Pediatric Hospitalist Programs Research Articles

A Survey Study of Motivators for Pediatric Hospitalists to Work in the Community.

The loss of pediatric beds in the community has contributed to decreased access to pediatric inpatient and emergency services. Community pediatric hospitalist programs could reduce the overhead of inpatient care, promoting the financial feasibility of caring for hospitalized children closer to home. This study aims to determine which career motivators are the most important for pediatric hospitalists to begin working in, remain in, and leave the community setting. A survey was sent to a convenience sample of 269 community hospitalists from 31 different sites. Sites were invited if the program director was known to the authors. Responses were evaluated and χ-square or Fisher's exact test were used to compare the differences. One hundred twenty six community pediatric hospitalists completed the survey (response rate 49.1%). The 3 most important motivators for pediatric hospitalists to begin working in the community were work-life integration (80%), geographic location (75%), and flexible hours (71%). Pediatric hospitalists who planned to leave the community setting were more likely to cite mentoring and teaching opportunities (76% vs 32%, P = .0002), opportunities for research and quality improvement (29% vs 10%, P = .021), and paid time for nonclinical interests (52% vs 26%, P = .02) as very important. This study demonstrates key motivators for pediatric hospitalists to work in the community and elucidates motivators for transitioning to larger pediatric centers. This knowledge may be used to guide community pediatric hospital medicine recruitment and program development that could lead to improved retention.

P0186 / #1642: MORTALITY REDUCTION BASED “ BABY JAGUAR “ QUALITY INITIATIVE AND PEDIATRIC ACUTE EXTENSIVE CARE IN PUBLIC HOSPITAL GUATEMALA

Aims & Objectives: Demostrate the impact of quality initiative to promote attention of pediatric acute patients admitted to pediatric intensive care unit and medical wards Hospital General San Juan de Dios in Guatemala City, Guatemala. Methods: Since 2014 in Pediatrics in Hospital General San Juan de Dios, a increase of admissions to PICU, improve attention based early recognition, rapid response team and acute patient approach outside the PICU. Crew resource management and quality assesment initiative were developed based respiratory therapist, pediatric hospitalist program, mechanical ventilation, monitoring and decison making widespread in wards as the same in PICU are promoted. Measure number of admissions and mortality per year. Results: Since 2014 the PICU increases the attention from 22 to 50 patients in Invasive or Non Invasive Ventilation and Acute Care based in Extensive Care and Rapid Response Team. A Simulation Center, the quality initiative “ Baby Jaguar “ allow the attention of more than 10,873 patients admitted since 2014 to 2019. The number of patients rises based in extensive care, deteriorating child approach and rapid response team. The crew with pediatrics residents, nurses, respiratory therapist, psychologist, nutritionist and pediatrics hospitalist reachs global reduction mortality of 36 % per year. (717 vrs 454). No intervention in construction or equipment; the main intervention was change the attention model. Conclusions: The pediatric acute care, deteriorating child and extensive care approach based in quality assurance improve the results in mortality based in monitoring, decision making and rapid response team in public hospital in resource strain public hospital

Newborn Care Curriculum: Newborn Medications.

Based on a 2014 newborn education needs assessment, 39.6% of surveyed pediatric hospitalists expressed interest in receiving more education on newborn medications, and 94% were interested in computer-based learning modules as the method of learning. Thus, this module was designed to serve as a self-study tool or as a tool for small-group teaching. Initially designed for pediatric hospitalists, the module can be used for any learner interested in newborn care as it is meant to provide practical applications to the bedside clinician. This module was first implemented as part of the multimodule Newborn Care Curriculum within the pediatric hospitalist division at Children's National Health System in Washington, DC, from May to June 2016. The module was well received, demonstrating an overall increase in learners' knowledge after completion of the module. Feedback from learners indicated that this learning tool met their overall needs. Eighty-three percent of learners agreed or strongly agreed that the material presented in the module would change their clinical practice, and 92% agreed or strongly agreed that the module increased their comfort with teaching. As pediatric hospitalist programs expand in their breadth of clinical roles, they also expand pediatric hospitalists' roles in newborn medicine. The results of the initial implementation of this module suggest that it is a useful tool to assist pediatric hospitalists with their evolving roles in newborn medicine and ultimately improve overall patient care delivery.

Pediatric Medication Safety in Adult Community Hospital Settings: A Glimpse Into Nationwide Practice.

Most children in the United States are treated in adult settings. Studies show that the pediatric population is vulnerable to medication errors. It can be extrapolated that children cared for in adult settings are at equal or higher risk for errors. The goal of this study was to assess the existing pediatric medication safety infrastructure within adult hospitals. Questionnaire developed through Research Electronic Data Capture (REDCap) and distributed to pediatric hospitalist programs listed on the American Academy of Pediatrics, Section on Hospital Medicine web site and members of the American Academy of Pediatrics Quality Improvement Innovation Networks listserv. There were >20 questions regarding the use of various safety measures and characteristics of the hospital. Thirty-eight program staff and 26 Quality Improvement Innovation Networks listserv members completed the survey (total = 64). Of these, 90.6% use order sets or computerized provider order entry with pediatric weight-based dosing, 79.7% review pediatric medication safety events or concerns, 58.7% were aware that their hospital had defined or documented maximum doses on orders, and 50.0% had milligram-per-kilogram dosing required to be in the order. A majority of respondents document weights only in the metric system (kilograms or grams) in both the emergency department and the pediatric unit (84.4% and 92.1%, respectively). A total of 57.8% of hospitals had pharmacists trained in pediatrics, with hospitals with >300 beds more likely to have a pediatric pharmacist than those with <300 beds (75% vs 44%, P ≤ .05). Pediatric medication safety infrastructure shows variations within the sites surveyed. Our results indicate that certain deficiencies are more widespread than others, providing opportunities for targeted, but hospital-specific interventions.

The Impact of Telemedicine Intensivist Support and a Pediatric Hospitalist Program on a Community Hospital

Because of centralization of care, pediatric patients often require transfer for subspecialty care. We evaluated the impact of telemedicine critical care consultation and a pediatric hospitalist program on enabling patients to remain at a community hospital. This is a retrospective chart review of pediatric patients at a community hospital receiving critical care consultation from a tertiary children's hospital from January 2006 to October 2009. Patient cohorts differed by modality of intensivist consultation (telephone versus telemedicine) and modality of inpatient ward care at the community hospital (primary care physician versus hospitalist). Patients were compared for differences in transfer rate and rate of diversion from the pediatric intensive care unit to the tertiary ward. One hundred fifty-three charts were analyzed: 41 from prior to hospitalist and telemedicine implementation (Cohort 1), 56 from post-implementation of telemedicine but pre-hospitalist program (Cohort 2), and 56 after implementation of both the telemedicine and hospitalist programs (Cohort 3). Baseline data did not differ among cohorts. Transfer rates after intensivist consultation were lower after implementation of telemedicine consultation (100%, 85.7%, and 87.5% in Cohorts 1-3, respectively; p=0.04). The proportion of transferred patients who were diverted to the tertiary ward decreased over time (19.5%, 14.5%, and 6.1% in Cohorts 1-3, respectively; p=0.003). Telemedicine consultation between pediatric intensivists and community hospital physicians combined with a pediatric hospitalist program at the community hospital has the potential to improve triage of pediatric patients and reduce the need to transfer patients.

Survey of academic pediatric hospitalist programs in the US: Organizational, administrative, and financial factors

Many pediatric academic centers have hospital medicine programs. Anecdotal data suggest that variability exists in program structure. To provide a description of the organizational, administrative, and financial structures of academic pediatric hospital medicine (PHM). This online survey focused on the organizational, administrative, and financial aspects of academic PHM programs, which were defined as hospitalist programs at US institutions associated with accredited pediatric residency program (n = 246) and identified using the Accreditation Council for Graduate Medical Education (ACGME) Fellowship and Residency Electronic Interactive Database. PHM directors and/or residency directors were targeted by both mail and the American Academy of Pediatrics Section on Hospital Medicine LISTSERV. The overall response rate was 48.8% (120/246). 81.7% (98/120) of hospitals reported having an academic PHM program, and 9.1% (2/22) of hospitals without a program reported plans to start a program in the next 3 years. Over a quarter of programs provide coverage at multiple sites. Variability was identified in many program factors, including hospitalist workload and in-house coverage provided. Respondents reported planning increased in-house hospitalist coverage coinciding with the 2011 ACGME work-hour restrictions. Few programs reported having revenues greater than expenses (26% single site, 4% multiple site). PHM programs exist in the majority of academic centers, and there appears to be variability in many program factors. This study provides the most comprehensive data on academic PHM programs and can be used for benchmarking as well as program development.

