Rajendu Srivastava, MD, FRCP(C), MPH

Knowledge

Skills

Attitudes

Systems Organization and Improvement

Knowledge

Skills

Attitudes

Systems Organization and Improvement

Knowledge

Skills

Attitudes

Systems Organization and Improvement

Since the term hospitalist was coined in 1996,1 the field of hospital medicine has grown exponentially. Hospitalists are caring for increasing numbers of adultsincluding Medicare beneficiaries in hospitals across the United States.2 Pediatric hospital medicine has grown in parallel. By 1998, 50% of pediatric department chairs across the US and Canada had implemented hospitalist programs, with another 27% reporting they were soon to do so.3 A bit more than a decade later, pediatric hospitalists can be found in nearly every major academic medical center, and in a large proportion of community hospitals throughout the US and Canada.

In the past several years, major advances have begun to occur in the manner in which hospital medicine research is conducted. In this article, we will describe the manner in which pediatric hospital medicine research has advanced over the past several years, culminating in the conduct of several large multicenter research projects through the Pediatric Research in Inpatient Settings (PRIS) Network. We believe that lessons learned in the development of PRIS could help foster the growth of other current and future networks of hospitalist researchers, and lay the groundwork for national improvement efforts.

HOSPITAL MEDICINE RESEARCH: GROWTH AND DEVELOPMENT

In 2001, a small group of thought leaders in pediatric hospital medicine (see Acknowledgements) conceived the notion of starting a hospitalist research network, which they named the Pediatric Research in Inpatient Settings (PRIS) Network.4 PRIS was modeled in part after a successful pediatric primary care network.5 Since hospitalists in institutions across the country were being tasked to improve the care of hospitalized patients, and to lead diverse quality and safety initiatives, why not create a network to facilitate identification of high priority problems and evidence‐based approaches to them, and coordinate improvement efforts? The ambitious goal of the fledgling network was to conduct transformative research into inpatient healthcare delivery and discover both condition‐dependent and condition‐independent processes of care that were linked to patient outcomes.

PRIS began as (and remains) an open research networkfrom the outset, any hospitalist could join. The notion of this network, even in its earliest stages, was sufficiently appealing to professional societies that the Society of Hospital Medicine (SHM), the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) agreed to cosponsor the network, fostering its early growth. The community of pediatric hospitalists was tremendously supportive as well; over 300 hospitalists initially signed up to participate. Initial studies were generated through surveys of members, through which variability in systemic organization and variation in the management of clinical conditions and systems‐based issues across inpatient settings was identified and quantified.68

In the 2000s, as PRIS grew as a network, the research capacity of individuals within the field also grew. An increasing number of hospitalists began dedicating their academic careers to pursuing rigorous methodological training and conducting pediatric hospital medicine research. A series of studies began to emerge analyzing data from large administrative datasets that described the variation in hospital care (but lack clinical results and clinical outcomes outside of the hospital setting), such as the Pediatric Health Information Systems (PHIS) database operated by the Children's Hospital Association (formerly known as the Child Health Corporation of America).913 Pediatric hospital medicine fellowships began to appear,14 and over time, a cohort of hospitalist investigators with sufficient independence to mentor others arose.

THE REDESIGN OF PRIS

In 2009, a Pediatric Hospital Medicine Roundtable of 22 international leaders was convened under the guidance of SHM, APA, and AAP.15 This initiative, roughly a decade after the inception of the field, was critical to bringing pediatric hospitalist research and PRIS to the next level. It was recognized in that meeting that while PRIS had made a good start, it would not be possible to grow the network to the point of conducting top quality multicenter studies without the active involvement of a larger number of rigorously trained hospitalist researchers. To stimulate the network's growth, the existing PRIS Steering Committeea diverse group of clinical, educational, administrative, and research leaders in the fieldfacilitated the transfer of leadership to a new Executive Council led entirely by trained researchers (see Table 1), with the support of the APA. The Executive Council subsequently developed a series of standard operating procedures (see Table 2) that have created a transparent process to deal with important, but often difficult, academic issues that networks face.

DEVELOPMENT OF MULTICENTER RESEARCH PROJECTS

The redesign of PRIS did not alter its objective: to build the evidence base regarding the optimal inpatient management of children. Evidence on how best to care for many pediatric conditions remains lacking, largely due to the facts that: a) death, the most definitive and readily measured of outcomes, is rare in pediatric hospitals; b) many pediatric conditions are relatively uncommon in any single hospital; and c) few validated, well‐developed metrics of inpatient pediatric quality exist.

As PRIS sought to launch multicenter studies of inpatient care quality, it continued to receive strong support from the APA, SHM, and AAP, and gained the support of a new partner, the Children's Hospital Association, which is comprised of a large group of children's hospitals across Canada and the US. The membership of PRIS grew to involve over 600 pediatric hospitalists from more than 75 hospitals.4 With a core group of funded hospitalist investigators, and strong support from partner organizations, the network sought and received funding for 3 major studies that are currently underway. Release of the federal government's Affordable Care Act and Comparative Effectiveness Research portfolio stimulated much of this work, stimulating the network to reach out to existing and new stakeholders and successfully compete for several multicenter studies.

RELEVANCE TO OTHER NETWORKS

We believe that the story of PRIS' development, current studies, and future plans has relevance to other adult, as well as pediatric, hospital medicine networks (see Table 3). As in pediatrics, a growing group of midcareer adult hospital medicine investigators has emerged, with proven track records in attracting federal funding and conducting research germane to our field. Some have previously worked together on large‐scale multisite studies.2023 A core group have come together to form the HOspital MEdicine Reengineering Network (HOMERUN).24 HOMERUN has recently secured funding from the Association of American Medical Colleges (AAMC) for a project that is linking clinical data from several hospitals to a centralized database, a project analogous to PHIS+, and will allow for Comparative Effectiveness Research studies that have more accurate case ascertainment (by using clinical data to build cohorts) and ensuring additional power by securing a larger number of cases. Defining which clinical questions to address first will help establish this new entity as a leader in hospital medicine research. Attracting stakeholder involvement will help make these endeavors successful. In recent months, PRIS and HOMERUN jointly collaborated on the submission of a large Centers for Medicare and Medicaid Innovation (CMMI) proposal to extend the work of I‐PASS to include several internal medicine and additional pediatric resident and hospitalist care settings. Future collaborations between networks may help foster more rapid advances in care.

Another pediatric hospitalist network has also emerged in the past few years, with a focus on quality improvement across inpatient pediatric settings, the Value in Pediatrics (VIP) Network.25 Although still early in its development, VIP has already successfully engaged in national quality improvement work regarding benchmarking care provided for children with bronchiolitis, reducing patient identification (ID) band errors, and improving discharge communications. VIP recently became part of the AAP's Quality Improvement Innovation Network (QuINN) group through which it is receiving infrastructure support.

As they develop, hospital medicine research and improvement networks will seek to systematically design and rigorously execute multicenter projects that provide answers to those clinical questions which practicing hospitalists face on a daily basis. As they do so, mentoring of both junior investigators and novice investigators will be necessary for the longevity of networks. To foster junior investigators, PRIS has undertaken a series of workshops presented at various national conferences, in addition to working with junior investigators directly on its currently funded studies.

CONCLUSION

Hospitalists' engagement in research and quality improvement networks builds upon their already successful engagement in clinical care, education, and quality improvement at a local level. A research and improvement mission that is tightly coupled with the day‐to‐day needs of these other important hospitalist activities creates a synergy with the potential to lead to transformative advances in patient care. If hospitalists can discover how best to deliver care, train the next generation of providers, and work to implement needed improvements at a local and national level, they will have an unprecedented opportunity to improve the care and health of children and adults.

Since the term hospitalist was coined in 1996,1 the field of hospital medicine has grown exponentially. Hospitalists are caring for increasing numbers of adultsincluding Medicare beneficiaries in hospitals across the United States.2 Pediatric hospital medicine has grown in parallel. By 1998, 50% of pediatric department chairs across the US and Canada had implemented hospitalist programs, with another 27% reporting they were soon to do so.3 A bit more than a decade later, pediatric hospitalists can be found in nearly every major academic medical center, and in a large proportion of community hospitals throughout the US and Canada.

In the past several years, major advances have begun to occur in the manner in which hospital medicine research is conducted. In this article, we will describe the manner in which pediatric hospital medicine research has advanced over the past several years, culminating in the conduct of several large multicenter research projects through the Pediatric Research in Inpatient Settings (PRIS) Network. We believe that lessons learned in the development of PRIS could help foster the growth of other current and future networks of hospitalist researchers, and lay the groundwork for national improvement efforts.

HOSPITAL MEDICINE RESEARCH: GROWTH AND DEVELOPMENT

In 2001, a small group of thought leaders in pediatric hospital medicine (see Acknowledgements) conceived the notion of starting a hospitalist research network, which they named the Pediatric Research in Inpatient Settings (PRIS) Network.4 PRIS was modeled in part after a successful pediatric primary care network.5 Since hospitalists in institutions across the country were being tasked to improve the care of hospitalized patients, and to lead diverse quality and safety initiatives, why not create a network to facilitate identification of high priority problems and evidence‐based approaches to them, and coordinate improvement efforts? The ambitious goal of the fledgling network was to conduct transformative research into inpatient healthcare delivery and discover both condition‐dependent and condition‐independent processes of care that were linked to patient outcomes.

PRIS began as (and remains) an open research networkfrom the outset, any hospitalist could join. The notion of this network, even in its earliest stages, was sufficiently appealing to professional societies that the Society of Hospital Medicine (SHM), the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) agreed to cosponsor the network, fostering its early growth. The community of pediatric hospitalists was tremendously supportive as well; over 300 hospitalists initially signed up to participate. Initial studies were generated through surveys of members, through which variability in systemic organization and variation in the management of clinical conditions and systems‐based issues across inpatient settings was identified and quantified.68

In the 2000s, as PRIS grew as a network, the research capacity of individuals within the field also grew. An increasing number of hospitalists began dedicating their academic careers to pursuing rigorous methodological training and conducting pediatric hospital medicine research. A series of studies began to emerge analyzing data from large administrative datasets that described the variation in hospital care (but lack clinical results and clinical outcomes outside of the hospital setting), such as the Pediatric Health Information Systems (PHIS) database operated by the Children's Hospital Association (formerly known as the Child Health Corporation of America).913 Pediatric hospital medicine fellowships began to appear,14 and over time, a cohort of hospitalist investigators with sufficient independence to mentor others arose.

THE REDESIGN OF PRIS

In 2009, a Pediatric Hospital Medicine Roundtable of 22 international leaders was convened under the guidance of SHM, APA, and AAP.15 This initiative, roughly a decade after the inception of the field, was critical to bringing pediatric hospitalist research and PRIS to the next level. It was recognized in that meeting that while PRIS had made a good start, it would not be possible to grow the network to the point of conducting top quality multicenter studies without the active involvement of a larger number of rigorously trained hospitalist researchers. To stimulate the network's growth, the existing PRIS Steering Committeea diverse group of clinical, educational, administrative, and research leaders in the fieldfacilitated the transfer of leadership to a new Executive Council led entirely by trained researchers (see Table 1), with the support of the APA. The Executive Council subsequently developed a series of standard operating procedures (see Table 2) that have created a transparent process to deal with important, but often difficult, academic issues that networks face.

