Karen Wilson, MD, MPH

Pediatric hospital medicine (PHM) fellowship programs came into existence approximately 20 years ago in Canada,[1] and since that time the number of programs in North America has grown dramatically. The first 3 PHM fellowship programs in the United States were initiated in 2003, and by 2008 there were 7 active programs. Just 5 years later in 2013, there were 20 fellowship programs in existence. Now, in 2015, there are over 30 programs, with several more in development. The goal of postresidency training in PHM is to improve the care of hospitalized children by training future hospitalists to provide high‐quality, evidence‐based clinical care and to generate new knowledge and scholarship in areas such as clinical research, patient safety and quality improvement, medical education, practice management, and patient outcomes.[2] Many pediatric hospitalists want to be able to perform research or quality improvement, but feel that they lack the time, skills, resources, and mentorship to do so.[3] To date, fellowship‐trained hospitalists have a demonstrated track record of contributing to the body of literature that is shaping the care of hospitalized children.[4, 5]

At present, PHM is not a recognized subspecialty of the American Board of Pediatrics (ABP) and therefore does not fall under the purview of the Accreditation Council of Graduate Medical Education (ACGME), leading to concern from some about the variability in depth and breadth of training across programs.[1] The development and publication of the PHM Core Competencies in 2010 helped define the scope of practice of pediatric hospitalists and provide guidelines for training programs, specifically with respect to clinical and nonclinical areas for assessment of competency.[6] Furthermore, studies of early career hospitalists have identified areas for future fellowship curriculum development, such as core procedural skills, quality improvement, and practice management.[7]

In an effort to address training variability across programs, PHM fellowship directors (FDs) have come together as an organized group, first meeting in 2008, with the primary goal of defining training standards and sharing curricular resources. Annual meetings of the FDs, sponsored by the American Academy of Pediatrics Section on Hospital Medicine (AAP‐SOHM), began in 2012. A key objective of this annual meeting has been to develop a standardized fellowship curriculum for use across programs as well as to determine gaps in training that need to be addressed. During this process, we have received input from key stakeholders including community hospitalists, internal medicine‐pediatrics hospitalists, and the PHM Certification Steering Committee, which organized the application for subspecialty certification to the ABP. To inform this process of curriculum standardization, we fielded a survey of PHM fellowship directors. The purpose of this article is to summarize the current curricula, operations, and logistics of PHM fellowship programs.

METHODS

This was a cross‐sectional study of 31 PHM fellowship programs across the United States and Canada in April 2014. Inclusion criteria included all pediatric fellowships that were self‐identified to the AAP‐SOHM as providing a hospital medicine fellowship option. This included both PHM fellowships as well as academic general pediatric fellowships with a hospitalist track. A web‐based survey (SurveyMonkey, Inc.) was distributed by e‐mail to the FDs at the 31 training programs (see Supporting Information in the online version of this article). To enhance content validity of survey responses, survey questions were designed using an iterative consensus process among the authors, who included junior and senior FDs and represented the 2014 annual FD meeting planning committee. Items were created to gather feedback on the following key areas of PHM fellowships: program demographics, types of required and elective clinical rotations, graduate coursework offerings, amount of time spent in clinical activities, fellow billing practices, and description of fellows' research activities. The survey consisted of 30 multiple‐choice and short‐answer questions. Follow‐up e‐mail reminders were sent to all FDs 2 weeks and 4 weeks after the initial request was sent. Survey completion was voluntary, and no incentives were offered. The study was determined to be exempt by the Stanford University Institutional Review Board. Data were summarized using frequency distributions. No subgroup comparisons were made.

RESULTS

Program directors from 27/31 (87%) PHM fellowship programs responded to the survey; 25 were active programs, and 2 were under development. Responding programs represented all 4 major regions of the country and Canada, with varying program initiation dates, ranging from 1997 to 2013.

Fellow Clinical Activities

The average amount of total clinical time (weeks on service) across responding programs was 50% (range, 20%65%). When looking specifically at time on the inpatient general pediatric service, number of weeks varied by year of training and by institution, with 12 to 41 weeks in the first year of fellowship, 6 to 41 weeks in the second year of fellowship, and 6 to 28 weeks in the third year of fellowship (Figure 1). Though the range is large, on average, fellows spend 17 weeks on inpatient general pediatrics service during each year of training. Of note, the median number of weeks on inpatient general pediatrics service by year of training was 15 weeks, 16 weeks, and 16.5 weeks, respectively. In addition to inpatient general pediatrics service time, most programs require other clinical rotations, with sedation, complex care, and inpatient pediatrics at community sites being the most frequent (Figure 2). Of the 6 responding 1‐year programs, 5 (83%) allow fellows to bill/generate clinical revenue at some point during their training. Of the 15 responding 2‐year programs, 11 (73%) allow fellows to bill/generate clinical revenue at some point during their training. Of the 4 responding 3‐year programs, 2 (50%) allow their fellows to bill/generate clinical revenue at some point during their training.