Community Pediatric Hospitalists Providing Care in the Emergency Department

Community hospital pediatric inpatient programs are being threatened by current financial and demographic trends. We describe a model of care and report on the financial implications associated with combining emergency department (ED) and inpatient care of pediatric patients. We determine whether this type of model could generate sufficient revenue to support physician salaries for continuous in-house coverage in community hospitals. Financial productivity and selected performance indicators were obtained from a retrospective review of registration and billing records. Data were obtained from 2 community-based pediatric hospitalist programs, which are part of a single health system and included care delivered in the ED and inpatient settings during a 1-year period from July 1, 2008, to July 1, 2009. Together, the combined programs were able to generate 6079 total relative value units and collections of $244,828 annually per full-time equivalent (FTE). Salary, benefits, and practice expenses totaled $235,674 per FTE. Thus, combined daily revenues exceeded expenses and provided 104% of physician salary, benefits, and practice expenses. However, 1 program generated a net profit of $329,715 ($40,706 per FTE), whereas the other recorded a loss of $207,969 ($39,994 per FTE). Emergency department throughput times and left-without-being-seen rates at both programs were comparable to national benchmarks. Incorporating ED care into a pediatric hospitalist program can be an effective strategy to maintain the financial viability of pediatric services at community hospitals with low inpatient volumes that seek to provide 24-hour pediatric staffing.

Consultative pediatrics in the new millenium

The pediatric hospitalist program at the Children's Hospital of Pittsburgh (CHP)-the Diagnostic Referral Service (DRS)-was first described in the pediatric literature in 1988. At that time, the group consisted of 5 members with a variety of inpatient and outpatient responsibilities. Since then, there has been a significant nationwide growth in pediatric hospital medicine. In the same time frame, the DRS has also grown significantly, with new and enhanced responsibilities in both the inpatient and outpatient settings. This work reflects on the recent trends in pediatrics that resulted in the growth of specialists in hospital medicine and in the evolution of the DRS responsibilities. A detailed description of the unique changes in the DRS is provided as a model for effective care of children in the modern era.

In response to: Characteristics of Pediatric Hospital Medicine Fellowships and Training Program

We applaud the Pediatric Hospital Medicine fellowship directors for their collaboration in the development of core competencies that can be applied to all pediatric hospitalist programs. We found wide variability in the structure and requirements of the programs and believe that the establishment of core competencies will likely be of benefit in bringing greater uniformity and structure to curricula in the training programs. Regarding the findings of the survey undertaken by Dr. Manicone, we believe a few issues deserve clarification and may lead to different conclusions. First, Dr. Manicone asked program directors to try to determine which of the deidentified programs in our tables were most likely to be their own program. We are unable, as is he, to infer how many, if any, were able to guess correctly. If a program director guessed incorrectly, undoubtedly they would, by definition, feel their program was not represented accurately. Second, our study was conducted in early 2007, and his 2 years later. It is possible, even likely, that some of these programs have modified their training during that time period. This may be one reason a program director might believe the description of their program is inaccurate at this time. Third, Dr. Manicone notes that he was not the program director of the Children’s National Medical Center at the time of the survey and was not interviewed by our research team. It is certainly possible that the program directors of several other medical centers may have also changed since the time of our study. If that is the case, it would not be surprising that new program directors might characterize specific components of their training programs in different ways than the program directors we interviewed. Finally, and perhaps most importantly, due to the newness and small size of the fellowship programs in our study, many directors reported that some requirements (especially for administration and research training) are made uniquely on a fellow-by-fellow basis. Allowing a trainee to tailor a program to fit his or her specific needs creates a unique and hopefully ideal learning experience for the fellows. However, this does not translate into specific fellowship requirements or opportunities as a whole. Hopefully, the core competencies can address these discrepancies, to the benefit of future trainees. We believe this final point is illustrated clearly by the results of the survey conducted by Dr. Manicone. The program attributes in the article rated as most accurately depicted in his study were the assigned clinical duties and billing independence. These were often the only clearly proscribed requirements articulated by a program director during our interviews. In contrast, other program requirements, including formal research training, often were identified as being determined on a case-by-case basis, according to the needs of the fellow, without firm expectations or requirements.

