Challenges in Pediatric Hospital Medicinecms.hfes.org/Cms/media/CmsImages/Challenges-in-Pediatric-Hospit… · GOALS/OBJECTIVES •Recognize the ... 314 43 + 3 fellows Yes Yes Ortho

CHALLENGES IN PEDIATRIC HOSPITAL MEDICINE

TRANSITIONS FROM TRAINING AND CHALLENGES WITHIN THE WORKFORCE

DISCLOSURES

• None

• Dr. Sophia Sterner, MD FAAP• Pediatric Hospitalist at Children’s Mercy Kansas City – Kansas City, MO

• Physician Lead 5HH High Reliability Unit – Children’s Mercy Hospital

• Assistant Professor of Pediatrics – Univ. of Missouri Kansas City School of Medicine

GOALS/OBJECTIVES

• Recognize the general model for pediatric training as stipulated by the ACGME

• Accreditation Council for Graduate Medical Education

• Briefly discuss the recent literature available that addresses changes made in residency training – specifically duty hour reform and patient handoff

• Highlight different forms of hospitalist programs available in the United States and discuss the challenges that practicing hospitalists have in these settings

• Through discussion with the audience - identify possible interventions that can help overcome difficulties faced by training programs, new graduates and practicing hospitalists today.

SESSION FORMAT

Panel Discussion

Breakout session

Share/Report

PANEL SESSION 1 - INTRODUCTIONS

• Dr. Angie Etzenhouser, MD• Pediatric Hospitalist at Children’s Mercy Kansas City – Kansas City, MO

• Associate Director, Pediatric Residency Program – Children’s Mercy Hospital

• Assistant Professor of Pediatrics – Univ. of Missouri Kansas City School of Medicine

• Dr. Heather Dahlquist, MD• Pediatric Hospitalist at Yale-New Haven Children’s Hospital – New Haven, CT

• Assistant Clinical Professor of Pediatrics – Yale University School of Medicine

• Dr. Alex Hogan, MD, MS, FAAP• Pediatric Hospitalist at Connecticut Children’s Medical Center – Hartford, CT

• Assistant Professor of Pediatrics – University of Connecticut School of Medicine

BACKGROUND

• Long hours adversely affect resident well-being and patient safety

• Human performance declines after approx 16 hrs of wakefulness

• Lapses of attention, performance failures increase when

<4-5 hours of sleep/24 hours

DUTY HOUR REFORM

• 2003 ACGME

• No more than 30 consecutive hours

• No more than 80 hours/week

• 1 day in 7 free from educational/clinical responsibilities

• 10 hour rest period between shifts after in-house call

DUTY HOUR REFORM

• 2011 ACGME• Max 16 hour shifts for interns (first year residents)

24+4 hours for senior residents (2nd year +)

• Max of 6 consecutive night shifts

• Rest period of 8 hours after standard shift, 14 hours after 24 hour shift

Breaks can be shorter than 8 hours for extenuating circumstances

• 2016 ACGME• FIRST and iCompare studies

• Eliminated 16 hour rule for interns

• All residents max 24+4 hours

PERCEPTIONS OF DUTY HOUR REFORM

Positive Impact

• Improved compliance with guidelines (prescribing d/c meds, reduced mean LOS)

• Regulation of extended work hours, night shifts have most impact

• Benefit to patient safety, resident well-being

Negative/No Impact

• Most studies show no change or improvement in complication/mortality rates

• Overall increase in cost – hire more faculty, extenders to cover resident workload

• Decreased perception of professionalism

• Concern for work compression

• No actual change for resident sleep

PERCEPTIONS OF DUTY HOUR REFORM

• Unknown

• Quality of training

• Transition to faculty life – no duty hour limitations

• Increase in handoffs

HANDOFFS

2010 Joint Commission

• Root cause of sentinel events• Communication involved in 80%

2011 ACGME

• Training programs required to teach,monitor handoffs

2017 Joint Commission Sentinel Event Alert

• Recommendation for standardization of handoff process

HANDOFFS

• Effective handoffs should have:

• Structured format (written and verbal)

• Environment free from interruptions

RECENT GRADUATE EXPERIENCES AND CHALLENGES

• Heather Dahlquist, MD• Graduated residency in 2016

• Now works at Yale Children’s Hospital and Lawrence + Memorial Hospital

• Alex Hogan, MD, MS, FAAP• Graduated hospitalist fellowship in 2017

• Now works at Connecticut Children’s Hospital

CHALLENGES TRANSITIONING FROM MEDICAL TRAINING TO INDEPENDENT PRACTICE

Residency Training

• Large, university affiliated hospital

• Pediatric trained support staff available

• Pediatric specialty doctors in the hospital to help with complex patients

Independent Practice

• Wide variety of settings

• Availability of pediatric trained support staff varies

• Availability of pediatric subspecialty doctors varies

Additional Challenge: getting “back to the bedside”

• Problem: Documentation in the electronic medical record is time consuming

For billing and legal purposes, documentation needs to be detailed

• Problem: making appointments, calling other providers, coordinating lab tests and imaging is time consuming

This all takes time away from spending time with patients

• Interventions in place: Documentation templates, unit coordinators

FELLOWSHIP CURRICULUM

Domain Examples Additional Requirements

Core Clinical Rotations Hospital Medicine

Complex Care

Co-management

Critical Care

1 Month at Community Site

3 Months at Tertiary Care

Systems and Scholarship General Training in ALL, with Focus in 1:

Quality Improvement

Clinical/Translational Research

Medical Education

Leadership

Advocacy

Must meet requirement for

“Scholarly Activity” in at

least 1 domain. (National

Presentation, Manuscript,

Curriculum etc)

Individualized

Curriculum

Clinical or Non-Clinical activities.

Must be determined by learning needs

and career plans of each fellow along

with mentorship.

PERCEIVED NEEDS

• Fellowship-trained attendings feel MORE competent in:

• Management medical complexity

• Undertaking research projects

• Leading QI programs and

• Educating Trainees

• Feel LESS competent in:

• Newborn Care

• Pain Management

• Fellowship trained physicians perceived needs after fellowship:

• Hospital program management

• Practice guideline design

• Development of educational curricula

• Research skills

• Procedural skills

BREAKOUT SESSION 1 TOPICS

Variations in training causing

limitations or experience gaps in the workforce

Beth, Sonia, Sophia

Handoffs

*Increasing number/frequency

*Lack of consistency in format and information delivered

Alex & Angie

Getting back to the bedside

Increasing amount of time spent away from the patient –

documenting, coordinating care

Heather & Lisa

“

”

When you have seen one hospitalist program…..you have seen one hospitalist program

Hospital Beds Staffing Residents PICU Nursery

coverage

Specialty

services

In House

24/7

Back

Up Help

Children’s Mercy

Adele Hall314 43 + 3 fellows Yes Yes Yes Yes Yes

Univ. MN Masonic

Children’s257 43 Yes Yes Yes

Yale New Haven

Children’s221 11 Yes Yes Yes

Connecticut

Children’s187 12 + 4 APRN Yes Yes Yes Yes

Providence

Children’s148 4 Varies Yes Yes

Montefiore

Medical Center106 14 + 2 fellows Yes Yes

Children’s Mercy

Kansas53 43 + 3 fellows Yes limited Yes Yes

Stormont Vail &

St. Francis20 8 Yes Yes limited

St. Rose 14 3 + 3 locumsYale New Haven

Bridgeport12 2 + 4 others

Saint Mary’s

Hospital8 14 Yes limited

Lawrence +

Memorial Hospital7 5 Yes

Hospital Beds Staffing Residents PICU Other Services

Children’s Mercy

Adele Hall314 43 + 3 fellows Yes Yes Ortho Co-Management, Triage, Complex Care

Team

Univ. MN Masonic

Children’s257 43 Yes Yes Pediatric & nursery coverage - 2 community hosp.

