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PHM15: Physical Burnout for Hospitalists
Presenters: Allison Ballantine and Lisa Zaoutis
Physician burnout can be thought of as similar to water level in a reservoir during a drought – there is an imbalance between usage and replenishment. This leads to physician exhaustion, cynicism, and inefficiency. Burnout is a function of both the individual (younger, single, and less resilient are at higher risk) and the environment (high job demands with inadequate resources).
Burnout can affect:
- Job performance. With increased error rates, decreased cognitive function, decreased patient safety, and increased risk medmal litigation.
- Physician retention. A burned out physician is more likely to leave with subsequent practice disruption and cost.
- Physician health. Increased risk of depression, substance abuse, and suicidality.
Interventions can help prevent and mitigate burnout from both a personal and institutional perspective. Individuals can mitigate potential burnout through different strategies. These include having a strong support network and practicing mindfulness to decrease rumination about work related issues. Engaging in relaxing activities that provide reward with low effort as well as physical actions, such as ensuring private time with no calls, will lessen stresses.
Institutional efforts to decrease burnout need to focus on factors that address perceived fairness in the workplace, adequate financial compensation, social recognition, and an appropriate balance between responsibility and authority.
More resources can be found at the speakers’ website and through Christina Maslach, a leading researcher in the field.
Presenters: Allison Ballantine and Lisa Zaoutis
Physician burnout can be thought of as similar to water level in a reservoir during a drought – there is an imbalance between usage and replenishment. This leads to physician exhaustion, cynicism, and inefficiency. Burnout is a function of both the individual (younger, single, and less resilient are at higher risk) and the environment (high job demands with inadequate resources).
Burnout can affect:
- Job performance. With increased error rates, decreased cognitive function, decreased patient safety, and increased risk medmal litigation.
- Physician retention. A burned out physician is more likely to leave with subsequent practice disruption and cost.
- Physician health. Increased risk of depression, substance abuse, and suicidality.
Interventions can help prevent and mitigate burnout from both a personal and institutional perspective. Individuals can mitigate potential burnout through different strategies. These include having a strong support network and practicing mindfulness to decrease rumination about work related issues. Engaging in relaxing activities that provide reward with low effort as well as physical actions, such as ensuring private time with no calls, will lessen stresses.
Institutional efforts to decrease burnout need to focus on factors that address perceived fairness in the workplace, adequate financial compensation, social recognition, and an appropriate balance between responsibility and authority.
More resources can be found at the speakers’ website and through Christina Maslach, a leading researcher in the field.
Presenters: Allison Ballantine and Lisa Zaoutis
Physician burnout can be thought of as similar to water level in a reservoir during a drought – there is an imbalance between usage and replenishment. This leads to physician exhaustion, cynicism, and inefficiency. Burnout is a function of both the individual (younger, single, and less resilient are at higher risk) and the environment (high job demands with inadequate resources).
Burnout can affect:
- Job performance. With increased error rates, decreased cognitive function, decreased patient safety, and increased risk medmal litigation.
- Physician retention. A burned out physician is more likely to leave with subsequent practice disruption and cost.
- Physician health. Increased risk of depression, substance abuse, and suicidality.
Interventions can help prevent and mitigate burnout from both a personal and institutional perspective. Individuals can mitigate potential burnout through different strategies. These include having a strong support network and practicing mindfulness to decrease rumination about work related issues. Engaging in relaxing activities that provide reward with low effort as well as physical actions, such as ensuring private time with no calls, will lessen stresses.
Institutional efforts to decrease burnout need to focus on factors that address perceived fairness in the workplace, adequate financial compensation, social recognition, and an appropriate balance between responsibility and authority.
More resources can be found at the speakers’ website and through Christina Maslach, a leading researcher in the field.
PHM15: Preparing for Global Health Experiences
Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ
Summary:
Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries. The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.
The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:
- Pre-trip Training. Don’t go without some idea of what to expect
- Pre-travel preparations. Get your vaccines, travel plans, licensure, scope of practice taken care of.
- Preceptorship by host and US faculty
- Post-travel evaluation and feedback
Key Takeaways:
Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH
Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ
Summary:
Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries. The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.
The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:
- Pre-trip Training. Don’t go without some idea of what to expect
- Pre-travel preparations. Get your vaccines, travel plans, licensure, scope of practice taken care of.
- Preceptorship by host and US faculty
- Post-travel evaluation and feedback
Key Takeaways:
Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH
Presenters: Gitanjli Arora, Phuc Le, and Christiana Russ
Summary:
Overseas medical missions can be rewarding experiences for both trainees as part of a supervised program and attending physicians. There is substantial inequity in the global distribution of disease versus health care providers with most providers being located in developed countries and higher disease burdens in underdeveloped countries. The goal of global healthcare training is mutual benefit, where the provider gains clinical experience and the host country gains enhanced medical care. Both provider and hosts gain increased cultural awareness.
The American Academy of Pediatrics guidelines for a meaningful international experience recommend 4 components:
- Pre-trip Training. Don’t go without some idea of what to expect
- Pre-travel preparations. Get your vaccines, travel plans, licensure, scope of practice taken care of.
- Preceptorship by host and US faculty
- Post-travel evaluation and feedback
Key Takeaways:
Providers in overseas medical missions will encounter challenging situations—culturally, ethically and medically. Get as much information beforehand. Be respectful of different cultural norms. Get a cultural ambassador. Keep in mind the Serenity Prayer. TH
Hospital Management of Patients Presenting with ALTE: An Evidence-Based Approach
In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.
Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.
In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.
In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.
Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.
In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.
In a presentation on guidelines for ALTE, Jack Percelay, SHM representative to the AAP Subcommittee, provided further insight to the work that has been done for the clinical entity known as apparent life-threatening events (ALTE) since a consensus statement was put forward by the NIH in 1986. The original statement emphasized 4 possible features to constitute ALTE: apnea, color change, change in tone or gagging. The imprecise nature of the definition, along with both provider and caretaker anxiety related to the diagnosis, have lead to a cascade of diagnostic testing and treatments for what is a symptom complex, not a disease.
