User login
NEW ORLEANS – Hospitalist comanagement of pediatric neurosurgical cases significantly shortens hospital length of stay without increasing readmissions or complications, according to a retrospective analysis of 526 patients.
The mean LOS fell from 8.6 days to 5.6 days and median LOS from 4 days to 3 days after the transition to hospitalist comanagement. Both differences were significant.
Comanagement also had a great impact on the variability of LOS, as demonstrated by a reduction in the standard deviation from 20.0 to 7.2, observed Dr. Catherine Sullivan, with Connecticut Children’s Medical Center in Hartford.
"It looked like our greatest effect was on the variability of the outliers," she said at Pediatric Hospital Medicine 2013.
Ten patients stayed for more than 50 days before hospitalist comanagement was implemented, whereas none did in the time after.
One extreme outlier stayed for about 400 days prior to comanagement, and likely explains the large discrepancy between the mean and median LOS, Dr. Sullivan explained.
The chart review involved 347 neurosurgical patients cared for in the 2 years prior to hospitalist comanagement and 179 patients cared for in the year after the launch of the program in March 2011. Children with routine ventriculoperitoneal shunt revision or those hospitalized for brief neurologic observations were excluded.
Two staff neurosurgeons provided education to hospitalists and pediatric residents prior to implementation.
Hospitalists provided care in the areas of nutrition, pulmonary clearance, pain management, rehabilitation, and discharge planning. Areas where hospitalists could write orders without running them by the neurosurgeon were hashed out in a departmental meeting at the attending level. A monthly hospitalist meeting was also dedicated to the project.
"We did really focus on that communication piece," Dr. Sullivan said. "I think that’s probably a challenge between many medical and surgical teams. It was a change in culture, and it has improved relationships between the two divisions."
About 80% of pediatric neurosurgical cases have been hospitalist-comanaged since the project began. The LOS reduction was maintained across neurosurgeons.
Despite the shorter stay, no differences have been observed in rates of complications or readmissions, Dr. Sullivan said.
The study sparked a lively debate, with audience members lauding the relevancy of the study, but also questioning whether the involvement of pediatric residents or other factors might have impacted LOS.
Dr. Sullivan acknowledged this was hard to tease out since the pediatric residents also began to follow these patients, and had done so "only peripherally" in the past.
"So whether the pediatric residents impacted the length of stay as much as, or more than, the hospitalists, is really not clear," she said.
Other attendees suggested performing subgroup analyses or a case-mix adjustment to strengthen the results, or applying a winsoring technique to address the statistical outliers.
"Because the data were so striking, one of the first things we did was to have our people go back and make sure we weren’t having an increase in readmissions, and, in fact, we weren’t," Dr. Sullivan remarked at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
An informal poll was performed, however, with only favorable responses received from both neurosurgeons regarding the areas of communication, management, and perceived provider and family satisfaction, she said.
The hospital is looking at expanding the project to include other surgical subspecialties such as orthopedics, urology, ENT, craniofacial, and ophthalmology, particularly for cases with high co-medical morbidities such as spinal fusion or Pierre Robin malformation sequences, Dr. Sullivan said.
Cost analyses are also ongoing, and the hospital is debating whether to have hospitalists meet with patients upon admission rather than after surgery. However, "it creates a staffing challenge of who is going to cover that visit," Dr. Sullivan said
Session comoderator and pediatric hospitalist Dr. Jack Percelay, with E.L.M.O. Pediatrics in New York, encouraged Dr. Sullivan and her colleagues to publish the data, observing that "it really struck a chord."
Dr. Sullivan and her coauthors reported having no financial disclosures.
NEW ORLEANS – Hospitalist comanagement of pediatric neurosurgical cases significantly shortens hospital length of stay without increasing readmissions or complications, according to a retrospective analysis of 526 patients.
The mean LOS fell from 8.6 days to 5.6 days and median LOS from 4 days to 3 days after the transition to hospitalist comanagement. Both differences were significant.
Comanagement also had a great impact on the variability of LOS, as demonstrated by a reduction in the standard deviation from 20.0 to 7.2, observed Dr. Catherine Sullivan, with Connecticut Children’s Medical Center in Hartford.
"It looked like our greatest effect was on the variability of the outliers," she said at Pediatric Hospital Medicine 2013.
Ten patients stayed for more than 50 days before hospitalist comanagement was implemented, whereas none did in the time after.
One extreme outlier stayed for about 400 days prior to comanagement, and likely explains the large discrepancy between the mean and median LOS, Dr. Sullivan explained.
The chart review involved 347 neurosurgical patients cared for in the 2 years prior to hospitalist comanagement and 179 patients cared for in the year after the launch of the program in March 2011. Children with routine ventriculoperitoneal shunt revision or those hospitalized for brief neurologic observations were excluded.
Two staff neurosurgeons provided education to hospitalists and pediatric residents prior to implementation.
Hospitalists provided care in the areas of nutrition, pulmonary clearance, pain management, rehabilitation, and discharge planning. Areas where hospitalists could write orders without running them by the neurosurgeon were hashed out in a departmental meeting at the attending level. A monthly hospitalist meeting was also dedicated to the project.
"We did really focus on that communication piece," Dr. Sullivan said. "I think that’s probably a challenge between many medical and surgical teams. It was a change in culture, and it has improved relationships between the two divisions."
About 80% of pediatric neurosurgical cases have been hospitalist-comanaged since the project began. The LOS reduction was maintained across neurosurgeons.
Despite the shorter stay, no differences have been observed in rates of complications or readmissions, Dr. Sullivan said.