DEVELOPMENT OF MULTICENTER RESEARCH PROJECTS

The redesign of PRIS did not alter its objective: to build the evidence base regarding the optimal inpatient management of children. Evidence on how best to care for many pediatric conditions remains lacking, largely due to the facts that: a) death, the most definitive and readily measured of outcomes, is rare in pediatric hospitals; b) many pediatric conditions are relatively uncommon in any single hospital; and c) few validated, well‐developed metrics of inpatient pediatric quality exist.

As PRIS sought to launch multicenter studies of inpatient care quality, it continued to receive strong support from the APA, SHM, and AAP, and gained the support of a new partner, the Children's Hospital Association, which is comprised of a large group of children's hospitals across Canada and the US. The membership of PRIS grew to involve over 600 pediatric hospitalists from more than 75 hospitals.4 With a core group of funded hospitalist investigators, and strong support from partner organizations, the network sought and received funding for 3 major studies that are currently underway. Release of the federal government's Affordable Care Act and Comparative Effectiveness Research portfolio stimulated much of this work, stimulating the network to reach out to existing and new stakeholders and successfully compete for several multicenter studies.

RELEVANCE TO OTHER NETWORKS

We believe that the story of PRIS' development, current studies, and future plans has relevance to other adult, as well as pediatric, hospital medicine networks (see Table 3). As in pediatrics, a growing group of midcareer adult hospital medicine investigators has emerged, with proven track records in attracting federal funding and conducting research germane to our field. Some have previously worked together on large‐scale multisite studies.2023 A core group have come together to form the HOspital MEdicine Reengineering Network (HOMERUN).24 HOMERUN has recently secured funding from the Association of American Medical Colleges (AAMC) for a project that is linking clinical data from several hospitals to a centralized database, a project analogous to PHIS+, and will allow for Comparative Effectiveness Research studies that have more accurate case ascertainment (by using clinical data to build cohorts) and ensuring additional power by securing a larger number of cases. Defining which clinical questions to address first will help establish this new entity as a leader in hospital medicine research. Attracting stakeholder involvement will help make these endeavors successful. In recent months, PRIS and HOMERUN jointly collaborated on the submission of a large Centers for Medicare and Medicaid Innovation (CMMI) proposal to extend the work of I‐PASS to include several internal medicine and additional pediatric resident and hospitalist care settings. Future collaborations between networks may help foster more rapid advances in care.

Another pediatric hospitalist network has also emerged in the past few years, with a focus on quality improvement across inpatient pediatric settings, the Value in Pediatrics (VIP) Network.25 Although still early in its development, VIP has already successfully engaged in national quality improvement work regarding benchmarking care provided for children with bronchiolitis, reducing patient identification (ID) band errors, and improving discharge communications. VIP recently became part of the AAP's Quality Improvement Innovation Network (QuINN) group through which it is receiving infrastructure support.

As they develop, hospital medicine research and improvement networks will seek to systematically design and rigorously execute multicenter projects that provide answers to those clinical questions which practicing hospitalists face on a daily basis. As they do so, mentoring of both junior investigators and novice investigators will be necessary for the longevity of networks. To foster junior investigators, PRIS has undertaken a series of workshops presented at various national conferences, in addition to working with junior investigators directly on its currently funded studies.

CONCLUSION

Hospitalists' engagement in research and quality improvement networks builds upon their already successful engagement in clinical care, education, and quality improvement at a local level. A research and improvement mission that is tightly coupled with the day‐to‐day needs of these other important hospitalist activities creates a synergy with the potential to lead to transformative advances in patient care. If hospitalists can discover how best to deliver care, train the next generation of providers, and work to implement needed improvements at a local and national level, they will have an unprecedented opportunity to improve the care and health of children and adults.

Since the term hospitalist was coined in 1996,1 the field of hospital medicine has grown exponentially. Hospitalists are caring for increasing numbers of adultsincluding Medicare beneficiaries in hospitals across the United States.2 Pediatric hospital medicine has grown in parallel. By 1998, 50% of pediatric department chairs across the US and Canada had implemented hospitalist programs, with another 27% reporting they were soon to do so.3 A bit more than a decade later, pediatric hospitalists can be found in nearly every major academic medical center, and in a large proportion of community hospitals throughout the US and Canada.

In the past several years, major advances have begun to occur in the manner in which hospital medicine research is conducted. In this article, we will describe the manner in which pediatric hospital medicine research has advanced over the past several years, culminating in the conduct of several large multicenter research projects through the Pediatric Research in Inpatient Settings (PRIS) Network. We believe that lessons learned in the development of PRIS could help foster the growth of other current and future networks of hospitalist researchers, and lay the groundwork for national improvement efforts.

HOSPITAL MEDICINE RESEARCH: GROWTH AND DEVELOPMENT

In 2001, a small group of thought leaders in pediatric hospital medicine (see Acknowledgements) conceived the notion of starting a hospitalist research network, which they named the Pediatric Research in Inpatient Settings (PRIS) Network.4 PRIS was modeled in part after a successful pediatric primary care network.5 Since hospitalists in institutions across the country were being tasked to improve the care of hospitalized patients, and to lead diverse quality and safety initiatives, why not create a network to facilitate identification of high priority problems and evidence‐based approaches to them, and coordinate improvement efforts? The ambitious goal of the fledgling network was to conduct transformative research into inpatient healthcare delivery and discover both condition‐dependent and condition‐independent processes of care that were linked to patient outcomes.

PRIS began as (and remains) an open research networkfrom the outset, any hospitalist could join. The notion of this network, even in its earliest stages, was sufficiently appealing to professional societies that the Society of Hospital Medicine (SHM), the Academic Pediatric Association (APA), and the American Academy of Pediatrics (AAP) agreed to cosponsor the network, fostering its early growth. The community of pediatric hospitalists was tremendously supportive as well; over 300 hospitalists initially signed up to participate. Initial studies were generated through surveys of members, through which variability in systemic organization and variation in the management of clinical conditions and systems‐based issues across inpatient settings was identified and quantified.68

In the 2000s, as PRIS grew as a network, the research capacity of individuals within the field also grew. An increasing number of hospitalists began dedicating their academic careers to pursuing rigorous methodological training and conducting pediatric hospital medicine research. A series of studies began to emerge analyzing data from large administrative datasets that described the variation in hospital care (but lack clinical results and clinical outcomes outside of the hospital setting), such as the Pediatric Health Information Systems (PHIS) database operated by the Children's Hospital Association (formerly known as the Child Health Corporation of America).913 Pediatric hospital medicine fellowships began to appear,14 and over time, a cohort of hospitalist investigators with sufficient independence to mentor others arose.

THE REDESIGN OF PRIS

In 2009, a Pediatric Hospital Medicine Roundtable of 22 international leaders was convened under the guidance of SHM, APA, and AAP.15 This initiative, roughly a decade after the inception of the field, was critical to bringing pediatric hospitalist research and PRIS to the next level. It was recognized in that meeting that while PRIS had made a good start, it would not be possible to grow the network to the point of conducting top quality multicenter studies without the active involvement of a larger number of rigorously trained hospitalist researchers. To stimulate the network's growth, the existing PRIS Steering Committeea diverse group of clinical, educational, administrative, and research leaders in the fieldfacilitated the transfer of leadership to a new Executive Council led entirely by trained researchers (see Table 1), with the support of the APA. The Executive Council subsequently developed a series of standard operating procedures (see Table 2) that have created a transparent process to deal with important, but often difficult, academic issues that networks face.

DEVELOPMENT OF MULTICENTER RESEARCH PROJECTS

The redesign of PRIS did not alter its objective: to build the evidence base regarding the optimal inpatient management of children. Evidence on how best to care for many pediatric conditions remains lacking, largely due to the facts that: a) death, the most definitive and readily measured of outcomes, is rare in pediatric hospitals; b) many pediatric conditions are relatively uncommon in any single hospital; and c) few validated, well‐developed metrics of inpatient pediatric quality exist.

As PRIS sought to launch multicenter studies of inpatient care quality, it continued to receive strong support from the APA, SHM, and AAP, and gained the support of a new partner, the Children's Hospital Association, which is comprised of a large group of children's hospitals across Canada and the US. The membership of PRIS grew to involve over 600 pediatric hospitalists from more than 75 hospitals.4 With a core group of funded hospitalist investigators, and strong support from partner organizations, the network sought and received funding for 3 major studies that are currently underway. Release of the federal government's Affordable Care Act and Comparative Effectiveness Research portfolio stimulated much of this work, stimulating the network to reach out to existing and new stakeholders and successfully compete for several multicenter studies.

RELEVANCE TO OTHER NETWORKS

We believe that the story of PRIS' development, current studies, and future plans has relevance to other adult, as well as pediatric, hospital medicine networks (see Table 3). As in pediatrics, a growing group of midcareer adult hospital medicine investigators has emerged, with proven track records in attracting federal funding and conducting research germane to our field. Some have previously worked together on large‐scale multisite studies.2023 A core group have come together to form the HOspital MEdicine Reengineering Network (HOMERUN).24 HOMERUN has recently secured funding from the Association of American Medical Colleges (AAMC) for a project that is linking clinical data from several hospitals to a centralized database, a project analogous to PHIS+, and will allow for Comparative Effectiveness Research studies that have more accurate case ascertainment (by using clinical data to build cohorts) and ensuring additional power by securing a larger number of cases. Defining which clinical questions to address first will help establish this new entity as a leader in hospital medicine research. Attracting stakeholder involvement will help make these endeavors successful. In recent months, PRIS and HOMERUN jointly collaborated on the submission of a large Centers for Medicare and Medicaid Innovation (CMMI) proposal to extend the work of I‐PASS to include several internal medicine and additional pediatric resident and hospitalist care settings. Future collaborations between networks may help foster more rapid advances in care.

Another pediatric hospitalist network has also emerged in the past few years, with a focus on quality improvement across inpatient pediatric settings, the Value in Pediatrics (VIP) Network.25 Although still early in its development, VIP has already successfully engaged in national quality improvement work regarding benchmarking care provided for children with bronchiolitis, reducing patient identification (ID) band errors, and improving discharge communications. VIP recently became part of the AAP's Quality Improvement Innovation Network (QuINN) group through which it is receiving infrastructure support.

As they develop, hospital medicine research and improvement networks will seek to systematically design and rigorously execute multicenter projects that provide answers to those clinical questions which practicing hospitalists face on a daily basis. As they do so, mentoring of both junior investigators and novice investigators will be necessary for the longevity of networks. To foster junior investigators, PRIS has undertaken a series of workshops presented at various national conferences, in addition to working with junior investigators directly on its currently funded studies.