Subsequent work in the field has clarified that an ALTE is not a risk factor for SIDS. Of the myriad of etiologies that can cause an ALTE, many will have a readily identifiable etiology that a good history and physical exam will diagnose. Most other diseases, if not diagnosed at initial presentation, will become apparent subsequently without any significant consequences (for example epilepsy). Two diagnoses, which if missed, may have significant consequences include child abuse and a cardiac arrhythmia.
In an effort to synthesize new data along with expert opinion, the American Academy of Pediatrics has convened a Subcommittee on the Guideline for ALTE, lead by Joel Tieder, to develop a new practice guideline. This guideline is still in development with certain areas not ready for broad dissemination. The highlight of the new guideline will be a proposal for a name change for ALTEs. Dr Percelay reports the proposed new name would be BRUE (pronounced “brew”), Brief Resolved Unexplained Event. He anticipates further information to be published that will offer a framework to specify which infants to consider at low risk of recurrence versus higher risk for significant pathology. For those infants identified as low risk, the guideline will offer specific evaluation and treatment recommendations. An anticipated key point of the new guideline will be that a careful history and physical is the cornerstone of the initial evaluation and that in the absence of specific historical or exam findings, diagnostic testing of well-appearing infants is of low value.
Society of Hospital Medicine Pediatric Committee Updates at HM15
During a session at the Society of Hospital Medicine's HM15 annual meeting, SHM Pediatric Committee chair Kris Rehm, MD, outlined a number of the committee's current endeavors. They include:
1) American Board of Pediatrics (ABP) Certification for Pediatric Hospitalists.
- Since 2010 a leadership group has worked on certification options.
- In 2013, determination was made that a two-year fellowship would be proposed to the ABP.
- Formal petition for certification was submitted to the ABP in October 2014, with clarification in March 2015.
- ABP is currently reviewing the proposal prior to its presentation to the American Board of Medical Specialties, with an expected minimum five-year horizon before a first exam.
2) SHM has developed multiple online ABP MOC learning platforms for pediatric hospitalists.
3) The SHM Pediatric Committee encourages pediatric hospitalists to seek Hospital Medicine Fellowship status to demonstrate one’s commitment to, and accomplishment in, hospital medicine.
4) A SHM pediatric discussion forum is ongoing.
5) The annual Pediatric Hospital Medicine meeting, jointly sponsored by APA, AAP and SHM will be in San Antonio, July 23-26. TH
During a session at the Society of Hospital Medicine's HM15 annual meeting, SHM Pediatric Committee chair Kris Rehm, MD, outlined a number of the committee's current endeavors. They include:
1) American Board of Pediatrics (ABP) Certification for Pediatric Hospitalists.
- Since 2010 a leadership group has worked on certification options.
- In 2013, determination was made that a two-year fellowship would be proposed to the ABP.
- Formal petition for certification was submitted to the ABP in October 2014, with clarification in March 2015.
- ABP is currently reviewing the proposal prior to its presentation to the American Board of Medical Specialties, with an expected minimum five-year horizon before a first exam.
2) SHM has developed multiple online ABP MOC learning platforms for pediatric hospitalists.
3) The SHM Pediatric Committee encourages pediatric hospitalists to seek Hospital Medicine Fellowship status to demonstrate one’s commitment to, and accomplishment in, hospital medicine.
4) A SHM pediatric discussion forum is ongoing.
5) The annual Pediatric Hospital Medicine meeting, jointly sponsored by APA, AAP and SHM will be in San Antonio, July 23-26. TH
During a session at the Society of Hospital Medicine's HM15 annual meeting, SHM Pediatric Committee chair Kris Rehm, MD, outlined a number of the committee's current endeavors. They include:
1) American Board of Pediatrics (ABP) Certification for Pediatric Hospitalists.
- Since 2010 a leadership group has worked on certification options.
- In 2013, determination was made that a two-year fellowship would be proposed to the ABP.
- Formal petition for certification was submitted to the ABP in October 2014, with clarification in March 2015.
- ABP is currently reviewing the proposal prior to its presentation to the American Board of Medical Specialties, with an expected minimum five-year horizon before a first exam.
2) SHM has developed multiple online ABP MOC learning platforms for pediatric hospitalists.
3) The SHM Pediatric Committee encourages pediatric hospitalists to seek Hospital Medicine Fellowship status to demonstrate one’s commitment to, and accomplishment in, hospital medicine.
4) A SHM pediatric discussion forum is ongoing.
5) The annual Pediatric Hospital Medicine meeting, jointly sponsored by APA, AAP and SHM will be in San Antonio, July 23-26. TH
Enhancing Physical Exam Skills, and Strategies to Teach Them
HM15 presenters: Verity Schaye, Michael Janjigian, Frank Volpicelli, Susan Hunt.
Performing a physical exam is the standard of care for evaluating patients. It has been shown to have higher diagnostic utility than many technology based tests. The physical exam is the Gold Standard for dermatological and mental status assessment for which technological tests are not readily available. The tradition “laying on of hands” has important benefits for the physician patient relationship.
The teaching of physical exam skills is increasingly problematic. Barriers include attending time, comfort and skill level as well as challenges of patient comfort and potential isolation issues.
The Peyton Model provides a better means of teaching physical exam skills than the traditional “See one, do one, teach one” model. The Peyton Model has four steps:
- Demonstration. The teacher performs the exam at normal speed without commentary.
- Deconstruction. The teacher performs the exam while describing the steps.
- Comprehension. The teacher performs the exam while the learner describes the steps.
- Performance. The learner performs the exam while also describing the steps.