Yale New Haven

Children’s221 11 Yes Yes Surgical Co-Management, Nursery

Connecticut

Children’s187 12 + 4 APRN Yes Yes

Providence

Children’s148 4 Varies Yes Nursery

Montefiore

Medical Center106 14 + 2 fellows Surgical Co-Management

Children’s Mercy

Kansas53 43 + 3 fellows EMU night coverage

Stormont Vail and

St. Francis20 8 NICU Level 3, Delivery attendance, ED consults

St. Rose 14 3 + 3 locums Bilirubin follow up clinic

Yale New Haven

Bridgeport12 2 + 4 others Post d/c and acute clinic visits, consults to

ED/Surg/Burns

Saint Mary’s

Hospital8 14

Lawrence +

Memorial Hospital7 5 Level 3 NICU night coverage, ED consults, nursery

and newborn deliveries

PANEL SESSION 2 - INTRODUCTIONS

• Dr. Sonia Chaudhry, MD• Neonatal Hospitalist at Connecticut Children’s Medical Center – Hartford, CT• Medical Director Newborn Nursery – Connecticut Children’s Medical Center• Assistant Professor of Pediatrics – University of Connecticut School of Medicine

• Dr. Beth Natt, MD, MPH, FAAP, SFHM• Pediatric Hospitalist at Danbury Hospital– Danbury, CT• Director of Pediatric Hospital Medicine, Regional Programs

– Connecticut Children’s Medical Center• Visiting Associate Professor – University of Connecticut School of Medicine

• Dr. Lisa Carney, MD FAAP• Pediatric Hospitalist at Children’s Mercy Kansas City – Kansas City, MO• Medical Director Code Blue Prevention – Children’s Mercy Hospital• Simulation Coordinator – Division of Pediatric Hospital Medicine• Assistant Professor of Pediatrics – Univ. of Missouri Kansas City School of Medicine

PEDIATRIC COMMUNITY HOSPITALIST

• ∼2000 hospitals in the United States with designated pediatric inpatient units

• Community Based Hospitals

• Excluding Children’s Hospitals / University Hospitals

• Role of Pediatric Hospitalists in a community hospital setting

• Inpatient Pediatric Care

• Newborn Nursery Care / DR resuscitations/stabilization

• Emergency Department Consultations

• Consultation to outpatient providers

• Advocacy for the needs of children within an adult – oriented system

• Liaison between the tertiary/academic centers, subspecialist and care of patients in the community

American Hospital Association. AHA Hospital Statistics. Chicago, IL: Health Forum LLC; 2014.

• Pediatric hospitalists in the community setting • CLINICAL CARE

• Increase in breadth of clinical knowledge and skills

• Generally addressed by subspecialists at the tertiary level / children’s hospital

• RECOGNIZING THE UNIQUE NEEDS OF PEDIATRIC PATIENTS in Adult Oriented Areas in the Community• Pediatric patients are “NOT SMALL ADULTS”

• Pharmacy

• Radiology

• Laboratory Services

• Respiratory Therapy

• LEADERSHIP• Advocating for pediatric patients and families

• Building services within the hospital to benefit patients

PEDIATRIC COMMUNITY HOSPITALIST

• Community Representation / Liaison• Build a relationship between the Primary Care Providers and Academic Center• Provide continuing education to varied learners

• Families/Patients• Nursing Staff / Hospital Staff• Administration• Public

• Unique Opportunity to provide care for patients and families • Tertiary Level Care closer to home

• Challenges for the Pediatric Hospitalist• Maintaining Skills Set• Subspecialist Care

• Adult Specialists• Co-Management

• Caring for Pediatric Patient in an Adult Setting

PEDIATRIC COMMUNITY HOSPITALIST

Working within a non children’s hospital

• Majority of children cared for in US are in a Community Hospital Setting

• Community Hospitals and Non-Free Standing Children’s Hospitals have challenges that are different from Free-Standing Children’s Hospitals