Figure 1

Figure 2

DISCUSSION

This is the most comprehensive description of pediatric hospital medicine fellowship curricula to date. Understanding the scope of these programs is an important first step in developing a standardized curriculum that can be used by all. The results of this survey indicate that although there is variability among PHM fellowship curricular content, several common themes exist.

The number of clinical weeks on the inpatient general pediatrics service varied from program to program, though the majority of programs require fellows to spend 15 to 16 weeks each year of training. The variability may be due in part to the way in which respondents defined the term week on clinical service. For example, if the fellow is primarily on a shift schedule, then he/she may only work 2 to 3 shifts in 1 week, which may have been viewed similarly to daily presence on a more traditional inpatient teaching service with 5 to 7 consecutive days of service. The current study did not explore the details of inpatient general pediatric clinical activities or exposure to opportunities to hone procedural skills, areas that are worth investigating as we move forward to better understand the needs of trainees.

Most residency training programs in general pediatrics require a significant amount of inpatient clinical time, specifically a minimum of 10 units or months, though only half of this time is required to be in inpatient general pediatrics.[8] Although nonfellowship trained early career hospitalists may feel adequately prepared to manage the clinical care of some hospitalized children, perceived competency is significantly lower than their fellowship‐trained colleagues with regard to care of the child with medical complexity and technology‐dependence, and with regard to provision of sedation for procedures.[7] The majority of FDs surveyed in our study indicated that additional clinical experience with sedation, complex care, and inpatient pediatrics at community sites were required of their fellows. Of note, many of these rotations are not commonly required in pediatric residency training programs; however, the PHM core competencies suggest that hospitalists should demonstrate proficiency in these areas to provide optimal care for hospitalized children. Our results suggest that current PHM fellowship curricula help address these clinical gaps. The requirement of these particular specialized experiences may reflect the clinical scope of practice that is expected from potential employers or may be related to staffing needs. It is well documented that the inpatient demographic of large pediatric tertiary care referral centers has changed over the past decade, with an increasing prevalence of children with medical complexity.[9, 10] In both tertiary referral centers and community hospitals, the expansion of the role of the hospitalist in providing specialized clinical services, such as sedation or surgical comanagement, has been significantly driven by financial factors, though a more recent focus on improvement of efficiency and quality of care within the hospital system has relied heavily on hospitalist input.[11, 12, 13] Important next steps in curriculum standardization include ensuring that training programs allow for adequate clinical exposure and proper assessment of competency in these areas, and determining the full complement of clinical training experiences that will produce hospitalists with a well‐defined scope of practice that adequately addresses the needs of hospitalized children.

Most fellowship‐trained hospitalists work primarily in university‐affiliated institutions with expectations for scholarly productivity.[5, 7] Fellowship‐trained hospitalists have made large contributions to the growing body of PHM literature, specifically in the realms of medical education, healthcare quality, clinical pediatrics, and healthcare outcomes.[4] Many PHM fellowship‐trained hospitalists have educational or administrative leadership roles.[2] Our results indicate that current PHM fellows continue to be active in a variety of research activities. In addition, FDs reported that the vast majority of programs included scholarship oversight committees, which ensure a mentored and structured research experience. Finally, most programs require or offer additional coursework, and many programs with university affiliations allow for attainment of graduate degrees. Inclusion of robust research training and infrastructure in all programs is a paramount goal of PHM fellowship training. This will allow graduates to be successful researchers, generating new knowledge and supporting the provision of high‐quality, evidence‐based, and value‐driven care for hospitalized children.

A unique feature of several PHM fellowship programs is that fellows are allowed to bill for clinical encounters. Many programs rely on clinical revenue to support fellow salaries.[14] For some programs, a portion of this clinical revenue comes from fellows billing for clinical encounters.[15] Programs that allow fellows to bill/generate clinical revenue have fellows working in attending roles without direct supervision, whereas nonbilling fellows have direct supervision by an attending.[15] In the current ABP training model, subspecialty fellows cannot independently bill for clinical encounters within their own subspecialty, though they can moonlight as long as they meet the duty hour requirements set forth by the ACGME.[16] FDs will need to consider the impact of this requirement on fellow autonomy and on financial revenue for funding fellow salaries if the field achieves ABP subspecialty status.