CONCLUSION

Hospitalists' engagement in research and quality improvement networks builds upon their already successful engagement in clinical care, education, and quality improvement at a local level. A research and improvement mission that is tightly coupled with the day‐to‐day needs of these other important hospitalist activities creates a synergy with the potential to lead to transformative advances in patient care. If hospitalists can discover how best to deliver care, train the next generation of providers, and work to implement needed improvements at a local and national level, they will have an unprecedented opportunity to improve the care and health of children and adults.

Apparent life‐threatening events (ALTEs) are frightening for the parent/guardian and represent a challenge for the healthcare provider. ALTEs are defined as worrisome episodes of any combination of apnea, color change, change in muscle tone, choking or gagging.1 ALTEs account for 0.6% to 0.8% of emergency department (ED) visits for children <12 months old,2, 3 have an average length of stay (LOS) of 4.4 days and an average cost of $15,000 per hospitalization.4

Gastroesophageal reflux disease (GERD) is common in infancy11 and also is the most commonly (in 31%55% of ALTE cases) attributed cause of ALTE.2, 4, 5 It has been speculated that chemosensitivity to gastric acid results in laryngospasm, bronchospasm, and apnea. However, several small studies have failed to prove a causal link between reflux episodes and apnea.69 Furthermore, although consensus guidelines for GERD have been developed,14 the clinical use of testing for GERD remains highly variable. A study of infants discharged with an ALTE (n = 12,067) from 36 children's hospitals in the United States revealed extensive variability in the use of pH probes and upper gastrointestinal x‐ray series to diagnose GERD.4

The incidence of adverse outcomes associated with GERD after an ALTE remains unknown. It is also unknown whether an association exists between long‐term gastrointestinal (GI) outcomes and testing demonstrative of GERD or a diagnosis of GERD during hospitalization for ALTE. The primary objective of our study was to determine, in patients with an ALTE, the adverse outcomes associated with GERD (failure‐to‐thrive, aspiration pneumonia, and/or anti‐reflux surgery), the incidence of readmission for second ALTE, and death. Our secondary objective was to determine risk factors for adverse outcomes associated with GERD following an ALTE.

METHODS

Participants

Patients were included if a computer search of ED chief complaint or hospital discharge diagnoses found one or more of the following keywords (or corresponding International Classification of Diseases, Ninth Revision [ICD‐9] codes if applicable): ALTE, altered mental status, apnea, breath‐holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurologic diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness. These diagnoses were chosen as potential proxy diagnoses or codes for possible ALTE, as ALTE did not have a corresponding ICD‐9 code at the time of this study.

Detailed review of the medical record included infants who were <12 months old at admission with a history consistent with ALTE, defined as an episode frightening to the observer with any combination of apnea, color change, change in muscle tone, choking, or gagging. Infants were excluded from the study if they had a previously documented underlying medical condition to explain the ALTE (such as a known seizure disorder) or had a clearly apparent diagnosis upon initial history and physical examination (such as bronchiolitis diagnosed in the emergency department) that would explain the event. Patients with unstable vital signs (eg, hypotension), trauma clearly apparent on admission, documented medication dosing error, or febrile seizure were also excluded. A complete list of exclusion criteria is found in Figure 1.

Figure 1

All hospital admissions, ED visits, and Pediatric GI clinic notes were reviewed for adverse outcomes associated with GERD, second ALTE admission, and death. The follow‐up time period included the original enrollment period (January 1, 1999 through December 31, 2003) through August 31, 2009.

RESULTS

Eleven hundred forty‐eight infants with ALTE met inclusion criteria, from 187,903 patients meeting initial search criteria. Six hundred seventy‐one patients were excluded and 8 patients had missing charts. The study population of the 469‐patient cohort is shown in Figure 1.

Demographics are displayed in Table 1. The mean age was 65 days. One hundred three (22%) were premature. One hundred eighty‐nine patients (40%) had a primary discharge diagnosis of GERD; details of the diagnoses for the remaining patients are in Figure 1. Median length of follow‐up for the cohort was 7.8 years. The entire study period was 10.7 years.

Eighteen patients (3.8%) had an adverse outcome associated with GERD. Four (0.9%) had aspiration pneumonia, 9 (1.9%) had failure‐to‐thrive, and 7 (1.5%) had a Nissen fundoplication (no patients had a gastrojejunal tube placed). Five patients had a gastrostomy tube placed at the time of fundoplication. Two patients had more than 1 adverse GI outcome; 1 patient had aspiration pneumonia and another had failure‐to‐thrive prior to their Nissen fundoplications.

Fifty‐six patients (11.9%) were readmitted for a second ALTE. Median time from index ALTE to second ALTE admission was 16.5 days (interquartile range: Q1, 8Q3, 32). Two (0.4%) patients died. Both (occurring at 18 months and 5.5 years after the initial ALTE hospitalization) were related to the children first developing seizure disorders and severe developmental delay. Neither of the patients who died had an index discharge diagnoses of GERD.

There was no significance of the following variables in predicting adverse outcomes associated with GERD: age, prematurity, gender, previous event, testing positive for reflux, primary discharge diagnosis of GERD, or discharge on anti‐reflux medications (see Table 2). Patients with adverse outcomes associated with GERD had longer mean LOS on the index ALTE hospitalization (4.3 days vs 2.4 days; P = 0.03) and a higher rate of neurologic impairment diagnosed in follow‐up (16.7% vs 4.4%; P = 0.02) than patients without long‐term adverse GI outcomes. Patients with neurological impairment diagnosed in follow‐up were more likely to eventually develop an adverse outcome associated with GERD, compared to patients without neurological impairment (odds ratio 8.4; 95% confidence interval 1.1516.1).

DISCUSSION

Our study had 2 main findings. First, infants admitted for an ALTE had a low percentage (3.8%) of adverse outcomes associated with GERD. Review of the literature provides little context to interpret this percentage. One study reports 9 per 100,000 of the general population <18 years of age having anti‐reflux surgery.24 The percentage of adverse outcomes associated with GERD converted to a rate in our study would likely reflect the bias of our center serving as a referral population for Utah and 5 surrounding states. Furthermore, there may be an additional bias of ALTE being a potential indication for anti‐reflux surgery for some clinicians, as well as confounding additional diagnoses (such as later neurologic impairment which might independently increase risk of study outcomes).

The second main finding of our study is that the development of neurologic impairment was predictive of developing adverse GI outcomes. As previous studies have shown that neurological impairment cannot be predicted during the initial ALTE hospitalization,14 adverse outcomes associated with GERD are similarly not predictable with current clinical approaches. Furthermore, the exact nature of the relationship between neurologic impairment and ALTEs remains unclear. While previous studies have described the increased prevalence of adverse neurological outcomes (such as seizures, developmental delay) in children who have had an ALTE, it is unclear what the precipitating reason for ALTE is in these infants (seizure, central apnea, GERD, etc).14

There is ongoing debate in the literature surrounding the optimal diagnosis of GERD in infants with ALTE. Recent guidelines state that investigations aimed to prove GERD causing an ALTE should include pH probe or impedance monitor testing, in combination with a sleep study, and discourages a GERD diagnosis based on upper GI‐series alone.14 Given the low use of pH probe and impedance monitoring at our institution during the study period (86% of the patients who had GI‐related testing had an upper GI‐series), we did not attempt to find the sensitivity or specificity of the different GI testing modalities for GERD in the setting of ALTE. The high use of upper‐GI series is not unique to our institutionone large study examining practice variation from 12,067 ALTE admissions in 36 children's hospitals, with 36.9% of infants (n = 4453) having a primary discharge diagnosis of gastroesophageal reflux, revealed that only 8.9% (SD 28%) received an esophageal pH probe, while 25.6% (SD 43.6%) had an upper GI‐series or swallow study.4

Given the difficulties in assigning a GERD diagnosis for ALTE infants, we focused on the long‐term adverse outcomes associated with GERD for the entire ALTE infant cohort. The 3 adverse outcomes we chose deserve some mention. Aspiration pneumonia is generally due to either primary aspiration (from dysfunctional swallowing) or secondary aspiration (from GERD). Failure‐to‐thrive can be due to ongoing GERD. Anti‐reflux surgery is often performed for severe GERD. While we believe that a prospective study with better diagnostic evaluations for GERD and apnea (such as pH probe or impedance monitor in combination with a sleep study) might help elucidate the unclear relationship between reflux episodes and ALTE, the low percentage of adverse outcomes associated with GERD after ALTE may suggest that such a study would be difficult both in terms of sample size and an unnecessary use of resources.

We also found that a high percentage (11.9%) of all patients had readmission for a second ALTE. This was substantially higher than the 2.5% readmission rate for second ALTE reported in a previous study of short‐term follow‐up (30 days).4 The number of readmissions in our study might be higher due to our comprehensive follow‐up, both in length of time and number of additional EDs and hospitals captured. Unfortunately, the retrospective nature of our study makes it difficult to determine if any interventions (prescription of anti‐reflux medication, education on reflux precautions) impacted the rate of readmission, as compliance was not measurable. Further studies should address why patients return with recurrent ALTE.

Interestingly, several potential risk factors did not predict long‐term adverse GI outcomes. For example, prematurity, a discharge diagnosis of GERD, or prescription of an anti‐reflux medication, were not associated with adverse GI outcomes. These findings support the concept that a diagnosis of GERD, at least as is commonly applied, is not meaningful in the setting of an ALTE. We did find associations with longer length of stay (LOS), and with eventual development of neurological impairment. Longer LOS might be a proxy for other subtle predictors that could influence adverse outcomes, such as requiring additional diagnostic tests prolonging hospitalization, or continued ALTEs while inpatient. The neurologic outcomes of patients with ALTE have been previously published, and the strong correlation between neurologic impairment and GERD has been well described.14, 25

There are several strengths of this study. This is the first study, to our knowledge, to look at adverse outcomes associated with GERD following ALTE, despite GERD being the most commonly attributed cause. The use of Intermountain Healthcare's electronic medical record system allowed for comprehensive tracking, over an extensive follow‐up period (median of 7.8 years), across 20 hospitals and EDs which care for the vast majority of pediatric patients in Utah. Finally, this large cohort of ALTE patients used clinical data from medical records and not only administrative data.

There are limitations of this study. This is a retrospective cohort study. Some of our study outcomes may be a result of pathophysiology other than GERD and, conversely, GERD may be a result of other issues (neurologic impairment). The small sample size and low percentage of the study outcomes make it possible that we did not detect true risk factors. Patients were lost to follow‐up if they moved or presented to a hospital not within the Intermountain Healthcare system. This study has slightly different patient numbers from 3 previously published studies for different outcomes on this cohort, as exclusion criteria for the different cohorts were different.14, 26, 27 Six patients had only their electronic medical record reviewed because the paper chart was missing.