This approach can be abbreviated for more advanced learners with the middle two steps being combined to a discussion between the teacher and learner to highlight any differences or changes in technique. TH
HM15 presenters: Verity Schaye, Michael Janjigian, Frank Volpicelli, Susan Hunt.
Performing a physical exam is the standard of care for evaluating patients. It has been shown to have higher diagnostic utility than many technology based tests. The physical exam is the Gold Standard for dermatological and mental status assessment for which technological tests are not readily available. The tradition “laying on of hands” has important benefits for the physician patient relationship.
The teaching of physical exam skills is increasingly problematic. Barriers include attending time, comfort and skill level as well as challenges of patient comfort and potential isolation issues.
The Peyton Model provides a better means of teaching physical exam skills than the traditional “See one, do one, teach one” model. The Peyton Model has four steps:
- Demonstration. The teacher performs the exam at normal speed without commentary.
- Deconstruction. The teacher performs the exam while describing the steps.
- Comprehension. The teacher performs the exam while the learner describes the steps.
- Performance. The learner performs the exam while also describing the steps.
This approach can be abbreviated for more advanced learners with the middle two steps being combined to a discussion between the teacher and learner to highlight any differences or changes in technique. TH
HM15 presenters: Verity Schaye, Michael Janjigian, Frank Volpicelli, Susan Hunt.
Performing a physical exam is the standard of care for evaluating patients. It has been shown to have higher diagnostic utility than many technology based tests. The physical exam is the Gold Standard for dermatological and mental status assessment for which technological tests are not readily available. The tradition “laying on of hands” has important benefits for the physician patient relationship.
The teaching of physical exam skills is increasingly problematic. Barriers include attending time, comfort and skill level as well as challenges of patient comfort and potential isolation issues.
The Peyton Model provides a better means of teaching physical exam skills than the traditional “See one, do one, teach one” model. The Peyton Model has four steps:
- Demonstration. The teacher performs the exam at normal speed without commentary.
- Deconstruction. The teacher performs the exam while describing the steps.
- Comprehension. The teacher performs the exam while the learner describes the steps.
- Performance. The learner performs the exam while also describing the steps.
This approach can be abbreviated for more advanced learners with the middle two steps being combined to a discussion between the teacher and learner to highlight any differences or changes in technique. TH
Keys to Successful Hospitalist Co-Management Programs
Summary
Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”
Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.
Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.
SHM identifies five keys to success for hospitalist co-management programs:
- Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
- Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
- Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
- Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
- Address financial issues. Most programs require some financial support to supplement billing revenue.
Summary
Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”
Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.
Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.
SHM identifies five keys to success for hospitalist co-management programs:
- Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
- Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
- Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
- Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
- Address financial issues. Most programs require some financial support to supplement billing revenue.
Summary
Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”
Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.
Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.
SHM identifies five keys to success for hospitalist co-management programs:
- Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
- Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
- Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
- Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
- Address financial issues. Most programs require some financial support to supplement billing revenue.
Derail Behavioral Emergencies in Hospitals
Summary
Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.
Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.
The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.
Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.
The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.
Summary
Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.
Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.
The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.
Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.
The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.
Summary
Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.
Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.
The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.
Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.
The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.
Pediatrics Preoperative Evaluation
Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]
One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]
Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]
In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.
In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.
METHODS
Setting/Program Structure
We conducted a retrospective chart review of all 214 patients with the diagnosis of neuromuscular scoliosis who were seen for a preoperative evaluation by a pediatric hospitalist at our institution from November 2009 through September 2012. Nemours/AI duPont Hospital for Children is a 200‐bed freestanding children's hospital with 11 pediatric orthopedic surgeons, 5 of whom perform spinal fusion surgery on patients with neuromuscular scoliosis. Our hospitalist group consists of 6 hospitalists, all of whom rotate on the medically complex comanagement service for 1 week at a time. The hospitalist who was assigned to the medically complex comanagement service for the week saw both postoperative patients and an average of 1 to 2 preoperative patients that week. All patients with neuromuscular scoliosis who were scheduled for spinal fusion surgery were seen preoperatively by a hospitalist. These patients included any with an underlying diagnosis of cerebral palsy, myopathy, skeletal dysplasia, or syndrome such as neurofibromatosis. Patients who were scheduled for spinal fusion surgery were referred to the hospitalists via the orthopedic scheduling department or perioperative services. These patients were typically seen in the general pediatrics outpatient area or in the outpatient orthopedics area of the hospital 1 to 2 months prior to surgery. The goal of the preoperative visit was to ensure patients were evaluated thoroughly before surgery. Hospitalists were given authority to delay or even cancel surgery, though in no case in this study was surgery cancelled. Hospitalists were responsible for following up on consultations and further studies obtained before surgery. Patients with a Cobb angle of more than 90 were by policy referred to pulmonology and cardiology for a preoperative evaluation. Further testing in those domains, such as pulmonary function testing or echocardiograms, was at the discretion of the appropriate specialist.
Study Procedure
After receiving approval from the hospital institutional review board, we performed a case series study. Three investigators (D.R., S.C., and D.P.) reviewed the preoperative visit note for each patient. We identified all patients who had spinal fusion surgery for neuromuscular scoliosis via International Classification of Diseases, 9th Revision (ICD‐9) codes, including that for neuromuscular scoliosis, and reviewed the patients' charts for preoperative visits. We used the preoperative note from the hospitalist as the definitive source for clinical information about the patient such as underlying diagnosis or etiology of the neuromuscular scoliosis. We used a structured data abstraction form to collect data regarding patient demographics, date of visit, time to surgery, type of surgery, number of standing daily (not as‐needed) preoperative prescription medications, and dependence on medical technology. We defined seizure disorder as present when a patient was taking standing prescription medication for seizures or had been recommended to take standing medication for seizures.