Regardless of whether or not PHM becomes a designated subspecialty of the ABP, FDs will continue to work together to develop a standard core curriculum that incorporates elements of clinical and nonclinical training to ensure that graduates not only provide high‐quality care for hospitalized children, but also generate new knowledge that advances the field in care delivery and quality of care in any setting. The results of this study will not only help to inform curriculum standardization, but also assessment and evaluation methods. Currently, PHM FDs meet annually and are nearing consensus on a standard 2‐year curriculum based on the PHM Core Competencies that incorporates core clinical, systems, and scholarly domains. We continue to solicit the input of stakeholders, including new FDs, community hospitalist leaders, internal medicine‐pediatrics hospitalist leaders, the Joint Council of Pediatric Hospital Medicine, and leaders of national organizations, such as the American Academy of Pediatrics, Academic Pediatrics Association, and Society of Hospital Medicine. Additional work around standardizing the fellowship application and recruitment process has resulted in our recent acceptance into the Fall Subspecialty Match through the National Residency Match Program, as well as development and implementation of a common fellowship application form. The FD group has recently formalized, voting into place an executive steering committee, which is responsible for the development and execution of long‐term goals that include finalizing a standardized curriculum, refining program and fellow assessment methods through critical evaluation of fellow metrics and outcomes, and standardization of evaluation methods.

Adopting a standard 2‐year curriculum may affect some programs, specifically those that are currently 1 year in duration. These programs would need to extend the length of their fellowship to allow for the breadth of experiences expected with a standardized 2‐year curriculum. This could result in significant financial challenges, effectively increasing the cost to administer the program. In addition, at present, programs have the flexibility to highlight individual areas of strength to attract candidates, allowing fellows to gain an in‐depth experience in domains such as clinical research, quality improvement, medical education, or health services research. With a standardized curriculum, some programs may have to assemble specific clinical and nonclinical experiences to meet the agreed‐upon expectations for PHM fellowship training. If these resources are not available, programs may need to seek relationships with other institutions to complete their offerings, a possibility that is being actively explored by this group. FDs continue to work with each other to share resources, identify training opportunities, and partner with each other to ensure that the requirements of a standard curriculum can be met.

This study has several limitations. First, it was a voluntary survey of program directors, and though we captured over 80% of programs at the time of the survey, there are currently more programs that have come into existence and more still that are in the development stage, leading to potential sampling error. Second, variable effort or accuracy by participants may have led to some degree of response error, such as content error or nonreporting error. Third, the survey questions focused on high‐level information, making it difficult to make nuanced comparisons between curricular elements or determine best curricular practice. In addition, this survey did not explore medical education and quality improvement activities of fellows, 2 major areas in which hospitalists play a major role in the inpatient setting.[1, 17, 18, 19, 20]

CONCLUSION

PHM fellowship programs have grown and continue to grow at a rapid rate. Variability in training is evident, both in clinical experiences and research experiences, though several common elements were identified in this study. The majority of programs are 2 years, and clinical experience comprises approximately 50% of training time, often including key rotations such as sedation, complex care, and rotations at community hospitals. Future directions include standardizing clinical training and expectations for scholarship, formulating appropriate methods for assessment of competency that can be used across programs, and seeking sustainable sources of funding.

Pediatric hospital medicine (PHM) fellowship programs came into existence approximately 20 years ago in Canada,[1] and since that time the number of programs in North America has grown dramatically. The first 3 PHM fellowship programs in the United States were initiated in 2003, and by 2008 there were 7 active programs. Just 5 years later in 2013, there were 20 fellowship programs in existence. Now, in 2015, there are over 30 programs, with several more in development. The goal of postresidency training in PHM is to improve the care of hospitalized children by training future hospitalists to provide high‐quality, evidence‐based clinical care and to generate new knowledge and scholarship in areas such as clinical research, patient safety and quality improvement, medical education, practice management, and patient outcomes.[2] Many pediatric hospitalists want to be able to perform research or quality improvement, but feel that they lack the time, skills, resources, and mentorship to do so.[3] To date, fellowship‐trained hospitalists have a demonstrated track record of contributing to the body of literature that is shaping the care of hospitalized children.[4, 5]

At present, PHM is not a recognized subspecialty of the American Board of Pediatrics (ABP) and therefore does not fall under the purview of the Accreditation Council of Graduate Medical Education (ACGME), leading to concern from some about the variability in depth and breadth of training across programs.[1] The development and publication of the PHM Core Competencies in 2010 helped define the scope of practice of pediatric hospitalists and provide guidelines for training programs, specifically with respect to clinical and nonclinical areas for assessment of competency.[6] Furthermore, studies of early career hospitalists have identified areas for future fellowship curriculum development, such as core procedural skills, quality improvement, and practice management.[7]