IMPLICATIONS

The results of this study extend previous work of various outcomes regarding well‐appearing infants following an ALTE.14, 26, 27 In these studies, 3.9% and 3% were ultimately diagnosed with epilepsy and developmental delay, respectively; 1.4% were diagnosed with abusive head trauma; and 0.6% required otolaryngologic surgical intervention. In these previous studies, there were few predictors of these outcomes, with testing demonstrating largely normal results during the index ALTE admission.

Our study helps clinicians place the outcomes of aspiration pneumonia, failure‐to‐thrive, and anti‐reflux surgery into the context of these other studies when discharging infants from the hospital after an ALTE. Collectively, these studies provide clinicians with the information that, in the setting of a well‐appearing infant, few diagnostic tests in their ALTE patients will yield a definitive diagnosis. Ultimately, close follow‐up with further investigations if symptoms recur will be an important part of diagnosing the etiology of the ALTE in these infants.

We found that well‐appearing infants with ALTE, regardless of attributed cause, are at low risk for adverse outcomes associated with GERD. Only the eventual development of neurologic impairment or an increased length of stay during index ALTE hospitalization was found to be predictive of these outcomes.

Apparent life‐threatening events (ALTEs) are frightening for the parent/guardian and represent a challenge for the healthcare provider. ALTEs are defined as worrisome episodes of any combination of apnea, color change, change in muscle tone, choking or gagging.1 ALTEs account for 0.6% to 0.8% of emergency department (ED) visits for children <12 months old,2, 3 have an average length of stay (LOS) of 4.4 days and an average cost of $15,000 per hospitalization.4

Gastroesophageal reflux disease (GERD) is common in infancy11 and also is the most commonly (in 31%55% of ALTE cases) attributed cause of ALTE.2, 4, 5 It has been speculated that chemosensitivity to gastric acid results in laryngospasm, bronchospasm, and apnea. However, several small studies have failed to prove a causal link between reflux episodes and apnea.69 Furthermore, although consensus guidelines for GERD have been developed,14 the clinical use of testing for GERD remains highly variable. A study of infants discharged with an ALTE (n = 12,067) from 36 children's hospitals in the United States revealed extensive variability in the use of pH probes and upper gastrointestinal x‐ray series to diagnose GERD.4

The incidence of adverse outcomes associated with GERD after an ALTE remains unknown. It is also unknown whether an association exists between long‐term gastrointestinal (GI) outcomes and testing demonstrative of GERD or a diagnosis of GERD during hospitalization for ALTE. The primary objective of our study was to determine, in patients with an ALTE, the adverse outcomes associated with GERD (failure‐to‐thrive, aspiration pneumonia, and/or anti‐reflux surgery), the incidence of readmission for second ALTE, and death. Our secondary objective was to determine risk factors for adverse outcomes associated with GERD following an ALTE.

METHODS

Participants

Patients were included if a computer search of ED chief complaint or hospital discharge diagnoses found one or more of the following keywords (or corresponding International Classification of Diseases, Ninth Revision [ICD‐9] codes if applicable): ALTE, altered mental status, apnea, breath‐holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurologic diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness. These diagnoses were chosen as potential proxy diagnoses or codes for possible ALTE, as ALTE did not have a corresponding ICD‐9 code at the time of this study.

Detailed review of the medical record included infants who were <12 months old at admission with a history consistent with ALTE, defined as an episode frightening to the observer with any combination of apnea, color change, change in muscle tone, choking, or gagging. Infants were excluded from the study if they had a previously documented underlying medical condition to explain the ALTE (such as a known seizure disorder) or had a clearly apparent diagnosis upon initial history and physical examination (such as bronchiolitis diagnosed in the emergency department) that would explain the event. Patients with unstable vital signs (eg, hypotension), trauma clearly apparent on admission, documented medication dosing error, or febrile seizure were also excluded. A complete list of exclusion criteria is found in Figure 1.

Figure 1

All hospital admissions, ED visits, and Pediatric GI clinic notes were reviewed for adverse outcomes associated with GERD, second ALTE admission, and death. The follow‐up time period included the original enrollment period (January 1, 1999 through December 31, 2003) through August 31, 2009.

RESULTS

Eleven hundred forty‐eight infants with ALTE met inclusion criteria, from 187,903 patients meeting initial search criteria. Six hundred seventy‐one patients were excluded and 8 patients had missing charts. The study population of the 469‐patient cohort is shown in Figure 1.

Demographics are displayed in Table 1. The mean age was 65 days. One hundred three (22%) were premature. One hundred eighty‐nine patients (40%) had a primary discharge diagnosis of GERD; details of the diagnoses for the remaining patients are in Figure 1. Median length of follow‐up for the cohort was 7.8 years. The entire study period was 10.7 years.

Eighteen patients (3.8%) had an adverse outcome associated with GERD. Four (0.9%) had aspiration pneumonia, 9 (1.9%) had failure‐to‐thrive, and 7 (1.5%) had a Nissen fundoplication (no patients had a gastrojejunal tube placed). Five patients had a gastrostomy tube placed at the time of fundoplication. Two patients had more than 1 adverse GI outcome; 1 patient had aspiration pneumonia and another had failure‐to‐thrive prior to their Nissen fundoplications.

Fifty‐six patients (11.9%) were readmitted for a second ALTE. Median time from index ALTE to second ALTE admission was 16.5 days (interquartile range: Q1, 8Q3, 32). Two (0.4%) patients died. Both (occurring at 18 months and 5.5 years after the initial ALTE hospitalization) were related to the children first developing seizure disorders and severe developmental delay. Neither of the patients who died had an index discharge diagnoses of GERD.

There was no significance of the following variables in predicting adverse outcomes associated with GERD: age, prematurity, gender, previous event, testing positive for reflux, primary discharge diagnosis of GERD, or discharge on anti‐reflux medications (see Table 2). Patients with adverse outcomes associated with GERD had longer mean LOS on the index ALTE hospitalization (4.3 days vs 2.4 days; P = 0.03) and a higher rate of neurologic impairment diagnosed in follow‐up (16.7% vs 4.4%; P = 0.02) than patients without long‐term adverse GI outcomes. Patients with neurological impairment diagnosed in follow‐up were more likely to eventually develop an adverse outcome associated with GERD, compared to patients without neurological impairment (odds ratio 8.4; 95% confidence interval 1.1516.1).

DISCUSSION

Our study had 2 main findings. First, infants admitted for an ALTE had a low percentage (3.8%) of adverse outcomes associated with GERD. Review of the literature provides little context to interpret this percentage. One study reports 9 per 100,000 of the general population <18 years of age having anti‐reflux surgery.24 The percentage of adverse outcomes associated with GERD converted to a rate in our study would likely reflect the bias of our center serving as a referral population for Utah and 5 surrounding states. Furthermore, there may be an additional bias of ALTE being a potential indication for anti‐reflux surgery for some clinicians, as well as confounding additional diagnoses (such as later neurologic impairment which might independently increase risk of study outcomes).

The second main finding of our study is that the development of neurologic impairment was predictive of developing adverse GI outcomes. As previous studies have shown that neurological impairment cannot be predicted during the initial ALTE hospitalization,14 adverse outcomes associated with GERD are similarly not predictable with current clinical approaches. Furthermore, the exact nature of the relationship between neurologic impairment and ALTEs remains unclear. While previous studies have described the increased prevalence of adverse neurological outcomes (such as seizures, developmental delay) in children who have had an ALTE, it is unclear what the precipitating reason for ALTE is in these infants (seizure, central apnea, GERD, etc).14

There is ongoing debate in the literature surrounding the optimal diagnosis of GERD in infants with ALTE. Recent guidelines state that investigations aimed to prove GERD causing an ALTE should include pH probe or impedance monitor testing, in combination with a sleep study, and discourages a GERD diagnosis based on upper GI‐series alone.14 Given the low use of pH probe and impedance monitoring at our institution during the study period (86% of the patients who had GI‐related testing had an upper GI‐series), we did not attempt to find the sensitivity or specificity of the different GI testing modalities for GERD in the setting of ALTE. The high use of upper‐GI series is not unique to our institutionone large study examining practice variation from 12,067 ALTE admissions in 36 children's hospitals, with 36.9% of infants (n = 4453) having a primary discharge diagnosis of gastroesophageal reflux, revealed that only 8.9% (SD 28%) received an esophageal pH probe, while 25.6% (SD 43.6%) had an upper GI‐series or swallow study.4

Given the difficulties in assigning a GERD diagnosis for ALTE infants, we focused on the long‐term adverse outcomes associated with GERD for the entire ALTE infant cohort. The 3 adverse outcomes we chose deserve some mention. Aspiration pneumonia is generally due to either primary aspiration (from dysfunctional swallowing) or secondary aspiration (from GERD). Failure‐to‐thrive can be due to ongoing GERD. Anti‐reflux surgery is often performed for severe GERD. While we believe that a prospective study with better diagnostic evaluations for GERD and apnea (such as pH probe or impedance monitor in combination with a sleep study) might help elucidate the unclear relationship between reflux episodes and ALTE, the low percentage of adverse outcomes associated with GERD after ALTE may suggest that such a study would be difficult both in terms of sample size and an unnecessary use of resources.

We also found that a high percentage (11.9%) of all patients had readmission for a second ALTE. This was substantially higher than the 2.5% readmission rate for second ALTE reported in a previous study of short‐term follow‐up (30 days).4 The number of readmissions in our study might be higher due to our comprehensive follow‐up, both in length of time and number of additional EDs and hospitals captured. Unfortunately, the retrospective nature of our study makes it difficult to determine if any interventions (prescription of anti‐reflux medication, education on reflux precautions) impacted the rate of readmission, as compliance was not measurable. Further studies should address why patients return with recurrent ALTE.

Interestingly, several potential risk factors did not predict long‐term adverse GI outcomes. For example, prematurity, a discharge diagnosis of GERD, or prescription of an anti‐reflux medication, were not associated with adverse GI outcomes. These findings support the concept that a diagnosis of GERD, at least as is commonly applied, is not meaningful in the setting of an ALTE. We did find associations with longer length of stay (LOS), and with eventual development of neurological impairment. Longer LOS might be a proxy for other subtle predictors that could influence adverse outcomes, such as requiring additional diagnostic tests prolonging hospitalization, or continued ALTEs while inpatient. The neurologic outcomes of patients with ALTE have been previously published, and the strong correlation between neurologic impairment and GERD has been well described.14, 25

There are several strengths of this study. This is the first study, to our knowledge, to look at adverse outcomes associated with GERD following ALTE, despite GERD being the most commonly attributed cause. The use of Intermountain Healthcare's electronic medical record system allowed for comprehensive tracking, over an extensive follow‐up period (median of 7.8 years), across 20 hospitals and EDs which care for the vast majority of pediatric patients in Utah. Finally, this large cohort of ALTE patients used clinical data from medical records and not only administrative data.