PATIENT CARE SETTINGS

Free Standing

Children’s Hospitals

• Dedicated Equipment

• Pediatric Focused System

• Pharmacists

• Equipment

• Safety (Code Systems)

• Electronic Medical Record

Non- Free

Standing Hospitals

• Resource allocation can vary

• Pediatrics less “lucrative“ than other departments

• Variable resources

• Pharmacy expertise

• Pediatric Nurses/ Specialists

• Time of day changes

• Breadth not Depth

PEDIATRIC HOSPITALISTS AS ADVOCATE

• Recognize need for Pediatric Specific Systems

• Learn to Finesse Adult system to “fit” pediatric needs

• Speak up for potential patient safety concerns and develop guidelines to assist non pediatric staff in caring for pediatric patients

AFFECTING HOSPITAL SYSTEMS

• Big Fish in a Small Pond

• Representation on Committees

• Soft Leadership

At a Free Standing Children’s Hospital, these roles would typically be covered by multiple key leaders; in the Community setting, often the head of the department

MAINTENANCE OF SKILLS & COMPETENCIES AT CMH KC

• 45+ Hospitalists all currently expected to have the same scope of practice; same competency level/skill set

• 2015 Needs/Self-Assessment Survey Completed with 98% response rate (47/48)

• Experience ranged from <1 to > 20 years (median 4 yrs; 1 completed fellowship training)

MAINTENANCE OF SKILLS & COMPETENCIES AT CMH KC

• Faculty Development Curriculum 2016-2017 utilizing Simulation with content experts; hands on, didactic, e-learn

• CME and MOC Part 2 credit

• Overall identified gaps/content areas for further training:

• Complex Medical Patients/Co-Management

• Advanced Airway Management

• Vascular Access/Medications/Code Cart

MAINTENANCE OF SKILLS & COMPETENCIES AT CMH KC

Significant Differences with years experience/education needs noted for two areas:

• Team/Communication Skills and Post-Resuscitation Care

Resident survey: Dip in self reported competency in resuscitation skills between PGY-3 and new faculty (0-2 years)

Future areas of focus based on Need/Scope of Practice: Endocrine, Sedation/Airway, Team Communication/Code Prevention, Newborn (PHM Boards)

Maintaining hospitalist skill sets & competencies

*Variations for each setting as needs & patient population vary

*Use of a simulation lab vs not having access to one

Angie & Lisa

Working as a pediatric

hospitalist in an adult setting

Beth & Sonia

Practicing in a setting lacking of

subspecialty support

Alex, Heather, & Sophia

BREAKOUT SESSION 2 TOPICS

CLOSING REMARKS

REFERENCES

• "Agency for Healthcare Research and Quality. TeamSTEPPS Curriculum Tools and Materials." http://www.ahrq.gov/. N.p., n.d. Web. 6 Feb 2012. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm.

• Auger KA, Landrigan CP, Gonzalez del Rey JA, Sieplinga KR, Sucharew HJ, Simmons JM. Better rested, but more stressed? Evidence of the effects of resident work hour restrictions. Acad Pediatr. 2012 Jul-Aug;12(4):335-43. doi: 10.1016/j.acap.2012.02.006. Epub 2012 May 22.

• Bilimoria, B., Chung, J.W., et al. “National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training.” NEJM. 374.8 (2016): 713-727.

• Bolster, L. Rourke, L. “The Effect of Restricting Residents’ Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review.” Journal of Graduate Medical Education. 2015 Sep;7(3):349-63

• Bordage, G. "Prototypes and Semantic Qualifiers: From Past to Present." Medical Education. 41.12 (2007): 1117-21.

• Cohen, M.D., and Hilligoss, P.B. "The Published Literature on Handoffs in Hospitals: Deficiencies Identified in an Extensive Review. " Quality and Safety in Health Care. 19.6 (2010): 493-497.

• Ferraris VA. Evidence and resident physician duty hours: Should scientific experiments be more suspect than universal implementation of an untested practice? J Thorac Cardiovasc Surg. 2017 Mar;153(3):632-635. doi: 10.1016/j.jtcvs.2016.09.091. Epub 2016 Nov 21.