In an effort to address training variability across programs, PHM fellowship directors (FDs) have come together as an organized group, first meeting in 2008, with the primary goal of defining training standards and sharing curricular resources. Annual meetings of the FDs, sponsored by the American Academy of Pediatrics Section on Hospital Medicine (AAP‐SOHM), began in 2012. A key objective of this annual meeting has been to develop a standardized fellowship curriculum for use across programs as well as to determine gaps in training that need to be addressed. During this process, we have received input from key stakeholders including community hospitalists, internal medicine‐pediatrics hospitalists, and the PHM Certification Steering Committee, which organized the application for subspecialty certification to the ABP. To inform this process of curriculum standardization, we fielded a survey of PHM fellowship directors. The purpose of this article is to summarize the current curricula, operations, and logistics of PHM fellowship programs.

METHODS

This was a cross‐sectional study of 31 PHM fellowship programs across the United States and Canada in April 2014. Inclusion criteria included all pediatric fellowships that were self‐identified to the AAP‐SOHM as providing a hospital medicine fellowship option. This included both PHM fellowships as well as academic general pediatric fellowships with a hospitalist track. A web‐based survey (SurveyMonkey, Inc.) was distributed by e‐mail to the FDs at the 31 training programs (see Supporting Information in the online version of this article). To enhance content validity of survey responses, survey questions were designed using an iterative consensus process among the authors, who included junior and senior FDs and represented the 2014 annual FD meeting planning committee. Items were created to gather feedback on the following key areas of PHM fellowships: program demographics, types of required and elective clinical rotations, graduate coursework offerings, amount of time spent in clinical activities, fellow billing practices, and description of fellows' research activities. The survey consisted of 30 multiple‐choice and short‐answer questions. Follow‐up e‐mail reminders were sent to all FDs 2 weeks and 4 weeks after the initial request was sent. Survey completion was voluntary, and no incentives were offered. The study was determined to be exempt by the Stanford University Institutional Review Board. Data were summarized using frequency distributions. No subgroup comparisons were made.

RESULTS

Program directors from 27/31 (87%) PHM fellowship programs responded to the survey; 25 were active programs, and 2 were under development. Responding programs represented all 4 major regions of the country and Canada, with varying program initiation dates, ranging from 1997 to 2013.

Fellow Clinical Activities

The average amount of total clinical time (weeks on service) across responding programs was 50% (range, 20%65%). When looking specifically at time on the inpatient general pediatric service, number of weeks varied by year of training and by institution, with 12 to 41 weeks in the first year of fellowship, 6 to 41 weeks in the second year of fellowship, and 6 to 28 weeks in the third year of fellowship (Figure 1). Though the range is large, on average, fellows spend 17 weeks on inpatient general pediatrics service during each year of training. Of note, the median number of weeks on inpatient general pediatrics service by year of training was 15 weeks, 16 weeks, and 16.5 weeks, respectively. In addition to inpatient general pediatrics service time, most programs require other clinical rotations, with sedation, complex care, and inpatient pediatrics at community sites being the most frequent (Figure 2). Of the 6 responding 1‐year programs, 5 (83%) allow fellows to bill/generate clinical revenue at some point during their training. Of the 15 responding 2‐year programs, 11 (73%) allow fellows to bill/generate clinical revenue at some point during their training. Of the 4 responding 3‐year programs, 2 (50%) allow their fellows to bill/generate clinical revenue at some point during their training.

Figure 1

Figure 2

DISCUSSION

This is the most comprehensive description of pediatric hospital medicine fellowship curricula to date. Understanding the scope of these programs is an important first step in developing a standardized curriculum that can be used by all. The results of this survey indicate that although there is variability among PHM fellowship curricular content, several common themes exist.

The number of clinical weeks on the inpatient general pediatrics service varied from program to program, though the majority of programs require fellows to spend 15 to 16 weeks each year of training. The variability may be due in part to the way in which respondents defined the term week on clinical service. For example, if the fellow is primarily on a shift schedule, then he/she may only work 2 to 3 shifts in 1 week, which may have been viewed similarly to daily presence on a more traditional inpatient teaching service with 5 to 7 consecutive days of service. The current study did not explore the details of inpatient general pediatric clinical activities or exposure to opportunities to hone procedural skills, areas that are worth investigating as we move forward to better understand the needs of trainees.

