Jack M. Percelay

Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value

BACKGROUND Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work groups results. METHODS A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Child life services

Child life programs have become standard in most large pediatric centers and even on some smaller pediatric inpatient units to address the psychosocial concerns that accompany hospitalization and other health care experiences. The child life specialist focuses on the strengths and sense of well-being of children while promoting their optimal development and minimizing the adverse effects of children’s experiences in health care or other potentially stressful settings. Using play and psychological preparation as primary tools, child life interventions facilitate coping and adjustment at times and under circumstances that might prove overwhelming otherwise. Play and age-appropriate communication may be used to (1) promote optimal development, (2) present information, (3) plan and rehearse useful coping strategies for medical events or procedures, (4) work through feelings about past or impending experiences, and (5) establish therapeutic relationships with children and parents to support family involvement in each child’s care, with continuity across the care continuum. The benefits of this collaborative work with the family and health care team are not limited to the health care setting; it may also optimize reintegration into schools and the community.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Pediatric observation units.

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary

* Abbreviations: ALTE — : apparent life-threatening event BRUE — : brief resolved unexplained event SIDS — : sudden infant death syndrome This clinical practice guideline has 2 primary objectives. First, it recommends the replacement of the term “apparent life-threatening event” (ALTE) with a new term, “brief resolved unexplained event” (BRUE). Second, it provides an approach to evaluation and management that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Clinicians should use the term BRUE to describe an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. Moreover, clinicians should diagnose a BRUE only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination (see Tables 2 and 3 in www.pediatrics.org/cgi/doi/10.1542/peds.2016-0590). Among infants who present for medical attention after a BRUE, the guideline identifies (1) lower-risk patients on the basis of history and physical examination, for whom evidence-based guidelines for evaluation and management are offered, and (2) higher-risk patients, whose history and physical examination suggest the need for further investigation, monitoring, and/or treatment, but for whom recommendations are not offered (because of insufficient evidence or the availability of guidance from other clinical practice guidelines specific to their presentation or diagnosis). Recommendations in this guideline apply only to lower-risk patients, who …

Pediatric hospitalists working in community hospitals.

Pediatric hospitalists are increasingly common in community hospitals and are playing increasingly important roles. Scope of practice and staffing models vary significantly by program. Unique aspects of small pediatric hospital medicine programs in hospitals with limited pediatric subspecialty and surgical support are discussed, including clinical and logistic considerations, training needs, and advocacy roles.

Institutions and Individuals: What Makes A Hospitalist “Academic”?

As pediatric hospital medicine (PHM) develops and matures, attempts have been made to describe the field and the individuals who practice it.1–3 Defining what PHM practitioners do is complex, and descriptive categories are often presented with dichotomous alternatives regarding responsibilities (eg, teaching or not, research/scholarly activity or not) and scope of practice (eg, limited to inpatient service or broader, full array of resources or not). Frequently, the differences are overly simplified according to the type of institution in which the pediatric hospitalists work, labeled “academic centers” and “community hospitals.”1,3,4 However, the designation of 1 setting as “academic” implies that the alternative (community hospitals) is not academic, a distinction that spills over to labeling individual hospitalists as academic or nonacademic. According to Freed and Dunham,1 academic hospitalists are those with a full-time faculty appointment, whereas hospitalists with a part-time or no faculty appointment are considered nonacademic. Appointments are conferred by universities, however, so this definition of academic largely reverts to the type of institution in which the pediatric hospitalist works rather than the type of work the pediatric hospitalist does. We propose that the alternative to community hospitals is better described as “university/children’s hospitals” than academic centers because hospitalists may perform …

A Proposed Dashboard for Pediatric Hospital Medicine Groups

In February of 2009, the Society of Hospital Medicine, the Section on Hospital Medicine of the American Academy of Pediatrics, and the Academic Pediatric Association sponsored a strategic planning meeting to create a vision of the future for Pediatric Hospital Medicine (PHM). One of the outcomes of that meeting was a mandate to create a dashboard for PHM groups. Given that PHM is the fastest growing area of pediatrics,1 and that pediatric hospitalists and their groups are becoming responsible for more patients and more processes in hospitals,2 an important part of the growth of the specialty will be continuous improvement and monitoring. As with all areas of medicine, improvement comes from identification of gaps in performance or services and the subsequent improvement cycles that follow. This proposed dashboard attempts to build a framework for groups to monitor, compare, and improve performance. In addition to groups monitoring their own performance over time, it is envisioned that, as groups begin to populate this dashboard, there will be a transparent repository for the dashboards that allow for comparison among similar groups. In July 2009, a call for participation in the creation of the dashboard was sent to the PHM Listserv of the American Academy of Pediatrics. In addition to the 3 original hospitalists named to start the project (P.H., J.D., E.R.), 8 others volunteered to form the PHM Dashboard Committee (the Committee).The Committee met numerous times via conference call and agreed to the following guiding principles: 1. The dashboard should be as broadly applicable as possible 2. The dashboard should focus on the PHM group, and not the individual hospitalist 3. The dashboard should use the simplest possible methods for achieving measurement aims 4. Dashboard items should be selected and/or customized to best help each unique PHM group: each group’s dashboard may look different Subsequently, …

Dr Watson and the Case of Observation-Level Care

Sherlock Holmes accused Dr Watson of seeing but not observing. Were Dr Watson a pediatric hospitalist, utilization reviewers would accuse him of observing but not hospitalizing or, more technically, of providing “observation-level care” rather than “inpatient-level care.” In this issue of Pediatrics , Fieldston et al1 convincingly demonstrate that there is no consistent difference between these 2 levels of care as applied to the pediatric population. Having excluded all potential rational explanations for these differences in billing status, the sole remaining conclusion (“no matter how improbable,” as Holmes would say) is that this is an arbitrary distinction used by payers to decrease reimbursement to both hospitals and physicians. Because pediatric hospital stays are frequently ≤2 days, hospitals caring for children, pediatricians, and families of hospitalized children are put at increased financial risk from this reduced reimbursement. Instead of spending our energy fighting each individual designation of observation-versus inpatient-level care, the pediatric community should lobby aggressively to change what is a fundamentally flawed construct. Fieldston et al1 analyzed 2010 Pediatric Health Information System billing data for ∼200 000 patient stays of ≤2 days at 33 large children’s hospitals. Their assessment revealed marked variability in the use of observation status across hospitals (range: 2%–45% of all 2-day stays designated as observation status) and within individual hospitals according to diagnosis (range: 2%–55% [most >25%]) (Fig 3 … Address correspondence to Jack Martin Percelay, MD, MPH, ELMO Pediatrics, 1214 Fifth Ave, #35J, New York, NY 10029. E-mail: jpercelaymd{at}gmail.com

Toto, I don't think we're on the adult inpatient unit anymore

T he March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4-day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA). As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/imitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the ‘‘medical home’’ concept. We zealously advocate for family-centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes. Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al. highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al. explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious