Development and Implementation of a Peer Curbside Consult Service for Pediatric Hospitalists

Our goal was to provide decision support for challenging cases in our hospital medicine division of more than 75 physicians and advanced practice providers across 7 affiliate sites. Practice locations include a freestanding children’s hospital, 6 regional community sites providing general pediatric and newborn care, and 1 specialty care hospital. A group of hospitalists, including division leadership, interested in developing and participating as consultants met to establish program goal and plan for the implementation. We performed a literature review to identify examples of peer consult programs and potential obstacles.^4,9–12 

To monitor the impact of the program and seek user feedback, both requesting and consultant hospitalists were surveyed after completion of consultation. Postconsultation surveys were initially distributed and stored on the online survey platform SurveyMonkey.com. After institutional review board approval, the survey was transitioned to Research Electronic Data Capture.¹³ 

We describe the development and implementation of this peer consult service, including survey description, using the Template for Intervention Description and Replication (TIDieR) Checklist, a 12-point item outline that aims to provide transparent and complete reporting, enabling replicability of interventions.¹⁴ 

The institutional review board approved and deemed this program exempt.

The results are presented and framed by each specific question of the TIDieR checklist.¹⁴ 

The title of Peer Curbside Consult Service (PCCS) denoted that the consult program was intended to be of use between 2 colleagues as described previously.

Before program development, our division had a well-established weekly case conference to discuss challenging cases. The main impetus for this program’s development was a case involving a potential delay in a serious diagnosis. We determined that this case would have been discussed at the case conference had it occurred during the patient admission. Peer consultation could have supported the diagnostic and management decision-making. We wanted division members to have access to decision support every day of the week.

No physical or informational materials were necessary for the use of the PCCS. Hospitalists may use any reference materials needed to aid in the consultation.

A hospitalist requested peer consultation directly from the consultant either in person or by telephone. The consultant and requesting hospitalist determined the urgency and timing for the consultation. Although we did not outline a timeframe for consultant response, it is understood within the consultant group that the goal was to provide just-in-time support. Within 1 week of consultation, both parties were electronically surveyed about their experiences with the process.

Because the intent of this service was to provide timely access to advice from a trusted colleague, consultants provided verbal recommendations only. To comply with the Health Insurance Portability and Accountability Act, consultants did not access or use the electronic medical records or document recommendations in a patient chart, and disclosure of protected health information was discouraged.

The service was coordinated and managed by a hospitalist program manager, who was also a consultant. His or her administrative responsibilities included recruitment and scheduling of consultants, weekly division reminder e-mails, consult tracking, and survey distribution. Consultants reported completed consultations by responding to an e-mail from the program manager at the end of a service week. After identification of the requesting hospitalist, postconsultation surveys were e-mailed to both the requesting and consultant hospitalist.

The service coverage was disseminated on a scheduling Web site platform (amion.com) and division-wide weekly reminder emails. If physicians outside the division were covering services (ie, pediatric chief residents), the appropriate individual was e-mailed the consultant contact information.

Two consultant hospitalists were assigned weekly, Monday through Sunday, including holidays. Dual coverage allowed for flexibility and potential for small group discussion between the requesting hospitalist and consultants. The expectation was that consultants were available during the daytime hours.

Hospitalists volunteered their time as consultants for this service. Initially, the group consisted of 8 hospitalists with varying years of practice, community site experience, and areas of expertise. Additional consultants volunteered at the beginning of the second year of the service, and now total 11 consultants (Table 1). The time commitment per hospitalist averaged 10 weeks per year. There was no training or educational session provided for the consultants. Consulting hospitalists received no direct compensation but did receive credit toward the faculty incentive program.

We stressed the use of in-person or telephone communication for the most expedient response from consultants. The method of communication for the actual consultation was determined by the consultant and requesting hospitalist, and has included in-person, telephone, and Zoom.

Because the consultants do not need to be physically present to see the patient or access the medical record, consultations can occur wherever the consultant was available to hold a conversation. This was especially important as our divisional members were spread among many clinical sites and in-person consultation may not be feasible.

Initial program development began in February 2020. As COVID-19 began affecting our geographic region, it became apparent that division members needed more clinical decision support because of increased medical uncertainty and reduced in-person peer support because fewer hospitalists were physically present within the office when not working clinical shifts. The implementation of the program was expedited to address these new needs and was operational by April 2020. In the past 24 months, the program has received 60 consults, or about 2 to 3 consults per month.

Our priority was to ensure equitable access and serve the needs of all members regardless of practice environments. Before implementation, we learned that the community sites have their own informal system of peer consultation. We did not alter this inherent support system but augmented it by recruiting consultants who practice at community sites and have specialized clinical expertise (ie, neonatal intensive care unit, newborn care). We asked community site leaders to encourage use of the PCCS with their groups and ensured the consult schedule was accessible to those who work at community sites.

The PCCS infrastructure and procedures did not need to change since implementation was based on feedback received from requesting and consultant hospitalists. The requesting hospitalist survey has been modified twice since implementation, adding questions about changes to patient care management after consultation and years in practice.

Postconsultation surveys from requesting and consultant hospitalists were used to understand service utilization and solicit feedback that could improve service delivery (Tables 2 and 3, respectively). Requesting hospitalist surveys were voluntary and anonymous and reviewed in aggregate every 3 months. Survey questions were based on an initial proposed needs assessment, which was not conducted because of time constraints imposed by the pandemic. Besides surveys, we encouraged division members to provide feedback or questions to the PCCS-specific e-mail address, which was monitored by the program manager.

From the initiation of PCCS to April 2022, the postconsultation survey completion rates were 70% and 89% for requesting and consultant hospitalists, respectively. There were no concerns about access to the service or response time of consultants based on survey review and PCCS e-mail monitoring. Consultants also received interim updates about the program usage and user feedback. Preliminary data are presented in Supplemental Table 4 and Supplemental Figs 1–3.

We present the development and successful implementation of a peer consult service to provide clinical decision support for challenging cases for pediatric hospitalists at our institution. The program augmented preexisting, robust informal peer consultation at community sites and well-attended weekly case conferences, in addition to the innumerable curbside consults that occur outside of the program. This well-received peer consult service offered opportunities to support our colleagues. Furthermore, this consult service continues to thrive as more hospitalists are now onsite, suggesting the consult program has become part of the division’s culture.

This type of program can be generalizable to other divisions but would need to be tailored to the group’s needs. For example, because our program did not have administrative support, it was intentionally lean in terms of infrastructure and procedures, which is different compared with another more formalized programs.^11,12,15,16  By sharing our experiences, we hope that it may be possible for another hospital medicine divisions to implement similar programs.