We recorded patient comorbidities related to the gastrointestinal, cardiac, and pulmonary systems. Prior to chart review, we agreed on standard definitions for significant problems in these arenas. We defined a significant problem as one in which a standing prescription medication was required, medical technology was required, or a subspecialist was consulted on a regular basis. To establish inter‐rater reliability using this definition, the 3 investigators independently reviewed an initial series of 5 charts. Inter‐rater reliability was established at 90%.
Main Outcome Measures
We recorded whether the hospitalist made any preoperative recommendations. Recommendations were categorized as: change in medication, changes in nutrition, laboratory or imaging studies, other diagnostic tests, or subspecialty referral. We defined a medication change as any change that involved a new prescription medication to be used on a standing basis, a change in dosing to a standing prescription medication, or the discontinuing of a standing prescription medication. We did not include changes in medications used on an as‐needed basis. We also recorded whether the hospitalist made any recommendations regarding further preoperative evaluation such as laboratory studies, imaging studies, other studies, or consultation with a subspecialist. We did not include laboratory studies that are routinely obtained preoperatively such as coagulation studies or blood count. We then recorded whether the hospitalist contacted a subspecialist or requested that an evaluation be done by that subspecialist prior to surgery.
Analysis
We used Stata 12 software (StataCorp, College Station, TX) to conduct all analyses. We used frequencies to describe categorical variables. Linear variables were not normally distributed and were therefore described using median and interquartile range. We calculated the simple, unadjusted odds ratio (OR) (95% confidence interval [CI]) of the hospitalist making a recommendation during the preoperative visit based on each variable. We defined statistical significance as a P value <0.05.
RESULTS
Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.
Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.
| Type of Recommendation | n (%) |
|---|---|
| |
| Changes in regimen | |
| Medication change (start new, discontinue, change dose) | 82 (38%) |
| Nutrition modification | 46 (21%) |
| Further diagnostic evaluation | |
| Laboratory studies | 41 (19%) |
| Imaging studies | 11 (5%) |
| Pulmonary function tests | 6 (3%) |
| Electrocardiograms | 6 (3%) |
| Referral to or contacted subspecialist | 76 (36%) |
Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.
| Characteristics | Number (%) or Median (IQR) | Recommendations? | ||
|---|---|---|---|---|
| Yes, n=155 | No, n=59 | Odds of Recommendation, OR (95% CI) | ||
| ||||
| Demographics | ||||
| Gender, female | 106 (50%) | 77 (60%) | 29 (49%) | 0.97 (0.53‐1.78) |
| Age, y | 13 (1016) | 13 (1016) | 12 (1016) | 1.05 (0.98‐1.12) |
| Year of visit | ||||
| 2009 | 41 (19%) | 32 (21%) | 9 (15%) | Ref |
| 2010 | 65 (30%) | 47 (30%) | 18 (30%) | 0.73 (0.29‐1.84) |
| 2011 | 64 (30%) | 43 (28%) | 21 (36%) | 0.58 (0.23‐1.42) |
| 2012 | 44 (21%) | 33 (21%) | 11 (19%) | 0.84 (0.31‐2.31) |
| Days from visit to surgery | 34 (1445) | 35 (1747) | 27 (841) | 1.02 (1.001.03) |
| Type of surgerya | ||||
| PSF | 184 (86%) | 139 (90%) | 45 (76%) | 2.70 (1.22‐5.97) |
| Growing rod | 9 (4.7%) | 6 (4%) | 3 (5%) | 0.75 (0.18‐3.11) |
| Cervical fusion | 17 (7.9%) | 9 6%) | 8 (13%) | 0.39 (0.14‐1.07) |
| Halo, then PSF | 4 (1.9%) | 1 (0.6%) | 3 (5%) | 0.12 (0.01‐1.19) |
| Underlying diseasea | ||||
| Cerebral palsy | 78 (36%) | 63 (41%) | 15 (25%) | 2.01 (1.03‐3.92) |
| Neuropathy | 4 (2%) | 4 (3%) | 0 (0%) | All had recommendations |
| Myopathy | 19 (9%) | 16 (10%) | 3 (5%) | 2.14 (0.60‐7.66) |
| Metabolic disorder | 6 (3%) | 4 (3%) | 2 (3%) | 0.75 (0.13‐4.23) |
| Skeletal dysplasia | 38 (18%) | 19 (12%) | 19 (32%) | 0.29 (0.14‐0.61) |
| Spina bifida | 7 (3%) | 6 (4%) | 1 (2%) | 2.33 (1.90‐3.48) |
| Genetic disorder (including osteogenesis imperfecta) | 40 (19%) | 28 (18%) | 12 (20%) | 0.86 (0.41‐1.84) |
| Other | 22 (10%) | 15 (10%) | 7 (12%) | 0.79 (0.31‐2.06) |
| Number of preoperative prescription medications | 2 (15) | 3 (15) | 1 (03) | 1.19 (1.06‐1.34) |
| Institutionalized | 9 (4.2%) | 6 (4%) | 3 (5%) | 0.75 (0.18‐3.11) |
| Nonambulatory | 114 (54%) | 90 (59%) | 24 (41%) | 2.02 (1.09‐3.74) |
| Dependence on technologya | ||||
| Feeding tube | 89 (41.6%) | 66 (43%) | 23 (39%) | 1.16 (0.63‐2.14) |
| Baclofen pump | 20 (9.3%) | 18 (12%) | 2 (3%) | 3.74 (0.84‐16.67) |
| Ventriculoperitoneal shunt | 24 (11.2%) | 18 (12%) | 6 (10%) | 1.16 (0.44‐3.08) |
| Vagal nerve stimulator/deep brain stimulator | 8 (3.7%) | 6 (4%) | 2 (3%) | 1.15 (0.22‐5.85) |
| Tracheostomy | 13 (6.1%) | 9 (6%) | 4 (7%) | 0.85 (0.25‐2.86) |
| Home mechanical ventilation (not BiPAP) | 6 (2.8%) | 5 (3%) | 1 (2%) | 1.93 (0.22‐16.90) |
| Home oxygen, BiPAP, or CPAP | 25 (11.7%) | 22 (14%) | 3 (5%) | 3.09 (0.89‐10.73) |
| Seizure disorder | 70 (33%) | 59 (38%) | 11 (19%) | 2.68 (1.29‐5.57) |
| Significant GI comorbidity | 102 (48%) | 86 (55%) | 16 (27%) | 3.35 (1.74‐6.45) |
| Significant cardiac comorbidity | 37 (17.3%) | 26 (17%) | 11 (19%) | 0.88 (0.40‐1.92) |
| Significant pulmonary comorbidity | 78 (36.4%) | 57 (37%) | 21 (36%) | 1.05 (0.56‐1.97) |
DISCUSSION
This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.