There are limitations of this study. This is a retrospective cohort study. Some of our study outcomes may be a result of pathophysiology other than GERD and, conversely, GERD may be a result of other issues (neurologic impairment). The small sample size and low percentage of the study outcomes make it possible that we did not detect true risk factors. Patients were lost to follow‐up if they moved or presented to a hospital not within the Intermountain Healthcare system. This study has slightly different patient numbers from 3 previously published studies for different outcomes on this cohort, as exclusion criteria for the different cohorts were different.14, 26, 27 Six patients had only their electronic medical record reviewed because the paper chart was missing.

IMPLICATIONS

The results of this study extend previous work of various outcomes regarding well‐appearing infants following an ALTE.14, 26, 27 In these studies, 3.9% and 3% were ultimately diagnosed with epilepsy and developmental delay, respectively; 1.4% were diagnosed with abusive head trauma; and 0.6% required otolaryngologic surgical intervention. In these previous studies, there were few predictors of these outcomes, with testing demonstrating largely normal results during the index ALTE admission.

Our study helps clinicians place the outcomes of aspiration pneumonia, failure‐to‐thrive, and anti‐reflux surgery into the context of these other studies when discharging infants from the hospital after an ALTE. Collectively, these studies provide clinicians with the information that, in the setting of a well‐appearing infant, few diagnostic tests in their ALTE patients will yield a definitive diagnosis. Ultimately, close follow‐up with further investigations if symptoms recur will be an important part of diagnosing the etiology of the ALTE in these infants.

We found that well‐appearing infants with ALTE, regardless of attributed cause, are at low risk for adverse outcomes associated with GERD. Only the eventual development of neurologic impairment or an increased length of stay during index ALTE hospitalization was found to be predictive of these outcomes.

Apparent life‐threatening events (ALTEs) are frightening for the parent/guardian and represent a challenge for the healthcare provider. ALTEs are defined as worrisome episodes of any combination of apnea, color change, change in muscle tone, choking or gagging.1 ALTEs account for 0.6% to 0.8% of emergency department (ED) visits for children <12 months old,2, 3 have an average length of stay (LOS) of 4.4 days and an average cost of $15,000 per hospitalization.4

Gastroesophageal reflux disease (GERD) is common in infancy11 and also is the most commonly (in 31%55% of ALTE cases) attributed cause of ALTE.2, 4, 5 It has been speculated that chemosensitivity to gastric acid results in laryngospasm, bronchospasm, and apnea. However, several small studies have failed to prove a causal link between reflux episodes and apnea.69 Furthermore, although consensus guidelines for GERD have been developed,14 the clinical use of testing for GERD remains highly variable. A study of infants discharged with an ALTE (n = 12,067) from 36 children's hospitals in the United States revealed extensive variability in the use of pH probes and upper gastrointestinal x‐ray series to diagnose GERD.4

The incidence of adverse outcomes associated with GERD after an ALTE remains unknown. It is also unknown whether an association exists between long‐term gastrointestinal (GI) outcomes and testing demonstrative of GERD or a diagnosis of GERD during hospitalization for ALTE. The primary objective of our study was to determine, in patients with an ALTE, the adverse outcomes associated with GERD (failure‐to‐thrive, aspiration pneumonia, and/or anti‐reflux surgery), the incidence of readmission for second ALTE, and death. Our secondary objective was to determine risk factors for adverse outcomes associated with GERD following an ALTE.

METHODS

Participants

Patients were included if a computer search of ED chief complaint or hospital discharge diagnoses found one or more of the following keywords (or corresponding International Classification of Diseases, Ninth Revision [ICD‐9] codes if applicable): ALTE, altered mental status, apnea, breath‐holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurologic diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness. These diagnoses were chosen as potential proxy diagnoses or codes for possible ALTE, as ALTE did not have a corresponding ICD‐9 code at the time of this study.

Detailed review of the medical record included infants who were <12 months old at admission with a history consistent with ALTE, defined as an episode frightening to the observer with any combination of apnea, color change, change in muscle tone, choking, or gagging. Infants were excluded from the study if they had a previously documented underlying medical condition to explain the ALTE (such as a known seizure disorder) or had a clearly apparent diagnosis upon initial history and physical examination (such as bronchiolitis diagnosed in the emergency department) that would explain the event. Patients with unstable vital signs (eg, hypotension), trauma clearly apparent on admission, documented medication dosing error, or febrile seizure were also excluded. A complete list of exclusion criteria is found in Figure 1.

Figure 1

All hospital admissions, ED visits, and Pediatric GI clinic notes were reviewed for adverse outcomes associated with GERD, second ALTE admission, and death. The follow‐up time period included the original enrollment period (January 1, 1999 through December 31, 2003) through August 31, 2009.

RESULTS

Eleven hundred forty‐eight infants with ALTE met inclusion criteria, from 187,903 patients meeting initial search criteria. Six hundred seventy‐one patients were excluded and 8 patients had missing charts. The study population of the 469‐patient cohort is shown in Figure 1.

Demographics are displayed in Table 1. The mean age was 65 days. One hundred three (22%) were premature. One hundred eighty‐nine patients (40%) had a primary discharge diagnosis of GERD; details of the diagnoses for the remaining patients are in Figure 1. Median length of follow‐up for the cohort was 7.8 years. The entire study period was 10.7 years.

Eighteen patients (3.8%) had an adverse outcome associated with GERD. Four (0.9%) had aspiration pneumonia, 9 (1.9%) had failure‐to‐thrive, and 7 (1.5%) had a Nissen fundoplication (no patients had a gastrojejunal tube placed). Five patients had a gastrostomy tube placed at the time of fundoplication. Two patients had more than 1 adverse GI outcome; 1 patient had aspiration pneumonia and another had failure‐to‐thrive prior to their Nissen fundoplications.

Fifty‐six patients (11.9%) were readmitted for a second ALTE. Median time from index ALTE to second ALTE admission was 16.5 days (interquartile range: Q1, 8Q3, 32). Two (0.4%) patients died. Both (occurring at 18 months and 5.5 years after the initial ALTE hospitalization) were related to the children first developing seizure disorders and severe developmental delay. Neither of the patients who died had an index discharge diagnoses of GERD.

There was no significance of the following variables in predicting adverse outcomes associated with GERD: age, prematurity, gender, previous event, testing positive for reflux, primary discharge diagnosis of GERD, or discharge on anti‐reflux medications (see Table 2). Patients with adverse outcomes associated with GERD had longer mean LOS on the index ALTE hospitalization (4.3 days vs 2.4 days; P = 0.03) and a higher rate of neurologic impairment diagnosed in follow‐up (16.7% vs 4.4%; P = 0.02) than patients without long‐term adverse GI outcomes. Patients with neurological impairment diagnosed in follow‐up were more likely to eventually develop an adverse outcome associated with GERD, compared to patients without neurological impairment (odds ratio 8.4; 95% confidence interval 1.1516.1).

DISCUSSION

Our study had 2 main findings. First, infants admitted for an ALTE had a low percentage (3.8%) of adverse outcomes associated with GERD. Review of the literature provides little context to interpret this percentage. One study reports 9 per 100,000 of the general population <18 years of age having anti‐reflux surgery.24 The percentage of adverse outcomes associated with GERD converted to a rate in our study would likely reflect the bias of our center serving as a referral population for Utah and 5 surrounding states. Furthermore, there may be an additional bias of ALTE being a potential indication for anti‐reflux surgery for some clinicians, as well as confounding additional diagnoses (such as later neurologic impairment which might independently increase risk of study outcomes).

The second main finding of our study is that the development of neurologic impairment was predictive of developing adverse GI outcomes. As previous studies have shown that neurological impairment cannot be predicted during the initial ALTE hospitalization,14 adverse outcomes associated with GERD are similarly not predictable with current clinical approaches. Furthermore, the exact nature of the relationship between neurologic impairment and ALTEs remains unclear. While previous studies have described the increased prevalence of adverse neurological outcomes (such as seizures, developmental delay) in children who have had an ALTE, it is unclear what the precipitating reason for ALTE is in these infants (seizure, central apnea, GERD, etc).14

There is ongoing debate in the literature surrounding the optimal diagnosis of GERD in infants with ALTE. Recent guidelines state that investigations aimed to prove GERD causing an ALTE should include pH probe or impedance monitor testing, in combination with a sleep study, and discourages a GERD diagnosis based on upper GI‐series alone.14 Given the low use of pH probe and impedance monitoring at our institution during the study period (86% of the patients who had GI‐related testing had an upper GI‐series), we did not attempt to find the sensitivity or specificity of the different GI testing modalities for GERD in the setting of ALTE. The high use of upper‐GI series is not unique to our institutionone large study examining practice variation from 12,067 ALTE admissions in 36 children's hospitals, with 36.9% of infants (n = 4453) having a primary discharge diagnosis of gastroesophageal reflux, revealed that only 8.9% (SD 28%) received an esophageal pH probe, while 25.6% (SD 43.6%) had an upper GI‐series or swallow study.4

Given the difficulties in assigning a GERD diagnosis for ALTE infants, we focused on the long‐term adverse outcomes associated with GERD for the entire ALTE infant cohort. The 3 adverse outcomes we chose deserve some mention. Aspiration pneumonia is generally due to either primary aspiration (from dysfunctional swallowing) or secondary aspiration (from GERD). Failure‐to‐thrive can be due to ongoing GERD. Anti‐reflux surgery is often performed for severe GERD. While we believe that a prospective study with better diagnostic evaluations for GERD and apnea (such as pH probe or impedance monitor in combination with a sleep study) might help elucidate the unclear relationship between reflux episodes and ALTE, the low percentage of adverse outcomes associated with GERD after ALTE may suggest that such a study would be difficult both in terms of sample size and an unnecessary use of resources.

We also found that a high percentage (11.9%) of all patients had readmission for a second ALTE. This was substantially higher than the 2.5% readmission rate for second ALTE reported in a previous study of short‐term follow‐up (30 days).4 The number of readmissions in our study might be higher due to our comprehensive follow‐up, both in length of time and number of additional EDs and hospitals captured. Unfortunately, the retrospective nature of our study makes it difficult to determine if any interventions (prescription of anti‐reflux medication, education on reflux precautions) impacted the rate of readmission, as compliance was not measurable. Further studies should address why patients return with recurrent ALTE.

Interestingly, several potential risk factors did not predict long‐term adverse GI outcomes. For example, prematurity, a discharge diagnosis of GERD, or prescription of an anti‐reflux medication, were not associated with adverse GI outcomes. These findings support the concept that a diagnosis of GERD, at least as is commonly applied, is not meaningful in the setting of an ALTE. We did find associations with longer length of stay (LOS), and with eventual development of neurological impairment. Longer LOS might be a proxy for other subtle predictors that could influence adverse outcomes, such as requiring additional diagnostic tests prolonging hospitalization, or continued ALTEs while inpatient. The neurologic outcomes of patients with ALTE have been previously published, and the strong correlation between neurologic impairment and GERD has been well described.14, 25

There are several strengths of this study. This is the first study, to our knowledge, to look at adverse outcomes associated with GERD following ALTE, despite GERD being the most commonly attributed cause. The use of Intermountain Healthcare's electronic medical record system allowed for comprehensive tracking, over an extensive follow‐up period (median of 7.8 years), across 20 hospitals and EDs which care for the vast majority of pediatric patients in Utah. Finally, this large cohort of ALTE patients used clinical data from medical records and not only administrative data.

