Comanagement of Surgical Pediatric Patients in the Acute Care Inpatient Setting

Children undergoing surgical procedures with postoperative hospitalization in acute care units, outside of intensive care, are increasingly managed collaboratively by both a surgical team and a pediatric team rather than a surgical team alone.¹  Traditional consultation involves a primary team requesting a specialty team to evaluate a patient and render recommendations regarding 1 discrete aspect of care without actively managing the overall care of the patient.²  In contrast, comanagement refers to an arrangement involving active participation by the consultant, including order management, while actively involving patients and families, along with the surgical team, in shared medical decision-making. Comanagement has been defined by the Society of Hospital Medicine as “the shared responsibility, authority and accountability for the care of a hospitalized patient across clinical specialties” with 1 primary attending physician of record.³ 

Given the heterogeneity of patients and practices, there is no strong evidence that 1 care model works best for pediatric patients with primary surgical issues in all settings. Regardless, comanagement programs for pediatric patients are being implemented with increasing frequency. A large national survey study found that >40% of pediatric surgery programs and >60% of pediatric orthopedics programs employ comanagement for at least some patients.⁴  Another study found that the number of pediatric hospital medicine programs involved in caring for surgical patients increased from 44% to 90% between 1997 and 2020.¹  This mirrors a pattern in care of adult surgical patients.¹  In light of these developments, physicians, families, and health care systems can benefit from central tenets should comanagement be pursued. This clinical report, developed through expert consensus using a modified Delphi approach, seeks to contribute to comanagement best practice development and implementation.

Comanagement models of care vary depending on resources, capacity, and team structures. The role of the pediatric provider in acute care is often filled by a pediatric hospitalist, general pediatrician, complex care team, anesthesiologist, or advanced practice nurse with or without pediatric trainees. For readability, “pediatric team” is used throughout this document to refer to these medical (nonsurgical) providers.

Models of pediatric comanagement of surgical patients may be different depending on location, resources, patient population, and the availability of providers with pediatric expertise. Consider the differences between:

• A 6-year-old otherwise healthy child in a community hospital with appendicitis; and

• A 6-year-old medically complex child with severe neurologic impairment, gastrostomy tube dependency, acquired hydrocephalus with ventriculoperitoneal shunt, and baclofen pump for cerebral palsy-related spasticity undergoing electively timed major orthopedic surgery at a children’s hospital.

In the first case, a general surgical team may not be onsite 24/7. The American Academy of Pediatrics (AAP) recommends that in settings without surgical specialty pediatric expertise, patients weighing less than 40 kg or younger than 14 years of age may benefit from formal consultation with a pediatric provider.⁵ 

In the second case, regarding a child with medical complexity,⁵  given the number of medical issues, systems, and care providers involved, holistic management and care coordination might be better achieved with an inpatient pediatric team providing surgical comanagement in concert with the patient’s surgical team and medical home.^6,7  Prioritized time-intensive patient- and family-centered care coordination is a critical aspect of the care of hospitalized children, especially those with medical complexity.⁶ 

These examples highlight the diversity of potential comanagement opportunities and practices with varying pediatric resources and patient needs, suggesting 1 approach does not fit all institutions or patient types. The Society of Hospital Medicine has developed a comanagement white paper³  and best practices toolbox aimed at internal medicine hospitalists’ comanagement of adult patients. These recommendations, however, do not necessarily apply to pediatric patients or to the various configurations seen in pediatric-surgical comanagement practices.

At the same time, rigorous evaluation of best practices or the impact of pediatric comanagement is limited. The most commonly reported scenario, hospitalist-surgical comanagement, has been evaluated only in retrospective single site studies^8–10  that have suggested improvements in nurse satisfaction, guideline implementation, and quality outcomes. These studies also suggest an impact on patient and system costs and a focus on value-based care, as measured by quality indices.¹¹  The paucity of pediatric-focused data regarding the financial impact on surgical teams related to global fees and surgical and pediatric trainee education in pediatric inpatient care suggests opportunities for further study.

Descriptions of comanagement structure vary by location and need and are in different stages of development at different institutions.^12,13  Although specific Current Procedural Terminology codes and modifiers allow appropriate reporting of comanagement, local variation exists in knowledge of these resources.¹⁴ 

This clinical report was developed in the context of the lack of strong evidence about best practices in pediatric-surgical comanagement. This report aims to guide new and existing pediatric-surgical comanagement programs by offering recommendations for providers and health systems. Recommendations are offered for essential components of effective comanagement programs in the domains of: (I) operational and structural elements; (II) clinical elements; and (III) elements relating to quality, training, and education. This clinical report will help institutions establish new programs and assist existing programs to refine their clinical care goals and recommend benchmark measures for programs to track.