The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.
We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.
We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.
Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]
CONCLUSIONS
A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.
- 2012 State of Hospital Medicine Report, Society of Hospital Medicine. Further information available at: http://www.hospitalmedicine.org/survey.
- , , , et al.; Hospitalist‐Orthopedic Team Trial Investigators. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
- , , , et al. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–178, discussion 179–180.
- , , , et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165(7):796–801.
- , , . Hospitalist care of the medically complex child. Pediatr Clin North Am. 2005;52(4):1165–1167.
- , , , et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–646.
- , , , et al. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126(4):647–655.
- , , , et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538.
- , , , et al. Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2:23–30.
- , , , et al. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr. 2013;3(3):233–241.
- , , , et al. Perioperative processes and outcomes after implementation of a hospitalist‐run preoperative clinic. J Hosp Med. 2012 7:697–701.
- , , , , . Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010;170(15):1365–1374.
- , , , et al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167(21):2338–2344.
- , , , et al. Standardizing care for high‐risk patients in spine surgery: the Northwestern High‐Risk Spine Protocol. Spine. 2010;35(25):2232–2238.
- , , , . Neuromuscular scoliosis: clinical evaluation pre‐ and postoperative. J Pediatr Orthop. 2000;9:217–220.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008:3:398–402.
Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]
One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]
Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]
In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.
In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.
METHODS
Setting/Program Structure
We conducted a retrospective chart review of all 214 patients with the diagnosis of neuromuscular scoliosis who were seen for a preoperative evaluation by a pediatric hospitalist at our institution from November 2009 through September 2012. Nemours/AI duPont Hospital for Children is a 200‐bed freestanding children's hospital with 11 pediatric orthopedic surgeons, 5 of whom perform spinal fusion surgery on patients with neuromuscular scoliosis. Our hospitalist group consists of 6 hospitalists, all of whom rotate on the medically complex comanagement service for 1 week at a time. The hospitalist who was assigned to the medically complex comanagement service for the week saw both postoperative patients and an average of 1 to 2 preoperative patients that week. All patients with neuromuscular scoliosis who were scheduled for spinal fusion surgery were seen preoperatively by a hospitalist. These patients included any with an underlying diagnosis of cerebral palsy, myopathy, skeletal dysplasia, or syndrome such as neurofibromatosis. Patients who were scheduled for spinal fusion surgery were referred to the hospitalists via the orthopedic scheduling department or perioperative services. These patients were typically seen in the general pediatrics outpatient area or in the outpatient orthopedics area of the hospital 1 to 2 months prior to surgery. The goal of the preoperative visit was to ensure patients were evaluated thoroughly before surgery. Hospitalists were given authority to delay or even cancel surgery, though in no case in this study was surgery cancelled. Hospitalists were responsible for following up on consultations and further studies obtained before surgery. Patients with a Cobb angle of more than 90 were by policy referred to pulmonology and cardiology for a preoperative evaluation. Further testing in those domains, such as pulmonary function testing or echocardiograms, was at the discretion of the appropriate specialist.
Study Procedure
After receiving approval from the hospital institutional review board, we performed a case series study. Three investigators (D.R., S.C., and D.P.) reviewed the preoperative visit note for each patient. We identified all patients who had spinal fusion surgery for neuromuscular scoliosis via International Classification of Diseases, 9th Revision (ICD‐9) codes, including that for neuromuscular scoliosis, and reviewed the patients' charts for preoperative visits. We used the preoperative note from the hospitalist as the definitive source for clinical information about the patient such as underlying diagnosis or etiology of the neuromuscular scoliosis. We used a structured data abstraction form to collect data regarding patient demographics, date of visit, time to surgery, type of surgery, number of standing daily (not as‐needed) preoperative prescription medications, and dependence on medical technology. We defined seizure disorder as present when a patient was taking standing prescription medication for seizures or had been recommended to take standing medication for seizures.
We recorded patient comorbidities related to the gastrointestinal, cardiac, and pulmonary systems. Prior to chart review, we agreed on standard definitions for significant problems in these arenas. We defined a significant problem as one in which a standing prescription medication was required, medical technology was required, or a subspecialist was consulted on a regular basis. To establish inter‐rater reliability using this definition, the 3 investigators independently reviewed an initial series of 5 charts. Inter‐rater reliability was established at 90%.
Main Outcome Measures
We recorded whether the hospitalist made any preoperative recommendations. Recommendations were categorized as: change in medication, changes in nutrition, laboratory or imaging studies, other diagnostic tests, or subspecialty referral. We defined a medication change as any change that involved a new prescription medication to be used on a standing basis, a change in dosing to a standing prescription medication, or the discontinuing of a standing prescription medication. We did not include changes in medications used on an as‐needed basis. We also recorded whether the hospitalist made any recommendations regarding further preoperative evaluation such as laboratory studies, imaging studies, other studies, or consultation with a subspecialist. We did not include laboratory studies that are routinely obtained preoperatively such as coagulation studies or blood count. We then recorded whether the hospitalist contacted a subspecialist or requested that an evaluation be done by that subspecialist prior to surgery.
