Caring for Hospitalized Children Can Mean Taking on Different Roles

Caring for hospitalized children and adolescents has become increasingly complex and often involves multiple physicians beyond the traditional primary care pediatrician, including hospitalists, medical subspecialists, surgical specialists, and hospital attending physicians.

In a new report published in Pediatrics, Patricia S. Lye, MD, and the Committee on Hospital Care and Section on Hospital Medicine summarize “the responsibilities of the pediatrician and other involved physicians in ensuring that children receive coordinated and comprehensive medical care delivered within the context of their medical homes as inpatients, and that care is appropriately continued on an outpatient basis.”

According to Lye and colleagues, illness that warrant hospitalization are becoming more complex and often require specialty consultations. It is becoming less common for the primary care pediatrician to be directly responsible for clinical management of the hospitalized child; instead, the responsibility of attending physician now may fall on the pediatric hospitalist, fulltime teaching attending pediatrician, pediatric medical subspecialist, or surgical specialist.

Therefore, it is vital that all physicians who treat this patient population understanding the functions that are essential components of this coordination and oversight role. Some of the key points from the AAP report are as follows:

• For any child who requires hospital admission, an initial assessment made before or at the time of hospitalization that includes a history of the present illness; complete medical history; pain assessment; drug and food allergies; review of systems; review of immunizations; medication reconciliation; assessment of growth (including BMI), nutritional, developmental, educational, and emotional status; review of family and social history, including review of behavioral and environmental risk factors and cultural or ethnic issues; and a physical examination.
• The attending physician integrates and coordinates the input of all physicians and other ancillary providers when multiple providers are involved in the patient’s care. Duties include directing the overall care of the child, coordinating input from consultants, confirming that the child and the family understand the information from all consultants, considering the options when consultants disagree, planning for discharge from the hospital, and efficiently using inpatient resources.
• The process for handoffs and sign-outs should be standardized and include opportunities for verbal interchange and links to the hospital information system to ensure up-to-date and accurate information.
• Preparation for discharge needs to begin at admission and engage the family at all stages. Discharge criteria are set at admission and reviewed at least daily by members of the team and the patient and family. When going home, an assessment of the child’s needs should be made; plans should be formulated; medications should be reconciled, including clarifying that some medications may purposely be discontinued at the time of discharge; and appropriate training and education should be completed.
• The continued involvement of the primary care pediatrician ensures that discharge planning is proceeding effectively. It improves the primary care pediatrician’s understanding of the patient’s hospital course to facilitate optimal transitional and ongoing outpatient care.
• If treatment is not completed during hospitalization, appropriate outpatient management must be arranged. The attending physician, together with other members of the health care team and the family, is responsible for evaluating whether the outpatient treatment plan seems feasible for the child’s family to undertake and modifying the plan if needed.

Care coordination, according to Lye and colleagues, “must include continual involvement of the family, timely legible communication between inpatient and outpatient physicians, meticulous handoffs at every transition, and clear delineation of the responsibilities of all involved physicians during the hospital stay and when the child returns home.”

For more information:

• American Academy of Pediatrics Section on Hospital Medicine
• Journal of Hospital Medicine—Pediatric hospital medicine core competencies: Development and methodology
• New England Journal of Medicine—The Growth of Hospitalists and the Changing Face of Primary Care