Using existing comanagement literature from both pediatric and internal medicine programs, we used a modified Delphi procedure¹⁵  to solicit expert opinion regarding the key components needed for a successful pediatric inpatient acute care (nonintensive care) comanagement program. Twenty-five expert AAP members were identified, including leaders of the AAP Sections on Orthopedics, Neurosurgery, General Surgery, Urology, Anesthesiology, Otolaryngology, and Hospital Medicine in rounds 1 and 3. The development of initial principles (first round) was initiated by emailing surveys to leaders of AAP sections with support of AAP Surgical Section leadership (Table 1).

Principles were then narrowed during a 2016 in-person core working group meeting of the AAP Section on Hospital Medicine Surgical Care Subcommittee members (second round). The third voting round occurred via e-mail to the full panel and expanded stakeholders, including leaders of the Section on Hospital Medicine Community Hospital Subcommittee.

Overall, stakeholder perception of “successful” comanagement programs featured clear expectations of communication, roles, and collaboration. The following broad categories detail the consensus expert opinion for elements of a successful pediatric surgical comanagement program at 2 levels: foundational and recommended. The levels of support (Fig 1) were determined using median expert panel scores assigned between 4 and 5 (“very important” or foundational) or 3 and 4 (“important” or recommended). Elements with a median score of ≤3 (“emerging”) were deemed inadequate for inclusion at the time.

Elements were divided into 3 major categories: (1) operational and structural elements, (2) clinical elements, and (3) elements related to quality, training, and education. General themes generated via Round 1 are outlined in Table 1.

It is important for any comanagement program that the practice structure, leadership, operation, and oversight, including safety reporting structure and untoward event designation, are defined. As noted in other AAP statements,¹⁶  many of the responsibilities for managing the care of pediatric inpatients are being coordinated between hospitals and physicians as part of integrated delivery systems or accountable care organizations that use a variety of payment methodologies: prospective payment, case rate methodologies, or bundled or global fee arrangements. Pediatricians and pediatric specialists should collaborate with hospitalists, anesthesiologists and pain specialists, hospital quality assurance managers, case managers, medical directors, and administrators to define workflows and policies to optimize efficiency and clinical outcomes for patients requiring hospital care.

The following specific pediatric-surgical collaborative care operational and structural elements were identified:

1. Identify pediatric and surgeon leaders or champions. These leaders should involve others in their group and incorporate other key stakeholders, including medical specialists, anesthesiologists and pain specialists, behavioral health specialists, intensivists, community providers, nurses, and therapists.

2. Identify and articulate the rationale and goals of the program.

3. Clearly delineate program resources, such as sufficient physician and support team staffing and administrative support.

4. Elucidate documentation expectations for both medical and surgical services.

1. Ensure that coding and billing responsibilities are clearly outlined.

2. Elicit hospital leadership support of the comanagement program. Clearly address concerns related to jurisdiction and collaborative care before, early in, and throughout the implementation process.

3. Develop and routinely review written service agreement highlighting program details and responsibilities detailed in section II below.

The key components around clinical care are clarity and communication. Although joint patient- and family-centered rounds with pediatric and surgical teams are ideal, this is often not possible, making timely intrateam communication even more important. Pediatric teams may also serve as a conduit for communication with pediatric subspecialists, ancillary services, and primary care providers.

1. Define patient selection criteria for comanagement. Depending on the needs and challenges of different environments, determine at a program level whether all surgical patients are comanaged versus select patients based on medical or surgical factors.

2. Delineate specific clinical issues as primary responsibility of 1 service or a shared responsibility. A clinical conflict resolution hierarchy and escalation strategy is needed when management opinions differ. “Management” includes evaluation, planning, and order writing that is communicated with nursing, other providers, and families about the care plan. Examples of discrete clinical responsibilities could include antibiotics or pain management—including involvement of pain specialists and anesthesiologists—drain and wound care, and postoperative fever evaluation.

   • Ensure providers avoid practicing outside their scope of practice as dictated by national board certification, local regulations, and delineation of privileges.¹⁷ 

   • Surgical teams should remain primarily responsible for surgical issues throughout the hospitalization.