The study sparked a lively debate, with audience members lauding the relevancy of the study, but also questioning whether the involvement of pediatric residents or other factors might have impacted LOS.
Dr. Sullivan acknowledged this was hard to tease out since the pediatric residents also began to follow these patients, and had done so "only peripherally" in the past.
"So whether the pediatric residents impacted the length of stay as much as, or more than, the hospitalists, is really not clear," she said.
Other attendees suggested performing subgroup analyses or a case-mix adjustment to strengthen the results, or applying a winsoring technique to address the statistical outliers.
"Because the data were so striking, one of the first things we did was to have our people go back and make sure we weren’t having an increase in readmissions, and, in fact, we weren’t," Dr. Sullivan remarked at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
An informal poll was performed, however, with only favorable responses received from both neurosurgeons regarding the areas of communication, management, and perceived provider and family satisfaction, she said.
The hospital is looking at expanding the project to include other surgical subspecialties such as orthopedics, urology, ENT, craniofacial, and ophthalmology, particularly for cases with high co-medical morbidities such as spinal fusion or Pierre Robin malformation sequences, Dr. Sullivan said.
Cost analyses are also ongoing, and the hospital is debating whether to have hospitalists meet with patients upon admission rather than after surgery. However, "it creates a staffing challenge of who is going to cover that visit," Dr. Sullivan said
Session comoderator and pediatric hospitalist Dr. Jack Percelay, with E.L.M.O. Pediatrics in New York, encouraged Dr. Sullivan and her colleagues to publish the data, observing that "it really struck a chord."
Dr. Sullivan and her coauthors reported having no financial disclosures.
NEW ORLEANS – Hospitalist comanagement of pediatric neurosurgical cases significantly shortens hospital length of stay without increasing readmissions or complications, according to a retrospective analysis of 526 patients.
The mean LOS fell from 8.6 days to 5.6 days and median LOS from 4 days to 3 days after the transition to hospitalist comanagement. Both differences were significant.
Comanagement also had a great impact on the variability of LOS, as demonstrated by a reduction in the standard deviation from 20.0 to 7.2, observed Dr. Catherine Sullivan, with Connecticut Children’s Medical Center in Hartford.
"It looked like our greatest effect was on the variability of the outliers," she said at Pediatric Hospital Medicine 2013.
Ten patients stayed for more than 50 days before hospitalist comanagement was implemented, whereas none did in the time after.
One extreme outlier stayed for about 400 days prior to comanagement, and likely explains the large discrepancy between the mean and median LOS, Dr. Sullivan explained.
The chart review involved 347 neurosurgical patients cared for in the 2 years prior to hospitalist comanagement and 179 patients cared for in the year after the launch of the program in March 2011. Children with routine ventriculoperitoneal shunt revision or those hospitalized for brief neurologic observations were excluded.
Two staff neurosurgeons provided education to hospitalists and pediatric residents prior to implementation.
Hospitalists provided care in the areas of nutrition, pulmonary clearance, pain management, rehabilitation, and discharge planning. Areas where hospitalists could write orders without running them by the neurosurgeon were hashed out in a departmental meeting at the attending level. A monthly hospitalist meeting was also dedicated to the project.
"We did really focus on that communication piece," Dr. Sullivan said. "I think that’s probably a challenge between many medical and surgical teams. It was a change in culture, and it has improved relationships between the two divisions."
About 80% of pediatric neurosurgical cases have been hospitalist-comanaged since the project began. The LOS reduction was maintained across neurosurgeons.
Despite the shorter stay, no differences have been observed in rates of complications or readmissions, Dr. Sullivan said.
The study sparked a lively debate, with audience members lauding the relevancy of the study, but also questioning whether the involvement of pediatric residents or other factors might have impacted LOS.
Dr. Sullivan acknowledged this was hard to tease out since the pediatric residents also began to follow these patients, and had done so "only peripherally" in the past.
"So whether the pediatric residents impacted the length of stay as much as, or more than, the hospitalists, is really not clear," she said.
Other attendees suggested performing subgroup analyses or a case-mix adjustment to strengthen the results, or applying a winsoring technique to address the statistical outliers.
"Because the data were so striking, one of the first things we did was to have our people go back and make sure we weren’t having an increase in readmissions, and, in fact, we weren’t," Dr. Sullivan remarked at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
An informal poll was performed, however, with only favorable responses received from both neurosurgeons regarding the areas of communication, management, and perceived provider and family satisfaction, she said.
The hospital is looking at expanding the project to include other surgical subspecialties such as orthopedics, urology, ENT, craniofacial, and ophthalmology, particularly for cases with high co-medical morbidities such as spinal fusion or Pierre Robin malformation sequences, Dr. Sullivan said.
Cost analyses are also ongoing, and the hospital is debating whether to have hospitalists meet with patients upon admission rather than after surgery. However, "it creates a staffing challenge of who is going to cover that visit," Dr. Sullivan said
Session comoderator and pediatric hospitalist Dr. Jack Percelay, with E.L.M.O. Pediatrics in New York, encouraged Dr. Sullivan and her colleagues to publish the data, observing that "it really struck a chord."
Dr. Sullivan and her coauthors reported having no financial disclosures.
AT PEDIATRIC HOSPITAL MEDICINE 2013
Major finding: After the transition to hospitalist comanagement, the mean length of stay fell significantly, from 8.6 days to 5.6 days, and the median LOS fell from 4 days to 3 days.
Data source: Chart review of 526 pediatric neurosurgery cases.
Disclosures: Dr. Sullivan and her coauthors reported having no financial disclosures.
