health care and its impact on children and families and the promotion of methods of reducing the trauma of receiving care. Patients and their families possess varying preferences on communication styles and shared decision-making, and clinicians must seek to understand these preferences so that they can deliver care in accordance with them. Additionally, clinicians must seek out and incorporate their patient’s values so decisions can be made together with the family. For example, some parents of children with complex chronic conditions prefer to complete the last portion of the healing process at home compared with others who would rather stay in the hospital. Patients and their families can have varying preferences regarding the style of discharge teaching, forms of communication, and level of involvement in the process. As such, clinicians may benefit from collaborative communication techniques, where a common set of goals and a complete understanding of differing perspectives among patients and clinicians are established.59 Feudtner59 wrote that collaborative communication “aims to be produced or conducted by two or more parties working together,” and that it “emphasizes the relationships between people, viewing interpersonal communication and relationships as inexorably entwined.”Equitable discharge processes support all patients, regardless of their background or individual needs.22 The concept of health equity has evolved since NAM released Crossing the Quality Chasm, and several authors have suggested their own contemporary views on the definition of health equity. Braveman et al60 explained that “health equity means that everyone has a fair and just opportunity to be as healthy as possible” and that “equity is not the same as equality. To equalize opportunities, those with worse health and fewer resources need more efforts expended to improve their health.” Current efforts in health equity are focusing on moving beyond simply providing consistent care regardless of the background of a patient and recognizing that equalizing the quality of care provided may require different approaches and levels of support for different patients. Intersectionality, diverse cultural backgrounds, and social determinants of health can be unique barriers to the delivery of high-quality care that may require varied approaches by clinicians.61 Directed self-reflection and exploration of implicit biases are often prerequisites to clinicians providing equitable care. To provide equitable care, clinicians must rely on their patient-centered communication and the discovery of patient needs, backgrounds, and desired outcomes of care.In the context of hospital discharge, equitable care is individualized to patient and family needs. Both patient- and family-level characteristics, such as language proficiency, health literacy, or and community characteristics, such as the availability of can have an on the success of discharge. care is provided when discharge information is communicated in a that patients and their families can understand and when the postdischarge of patients are For example, health is associated with rates of and for chronic with limited often receive discharge in the language and on safety at Additionally, health is associated with adherence errors after discharge To address these clinicians must ensure that their discharge information is by individual patients. Because is to an appropriate level in the language for discharge can support care that different patients and families may require different interventions to their desired must also incorporate the of their patients outside the hospital into planning for a high-quality discharge. is associated with lower rates of PCP follow-up and of medications, and patients often describe medication and as barriers to discharge plan Although hospital-based clinicians may supporting patients in these barriers no can be made without first that these barriers Pedi-BOOST standardized on these barriers and how to and case managers are experts in these areas and can provide Common strategies that support patients include medication and arrangement for follow-up with physicians the patient’s must seek out information regarding the of their patients outside the hospital to care for patients who require more is a to discharge processes exclusively as hospital based in the between inpatient and outpatient care. we that hospital discharge exists as its own hospital care and other of care delivery The the discharge begins from within the of the inpatient stay and across the of care, just as discharge processes start when a patient is admitted to the hospital and care after they the preparation that was done while in the hospital the patient and family the between the hospitalization and the care and on to the next in their care is the ideal to hospital and the entire hospitalization should be on achieving this goal. The of the various high-quality discharge processes outlined in our framework build the support and that to carry a patient and family across the Because discharge processes have such a broad with extensive effects they have an on the quality of care throughout the care By the NAM in the context of discharge, clinicians how the is what it and how to approach efforts to this our is to describe a holistic of discharge that high-quality discharge processes based on the NAM and discharge as a unique of the care to be We have described some current initiatives, but for gaps in the regarding the and impacts of specific discharge is safe, efficient, effective, timely, patient centered, and and these individual and support the delivery of high-quality care throughout the health By using this clinicians can more their current practices and focus their improvement This approach to discharge process improvement on the effective solutions while understanding the application of quality definitions to discharge. To discharge care with our definitions of high-quality hospital discharge, we must the greater context of our patients’ the entire care The discharge hospital, and needs as patients the discharge

Background:Pediatric hospital medicine is the most rapidly growing site‐based pediatric specialty. There are over 2500 unique members in the three core societies in which pediatric hospitalists are members: the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA) and the Society of Hospital Medicine (SHM). Pediatric hospitalists are fulfilling both clinical and system improvement roles within varied hospital systems. Defined expectations and competencies for pediatric hospitalists are needed.Methods:In 2005, SHM's Pediatric Core Curriculum Task Force initiated the project and formed the editorial board. Over the subsequent four years, multiple pediatric hospitalists belonging to the AAP, APA, or SHM contributed to the content of and guided the development of the project. Editors and collaborators created a framework for identifying appropriate competency content areas. Content experts from both within and outside of pediatric hospital medicine participated as contributors. A number of selected national organizations and societies provided valuable feedback on chapters. The final product was validated by formal review from the AAP, APA, and SHM.Results:The Pediatric Hospital Medicine Core Competencies were created. They include 54 chapters divided into four sections: Common Clinical Diagnoses and Conditions, Core Skills, Specialized Clinical Services, and Healthcare Systems: Supporting and Advancing Child Health. Each chapter can be used independently of the others. Chapters follow the knowledge, skills, and attitudes educational curriculum format, and have an additional section on systems organization and improvement to reflect the pediatric hospitalist's responsibility to advance systems of care.Conclusion:These competencies provide a foundation for the creation of pediatric hospital medicine curricula and serve to standardize and improve inpatient training practices. Journal of Hospital Medicine 2010;5(4)(Suppl 2):82–86. © 2010 Society of Hospital Medicine.

Pediatric hospital medicine is the most rapidly growing site-based pediatric specialty. There are over 2500 unique members in the three core societies in which pediatric hospitalists are members: the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA) and the Society of Hospital Medicine (SHM). Pediatric hospitalists are fulfilling both clinical and system improvement roles within varied hospital systems. Defined expectations and competencies for pediatric hospitalists are needed. In 2005, SHM's Pediatric Core Curriculum Task Force initiated the project and formed the editorial board. Over the subsequent four years, multiple pediatric hospitalists belonging to the AAP, APA, or SHM contributed to the content of and guided the development of the project. Editors and collaborators created a framework for identifying appropriate competency content areas. Content experts from both within and outside of pediatric hospital medicine participated as contributors. A number of selected national organizations and societies provided valuable feedback on chapters. The final product was validated by formal review from the AAP, APA, and SHM. The Pediatric Hospital Medicine Core Competencies were created. They include 54 chapters divided into four sections: Common Clinical Diagnoses and Conditions, Core Skills, Specialized Clinical Services, and Healthcare Systems: Supporting and Advancing Child Health. Each chapter can be used independently of the others. Chapters follow the knowledge, skills, and attitudes educational curriculum format, and have an additional section on systems organization and improvement to reflect the pediatric hospitalist's responsibility to advance systems of care. These competencies provide a foundation for the creation of pediatric hospital medicine curricula and serve to standardize and improve inpatient training practices.