   • Pain management is an important element of postoperative care, especially for patients undergoing extensive surgeries like spinal fusion or major reconstructive surgery. When available, collaboration with pediatric pain management, anesthesiology, complex care, and palliative care services that provide advanced postoperative pain care with continuous local anesthetic and analgesic infusions is an important part of providing comprehensive care to surgical patients. These services can also assist with the management of complex pain-related issues such as patients with substance use disorder, neuropathic pain, or acute-on-chronic pain.

3. Outline expectations and requirements for daily interservice patient care communication and responsibilities between the surgical, pediatric, and pain management services, nursing staff, and other care team members including social workers, therapists, and patients and families, as well as the primary care provider. The latter is particularly important for goal setting and safe transitions of care.

4. Consistently communicate the hospitalist and pediatric team’s role to the patient or family.

5. Establish a clear system of call triage so that nursing staff and other hospital staff understand which service to contact for which clinical issues.

1. Clearly identify which service will be the primary service (surgical or medical) for patient care and administrative purposes.

2. Implement integrated collaborative clinical pathways.^18,19  These shared models provide benefits toward standardizing care across surgical, pediatric, and anesthesiology teams as well as nursing and clinical pharmacy, and promote interdisciplinary team building.

3. Assure that providers adhere to ethical principles around comanagement. These arrangements should benefit patients and families rather than represent a source of self-referrals.

There was limited endorsement of inpatient pediatric team involvement in ambulatory preoperative and/or postoperative care.

1. Provide additional training for pediatric inpatient providers to develop content expertise on the perioperative course and management of patients undergoing common surgical procedures.

1. Collect program metric data to evaluate the comanagement process and impact on patient care. These data may include patient and family, physician and nursing satisfaction with pain management and team communication, and safety outcomes like surgical site infections.

2. Recognize surgical and pediatric trainee roles and educational needs in support of patient comanagement and evaluate the impact on surgical trainee skills in nonoperative patient management.

3. Recognize and define the role and education requirements of advanced practice providers (APPs), if applicable, on surgical and pediatric teams.

4. Promote the use of evidence-based continuing medical education on perioperative management for surgical specialists.

5. Establish routine joint review of program operations.

6. Establish case review and morbidity or mortality conferences to assess and improve patient care and build collaborative networks.

The goal of this clinical report is to optimize patient care and promote patient- and family-centered, high-quality, seamless care for surgical patients in the pediatric acute care setting. When comanagement is chosen as an approach to meet these needs, local collaboration must reflect each institution’s patient population and provider expertise.²⁰  By incorporating the opinions of national leaders across pediatric hospital medicine, surgical specialties, and anesthesiology, we have provided a framework for current and nascent comanagement programs in community and tertiary care settings. Although not specifically assessed in the surveys, stakeholders suggested that some elements may be more applicable to newer comanagement programs during development. Longstanding programs may run more smoothly because of established cultural norms around comanagement, whereas newer programs may expect a transitional period between program development and improved quality metrics.

The overall impact of comanagement on the care of pediatric patients, systems, and trainee education requires further evaluation. Given the high prevalence of collaborative care of hospitalized children across all hospital settings, these suggestions are provided to assist institutions and providers when patient comanagement is employed.

Rebecca E. Rosenberg, MD, MPH, FAAP

David M. Pressel, MD, PhD, FAAP, FHM

David I. Rappaport, MD, FAAP, FHM

Joshua M. Abzug, MD, FAAP

Geeta Singhal, MD, MEd, FAAP, Chairperson

Rachel Marek, MD, FAAP, Chairperson-Elect

Jessica M. Allan, MD, FAAP

Zoey Goore, MD, MPH, FAAP

Laura Nell Hodo, MD, FAAP

Dimple Khona, MD, MBA, ABOIM, IFMCP, FAAP, Community Hospitalist Representative

Tony Tarchichi, MD, FAAP

H. Barrett Fromme, MD, MHPE, FAAP, Immediate Past Chair

Jorge Ganem, MD, FAAP, Task Force on Diversity and Inclusion Chair

Eleanor Sharp, MD, MS, FAAP, Liaison, Section on Pediatric Trainees

S. Niccole Alexander, MPP

This statement is in grateful memory of Dr. Rebecca Rosenberg, who was its first author and inspiration, working on it even during her recent illness. Dr. Rosenberg's tireless dedication to pediatrics has benefited countless children and served as an inspiration to her colleagues locally and nationally. The authors also thank the members of the AAP Section on Hospital Medicine Surgical Care Subcommittee, including physicians from the AAP Sections of Hospital Medicine, Surgery, Orthopedics, Anesthesiology, and Neurosurgery, as well as members of the American Pediatric Surgical Association, for their contributions to this work.