As hospitalized children become more medically and socially complex, pediatric hospitalist programs increasingly have established comanagement systems to improve the care of patients and the experiences of their families.
Partnerships between surgical and pediatric providers have grown in both number and scope over the last 20 years or so. In contrast to traditional consultation models in which a specialist is asked to comment on or manage a specific clinical question, these programs typically allow pediatric hospitalists to coordinate the care of surgical patients actively and holistically throughout their hospitalization.
Although data are relatively limited, studies suggest that comanagement programs can improve care and reduce costs.
A new AAP clinical report Comanagement of Surgical Pediatric Patients in the Acute Care Inpatient Setting, from the Section on Hospital Medicine, provides guidance for hospitals as they seek to establish hospitalist comanagement programs for surgical patients. It is available at https://doi.org/10.1542/peds.2023-064775 and will be published in the January issue of Pediatrics.
The report recognizes the importance of tailoring the structure of the comanagement program to patients’ needs and the clinical scenario while also emphasizing some common themes. For instance, a distinction is made between a previously healthy child undergoing an appendectomy performed by a surgeon with limited pediatric expertise at a community hospital and a medically complex child with cerebral palsy and epilepsy undergoing femoral osteotomies for hip stabilization.
Pediatric expertise, key components
Data were generated using a modified Delphi approach over several years and included the perspective of pediatric experts in orthopedics, surgery, anesthesiology, urology, neurosurgery and hospital medicine.
Experts identified the following as key components of a successful pediatric hospitalist-surgical comanagement program:
- operational/structural elements, which are related to an overview and vision of the hospitalist-surgeon comanagement program;
- clinical elements, which reflect how the program helps manage patients on a daily basis, such as understanding the clinical roles of the surgical team, the pediatric team, nurses and others; and
- elements related to quality/education/training.
Respondents rated the importance of certain aspects of comanagement programs for the success and sustainability of the programs on a five-point Likert scale.
Operational/structural elements were viewed as particularly important during the program creation and implementation phases. They included identifying program champions, defining goals of the program, identifying billing and documentation responsibilities, and developing and reviewing written service agreements.
Clinical elements included patient selection for comanagement, delineation of clear clinical responsibilities (e.g., as in cases of pain, fever and antibiotics), establishing communication strategies with nursing staff, ensuring that patients and families understand the role of each provider, implementing clinical pathways for surgical patients and adherence to ethical standards for comanagement.
Notably, there was limited endorsement of the importance of hospitalist involvement in preoperative or postoperative ambulatory care.
Quality/education/training elements may be especially important in the maintenance and improvement of surgical comanagement programs. These elements emphasize the incorporation of both surgical and pediatric trainees, and the importance of collaboratively assessing patient outcomes to improve aspects of the program. Elements include emphasis on providing training for pediatric providers on the indications for surgical procedures and their typical course as well as reviewing data and quality improvement opportunities.
The clinical report provides an outline for pediatric hospitalist programs to develop, implement, assess and improve their respective surgeon-hospitalist comanagement programs. These principles will help children of all backgrounds undergo and recover from surgery in a way that is safe, efficient and patient- and family-centered.
Dr. Rappaport is a lead author of the clinical report.