Analysis
We used Stata 12 software (StataCorp, College Station, TX) to conduct all analyses. We used frequencies to describe categorical variables. Linear variables were not normally distributed and were therefore described using median and interquartile range. We calculated the simple, unadjusted odds ratio (OR) (95% confidence interval [CI]) of the hospitalist making a recommendation during the preoperative visit based on each variable. We defined statistical significance as a P value <0.05.
RESULTS
Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.
Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.
| Type of Recommendation | n (%) |
|---|---|
| |
| Changes in regimen | |
| Medication change (start new, discontinue, change dose) | 82 (38%) |
| Nutrition modification | 46 (21%) |
| Further diagnostic evaluation | |
| Laboratory studies | 41 (19%) |
| Imaging studies | 11 (5%) |
| Pulmonary function tests | 6 (3%) |
| Electrocardiograms | 6 (3%) |
| Referral to or contacted subspecialist | 76 (36%) |
Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.
| Characteristics | Number (%) or Median (IQR) | Recommendations? | ||
|---|---|---|---|---|
| Yes, n=155 | No, n=59 | Odds of Recommendation, OR (95% CI) | ||
| ||||
| Demographics | ||||
| Gender, female | 106 (50%) | 77 (60%) | 29 (49%) | 0.97 (0.53‐1.78) |
| Age, y | 13 (1016) | 13 (1016) | 12 (1016) | 1.05 (0.98‐1.12) |
| Year of visit | ||||
| 2009 | 41 (19%) | 32 (21%) | 9 (15%) | Ref |
| 2010 | 65 (30%) | 47 (30%) | 18 (30%) | 0.73 (0.29‐1.84) |
| 2011 | 64 (30%) | 43 (28%) | 21 (36%) | 0.58 (0.23‐1.42) |
| 2012 | 44 (21%) | 33 (21%) | 11 (19%) | 0.84 (0.31‐2.31) |
| Days from visit to surgery | 34 (1445) | 35 (1747) | 27 (841) | 1.02 (1.001.03) |
| Type of surgerya | ||||
| PSF | 184 (86%) | 139 (90%) | 45 (76%) | 2.70 (1.22‐5.97) |
| Growing rod | 9 (4.7%) | 6 (4%) | 3 (5%) | 0.75 (0.18‐3.11) |
| Cervical fusion | 17 (7.9%) | 9 6%) | 8 (13%) | 0.39 (0.14‐1.07) |
| Halo, then PSF | 4 (1.9%) | 1 (0.6%) | 3 (5%) | 0.12 (0.01‐1.19) |
| Underlying diseasea | ||||
| Cerebral palsy | 78 (36%) | 63 (41%) | 15 (25%) | 2.01 (1.03‐3.92) |
| Neuropathy | 4 (2%) | 4 (3%) | 0 (0%) | All had recommendations |
| Myopathy | 19 (9%) | 16 (10%) | 3 (5%) | 2.14 (0.60‐7.66) |
| Metabolic disorder | 6 (3%) | 4 (3%) | 2 (3%) | 0.75 (0.13‐4.23) |
| Skeletal dysplasia | 38 (18%) | 19 (12%) | 19 (32%) | 0.29 (0.14‐0.61) |
| Spina bifida | 7 (3%) | 6 (4%) | 1 (2%) | 2.33 (1.90‐3.48) |
| Genetic disorder (including osteogenesis imperfecta) | 40 (19%) | 28 (18%) | 12 (20%) | 0.86 (0.41‐1.84) |
| Other | 22 (10%) | 15 (10%) | 7 (12%) | 0.79 (0.31‐2.06) |
| Number of preoperative prescription medications | 2 (15) | 3 (15) | 1 (03) | 1.19 (1.06‐1.34) |
| Institutionalized | 9 (4.2%) | 6 (4%) | 3 (5%) | 0.75 (0.18‐3.11) |
| Nonambulatory | 114 (54%) | 90 (59%) | 24 (41%) | 2.02 (1.09‐3.74) |
| Dependence on technologya | ||||
| Feeding tube | 89 (41.6%) | 66 (43%) | 23 (39%) | 1.16 (0.63‐2.14) |
| Baclofen pump | 20 (9.3%) | 18 (12%) | 2 (3%) | 3.74 (0.84‐16.67) |
| Ventriculoperitoneal shunt | 24 (11.2%) | 18 (12%) | 6 (10%) | 1.16 (0.44‐3.08) |
| Vagal nerve stimulator/deep brain stimulator | 8 (3.7%) | 6 (4%) | 2 (3%) | 1.15 (0.22‐5.85) |
| Tracheostomy | 13 (6.1%) | 9 (6%) | 4 (7%) | 0.85 (0.25‐2.86) |
| Home mechanical ventilation (not BiPAP) | 6 (2.8%) | 5 (3%) | 1 (2%) | 1.93 (0.22‐16.90) |
| Home oxygen, BiPAP, or CPAP | 25 (11.7%) | 22 (14%) | 3 (5%) | 3.09 (0.89‐10.73) |
| Seizure disorder | 70 (33%) | 59 (38%) | 11 (19%) | 2.68 (1.29‐5.57) |
| Significant GI comorbidity | 102 (48%) | 86 (55%) | 16 (27%) | 3.35 (1.74‐6.45) |
| Significant cardiac comorbidity | 37 (17.3%) | 26 (17%) | 11 (19%) | 0.88 (0.40‐1.92) |
| Significant pulmonary comorbidity | 78 (36.4%) | 57 (37%) | 21 (36%) | 1.05 (0.56‐1.97) |
DISCUSSION
This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.
The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.
We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.
We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.
Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]
CONCLUSIONS
A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.
Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]
One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]
Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]
In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.
In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.