Most residency training programs in general pediatrics require a significant amount of inpatient clinical time, specifically a minimum of 10 units or months, though only half of this time is required to be in inpatient general pediatrics.[8] Although nonfellowship trained early career hospitalists may feel adequately prepared to manage the clinical care of some hospitalized children, perceived competency is significantly lower than their fellowship‐trained colleagues with regard to care of the child with medical complexity and technology‐dependence, and with regard to provision of sedation for procedures.[7] The majority of FDs surveyed in our study indicated that additional clinical experience with sedation, complex care, and inpatient pediatrics at community sites were required of their fellows. Of note, many of these rotations are not commonly required in pediatric residency training programs; however, the PHM core competencies suggest that hospitalists should demonstrate proficiency in these areas to provide optimal care for hospitalized children. Our results suggest that current PHM fellowship curricula help address these clinical gaps. The requirement of these particular specialized experiences may reflect the clinical scope of practice that is expected from potential employers or may be related to staffing needs. It is well documented that the inpatient demographic of large pediatric tertiary care referral centers has changed over the past decade, with an increasing prevalence of children with medical complexity.[9, 10] In both tertiary referral centers and community hospitals, the expansion of the role of the hospitalist in providing specialized clinical services, such as sedation or surgical comanagement, has been significantly driven by financial factors, though a more recent focus on improvement of efficiency and quality of care within the hospital system has relied heavily on hospitalist input.[11, 12, 13] Important next steps in curriculum standardization include ensuring that training programs allow for adequate clinical exposure and proper assessment of competency in these areas, and determining the full complement of clinical training experiences that will produce hospitalists with a well‐defined scope of practice that adequately addresses the needs of hospitalized children.

Most fellowship‐trained hospitalists work primarily in university‐affiliated institutions with expectations for scholarly productivity.[5, 7] Fellowship‐trained hospitalists have made large contributions to the growing body of PHM literature, specifically in the realms of medical education, healthcare quality, clinical pediatrics, and healthcare outcomes.[4] Many PHM fellowship‐trained hospitalists have educational or administrative leadership roles.[2] Our results indicate that current PHM fellows continue to be active in a variety of research activities. In addition, FDs reported that the vast majority of programs included scholarship oversight committees, which ensure a mentored and structured research experience. Finally, most programs require or offer additional coursework, and many programs with university affiliations allow for attainment of graduate degrees. Inclusion of robust research training and infrastructure in all programs is a paramount goal of PHM fellowship training. This will allow graduates to be successful researchers, generating new knowledge and supporting the provision of high‐quality, evidence‐based, and value‐driven care for hospitalized children.

A unique feature of several PHM fellowship programs is that fellows are allowed to bill for clinical encounters. Many programs rely on clinical revenue to support fellow salaries.[14] For some programs, a portion of this clinical revenue comes from fellows billing for clinical encounters.[15] Programs that allow fellows to bill/generate clinical revenue have fellows working in attending roles without direct supervision, whereas nonbilling fellows have direct supervision by an attending.[15] In the current ABP training model, subspecialty fellows cannot independently bill for clinical encounters within their own subspecialty, though they can moonlight as long as they meet the duty hour requirements set forth by the ACGME.[16] FDs will need to consider the impact of this requirement on fellow autonomy and on financial revenue for funding fellow salaries if the field achieves ABP subspecialty status.

Regardless of whether or not PHM becomes a designated subspecialty of the ABP, FDs will continue to work together to develop a standard core curriculum that incorporates elements of clinical and nonclinical training to ensure that graduates not only provide high‐quality care for hospitalized children, but also generate new knowledge that advances the field in care delivery and quality of care in any setting. The results of this study will not only help to inform curriculum standardization, but also assessment and evaluation methods. Currently, PHM FDs meet annually and are nearing consensus on a standard 2‐year curriculum based on the PHM Core Competencies that incorporates core clinical, systems, and scholarly domains. We continue to solicit the input of stakeholders, including new FDs, community hospitalist leaders, internal medicine‐pediatrics hospitalist leaders, the Joint Council of Pediatric Hospital Medicine, and leaders of national organizations, such as the American Academy of Pediatrics, Academic Pediatrics Association, and Society of Hospital Medicine. Additional work around standardizing the fellowship application and recruitment process has resulted in our recent acceptance into the Fall Subspecialty Match through the National Residency Match Program, as well as development and implementation of a common fellowship application form. The FD group has recently formalized, voting into place an executive steering committee, which is responsible for the development and execution of long‐term goals that include finalizing a standardized curriculum, refining program and fellow assessment methods through critical evaluation of fellow metrics and outcomes, and standardization of evaluation methods.