There are limitations of this study. This is a retrospective cohort study. Some of our study outcomes may be a result of pathophysiology other than GERD and, conversely, GERD may be a result of other issues (neurologic impairment). The small sample size and low percentage of the study outcomes make it possible that we did not detect true risk factors. Patients were lost to follow‐up if they moved or presented to a hospital not within the Intermountain Healthcare system. This study has slightly different patient numbers from 3 previously published studies for different outcomes on this cohort, as exclusion criteria for the different cohorts were different.14, 26, 27 Six patients had only their electronic medical record reviewed because the paper chart was missing.

IMPLICATIONS

The results of this study extend previous work of various outcomes regarding well‐appearing infants following an ALTE.14, 26, 27 In these studies, 3.9% and 3% were ultimately diagnosed with epilepsy and developmental delay, respectively; 1.4% were diagnosed with abusive head trauma; and 0.6% required otolaryngologic surgical intervention. In these previous studies, there were few predictors of these outcomes, with testing demonstrating largely normal results during the index ALTE admission.

Our study helps clinicians place the outcomes of aspiration pneumonia, failure‐to‐thrive, and anti‐reflux surgery into the context of these other studies when discharging infants from the hospital after an ALTE. Collectively, these studies provide clinicians with the information that, in the setting of a well‐appearing infant, few diagnostic tests in their ALTE patients will yield a definitive diagnosis. Ultimately, close follow‐up with further investigations if symptoms recur will be an important part of diagnosing the etiology of the ALTE in these infants.

We found that well‐appearing infants with ALTE, regardless of attributed cause, are at low risk for adverse outcomes associated with GERD. Only the eventual development of neurologic impairment or an increased length of stay during index ALTE hospitalization was found to be predictive of these outcomes.

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Hospitalist systems focus on providing acute treatments to patients and expediting hospital discharge, sometimes without regard for the need to work in concert with community providers, leading to fragmentation of care.1 This fragmentation, particularly at the transitions of care, such as when patients move from the outpatient setting to a hospitalist system and then back to their primary care providers (PCPs), can lead to communication breakdowns and delays in care, and may compromise patient outcomes.2 Suboptimal treatments, such as medication errors and the ordering of redundant tests can occur in either setting if prior treatment information is not relayed in a timely and accurate fashion. Landrigan et al.3 described a conceptual model in 2001 that recognized the complexity of the hospitalist‐PCP communication system. Specifically, optimal care of hospitalized children includes PCPs, family members, hospitalists, and support staff while meeting the communication needs of families and PCPs. Additionally, mediating a smooth transition into and out of the hospital needs to be measured carefully.3

Previous adult studies have reported that hospitalist systems sometimes create discontinuity of patient care, which can have a negative impact on the quality of care provided to patients if there is poor communication between hospitalists and PCPs.2, 4, 5 Existing research on hospitalist‐PCP communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist‐PCP communication.

The objective of this study was to qualitatively explore issues around communication between pediatric hospitalists and PCPs. Specifically, we sought to explore the quality of communication practices and barriers to optimal communication within the hospitalist‐PCP model at a tertiary care children's hospital. The results are serving as a needs assessment to guide the design of a quality improvement project with the aim of improving pediatric hospitalist‐PCP communication.

METHODS

RESULTS

Only 1 physician per practice was interviewed. No PCP who was able to be contacted declined an interview, although some did require multiple phone attempts to schedule the interview. PCPs were located in Salt Lake County (n = 6), in other Utah counties (n = 3), and in surrounding Intermountain West states (n = 3). From January 1, 2004 to December 31, 2004, we estimate that the hospitalist division cared for patients from approximately 35 practices (50% in Salt Lake County, 30% in other Utah counties, and 20% in surrounding Intermountain West states).

Hospitalists and PCPs agreed that overall quality of communication ranged from poor to very good (Table 2). Both parties acknowledged that significant barriers to optimal communication exist, yet the barriers differed for each group. Hospitalists and PCPs also agreed that optimal communication could improve many aspects of patient care and should take place upon discharge and admission of patients and with major clinical changes. Both hospitalists and PCPs also wanted accurate and timely information. One priority that the participants emphasized is the timely transfer of admission notification and the receipt of accurate and timely discharge summaries by PCPs.

DISCUSSION

Both pediatric hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow‐up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). However, there was discrepancy in the barriers to optimal communication for each group. Identifying and addressing these barriers can help both hospitalists and PCPs implement targeted interventions aimed at improving communication. As the number of pediatric hospitalist programs increases, the risk for hospitalist‐PCP communication breakdowns, which can have a negative impact on patient care, also increases.

Previous adult studies describe the scope of the problem around poor communication between hospitalists and PCPs.1, 912 Kripalani et al.10 reported recently that delays and omissions in communication are common at hospital discharge among adult hospitalists and that computer‐generated summaries, educational interventions, and standardized formats may facilitate more timely transfer of pertinent information. However, there is limited data on pediatric hospitalist‐PCP communication. Srivastava et al.5 found that 60% of community physicians thought hospitalist systems may impair communication with PCPs when evaluating community and hospital‐based physicians' attitudes regarding pediatric hospitalist systems.

PCPs can feel left out when their patients are cared for by hospitalists.13 One PCP in our study commented: Include the referral doc as part of the team. We're the ones who will take care of them after discharge. It seems like an autonomous thing down there and we're excluded from the patient care team. Additionally, patients want their PCPs to remain involved in their care as they transition into and out of the hospital setting.1, 13

The continuity visit model has been proposed by Wachter and Pantilat14 to describe a clinical encounter between the primary physician and hospitalized patient, when the patient has a different physician of record. In this model, the PCP can endorse the hospitalist model and the individual hospitalist, notice subtle findings that differ from the patient's baseline, and help clarify patient preferences regarding difficult situations by drawing on their previous relationship with the patient. This visit may also benefit the PCP by providing insights into the patient's illness, personality, or social support that he or she was unaware of previously. However, in order for the continuity visit to exist, the PCP has to be informed of their patient's admission in the first place. Ethical dilemmas also have been raised regarding who bears primary responsibility for maintaining open lines of communication when patients are hospitalized.15 Lo15 advocates that PCPs can and should be involved in meaningful ways in the inpatient care of their patients even when they are not acting as the treating physicians. Specifically, he suggests that PCPs personally visit particularly ill patients or those with difficult diagnoses and use frequent phone calls to all admitted patients.

Beyond telephone calls and continuity visits, hospitalists and PCPs rely on discharge summaries as a key part of the information transfer about a patient's hospitalization.1, 16, 17 These documents are rendered useless if they are inaccurate, illegible, or not delivered in a timely manner.18 In a study of California family physicians, discharge summaries were thought to be too detailed by 84% of PCPs, and reportedly arrived before the patient's first follow‐up appointment only 33% of the time.1 O'Leary et al.19 found that 41% of the Department of Medicine physicians surveyed believed that at least 1 of their patients hospitalized in the previous 6 months had experienced a preventable adverse event related to poor transfer of information at discharge. In our study, PCPs noted that discharge summaries often arrived in their offices well after the patient had been seen for their follow‐up appointment.

Both hospitalists and PCPs agree that a concise and precise discharge summary should include an overview of the hospitalization with important details highlighted. Similar to the findings of Pantilat et al.,1 in our study PCPs specifically want detailed information with regard to diagnoses, discharge medications, and what to expect when they see the patient in their clinic. Follow‐up phone calls to PCPs to see that they received written information and if they require further details is 1 solution to ensuring good follow‐up, yet this adds to the burden of communication and could be an additional barrier.

The teaching institutions in which physicians train also pose unique obstacles to optimal communication. In academic medical centers, medical students and residents perform a majority of the discharge duties (eg, writing prescriptions, dictating discharge summaries, making follow‐up appointments, and calling PCPs), and teaching these trainees the importance of timely and accurate communication becomes an added challenge. Educators have to find novel ways of providing incentives to residents and medical students to get them to effectively participate in this process. Plauth et al.20 reports that hospitalists feel they needed better training in residency around communicating, noting a meaningful underemphasis during residency training in regard to communication with referring physicians. These skills should be taught in medical school and supported by both hospitalists and PCPs throughout residency training.

Both hospitalists and PCPs also want easy and reliable ways to access their colleagues, which ideally would be automatic. One PCP commented: a weekly or semiweekly phone call would be nice. Another suggested to: fax a short note. One hospitalist acknowledged: a systematic approach would be betterwhether a fax or telephone call and make sure there is a way of checking to make sure the communication has happened. Another hospitalist simply remarked: it needs to be done on every patient.

Thus, it seems an improved communication system should be flexible enough to accommodate unique provider preferences, such as communication via phone, fax, or e‐mail. This is demonstrated by 1 PCP who preferred the phone, but most convenient is the periodic fax updates. I don't have to be taken away from seeing patients.

Lo15 calls for a standard to be established for delivering care within the patient‐PCP‐hospitalist triad. Phone calls and faxes are 2 readily available methods of communication. However, the frequent back‐and‐forth of missed calls, unreturned calls, and days‐off is certainly a factor in determining efficiency and effectiveness of phone calls.

E‐mail, if it is widely used by all participants, may be an effective option for delivery that could provide confirmation of receipt. However, the lack of universal e‐mail usage by all providers remains a barrier. Questions as to which method is more time consuming and for whom, need to be studied further. Patient confidentiality also requires that this protected health information arrive in the proper hands. Personal relationships can also contribute to successful communication. One provider may be more likely to contact another if they know each other through some personal connection, such as medical school, residency, or a social group.

Our study has several limitations. The sample size was small. We obtained responses from a sample of key stakeholders in the hospitalist‐PCP communication process. We were limited by the number of hospitalists at our institution as well as the interest and availability of PCPs to respond. We are unable to determine the total number of patients by respondent PCP practice cared for by the hospitalist division. This could influence the results depending on whether the respondent PCP was a frequent or infrequent utilizer of the hospitalist system. However, we feel reassured that we are not missing important information, because in our methods, a priori, we had intended to stop interviewing PCPs once theoretical saturation had been reached (ie, respondents did not identify any new information). In our study, that occurred with 12 PCPs.

We attempted to interview a single physician in a number of different practice settings in order to gain insight into the perceptions of that individual as well as those of their partners. The views expressed by these individuals may not represent the views of hospitalists and PCPs outside of our practice area. Furthermore, PCMC serves as both a community pediatric hospital and a tertiary‐referral center for a large area, yet the current experience of 1 hospitalist division and 1 cohort of referring PCPs may contain regional variation that contributed bias to the responses.