Assessing the Value of Pediatric Hospitalist Programs: The Perspective of Hospital Leaders

There has been a rapid increase in the number of pediatric hospitalist programs in the United States. As most pediatric hospitalist services are believed to be subsidized by hospitals, gaining a better understanding of the rationale for these subsidies is critical to the future success and existence of these programs. Our objective was to determine the rationale for pediatric hospitalist program subsidies from the perspective of hospital leaders. A survey was mailed to hospital executives from a national sample of 112 hospitals between October 2007 and February 2008. The overall response rate was 69% (N = 77). Twelve hospitals no longer used hospitalists to provide care for children, leaving 65 hospitals for the analysis. The majority of hospital leaders indicated they subsidize their pediatric hospitalist program (78%, n = 51) and the average proportion subsidized was 49% of program costs. The majority of hospitals (82%, n = 40) do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate their program will be able to cover its costs. Hospital leaders provided a broad rational for this subsidization but most commonly cited the nonmonetary benefits of patient (83%, n = 39) and referring physician satisfaction (81%, n = 38) as reason for their investment. Despite the fact that most pediatric hospitalist programs are unable to cover their costs, the majority of hospitals plan to continue subsidizing these programs. Discussions of the value added by hospitalists should not presume that hospital investment in hospitalist programs is based on monetary benefits alone.

Newborn Care by pediatric Hospitalists in a Community Hospital

To describe financial outcomes and physician productivity associated with the inclusion of well-newborn services in a pediatric hospitalist program in a community hospital. Retrospective review of professional billing records and physician activity logs for newborn and inpatient care, consultations, and procedures. Pediatric hospitalist program in a community hospital during a 24-month period from August 1, 2002, through July 31, 2004. Newborn care. Financial productivity. Pediatric hospitalists provided daily rounds and on-call services for inpatients and newborns with an average daily census of 3.1 inpatients and 7.9 newborns. Annual work relative value units production was 1508, and gross charges were $162,920 per staffed full-time equivalent. With mean work relative value unit production of 13.8 relative value units per day and average payment rates of $45 per total relative value unit, professional fees from inpatient and newborn care ($873 per day) did not cover salary, benefit, and practice expenses ($1460 per day), necessitating hospital support to cover annual program deficits of $206,744. Without the professional fees derived from newborn care, annual program deficits would have been $345,100, or $95,861 per staffed full-time equivalent. Community hospital pediatric hospitalist programs with dedicated 24-hour staffing and a low inpatient census can be expected to operate at a substantial financial deficit if hospitalist care is limited to inpatient care and procedures. Financial performance of these programs may be improved by expanding the role of the pediatric hospitalist to include newborn care.

Characteristics of the Pediatric Hospitalist Workforce: Its Roles and Work Environment

Over the past 10 years, the use of hospitalists has grown in both the adult and pediatric setting as a response to pressure to deliver cost-effective, high-quality care. However, there is a paucity of information regarding the variation in the clinical roles, educational responsibilities, work patterns, and employment characteristics of pediatric hospitalists. This lack of information hampers efforts to define the nature of the field and determine whether any formalized, additional training or experience should be required for physicians in this clinical practice domain. We conducted a telephone survey of a national sample of pediatric hospitalist program directors (n = 116). Questionnaire items focused on exploring the clinical roles, work patterns, employment characteristics, and training of pediatric hospitalists within each institution. Results were stratified by teaching hospitals, urban/rural location, hospital size, and membership in the National Association of Children's Hospitals and Related Institutions. The response rate was 97%. The majority of hospitals surveyed (70%) reported that hospitalists do not generate enough income from professional billing to pay their salaries. Fewer than half (39%) of respondents reported that their hospital measures pediatric clinical outcomes associated with hospitalist care. A total of 42% of hospitalist program directors reported that most of their hospitalists had an average duration of employment of <3 years. In programs with residents, hospitalists serve as teaching attendings for pediatric patients in almost all cases (89%). Hospital medicine is a rapidly growing enterprise. A better understanding of both its participants, as well as those affected by its practice, will enable planning for a future that meets as many needs as possible while ensuring the best possible care for children.

Headache in Pediatric Patients

Dr. Gladstein is Associate Professor of Pediatrics and Neurology, University of Maryland School of Medicine, and Director, Pediatric Headache Clinic and Pediatric Hospitalist Program, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201; E-mail: [email protected]. The author has disclosed that he is/was a member of the speakers bureaus of GlaxoSmithKline and Pfizer, Inc. The author also has disclosed that the use of triptans in the treatment of pediatric migraine as discussed in this article has not been approved by the U.S. Food and Drug Adminisration. Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.

