An updated AAP clinical report on the role of physicians in coordinating the care of hospitalized children reflects the changing inpatient practice environment.
The report emphasizes the child’s overall health; a greater focus on safety throughout the hospitalization; and an increasing presence of hospitalists. It also highlights the growing importance of communication among providers in inpatient and outpatient arenas as well as consultants.
The report, Physician’s Role in Coordinating Care of Hospitalized Children from the Committee on Hospital Care and Section on Hospital Medicine, is available at https://doi.org/10.1542/peds.2018-1503 and will be published in the August issue of Pediatrics.
Opportunity to improve care
While the hospitalization of a child should focus on the reason for the hospitalization, it also presents an opportunity to review the patient’s general health and well-being.
Some children do not receive regular pediatric care, so a review of general health may reveal significant issues that can impact the child’s health or that may have led to the hospitalization. A review of vaccination status, developmental status, school performance, and family and social issues — including a HEADSS (Home, Education, Activities/employment, Drugs, Suicidality, Sex) assessment of teenagers — may bring to light health care needs.
However, it is not the attending physician’s responsibility to see that all identified needs are addressed during the hospitalization. For example, a child recognized to be behind on immunizations does not need to get those vaccines in the hospital (although every vaccine opportunity should be maximized). Instead, the report suggests having a plan, such as referral to a medical home, to address identified gaps. Recognition of health care gaps and appropriate outpatient follow-up may prevent future admissions.
Good communications essential
Because a team of providers cares for a hospitalized child, good communication is essential to good outcomes. Communication between the inpatient service and medical home should take place on admission and discharge and during the hospitalization as necessary.
Within the hospital, care usually is coordinated among many providers, and the attending physician is responsible for ensuring accurate hand-offs. Literature supports using hand-off “bundles” for consistent and accurate transfer of data between providers.
Many hospitalized children receive consults from additional services or are co-managed between specialties. Delineation of responsibilities for consultation or co-management should reflect a general agreement between services, but a single attending should have final decision-making ability.
When the physician of record does not care for pediatric patients routinely or has a narrow clinical focus, consultation with a generalist (such as a hospitalist or general pediatrician) can provide a more holistic approach to the child and family as well as attention to pediatric issues, such as weight-dependent medication dosing and developmentally appropriate care.
Safety first
Ensuring the child’s safety during the hospitalization is an important focus. Safety includes direct care and hospital systems. Bedside safety can be as simple as handwashing and adherence to handoff bundles. The attending must be an advocate for the child, especially in non-children’s hospitals where systems often default to adult parameters such as radiation dosing.
Optimal care coordination will minimize trauma to the child and family, while attaining the desired health outcome.
Dr. Rauch, the lead author of the report, is a member of the AAP Committee on Hospital Care and former chair of the Section on Hospital Medicine Executive Committee.