Selection bias may have been introduced in our study by the inherent nature of phone interviews. We interviewed only providers with previous communication experience with our hospitalist division. These providers may have had a vested interest in the communication process. We did not interview those PCPs who did not have any communication with our hospitalist division or those who may have used the hospitalist division previously and decided to no longer use the division. Interviewing these groups may have provided additional insight into the communication issues mentioned here. Additionally, useful information could have been gleaned from trying to find out more from the 33% of PCPs who felt communication was poor. We anticipate further studies exploring this issue in more depth.

CONCLUSIONS

Hospitalists and PCPs agree that overall quality of communication ranges from poor to very good. Both PCPs and pediatric hospitalists acknowledge that significant barriers to optimal communication exist, yet the barriers differ for each group. They also agree that optimal communication would improve many aspects of patient care and should take place upon discharge and admission of patients and with major clinical changes.

Pediatric hospitalists and PCPs identified issues around optimal communication similar to those noted in the adult hospital medicine literature. Interventions to improve pediatric hospitalist‐PCP communication should at least address these 6 issues: (1) quality of communication; (2) barriers to communication; (3) methods of information sharing; (4) key data element requirements; (5) critical timing; and (6) perceived benefits. Such interventions will likely improve hospitalist‐PCP communication and potentially improve the quality of patient care. However, future studies will need to demonstrate the link between improved hospitalist‐PCP communication and improved patient care and outcomes.

Hospitalist systems focus on providing acute treatments to patients and expediting hospital discharge, sometimes without regard for the need to work in concert with community providers, leading to fragmentation of care.1 This fragmentation, particularly at the transitions of care, such as when patients move from the outpatient setting to a hospitalist system and then back to their primary care providers (PCPs), can lead to communication breakdowns and delays in care, and may compromise patient outcomes.2 Suboptimal treatments, such as medication errors and the ordering of redundant tests can occur in either setting if prior treatment information is not relayed in a timely and accurate fashion. Landrigan et al.3 described a conceptual model in 2001 that recognized the complexity of the hospitalist‐PCP communication system. Specifically, optimal care of hospitalized children includes PCPs, family members, hospitalists, and support staff while meeting the communication needs of families and PCPs. Additionally, mediating a smooth transition into and out of the hospital needs to be measured carefully.3

Previous adult studies have reported that hospitalist systems sometimes create discontinuity of patient care, which can have a negative impact on the quality of care provided to patients if there is poor communication between hospitalists and PCPs.2, 4, 5 Existing research on hospitalist‐PCP communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist‐PCP communication.

The objective of this study was to qualitatively explore issues around communication between pediatric hospitalists and PCPs. Specifically, we sought to explore the quality of communication practices and barriers to optimal communication within the hospitalist‐PCP model at a tertiary care children's hospital. The results are serving as a needs assessment to guide the design of a quality improvement project with the aim of improving pediatric hospitalist‐PCP communication.

METHODS

RESULTS

Only 1 physician per practice was interviewed. No PCP who was able to be contacted declined an interview, although some did require multiple phone attempts to schedule the interview. PCPs were located in Salt Lake County (n = 6), in other Utah counties (n = 3), and in surrounding Intermountain West states (n = 3). From January 1, 2004 to December 31, 2004, we estimate that the hospitalist division cared for patients from approximately 35 practices (50% in Salt Lake County, 30% in other Utah counties, and 20% in surrounding Intermountain West states).

Hospitalists and PCPs agreed that overall quality of communication ranged from poor to very good (Table 2). Both parties acknowledged that significant barriers to optimal communication exist, yet the barriers differed for each group. Hospitalists and PCPs also agreed that optimal communication could improve many aspects of patient care and should take place upon discharge and admission of patients and with major clinical changes. Both hospitalists and PCPs also wanted accurate and timely information. One priority that the participants emphasized is the timely transfer of admission notification and the receipt of accurate and timely discharge summaries by PCPs.

DISCUSSION

Both pediatric hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow‐up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). However, there was discrepancy in the barriers to optimal communication for each group. Identifying and addressing these barriers can help both hospitalists and PCPs implement targeted interventions aimed at improving communication. As the number of pediatric hospitalist programs increases, the risk for hospitalist‐PCP communication breakdowns, which can have a negative impact on patient care, also increases.

Previous adult studies describe the scope of the problem around poor communication between hospitalists and PCPs.1, 912 Kripalani et al.10 reported recently that delays and omissions in communication are common at hospital discharge among adult hospitalists and that computer‐generated summaries, educational interventions, and standardized formats may facilitate more timely transfer of pertinent information. However, there is limited data on pediatric hospitalist‐PCP communication. Srivastava et al.5 found that 60% of community physicians thought hospitalist systems may impair communication with PCPs when evaluating community and hospital‐based physicians' attitudes regarding pediatric hospitalist systems.

PCPs can feel left out when their patients are cared for by hospitalists.13 One PCP in our study commented: Include the referral doc as part of the team. We're the ones who will take care of them after discharge. It seems like an autonomous thing down there and we're excluded from the patient care team. Additionally, patients want their PCPs to remain involved in their care as they transition into and out of the hospital setting.1, 13

The continuity visit model has been proposed by Wachter and Pantilat14 to describe a clinical encounter between the primary physician and hospitalized patient, when the patient has a different physician of record. In this model, the PCP can endorse the hospitalist model and the individual hospitalist, notice subtle findings that differ from the patient's baseline, and help clarify patient preferences regarding difficult situations by drawing on their previous relationship with the patient. This visit may also benefit the PCP by providing insights into the patient's illness, personality, or social support that he or she was unaware of previously. However, in order for the continuity visit to exist, the PCP has to be informed of their patient's admission in the first place. Ethical dilemmas also have been raised regarding who bears primary responsibility for maintaining open lines of communication when patients are hospitalized.15 Lo15 advocates that PCPs can and should be involved in meaningful ways in the inpatient care of their patients even when they are not acting as the treating physicians. Specifically, he suggests that PCPs personally visit particularly ill patients or those with difficult diagnoses and use frequent phone calls to all admitted patients.

Beyond telephone calls and continuity visits, hospitalists and PCPs rely on discharge summaries as a key part of the information transfer about a patient's hospitalization.1, 16, 17 These documents are rendered useless if they are inaccurate, illegible, or not delivered in a timely manner.18 In a study of California family physicians, discharge summaries were thought to be too detailed by 84% of PCPs, and reportedly arrived before the patient's first follow‐up appointment only 33% of the time.1 O'Leary et al.19 found that 41% of the Department of Medicine physicians surveyed believed that at least 1 of their patients hospitalized in the previous 6 months had experienced a preventable adverse event related to poor transfer of information at discharge. In our study, PCPs noted that discharge summaries often arrived in their offices well after the patient had been seen for their follow‐up appointment.

Both hospitalists and PCPs agree that a concise and precise discharge summary should include an overview of the hospitalization with important details highlighted. Similar to the findings of Pantilat et al.,1 in our study PCPs specifically want detailed information with regard to diagnoses, discharge medications, and what to expect when they see the patient in their clinic. Follow‐up phone calls to PCPs to see that they received written information and if they require further details is 1 solution to ensuring good follow‐up, yet this adds to the burden of communication and could be an additional barrier.

The teaching institutions in which physicians train also pose unique obstacles to optimal communication. In academic medical centers, medical students and residents perform a majority of the discharge duties (eg, writing prescriptions, dictating discharge summaries, making follow‐up appointments, and calling PCPs), and teaching these trainees the importance of timely and accurate communication becomes an added challenge. Educators have to find novel ways of providing incentives to residents and medical students to get them to effectively participate in this process. Plauth et al.20 reports that hospitalists feel they needed better training in residency around communicating, noting a meaningful underemphasis during residency training in regard to communication with referring physicians. These skills should be taught in medical school and supported by both hospitalists and PCPs throughout residency training.

Both hospitalists and PCPs also want easy and reliable ways to access their colleagues, which ideally would be automatic. One PCP commented: a weekly or semiweekly phone call would be nice. Another suggested to: fax a short note. One hospitalist acknowledged: a systematic approach would be betterwhether a fax or telephone call and make sure there is a way of checking to make sure the communication has happened. Another hospitalist simply remarked: it needs to be done on every patient.

Thus, it seems an improved communication system should be flexible enough to accommodate unique provider preferences, such as communication via phone, fax, or e‐mail. This is demonstrated by 1 PCP who preferred the phone, but most convenient is the periodic fax updates. I don't have to be taken away from seeing patients.

Lo15 calls for a standard to be established for delivering care within the patient‐PCP‐hospitalist triad. Phone calls and faxes are 2 readily available methods of communication. However, the frequent back‐and‐forth of missed calls, unreturned calls, and days‐off is certainly a factor in determining efficiency and effectiveness of phone calls.

E‐mail, if it is widely used by all participants, may be an effective option for delivery that could provide confirmation of receipt. However, the lack of universal e‐mail usage by all providers remains a barrier. Questions as to which method is more time consuming and for whom, need to be studied further. Patient confidentiality also requires that this protected health information arrive in the proper hands. Personal relationships can also contribute to successful communication. One provider may be more likely to contact another if they know each other through some personal connection, such as medical school, residency, or a social group.

Our study has several limitations. The sample size was small. We obtained responses from a sample of key stakeholders in the hospitalist‐PCP communication process. We were limited by the number of hospitalists at our institution as well as the interest and availability of PCPs to respond. We are unable to determine the total number of patients by respondent PCP practice cared for by the hospitalist division. This could influence the results depending on whether the respondent PCP was a frequent or infrequent utilizer of the hospitalist system. However, we feel reassured that we are not missing important information, because in our methods, a priori, we had intended to stop interviewing PCPs once theoretical saturation had been reached (ie, respondents did not identify any new information). In our study, that occurred with 12 PCPs.

We attempted to interview a single physician in a number of different practice settings in order to gain insight into the perceptions of that individual as well as those of their partners. The views expressed by these individuals may not represent the views of hospitalists and PCPs outside of our practice area. Furthermore, PCMC serves as both a community pediatric hospital and a tertiary‐referral center for a large area, yet the current experience of 1 hospitalist division and 1 cohort of referring PCPs may contain regional variation that contributed bias to the responses.

Selection bias may have been introduced in our study by the inherent nature of phone interviews. We interviewed only providers with previous communication experience with our hospitalist division. These providers may have had a vested interest in the communication process. We did not interview those PCPs who did not have any communication with our hospitalist division or those who may have used the hospitalist division previously and decided to no longer use the division. Interviewing these groups may have provided additional insight into the communication issues mentioned here. Additionally, useful information could have been gleaned from trying to find out more from the 33% of PCPs who felt communication was poor. We anticipate further studies exploring this issue in more depth.