METHODS
Setting/Program Structure
We conducted a retrospective chart review of all 214 patients with the diagnosis of neuromuscular scoliosis who were seen for a preoperative evaluation by a pediatric hospitalist at our institution from November 2009 through September 2012. Nemours/AI duPont Hospital for Children is a 200‐bed freestanding children's hospital with 11 pediatric orthopedic surgeons, 5 of whom perform spinal fusion surgery on patients with neuromuscular scoliosis. Our hospitalist group consists of 6 hospitalists, all of whom rotate on the medically complex comanagement service for 1 week at a time. The hospitalist who was assigned to the medically complex comanagement service for the week saw both postoperative patients and an average of 1 to 2 preoperative patients that week. All patients with neuromuscular scoliosis who were scheduled for spinal fusion surgery were seen preoperatively by a hospitalist. These patients included any with an underlying diagnosis of cerebral palsy, myopathy, skeletal dysplasia, or syndrome such as neurofibromatosis. Patients who were scheduled for spinal fusion surgery were referred to the hospitalists via the orthopedic scheduling department or perioperative services. These patients were typically seen in the general pediatrics outpatient area or in the outpatient orthopedics area of the hospital 1 to 2 months prior to surgery. The goal of the preoperative visit was to ensure patients were evaluated thoroughly before surgery. Hospitalists were given authority to delay or even cancel surgery, though in no case in this study was surgery cancelled. Hospitalists were responsible for following up on consultations and further studies obtained before surgery. Patients with a Cobb angle of more than 90 were by policy referred to pulmonology and cardiology for a preoperative evaluation. Further testing in those domains, such as pulmonary function testing or echocardiograms, was at the discretion of the appropriate specialist.
Study Procedure
After receiving approval from the hospital institutional review board, we performed a case series study. Three investigators (D.R., S.C., and D.P.) reviewed the preoperative visit note for each patient. We identified all patients who had spinal fusion surgery for neuromuscular scoliosis via International Classification of Diseases, 9th Revision (ICD‐9) codes, including that for neuromuscular scoliosis, and reviewed the patients' charts for preoperative visits. We used the preoperative note from the hospitalist as the definitive source for clinical information about the patient such as underlying diagnosis or etiology of the neuromuscular scoliosis. We used a structured data abstraction form to collect data regarding patient demographics, date of visit, time to surgery, type of surgery, number of standing daily (not as‐needed) preoperative prescription medications, and dependence on medical technology. We defined seizure disorder as present when a patient was taking standing prescription medication for seizures or had been recommended to take standing medication for seizures.
We recorded patient comorbidities related to the gastrointestinal, cardiac, and pulmonary systems. Prior to chart review, we agreed on standard definitions for significant problems in these arenas. We defined a significant problem as one in which a standing prescription medication was required, medical technology was required, or a subspecialist was consulted on a regular basis. To establish inter‐rater reliability using this definition, the 3 investigators independently reviewed an initial series of 5 charts. Inter‐rater reliability was established at 90%.
Main Outcome Measures
We recorded whether the hospitalist made any preoperative recommendations. Recommendations were categorized as: change in medication, changes in nutrition, laboratory or imaging studies, other diagnostic tests, or subspecialty referral. We defined a medication change as any change that involved a new prescription medication to be used on a standing basis, a change in dosing to a standing prescription medication, or the discontinuing of a standing prescription medication. We did not include changes in medications used on an as‐needed basis. We also recorded whether the hospitalist made any recommendations regarding further preoperative evaluation such as laboratory studies, imaging studies, other studies, or consultation with a subspecialist. We did not include laboratory studies that are routinely obtained preoperatively such as coagulation studies or blood count. We then recorded whether the hospitalist contacted a subspecialist or requested that an evaluation be done by that subspecialist prior to surgery.
Analysis
We used Stata 12 software (StataCorp, College Station, TX) to conduct all analyses. We used frequencies to describe categorical variables. Linear variables were not normally distributed and were therefore described using median and interquartile range. We calculated the simple, unadjusted odds ratio (OR) (95% confidence interval [CI]) of the hospitalist making a recommendation during the preoperative visit based on each variable. We defined statistical significance as a P value <0.05.
RESULTS
Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.
Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.
| Type of Recommendation | n (%) |
|---|---|
| |
| Changes in regimen | |
| Medication change (start new, discontinue, change dose) | 82 (38%) |
| Nutrition modification | 46 (21%) |
| Further diagnostic evaluation | |
| Laboratory studies | 41 (19%) |
| Imaging studies | 11 (5%) |
| Pulmonary function tests | 6 (3%) |
| Electrocardiograms | 6 (3%) |
| Referral to or contacted subspecialist | 76 (36%) |
Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.
