Pediatric Hospital Medicine 2016, cosponsored by the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA), and the Society of Hospital Medicine (SHM), took place July 28–31 in Chicago. Didn’t make it? Here are all the news, research, and talking points you need to know.
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Shape Your Brain to Avoid Burnout
Presenter: Lisa Zaoutis, MD, FHM
Amid the skyscrapers of the Windy City, Pediatric Hospital Medicine (PHM) 2016 swept into town, bringing with it the denizens of pediatric hospitalist programs across the country. Some 1,150 attendees, composed of hospitalists, PHM program leaders, and advanced-care practitioners, gathered to educate and inspire one another in the care of hospitalized children.
Lisa Zaoutis, MD, FHM, director of the pediatric residency program at The Children’s Hospital of Philadelphia, kicked off the conference with the opening plenary. Initially titled “North Star and Space,” she quickly changed the title to “Changing Our Minds.” Touching on the disconnect between positive experiences that bring physicians into pediatric hospital medicine and negative experiences that often drive behavior, she started with the beginning: the evolution of our brains.
“We are wired toward the negative,” Dr. Zaoutis said. “We are Teflon for positive experiences and Velcro for negative experiences.”
Delving deeper into neuroanatomy, Dr. Zaoutis spoke of “amygdala hijack,” where chronic stress inherent to the professional lives of pediatric hospitalists leads to anxiety responses that are faster, more robust, and more easily triggered.
But all is not lost, Dr. Zaoutis noted, as our brains are more plastic than previously known. The “neural Darwinism” of our brains, she said, leads to epigenetic intracellular changes, more sensitive synapses, improved blood flow, and even new cells as a result of experience-dependent neuroplasticity. For example, London taxi drivers have thicker white matter in their hippocampus as a result of learning London city streets, and mindfulness meditators have thicker gray matter in regions that control attention and self-insight.
Key Takeaways
The lesson for pediatric hospitalists, according Dr. Zaoutis, is that you can shape your brain for greater joy.
“Consciously choose activities” that counter our evolutionary negativity bias, Dr. Zaoutis said.
Here’s how to do it:
- Have a positive experience. (You can create one or retrieve a prior one.)
- Enrich it and install it by dwelling on it for at least 15–30 seconds.
- Absorb it into your body, which may require somatizing it. (Dr. Zaoutis presses her hand into her chest to aid in this.)
Further, spread this to your group by the old medical training technique of “see one, do one, teach one.” See if you can start your sign-out with the best thing that happened to you in the week. Most important, start with observing yourself.
Weijen Chang, MD, SFHM, is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California, San Diego (UCSD) School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to [email protected].
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New AAP Guideline on Evaluating, Managing Febrile Infants
Presenter: Kenneth Roberts, MD
One of PHM16’s most highly attended sessions was an update on the anticipated AAP guidelines for febrile infants ages 7–90 days. The updated guidelines stress the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.
The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C.
Exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.
The updated guideline will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment.
It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk.
Key Takeaway
An updated AAP guideline algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days, and 60–90 days will be coming in the near future. It will help standardize care in this population but should not be used as a substitute for clinical judgment.
Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.
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Promoting, Teaching Pediatric High-Value Care
Presenters: Lauren L. Walker, MD, FAAP; Alan Schroeder, MD, FAAP; Michael
Tchou, MD, FAAP; Jimmy Beck, MD, MEd; Lisa Herrmann, MD; Ricardo Quinonez, MD, FAAP
Pediatric hospitalists gathered to attend a fruitful discussion on not only how to change our way of thinking but also how to feed it forward to our trainees. The barriers to promoting and teaching high-value care are plenty and essentially universal to academic and community sites: We have had no formal teaching, there is cultural resistance, and there is lack of transparency on costs and charges.
The questions we perhaps should be asking ourselves, our trainees, and our families are:
- “What matters?” instead of “What’s the matter?”
- “Does that test benefit the patient? What are the harms of the test?” instead of “Will that test change our management?”
There is still a long way to go to move the pendulum to the side of value-based practice and teaching. There is still controversy on how and whether cost should be discussed with the family. Cost is more than just monetary value; family anxiety and patient harm may resonate more with families as we perfect our skills in shared decision making.
Key Takeaway
This serves as an exciting time to unite and better our understanding about why we do what we do and deliberately think about downstream effects. High-value care curriculum for medical students, residents, fellows, and even faculty is an area ripe for further research.
Akshata Hopkins, MD, FAAP, is an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.
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How to Design, Improve Educational Programs at Community Hospitals
Presenters: Christopher Russo, MD, FAAP; Laura Hodo, MD, and Lauren Wilson, MD
One session at PHM16 focused on ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.
During the didactic session, a general background of the importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy,” “exposure to different career paths,” and “transfer decision making.”
Some of the challenges discussed in regard to developing an educational structure in community settings included:
1. Logistics
- Making the case for education
- Legal framework (e.g., affiliation agreements, liability)
- Finances (e.g., GME funding)
- Paperwork burden (e.g., licensing, credentialing)
2. Learning environment
- Complementing clinical work with materials
- Autonomy/supervision balancing
- Developing clinical teachers
The didactic session also reviewed the six steps for curriculum development: general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation/feedback. Each of these was described in further detail with relevant examples.
Groups were broken into small groups based on four learner types: medical students, family medicine residents, pediatric residents, and PHM fellows. Within each group, a “program development matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.
A separate “curriculum development matrix” was used during breakout groups that focused on curriculum development. This matrix was broken into three areas: educational strategies, implementation, and evaluation/feedback. These were further broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short- and long-term goals with action steps for both of these matrix subgroups.
Key Takeaway
Overall, the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools for sites that wish to develop or improve their current educational framework.
Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children’s National Health System Community Hospital Services in Washington, D.C.
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Tips on Meeting Needs of Children with a Medical Complexity
Presenters: Mary L. Ehlenbach, MD, FAAP; Megan Z. Cardoso, MD, FAAP, and Christina Kleier, ARNP, PNP
This session at PHM16 was focused on logistical tips on how to build a pediatric complex-care program. Presenters opened with a discussion on how to define children with medical complexity. This involved reviewing different methods, including using research-based aggregation of ICD-10 codes, relying on referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about one-third of healthcare spending. Because of advances in technology and medicine, this group of children is growing in numbers. It currently makes up about 10% of all pediatric admissions.
Key Takeaways
1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.
2. When working to initiate a complex-care program:
- Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
- Ensure the team composition is sustainable and meets the needs of the patients.
- Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
- Include team members who are nonclinical to aid in improving hospital revenue and highlighting program benefits to the institution.
Margaret Rush, MD, is a hospitalist fellow at Children’s National Medical Center in Washington, D.C.
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A Picture Is Worth a Thousand Words
Presenter: Kenneth Roberts, MD
PHM16’s “Visual Diagnosis: Signs and Why They Matter” session was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses or overdiagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.
Many of the presented cases highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.
In other instances, such as with Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis was necessary to help guide management and future treatment, including subspecialty evaluation.
Key Takeaway
Many diseases with visual presentations will have a benign course and require no treatment. Acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.
This session underscores the need for experience and exposure to various signs not only with rare medical conditions but also in common illnesses such as Kawasaki disease and scarlet fever that may present similarly.
Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.