Adopting a standard 2‐year curriculum may affect some programs, specifically those that are currently 1 year in duration. These programs would need to extend the length of their fellowship to allow for the breadth of experiences expected with a standardized 2‐year curriculum. This could result in significant financial challenges, effectively increasing the cost to administer the program. In addition, at present, programs have the flexibility to highlight individual areas of strength to attract candidates, allowing fellows to gain an in‐depth experience in domains such as clinical research, quality improvement, medical education, or health services research. With a standardized curriculum, some programs may have to assemble specific clinical and nonclinical experiences to meet the agreed‐upon expectations for PHM fellowship training. If these resources are not available, programs may need to seek relationships with other institutions to complete their offerings, a possibility that is being actively explored by this group. FDs continue to work with each other to share resources, identify training opportunities, and partner with each other to ensure that the requirements of a standard curriculum can be met.

This study has several limitations. First, it was a voluntary survey of program directors, and though we captured over 80% of programs at the time of the survey, there are currently more programs that have come into existence and more still that are in the development stage, leading to potential sampling error. Second, variable effort or accuracy by participants may have led to some degree of response error, such as content error or nonreporting error. Third, the survey questions focused on high‐level information, making it difficult to make nuanced comparisons between curricular elements or determine best curricular practice. In addition, this survey did not explore medical education and quality improvement activities of fellows, 2 major areas in which hospitalists play a major role in the inpatient setting.[1, 17, 18, 19, 20]

CONCLUSION

PHM fellowship programs have grown and continue to grow at a rapid rate. Variability in training is evident, both in clinical experiences and research experiences, though several common elements were identified in this study. The majority of programs are 2 years, and clinical experience comprises approximately 50% of training time, often including key rotations such as sedation, complex care, and rotations at community hospitals. Future directions include standardizing clinical training and expectations for scholarship, formulating appropriate methods for assessment of competency that can be used across programs, and seeking sustainable sources of funding.

Pediatric hospital medicine (PHM) fellowship programs came into existence approximately 20 years ago in Canada,[1] and since that time the number of programs in North America has grown dramatically. The first 3 PHM fellowship programs in the United States were initiated in 2003, and by 2008 there were 7 active programs. Just 5 years later in 2013, there were 20 fellowship programs in existence. Now, in 2015, there are over 30 programs, with several more in development. The goal of postresidency training in PHM is to improve the care of hospitalized children by training future hospitalists to provide high‐quality, evidence‐based clinical care and to generate new knowledge and scholarship in areas such as clinical research, patient safety and quality improvement, medical education, practice management, and patient outcomes.[2] Many pediatric hospitalists want to be able to perform research or quality improvement, but feel that they lack the time, skills, resources, and mentorship to do so.[3] To date, fellowship‐trained hospitalists have a demonstrated track record of contributing to the body of literature that is shaping the care of hospitalized children.[4, 5]

At present, PHM is not a recognized subspecialty of the American Board of Pediatrics (ABP) and therefore does not fall under the purview of the Accreditation Council of Graduate Medical Education (ACGME), leading to concern from some about the variability in depth and breadth of training across programs.[1] The development and publication of the PHM Core Competencies in 2010 helped define the scope of practice of pediatric hospitalists and provide guidelines for training programs, specifically with respect to clinical and nonclinical areas for assessment of competency.[6] Furthermore, studies of early career hospitalists have identified areas for future fellowship curriculum development, such as core procedural skills, quality improvement, and practice management.[7]

In an effort to address training variability across programs, PHM fellowship directors (FDs) have come together as an organized group, first meeting in 2008, with the primary goal of defining training standards and sharing curricular resources. Annual meetings of the FDs, sponsored by the American Academy of Pediatrics Section on Hospital Medicine (AAP‐SOHM), began in 2012. A key objective of this annual meeting has been to develop a standardized fellowship curriculum for use across programs as well as to determine gaps in training that need to be addressed. During this process, we have received input from key stakeholders including community hospitalists, internal medicine‐pediatrics hospitalists, and the PHM Certification Steering Committee, which organized the application for subspecialty certification to the ABP. To inform this process of curriculum standardization, we fielded a survey of PHM fellowship directors. The purpose of this article is to summarize the current curricula, operations, and logistics of PHM fellowship programs.

METHODS

This was a cross‐sectional study of 31 PHM fellowship programs across the United States and Canada in April 2014. Inclusion criteria included all pediatric fellowships that were self‐identified to the AAP‐SOHM as providing a hospital medicine fellowship option. This included both PHM fellowships as well as academic general pediatric fellowships with a hospitalist track. A web‐based survey (SurveyMonkey, Inc.) was distributed by e‐mail to the FDs at the 31 training programs (see Supporting Information in the online version of this article). To enhance content validity of survey responses, survey questions were designed using an iterative consensus process among the authors, who included junior and senior FDs and represented the 2014 annual FD meeting planning committee. Items were created to gather feedback on the following key areas of PHM fellowships: program demographics, types of required and elective clinical rotations, graduate coursework offerings, amount of time spent in clinical activities, fellow billing practices, and description of fellows' research activities. The survey consisted of 30 multiple‐choice and short‐answer questions. Follow‐up e‐mail reminders were sent to all FDs 2 weeks and 4 weeks after the initial request was sent. Survey completion was voluntary, and no incentives were offered. The study was determined to be exempt by the Stanford University Institutional Review Board. Data were summarized using frequency distributions. No subgroup comparisons were made.