| Characteristics | Number (%) or Median (IQR) | Recommendations? | ||
|---|---|---|---|---|
| Yes, n=155 | No, n=59 | Odds of Recommendation, OR (95% CI) | ||
| ||||
| Demographics | ||||
| Gender, female | 106 (50%) | 77 (60%) | 29 (49%) | 0.97 (0.53‐1.78) |
| Age, y | 13 (1016) | 13 (1016) | 12 (1016) | 1.05 (0.98‐1.12) |
| Year of visit | ||||
| 2009 | 41 (19%) | 32 (21%) | 9 (15%) | Ref |
| 2010 | 65 (30%) | 47 (30%) | 18 (30%) | 0.73 (0.29‐1.84) |
| 2011 | 64 (30%) | 43 (28%) | 21 (36%) | 0.58 (0.23‐1.42) |
| 2012 | 44 (21%) | 33 (21%) | 11 (19%) | 0.84 (0.31‐2.31) |
| Days from visit to surgery | 34 (1445) | 35 (1747) | 27 (841) | 1.02 (1.001.03) |
| Type of surgerya | ||||
| PSF | 184 (86%) | 139 (90%) | 45 (76%) | 2.70 (1.22‐5.97) |
| Growing rod | 9 (4.7%) | 6 (4%) | 3 (5%) | 0.75 (0.18‐3.11) |
| Cervical fusion | 17 (7.9%) | 9 6%) | 8 (13%) | 0.39 (0.14‐1.07) |
| Halo, then PSF | 4 (1.9%) | 1 (0.6%) | 3 (5%) | 0.12 (0.01‐1.19) |
| Underlying diseasea | ||||
| Cerebral palsy | 78 (36%) | 63 (41%) | 15 (25%) | 2.01 (1.03‐3.92) |
| Neuropathy | 4 (2%) | 4 (3%) | 0 (0%) | All had recommendations |
| Myopathy | 19 (9%) | 16 (10%) | 3 (5%) | 2.14 (0.60‐7.66) |
| Metabolic disorder | 6 (3%) | 4 (3%) | 2 (3%) | 0.75 (0.13‐4.23) |
| Skeletal dysplasia | 38 (18%) | 19 (12%) | 19 (32%) | 0.29 (0.14‐0.61) |
| Spina bifida | 7 (3%) | 6 (4%) | 1 (2%) | 2.33 (1.90‐3.48) |
| Genetic disorder (including osteogenesis imperfecta) | 40 (19%) | 28 (18%) | 12 (20%) | 0.86 (0.41‐1.84) |
| Other | 22 (10%) | 15 (10%) | 7 (12%) | 0.79 (0.31‐2.06) |
| Number of preoperative prescription medications | 2 (15) | 3 (15) | 1 (03) | 1.19 (1.06‐1.34) |
| Institutionalized | 9 (4.2%) | 6 (4%) | 3 (5%) | 0.75 (0.18‐3.11) |
| Nonambulatory | 114 (54%) | 90 (59%) | 24 (41%) | 2.02 (1.09‐3.74) |
| Dependence on technologya | ||||
| Feeding tube | 89 (41.6%) | 66 (43%) | 23 (39%) | 1.16 (0.63‐2.14) |
| Baclofen pump | 20 (9.3%) | 18 (12%) | 2 (3%) | 3.74 (0.84‐16.67) |
| Ventriculoperitoneal shunt | 24 (11.2%) | 18 (12%) | 6 (10%) | 1.16 (0.44‐3.08) |
| Vagal nerve stimulator/deep brain stimulator | 8 (3.7%) | 6 (4%) | 2 (3%) | 1.15 (0.22‐5.85) |
| Tracheostomy | 13 (6.1%) | 9 (6%) | 4 (7%) | 0.85 (0.25‐2.86) |
| Home mechanical ventilation (not BiPAP) | 6 (2.8%) | 5 (3%) | 1 (2%) | 1.93 (0.22‐16.90) |
| Home oxygen, BiPAP, or CPAP | 25 (11.7%) | 22 (14%) | 3 (5%) | 3.09 (0.89‐10.73) |
| Seizure disorder | 70 (33%) | 59 (38%) | 11 (19%) | 2.68 (1.29‐5.57) |
| Significant GI comorbidity | 102 (48%) | 86 (55%) | 16 (27%) | 3.35 (1.74‐6.45) |
| Significant cardiac comorbidity | 37 (17.3%) | 26 (17%) | 11 (19%) | 0.88 (0.40‐1.92) |
| Significant pulmonary comorbidity | 78 (36.4%) | 57 (37%) | 21 (36%) | 1.05 (0.56‐1.97) |
DISCUSSION
This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.
The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.
We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.
We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.
Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]
CONCLUSIONS
A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.
- 2012 State of Hospital Medicine Report, Society of Hospital Medicine. Further information available at: http://www.hospitalmedicine.org/survey.
- , , , et al.; Hospitalist‐Orthopedic Team Trial Investigators. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
- , , , et al. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–178, discussion 179–180.
- , , , et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165(7):796–801.
- , , . Hospitalist care of the medically complex child. Pediatr Clin North Am. 2005;52(4):1165–1167.
- , , , et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–646.
- , , , et al. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126(4):647–655.
- , , , et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538.
- , , , et al. Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2:23–30.
- , , , et al. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr. 2013;3(3):233–241.
- , , , et al. Perioperative processes and outcomes after implementation of a hospitalist‐run preoperative clinic. J Hosp Med. 2012 7:697–701.
- , , , , . Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010;170(15):1365–1374.
- , , , et al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167(21):2338–2344.
- , , , et al. Standardizing care for high‐risk patients in spine surgery: the Northwestern High‐Risk Spine Protocol. Spine. 2010;35(25):2232–2238.
- , , , . Neuromuscular scoliosis: clinical evaluation pre‐ and postoperative. J Pediatr Orthop. 2000;9:217–220.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008:3:398–402.
- 2012 State of Hospital Medicine Report, Society of Hospital Medicine. Further information available at: http://www.hospitalmedicine.org/survey.
- , , , et al.; Hospitalist‐Orthopedic Team Trial Investigators. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
- , , , et al. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma. 2006;20(3):172–178, discussion 179–180.
- , , , et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med. 2005;165(7):796–801.
- , , . Hospitalist care of the medically complex child. Pediatr Clin North Am. 2005;52(4):1165–1167.
- , , , et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–646.
- , , , et al. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126(4):647–655.
- , , , et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538.
- , , , et al. Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2:23–30.
- , , , et al. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr. 2013;3(3):233–241.
- , , , et al. Perioperative processes and outcomes after implementation of a hospitalist‐run preoperative clinic. J Hosp Med. 2012 7:697–701.
- , , , , . Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010;170(15):1365–1374.
- , , , et al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167(21):2338–2344.
- , , , et al. Standardizing care for high‐risk patients in spine surgery: the Northwestern High‐Risk Spine Protocol. Spine. 2010;35(25):2232–2238.
- , , , . Neuromuscular scoliosis: clinical evaluation pre‐ and postoperative. J Pediatr Orthop. 2000;9:217–220.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008:3:398–402.
© 2013 Society of Hospital Medicine