OPEN ACCESSJuly 20, 2009Pediatric Hospital Medicine Elective Jennifer Walthall, MD, FAAP, FAAEM, Michele Saysana, MD, FAAP, Jeffrey Sperring, MD, FAAP Jennifer Walthall, MD, FAAP, FAAEM Indiana University School of Medicine Google Scholar More articles by this author , Michele Saysana, MD, FAAP Indiana University School of Medicine Google Scholar More articles by this author , Jeffrey Sperring, MD, FAAP Indiana University School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.3160 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractPediatric hospital medicine is a relatively new field in pediatrics and has seen rapid expansion in community and academic hospitals. Residents in training are often exposed only to modeling of clinical aspects of hospital medicine and are also time limited in the ability to experience the administrative components, quality improvement, transitioning of care, and opportunity for procedures in which practicing hospitalists must have competency for daily practice. Thus, we created this pediatric hospital medicine elective to provide upper-level residents with exposure to the various roles of pediatric hospitalists. This pediatric hospital medicine elective curriculum includes goals and objectives for the rotation; a novel elective menu that allows for individualized learning; a calendar of events for residents that includes administrative meetings, preparation time for team didactics, and protected time for clinical pathway development; coding and billing pre- and posttests; a billing and coding lecture series; a procedural sedation introductory lecture; reading materials; an advocacy project for the ward; and mentoring session worksheets. During the first 6 years of our pediatric hospital medicine service, there was minimal resident exposure to the paradigm and no formal training venue for those interested in pursuing this career. We did a needs assessment survey in our residency to determine if residents wanted more exposure to what pediatric hospitalists do. Our residents responded that they were interested in pediatric hospital medicine as a specialty, would participate in a hospital medicine elective, and thought that hospital medicine was important to patient care. Thus, we developed this resource. On the basis of learner feedback from focus groups, which had 100% participation, we have modified this curriculum to incorporate detailed description of the menu options, as well as expanded the procedural sedation component. Educational Objectives By using this resource, learners will be able to: Define and demonstrate the clinical and administrative responsibilities of a pediatric hospitalist, including, but not limited to, attention to length of stay, quality inpatient indicators, family and patient satisfaction, team communication, referring physician satisfactory transition of care, and current evidence-based pediatric practice.Bill, code, and document as pediatric hospitalists.Demonstrate evidence of developing a lifelong learning plan.Demonstrate proficiency in completing an academic project, which can include continuing quality improvement, formal academic didactics, research, or clinical pathway/protocol development.Demonstrate the ability to advocate for patients and families by focusing on family health care needs and systems-based improvements. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Evaluation Exit.doc Coding and Billing I.ppt Coding and Billing II.ppt Coding and Billing III.ppt Advocacy Sample.doc Pediatric Hospitalist Rotation for House Staff.doc Template Exit Letter.doc Ward Advocacy Evaluation.doc Transitioning Care Phone Script and Evaluation.doc Sample Calendar.pub Pediatric Procedural Sedation I.ppt Ward Advocacy.pub Gastroenteritis Order Set.doc Hospitalist Menu.pub Pediatric Hospital Medicine Menu Item Description.doc Pediatric Hospital Medicine Post test.doc Pediatric Hospital Medicine Pre test.doc Gastroenteritis order set.doc Template exit letter.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationWalthall J, Saysana M, Sperring J. Pediatric Hospital Medicine Elective. MedEdPORTAL. 2009;5:3160. https://doi.org/10.15766/mep_2374-8265.3160 Copyright & Permissions© 2009 Walthall et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-Share Alike license.KeywordsForms and Records ControlHospitalsBilling and CodingHospitalistsDocumentation Disclosures None to report. Funding/Support None to report. Prior Presentations Pediatric hospital medicine resident education: sharing experience with a novel pilot curriculum. Presented at: Pediatric Academic Society Meeting; May 2007. Loading ...

To our knowledge, no widely used pediatric standards for hospital discharge care exist, despite nearly 10 000 pediatric discharges per day in the United States. This lack of standards undermines the quality of pediatric hospital discharge, hinders quality-improvement efforts, and adversely affects the health and well-being of children and their families after they leave the hospital. In this article, we first review guidance regarding the discharge process for adult patients, including federal law within the Social Security Act that outlines standards for hospital discharge; a variety of toolkits that aim to improve discharge care; and the research evidence that supports the discharge process. We then outline a framework within which to organize the diverse activities that constitute discharge care to be executed throughout the hospitalization of a child from admission to the actual discharge. In the framework, we describe processes to (1) initiate pediatric discharge care, (2) develop discharge care plans, (3) monitor discharge progress, and (4) finalize discharge. We contextualize these processes with a clinical case of a child undergoing hospital discharge. Use of this narrative review will help pediatric health care professionals (eg, nurses, social workers, and physicians) move forward to better understand what works and what does not during hospital discharge for children, while steadily improving their quality of care and health outcomes.

Pediatric hospitalist (PH) presence is rapidly increasing, yet little is known about pediatric resident exposure to hospitalists, or how this affects resident education/career decisions. To determine resident exposure to pediatric hospitalists; examine resident opinions regarding hospitalists' roles; examine resident opinion of hospital medicine career training needs; explore how resident exposure to hospitalists affects career choices. Survey of random sample of 300 residents from the American Academy of Pediatrics Section on Residents database. Two-hundred seventy-nine pediatric residents surveyed; 120(43%) responded with variance by question; 90% work with hospitalists during residency. Of this national sample, 82% cite hospitalists as enhancing education. A majority (64%) believe pediatric hospitalists are better than primary care physicians at caring for complex inpatients; 28% felt PH provided better care for routine admissions. Over one-third surveyed are considering a career in Pediatric Hospital Medicine (PHM); 7% plan to enter the field upon graduation. Residents cited opportunities to participate in education, flexible hours, and better salaries as the top 3 reasons to become a hospitalist. Ten percent felt there was no difference between resident and hospitalist positions; 21% see PHM as a short-term job without long-term potential. Of residents entering Primary Care, a majority (59%) stated that the availability of hospitalists would positively influence their choice of a practice position; 7% said they were "less likely to choose to practice Primary Care Pediatrics because of hospitalists." PH have a role in physician training. While PHM has become a career consideration for trainees, more work needs to be done to improve the perception of PHM as a viable long-term career.