RESULTS

Program directors from 27/31 (87%) PHM fellowship programs responded to the survey; 25 were active programs, and 2 were under development. Responding programs represented all 4 major regions of the country and Canada, with varying program initiation dates, ranging from 1997 to 2013.

Fellow Clinical Activities

The average amount of total clinical time (weeks on service) across responding programs was 50% (range, 20%65%). When looking specifically at time on the inpatient general pediatric service, number of weeks varied by year of training and by institution, with 12 to 41 weeks in the first year of fellowship, 6 to 41 weeks in the second year of fellowship, and 6 to 28 weeks in the third year of fellowship (Figure 1). Though the range is large, on average, fellows spend 17 weeks on inpatient general pediatrics service during each year of training. Of note, the median number of weeks on inpatient general pediatrics service by year of training was 15 weeks, 16 weeks, and 16.5 weeks, respectively. In addition to inpatient general pediatrics service time, most programs require other clinical rotations, with sedation, complex care, and inpatient pediatrics at community sites being the most frequent (Figure 2). Of the 6 responding 1‐year programs, 5 (83%) allow fellows to bill/generate clinical revenue at some point during their training. Of the 15 responding 2‐year programs, 11 (73%) allow fellows to bill/generate clinical revenue at some point during their training. Of the 4 responding 3‐year programs, 2 (50%) allow their fellows to bill/generate clinical revenue at some point during their training.

Figure 1

Figure 2

DISCUSSION

This is the most comprehensive description of pediatric hospital medicine fellowship curricula to date. Understanding the scope of these programs is an important first step in developing a standardized curriculum that can be used by all. The results of this survey indicate that although there is variability among PHM fellowship curricular content, several common themes exist.

The number of clinical weeks on the inpatient general pediatrics service varied from program to program, though the majority of programs require fellows to spend 15 to 16 weeks each year of training. The variability may be due in part to the way in which respondents defined the term week on clinical service. For example, if the fellow is primarily on a shift schedule, then he/she may only work 2 to 3 shifts in 1 week, which may have been viewed similarly to daily presence on a more traditional inpatient teaching service with 5 to 7 consecutive days of service. The current study did not explore the details of inpatient general pediatric clinical activities or exposure to opportunities to hone procedural skills, areas that are worth investigating as we move forward to better understand the needs of trainees.

Most residency training programs in general pediatrics require a significant amount of inpatient clinical time, specifically a minimum of 10 units or months, though only half of this time is required to be in inpatient general pediatrics.[8] Although nonfellowship trained early career hospitalists may feel adequately prepared to manage the clinical care of some hospitalized children, perceived competency is significantly lower than their fellowship‐trained colleagues with regard to care of the child with medical complexity and technology‐dependence, and with regard to provision of sedation for procedures.[7] The majority of FDs surveyed in our study indicated that additional clinical experience with sedation, complex care, and inpatient pediatrics at community sites were required of their fellows. Of note, many of these rotations are not commonly required in pediatric residency training programs; however, the PHM core competencies suggest that hospitalists should demonstrate proficiency in these areas to provide optimal care for hospitalized children. Our results suggest that current PHM fellowship curricula help address these clinical gaps. The requirement of these particular specialized experiences may reflect the clinical scope of practice that is expected from potential employers or may be related to staffing needs. It is well documented that the inpatient demographic of large pediatric tertiary care referral centers has changed over the past decade, with an increasing prevalence of children with medical complexity.[9, 10] In both tertiary referral centers and community hospitals, the expansion of the role of the hospitalist in providing specialized clinical services, such as sedation or surgical comanagement, has been significantly driven by financial factors, though a more recent focus on improvement of efficiency and quality of care within the hospital system has relied heavily on hospitalist input.[11, 12, 13] Important next steps in curriculum standardization include ensuring that training programs allow for adequate clinical exposure and proper assessment of competency in these areas, and determining the full complement of clinical training experiences that will produce hospitalists with a well‐defined scope of practice that adequately addresses the needs of hospitalized children.