Redefining the Community Pediatric Hospitalist

The use of pediatric hospitalists in community hospitals has increased over the past decade in response to the desire to provide high-quality pediatric care. Many hospitals are challenged to create financially independent and productive programs. To evaluate an alternative approach to traditional community hospital pediatric care of having pediatricians work in a combined pediatric Emergency Department (PED)/inpatient unit. Franklin Square Hospital Center converted its pediatric hospitalist program from a traditional inpatient with partial Emergency Department (ED) coverage program to one that covers a combined PED/inpatient unit. Outcome categories were compared between the year before opening, 2003, to the year after, 2004. Measures included total part B billing, overall patient satisfaction scores for the PED and inpatient unit from the Press Ganey patient satisfaction survey, perception of wait times and time to admission, and risk-adjusted inpatient length of stay (ALOS). Part B billings from the 5.5 Full Time Equivalent (FTE) pediatric hospitalists increased 82% from increased 61% from 2003 to 2004, from 1,631,583 dollars in 2003 to 2,967,715 dollars in 2004 as a result of increased volume of ED patients seen by pediatricians. The mean inpatient satisfaction score did not significantly change, 75.7 in 2003 and 79.0 in 2004 (P = 0.432), but the mean PED score significantly increased from 75.8 to 83.4 (P = 0.0001). Mean scores of the efficiency measures on the survey increased for PED patients, with the mean score for wait time to treatment increasing from 62.0 to 75.3 (P < 0.0001). Total throughput time through the ED improved significantly as well from 143 minutes to 122 minutes (P = 0.0003). Risk-adjusted length of stay performance did not change; for calendar year 2003, the mean monthly ALOS was 1.883 (95% range 1.503, 2.263), compared with a 2004 mean monthly ALOS of 1.869 (95% range 1.523, 2.216). Implementation of a combined PED/inpatient unit was associated with increased billing by hospitalists, increased satisfaction scores of ED patients, and decreased ED throughput times. Pediatric hospitalist programs that want to improve financial and patient outcomes in a community setting could consider adopting the combined unit approach.

Guiding Principles for Pediatric Hospitalist Programs

Pediatric hospitalist programs have become increasingly popular recently, emulating the growth and success of adult hospitalist programs. This statement provides an overview of hospitalist programs, factors influencing their growth, and their expected benefits. Six guiding principles for the establishment of pediatric hospitalist programs are identified in this statement concerning voluntary referrals; local design; minimum physician-training requirements; arrangement for appropriate follow-up; communication among primary care physicians, subspecialists, and hospitalists; and data collection and outcome measurements.

How pediatric hospitalist programs can affect graduate medical education.

How pediatric hospitalist programs can affect graduate medical education.

Communication helps reduce risks for hospitalists, PCPs

![Figure][1] Dr. Maggioni While pediatric hospitalist programs earn high marks for quality of care and patient satisfaction, concerns about disruptions in the continuity of care persist. Risk managers advise those participating in hospitalist systems to take steps to reduce the

Evaluation of an Innovative Pediatric Hospitalist Program in an Academic Health Sciences Centre in Toronto, Canada

Evaluation of an Innovative Pediatric Hospitalist Program in an Academic Health Sciences Centre in Toronto, Canada

Establishing a pediatric hospitalist program at an Academic Medical Center.

Academic medical centers have been challenged to respond to a rapidly changing and increasingly competitive health care environment. The Pediatric Consultation and Referral Service (PCRS) at Rainbow Babies & Children's Hospital (RB&C)/University Hospitals of Cleveland was established in 1993 with the goal of providing rapid access to community-based physicians for the referral of patients requiring urgent hospitalization within the broad scope of general pediatrics. We describe our initial 3-year experience in the planning, implementation, and evaluation of a pediatric hospitalist program. PCRS provided care to 2,740 patients during the first 3 years of operation, 63% (1,716) of whom were under age 3 years. Leading primary diagnoses in order of decreasing frequency were asthma, pneumonia, bronchiolitis, febrile illness, gastroenteritis, seizures, croup, apnea, and cellulitis. Third-party payer mix was: Medicaid 42%, managed care 42%, indemnity insurance 10%, self-pay 6%, and Bureau for Children with Medical Handicaps 1%. From survey data, referring physicians and pediatric residents assessed perceptions of access, collegiality, and quality of care in a highly favorable manner. Subspecialty colleagues perceived access and collegiality very favorably but rated quality of care substantially lower than referring physicians and residents did. Our experience demonstrates that a pediatric hospitalist program is logistically and economically feasible and may contribute to the patient care, education, and research missions of academic medical centers. A well-structured program can provide community physicians with excellent access and support collegial relationships. Beyond increasing a medical center's patient referral base, a hospitalist program can potentially enhance the esteem of the discipline of general pediatrics and, it is hoped, promote general pediatrics as a viable career option for trainees.