References 1992 Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 1993 Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 1994 ### 1.1. Structure and Membership of the Writing Committee Members of the Writing Committee included experienced clinicians and specialists in cardiology, cardiac rehabilitation, quality improvement, outcomes research, epidemiology, and performance measures (PMs) methodology, as well as patient advocates. The Writing Committee also included representatives from the American Association for Cardiovascular and Pulmonary Rehabilitation (AACVPR), the American Academy of Family Physicians (AAFP), the American Medical Association–Physician Consortium for Performance Improvement (AMA-PCPI), the American Nurses Association (ANA), the American Society of Health-System Pharmacists (ASHP), the National Committee for Quality Assurance …

Quality Improvement Research in Pediatric Hospital Medicine and the Role of the Pediatric Research in Inpatient Settings (PRIS) Network

# PRO: Subspecialty status is the optimal path for PHM {#article-title-2} Is it time for pediatric hospital medicine (PHM) to become a full-fledged subspecialty? Yes! The Accreditation Council for Graduate Medical Education (ACGME) defines a subspecialty as “That which provides advanced GME in a narrow field of study within a medical specialty, eg, geriatric medicine within the field of internal medicine.” In addition, many authorities feel that a robust research agenda may be the sine qua non of a subspecialty. Does PHM meet these definitions? In April 2010, the Pediatric Hospital Medicine Core Competencies were published as a supplement in the Journal of Hospital Medicine , codifying our contribution to advanced graduate medical education. Of course the words you are reading reside in the inaugural issue of Hospital Pediatrics, the only official American Academy of Pediatrics (AAP)–sponsored journal other than the flagship Pediatrics . While quality improvement literature from pediatric hospitalists has been appearing in journals such as Pediatrics and the Journal of Hospital Medicine the volume of research has reached a point where a specific journal for pediatric hospitalists is now viable. Surveys of pediatric hospitalists show that we are interested in research, but we need more skills and mentors. Where will these come from? We must create them in fellowships. Not every pediatric hospitalist has to be fellowship trained (look at the current state of pediatric emergency medicine), but we need a core of clinician investigators who can expand our knowledge and add to the evidence base of inpatient pediatrics. There can be no doubt that care in pediatric and neonatal intensive care units and emergency rooms has improved dramatically since the advent of these subspecialties. While the current generation of pediatric hospitalists is actively engaged in quality improvement in local, regional, and national venues, the discipline will not truly advance until we can begin generating new knowledge by …

During transitions between sites of care, clinicians must build trust with colleagues to make decisions that ensure safe, high-quality care. This study explored factors that could influence trust between outpatient clinicians and pediatric hospitalists when children are referred for hospital admission. We conducted an analysis of 41 semistructured interviews with outpatient clinicians and pediatric hospitalists from May 2020 through October 2021 across three healthcare systems participating in a multisite comparative effectiveness study of pediatric direct and emergency department admissions. Qualitative interviews. A conceptual model for trust between outpatient clinicians and pediatric hospitalists during hospital admission referral. Interviews were professionally transcribed, verified for accuracy, and analyzed using a combination of inductive and deductive. We identified two primary domains: (1) interpersonal trust and (2) trust-by-proxy. Interpersonal trust included five relational factors that influenced collaboration between clinicians: antecedent relationships, confidence in others clinical abilities, understanding others' practice culture, recognition of available resources, and power dynamic. An individual clinicians' assessment of risk and past clinical experiences also influenced trust during clinical decision-making. Trust-by-proxy represented system-level factors that could influence trust, independent of any pre-existing relationships, including communication infrastructure, guidelines and protocols, the organizational culture, and professional courtesy. Interpersonal and system-level factors influence trust between outpatient clinicians and hospitalists during decision-making encounters. System-level factors may serve as a proxy for trust when clinicians do not have pre-existing interpersonal relationships. These factors could be explored as an explicit target of interventions to improve interdisciplinary collaboration and decision-making between hospitalists and primary care clinicians.