Most fellowship‐trained hospitalists work primarily in university‐affiliated institutions with expectations for scholarly productivity.[5, 7] Fellowship‐trained hospitalists have made large contributions to the growing body of PHM literature, specifically in the realms of medical education, healthcare quality, clinical pediatrics, and healthcare outcomes.[4] Many PHM fellowship‐trained hospitalists have educational or administrative leadership roles.[2] Our results indicate that current PHM fellows continue to be active in a variety of research activities. In addition, FDs reported that the vast majority of programs included scholarship oversight committees, which ensure a mentored and structured research experience. Finally, most programs require or offer additional coursework, and many programs with university affiliations allow for attainment of graduate degrees. Inclusion of robust research training and infrastructure in all programs is a paramount goal of PHM fellowship training. This will allow graduates to be successful researchers, generating new knowledge and supporting the provision of high‐quality, evidence‐based, and value‐driven care for hospitalized children.

A unique feature of several PHM fellowship programs is that fellows are allowed to bill for clinical encounters. Many programs rely on clinical revenue to support fellow salaries.[14] For some programs, a portion of this clinical revenue comes from fellows billing for clinical encounters.[15] Programs that allow fellows to bill/generate clinical revenue have fellows working in attending roles without direct supervision, whereas nonbilling fellows have direct supervision by an attending.[15] In the current ABP training model, subspecialty fellows cannot independently bill for clinical encounters within their own subspecialty, though they can moonlight as long as they meet the duty hour requirements set forth by the ACGME.[16] FDs will need to consider the impact of this requirement on fellow autonomy and on financial revenue for funding fellow salaries if the field achieves ABP subspecialty status.

Regardless of whether or not PHM becomes a designated subspecialty of the ABP, FDs will continue to work together to develop a standard core curriculum that incorporates elements of clinical and nonclinical training to ensure that graduates not only provide high‐quality care for hospitalized children, but also generate new knowledge that advances the field in care delivery and quality of care in any setting. The results of this study will not only help to inform curriculum standardization, but also assessment and evaluation methods. Currently, PHM FDs meet annually and are nearing consensus on a standard 2‐year curriculum based on the PHM Core Competencies that incorporates core clinical, systems, and scholarly domains. We continue to solicit the input of stakeholders, including new FDs, community hospitalist leaders, internal medicine‐pediatrics hospitalist leaders, the Joint Council of Pediatric Hospital Medicine, and leaders of national organizations, such as the American Academy of Pediatrics, Academic Pediatrics Association, and Society of Hospital Medicine. Additional work around standardizing the fellowship application and recruitment process has resulted in our recent acceptance into the Fall Subspecialty Match through the National Residency Match Program, as well as development and implementation of a common fellowship application form. The FD group has recently formalized, voting into place an executive steering committee, which is responsible for the development and execution of long‐term goals that include finalizing a standardized curriculum, refining program and fellow assessment methods through critical evaluation of fellow metrics and outcomes, and standardization of evaluation methods.

Adopting a standard 2‐year curriculum may affect some programs, specifically those that are currently 1 year in duration. These programs would need to extend the length of their fellowship to allow for the breadth of experiences expected with a standardized 2‐year curriculum. This could result in significant financial challenges, effectively increasing the cost to administer the program. In addition, at present, programs have the flexibility to highlight individual areas of strength to attract candidates, allowing fellows to gain an in‐depth experience in domains such as clinical research, quality improvement, medical education, or health services research. With a standardized curriculum, some programs may have to assemble specific clinical and nonclinical experiences to meet the agreed‐upon expectations for PHM fellowship training. If these resources are not available, programs may need to seek relationships with other institutions to complete their offerings, a possibility that is being actively explored by this group. FDs continue to work with each other to share resources, identify training opportunities, and partner with each other to ensure that the requirements of a standard curriculum can be met.

This study has several limitations. First, it was a voluntary survey of program directors, and though we captured over 80% of programs at the time of the survey, there are currently more programs that have come into existence and more still that are in the development stage, leading to potential sampling error. Second, variable effort or accuracy by participants may have led to some degree of response error, such as content error or nonreporting error. Third, the survey questions focused on high‐level information, making it difficult to make nuanced comparisons between curricular elements or determine best curricular practice. In addition, this survey did not explore medical education and quality improvement activities of fellows, 2 major areas in which hospitalists play a major role in the inpatient setting.[1, 17, 18, 19, 20]

CONCLUSION

PHM fellowship programs have grown and continue to grow at a rapid rate. Variability in training is evident, both in clinical experiences and research experiences, though several common elements were identified in this study. The majority of programs are 2 years, and clinical experience comprises approximately 50% of training time, often including key rotations such as sedation, complex care, and rotations at community hospitals. Future directions include standardizing clinical training and expectations for scholarship, formulating appropriate methods for assessment of competency that can be used across programs, and seeking sustainable sources of funding.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P < 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P < 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P < 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P < 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P < 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P < 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P < 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.