CONCLUSIONS

Hospitalists and PCPs agree that overall quality of communication ranges from poor to very good. Both PCPs and pediatric hospitalists acknowledge that significant barriers to optimal communication exist, yet the barriers differ for each group. They also agree that optimal communication would improve many aspects of patient care and should take place upon discharge and admission of patients and with major clinical changes.

Pediatric hospitalists and PCPs identified issues around optimal communication similar to those noted in the adult hospital medicine literature. Interventions to improve pediatric hospitalist‐PCP communication should at least address these 6 issues: (1) quality of communication; (2) barriers to communication; (3) methods of information sharing; (4) key data element requirements; (5) critical timing; and (6) perceived benefits. Such interventions will likely improve hospitalist‐PCP communication and potentially improve the quality of patient care. However, future studies will need to demonstrate the link between improved hospitalist‐PCP communication and improved patient care and outcomes.

Hospitalist systems focus on providing acute treatments to patients and expediting hospital discharge, sometimes without regard for the need to work in concert with community providers, leading to fragmentation of care.1 This fragmentation, particularly at the transitions of care, such as when patients move from the outpatient setting to a hospitalist system and then back to their primary care providers (PCPs), can lead to communication breakdowns and delays in care, and may compromise patient outcomes.2 Suboptimal treatments, such as medication errors and the ordering of redundant tests can occur in either setting if prior treatment information is not relayed in a timely and accurate fashion. Landrigan et al.3 described a conceptual model in 2001 that recognized the complexity of the hospitalist‐PCP communication system. Specifically, optimal care of hospitalized children includes PCPs, family members, hospitalists, and support staff while meeting the communication needs of families and PCPs. Additionally, mediating a smooth transition into and out of the hospital needs to be measured carefully.3

Previous adult studies have reported that hospitalist systems sometimes create discontinuity of patient care, which can have a negative impact on the quality of care provided to patients if there is poor communication between hospitalists and PCPs.2, 4, 5 Existing research on hospitalist‐PCP communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist‐PCP communication.

The objective of this study was to qualitatively explore issues around communication between pediatric hospitalists and PCPs. Specifically, we sought to explore the quality of communication practices and barriers to optimal communication within the hospitalist‐PCP model at a tertiary care children's hospital. The results are serving as a needs assessment to guide the design of a quality improvement project with the aim of improving pediatric hospitalist‐PCP communication.

METHODS

RESULTS

Only 1 physician per practice was interviewed. No PCP who was able to be contacted declined an interview, although some did require multiple phone attempts to schedule the interview. PCPs were located in Salt Lake County (n = 6), in other Utah counties (n = 3), and in surrounding Intermountain West states (n = 3). From January 1, 2004 to December 31, 2004, we estimate that the hospitalist division cared for patients from approximately 35 practices (50% in Salt Lake County, 30% in other Utah counties, and 20% in surrounding Intermountain West states).

Hospitalists and PCPs agreed that overall quality of communication ranged from poor to very good (Table 2). Both parties acknowledged that significant barriers to optimal communication exist, yet the barriers differed for each group. Hospitalists and PCPs also agreed that optimal communication could improve many aspects of patient care and should take place upon discharge and admission of patients and with major clinical changes. Both hospitalists and PCPs also wanted accurate and timely information. One priority that the participants emphasized is the timely transfer of admission notification and the receipt of accurate and timely discharge summaries by PCPs.

DISCUSSION

Both pediatric hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow‐up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). However, there was discrepancy in the barriers to optimal communication for each group. Identifying and addressing these barriers can help both hospitalists and PCPs implement targeted interventions aimed at improving communication. As the number of pediatric hospitalist programs increases, the risk for hospitalist‐PCP communication breakdowns, which can have a negative impact on patient care, also increases.

Previous adult studies describe the scope of the problem around poor communication between hospitalists and PCPs.1, 912 Kripalani et al.10 reported recently that delays and omissions in communication are common at hospital discharge among adult hospitalists and that computer‐generated summaries, educational interventions, and standardized formats may facilitate more timely transfer of pertinent information. However, there is limited data on pediatric hospitalist‐PCP communication. Srivastava et al.5 found that 60% of community physicians thought hospitalist systems may impair communication with PCPs when evaluating community and hospital‐based physicians' attitudes regarding pediatric hospitalist systems.

PCPs can feel left out when their patients are cared for by hospitalists.13 One PCP in our study commented: Include the referral doc as part of the team. We're the ones who will take care of them after discharge. It seems like an autonomous thing down there and we're excluded from the patient care team. Additionally, patients want their PCPs to remain involved in their care as they transition into and out of the hospital setting.1, 13

The continuity visit model has been proposed by Wachter and Pantilat14 to describe a clinical encounter between the primary physician and hospitalized patient, when the patient has a different physician of record. In this model, the PCP can endorse the hospitalist model and the individual hospitalist, notice subtle findings that differ from the patient's baseline, and help clarify patient preferences regarding difficult situations by drawing on their previous relationship with the patient. This visit may also benefit the PCP by providing insights into the patient's illness, personality, or social support that he or she was unaware of previously. However, in order for the continuity visit to exist, the PCP has to be informed of their patient's admission in the first place. Ethical dilemmas also have been raised regarding who bears primary responsibility for maintaining open lines of communication when patients are hospitalized.15 Lo15 advocates that PCPs can and should be involved in meaningful ways in the inpatient care of their patients even when they are not acting as the treating physicians. Specifically, he suggests that PCPs personally visit particularly ill patients or those with difficult diagnoses and use frequent phone calls to all admitted patients.

Beyond telephone calls and continuity visits, hospitalists and PCPs rely on discharge summaries as a key part of the information transfer about a patient's hospitalization.1, 16, 17 These documents are rendered useless if they are inaccurate, illegible, or not delivered in a timely manner.18 In a study of California family physicians, discharge summaries were thought to be too detailed by 84% of PCPs, and reportedly arrived before the patient's first follow‐up appointment only 33% of the time.1 O'Leary et al.19 found that 41% of the Department of Medicine physicians surveyed believed that at least 1 of their patients hospitalized in the previous 6 months had experienced a preventable adverse event related to poor transfer of information at discharge. In our study, PCPs noted that discharge summaries often arrived in their offices well after the patient had been seen for their follow‐up appointment.

Both hospitalists and PCPs agree that a concise and precise discharge summary should include an overview of the hospitalization with important details highlighted. Similar to the findings of Pantilat et al.,1 in our study PCPs specifically want detailed information with regard to diagnoses, discharge medications, and what to expect when they see the patient in their clinic. Follow‐up phone calls to PCPs to see that they received written information and if they require further details is 1 solution to ensuring good follow‐up, yet this adds to the burden of communication and could be an additional barrier.

The teaching institutions in which physicians train also pose unique obstacles to optimal communication. In academic medical centers, medical students and residents perform a majority of the discharge duties (eg, writing prescriptions, dictating discharge summaries, making follow‐up appointments, and calling PCPs), and teaching these trainees the importance of timely and accurate communication becomes an added challenge. Educators have to find novel ways of providing incentives to residents and medical students to get them to effectively participate in this process. Plauth et al.20 reports that hospitalists feel they needed better training in residency around communicating, noting a meaningful underemphasis during residency training in regard to communication with referring physicians. These skills should be taught in medical school and supported by both hospitalists and PCPs throughout residency training.

Both hospitalists and PCPs also want easy and reliable ways to access their colleagues, which ideally would be automatic. One PCP commented: a weekly or semiweekly phone call would be nice. Another suggested to: fax a short note. One hospitalist acknowledged: a systematic approach would be betterwhether a fax or telephone call and make sure there is a way of checking to make sure the communication has happened. Another hospitalist simply remarked: it needs to be done on every patient.

Thus, it seems an improved communication system should be flexible enough to accommodate unique provider preferences, such as communication via phone, fax, or e‐mail. This is demonstrated by 1 PCP who preferred the phone, but most convenient is the periodic fax updates. I don't have to be taken away from seeing patients.

Lo15 calls for a standard to be established for delivering care within the patient‐PCP‐hospitalist triad. Phone calls and faxes are 2 readily available methods of communication. However, the frequent back‐and‐forth of missed calls, unreturned calls, and days‐off is certainly a factor in determining efficiency and effectiveness of phone calls.

E‐mail, if it is widely used by all participants, may be an effective option for delivery that could provide confirmation of receipt. However, the lack of universal e‐mail usage by all providers remains a barrier. Questions as to which method is more time consuming and for whom, need to be studied further. Patient confidentiality also requires that this protected health information arrive in the proper hands. Personal relationships can also contribute to successful communication. One provider may be more likely to contact another if they know each other through some personal connection, such as medical school, residency, or a social group.

Our study has several limitations. The sample size was small. We obtained responses from a sample of key stakeholders in the hospitalist‐PCP communication process. We were limited by the number of hospitalists at our institution as well as the interest and availability of PCPs to respond. We are unable to determine the total number of patients by respondent PCP practice cared for by the hospitalist division. This could influence the results depending on whether the respondent PCP was a frequent or infrequent utilizer of the hospitalist system. However, we feel reassured that we are not missing important information, because in our methods, a priori, we had intended to stop interviewing PCPs once theoretical saturation had been reached (ie, respondents did not identify any new information). In our study, that occurred with 12 PCPs.

We attempted to interview a single physician in a number of different practice settings in order to gain insight into the perceptions of that individual as well as those of their partners. The views expressed by these individuals may not represent the views of hospitalists and PCPs outside of our practice area. Furthermore, PCMC serves as both a community pediatric hospital and a tertiary‐referral center for a large area, yet the current experience of 1 hospitalist division and 1 cohort of referring PCPs may contain regional variation that contributed bias to the responses.

Selection bias may have been introduced in our study by the inherent nature of phone interviews. We interviewed only providers with previous communication experience with our hospitalist division. These providers may have had a vested interest in the communication process. We did not interview those PCPs who did not have any communication with our hospitalist division or those who may have used the hospitalist division previously and decided to no longer use the division. Interviewing these groups may have provided additional insight into the communication issues mentioned here. Additionally, useful information could have been gleaned from trying to find out more from the 33% of PCPs who felt communication was poor. We anticipate further studies exploring this issue in more depth.

CONCLUSIONS

Hospitalists and PCPs agree that overall quality of communication ranges from poor to very good. Both PCPs and pediatric hospitalists acknowledge that significant barriers to optimal communication exist, yet the barriers differ for each group. They also agree that optimal communication would improve many aspects of patient care and should take place upon discharge and admission of patients and with major clinical changes.

Pediatric hospitalists and PCPs identified issues around optimal communication similar to those noted in the adult hospital medicine literature. Interventions to improve pediatric hospitalist‐PCP communication should at least address these 6 issues: (1) quality of communication; (2) barriers to communication; (3) methods of information sharing; (4) key data element requirements; (5) critical timing; and (6) perceived benefits. Such interventions will likely improve hospitalist‐PCP communication and potentially improve the quality of patient care. However, future studies will need to demonstrate the link between improved hospitalist‐PCP communication and improved patient care and outcomes.