• Freed GL, Dunham KM, Moran LM, Spera L; Resident work hour changes in children's hospitals: impact on staffing patterns and workforce needs.Research Advisory Committee of the American Board of Pediatrics. Pediatrics. 2012 Oct;130(4):700-4. doi: 10.1542/peds.2012-1131. Epub 2012 Sep 10.

• Jena, A.B., Schoemaker, L. “The effect of ACGME resident duty hour reforms on outcomes of physicians after completion of residency.” Health Aff (Millwood). 33.10 (2014): 1832-1840.

• Kaplan, D.M. "Perspective: Whither the Problem List? Organ-Based Documentation and Deficient Synthesis by Medical Trainees." Academic Medicine. 85.10 (2010): 1578-1582.

• Landrigan CP, Fahrenkopf AM, Lewin D, Sharek PJ, Barger LK, Eisner M, Edwards S, Chiang VW, Wiedermann BL, Sectish TC.Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics. 2008 Aug;122(2):250-8. doi: 10.1542/peds.2007-2306.

• Lin H, Lin E, Auditore S, Fanning J. A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. Acad Med. 2016 Jan;91(1):140-50. doi: 10.1097/ACM.0000000000000937. Review. PMID: 26445081

• Moeller A, Webber J, Epstein I. Resident duty hour modification affects perceptions in medical education, general wellness, and ability to provide patient care. BMC Med Educ. 2016 Jul 13;16:175. doi: 10.1186/s12909-016-0703-4. PMID:27411835

REFERENCES CONTINUED

• Ouyang D, Chen JH, Krishnan G, Hom J, Witteles R, Chi J. Patient Outcomes when Housestaff Exceed 80 Hours per Week. Am J Med. 2016 Sep;129(9):993-999.e1. doi: 10.1016/j.amjmed.2016.03.023. Epub 2016 Apr 18. PMID: 27103047

• Philibert I. What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles. J Grad Med Educ. 2016 Dec;8(5):795-805. doi: 10.4300/JGME-D-16-00642.1.

• Rajaram R, Saadat L, Chung J, Dahlke A, Yang AD, Odell DD, Bilimoria KY. Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care. BMJ Qual Saf. 2016 Dec;25(12):962-970. doi: 10.1136/bmjqs-2015-004794. Epub 2015 Dec 30. PMID: 26717986

• Rosenbluth G, Landrigan CP. Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatricproviders. Pediatr Clin North Am. 2012 Dec;59(6):1317-28. doi: 10.1016/j.pcl.2012.09.001. Epub 2012 Oct 12.

• Schumacher DJ, Frintner MP, Jain A, Cull W. The 2011 ACGME standards: impact reported by graduating residents on the working and learning environment. Acad Pediatr. 2014 Mar-Apr;14(2):149-54. doi: 10.1016/j.acap.2013.09.002.

• Solomon, B. A., and Felder, R.M. "Index of Learning Styles Questionnaire." North Carolina State University. N.p., 2011. Web. 6 Feb 2012. http://www.engr.ncsu.edu/learningstyles/ilsweb.html.

• Starmer, A.J., Spector, N.D., Srivastava, R., Allen, A.D., Landrigan, C.P., Sectish, T.C. et al. "I-PASS, a Mnemonic to Standardize Verbal Handoffs." Pediatrics. 129.2 (2012): 201-204.

• Starmer, A.J., Sectish, T.C., Simon, D., and Landrigan, C.P. "Impact of a Resident Handoff Bundle on Medical Error Rates and Written Handoff Miscommunications." Pediatric Academic Societies Annual Meeting. Denver, CO. 2011.

• Stucky ER, Dresselhaus TR, Dollarhide A, Shively M, Maynard G, Jain S, Wolfson T, Weinger MB, Rutledge T. Intern to attending: assessing stress among physicians. Acad Med. 2009 Feb;84(2):251-7. doi: 10.1097/ACM.0b013e3181938aad.