April 3, 2014 Presenters: Josh Schaffzin, Cincinnati Children’s Hospital Medical Center David Rappaport, Nemours/AI duPont Hospital for Children Becca Rosenberg, NYU Langone Medical Center    Introduction SOHM Listserve survey results Subcommittee ◦ Goals and Objectives ◦ Resources  Case studies – Establishing co-management for spinal fusion patients ◦ Nemours/AI duPont Hospital for Children ◦ Cincinnati Children’s Hospital Medical Center  Patient complexity increasing ◦ Beyond training of primary surgical providers  Hospital systems ◦ Increased focus quality care of hospitalized patients  Timely, efficient, effective, equitable, patient-centered, and safe  ‘Traditional’ model – Consult prn ◦ Call medical team if a problem arises ◦ Potentially too late to prevent undesired outcome  Co-Management Model ◦ Surgeon and hospitalist are partners ◦ Share responsibility for patient management and outcomes ◦ Anticipatory care and prevention Practice Arrangements Minimal Involvement Consultation Only Hands-off Approach Total Involvement Consultation Only Recommendations Only Formal Co-Management Proactive Approach Mandated Consultation Variable Involvement Hospitalist Team Primary Attending  Disseminated in July 2013 ◦ Asked questions about current practice scope and structure ◦ 64 respondents Proportion of Time Spent Pre-op Care (N=48) Post-op Care (N=61) <20% <20% 20-39% 41 (85%) 40-59% 60-79% 23 (38%) 28 (46%) 20-39% 40-59% 60-79% 80-99% All Practice Location Predominant Practice Site for Surgical Patient Care 25 20 15 10 5 0 Community Hospital Free Standing Children's Hospital Children's Hospital Within a Larger Hospital 35 All Types of Hospitals: Practice Partners 30 25 20 15 10 5 0 Adult Surgeons Pediatric Trained Surgeons Both 20 Community Hospitals: Practice Partners 15 10 5 0 Adult Surgeons Pediatric Trained Surgeons Both Practice Arrangements Co-Management (N=60) 39 (65%) Consultation No ‘Automatic’ (N=60) (N=59) Yes 54 (92%) Yes No NOTE: Not mutually exclusive 30 (50%) Yes No Practice Arrangements Number Affirmative Responses Comanagement Agreements by Specialty (N=39) 35 30 25 20 15 10 5 0 AIM: To advocate for high quality care, outcomes, and research for surgical patients cared for by pediatric hospitalists. GOALS: •To develop a supportive network of PH who care for surgical patients • To develop and share best practices in medical care of surgical patients •To develop standard outcome measures for programs with PH who care for surgical patients to demonstrate quality and value • To develop and share training and educational materials for hospitalists and trainees in the medical care of surgical patients •To advance a research agenda in collaboration with our hospitalist, surgical, and other partners to inform the care of surgical patients       Overall: quarterly webinars, conference meetings Clinical: Collect and begin to curate online repository of clinical guidelines for management of surgical patients Practice Management:  Develop, distribute, and measure PH needs assessment for practice management issues  Develop tool to assist PH in understanding local/state regulations in billing standards  Curate comanagement/consultation guidelines/templates Research: Develop research agenda including database proposals to examine exposures and outcomes with PH comanagement/ consultation Quality: Develop potential surgical comanagement measures to pilot Education: Develop curricula for evidence-based postoperative management Co-Leaders: Josh Schaffzin, Becca Rosenberg Core/Topic Leaders:  Practice Management: Katherine O’Connor, David Zipes  Clinical: Anjna Melwabi, David Rappaport  Research: Lisa McLeod, Tamara Simon  Quality Improvement: Josh Schaffzin, Becca Rosenberg  Education: Erin Shaughnessy  SHM Liaison: Moises Auron Pediatric Surgery Liasion: TBD We need some community hospitalists and other go-getters as part of the team! Email: [email protected]   SOHM website http://www.aap.org/en-us/about-the-aap/CommitteesCouncils-Sections/Section-on-HospitalMedicine/Pages/Surgical-Care-Subcommittee.aspx Hospital Medicine-Surgical Services Nemours/AI duPont Hospital for Children Surgical Co-Management Experience David Rappaport Comanagement: Our Experience • • • • How our program got started Structure of our program Challenges we have faced Some data from our program Our Setting • Tertiary children’s hospital in Wilmington DE, about 200 beds • Full service surgery department including transplants • Historically strong rehab and orthopedic programs – 12 pediatric orthopedists – 1800 orthopedic surgeries/year – Orthopedic residents/fellows • Large pediatric residency program • Two sentinel events involving complex ortho patients in 2004 How do We Define “Medically Complex” Patients? • Medically complex if any of following: – Chronic medical, neurologic, or skeletal problem requiring care by one or more specialists – Technology dependent – Multiple prescription medications – Caregiver/family request • Purposefully set up to cast wide net • We are not consulted on all (or even most) of these patients – Some automatic: neuromuscular scoliosis – Others: per primary attending physician Identification as Medically Complex Preoperative Evaluation -Primary Care Provider form -Hospitalist Preop Visit if necessary -Anesthesiology Evaluation -Subspecialty Evaluation/Testing, if necessary Postoperative Subspecialty Care? Yes No Multidisciplinary meeting? Yes Routine Surgical Preparation No Further eval necessary? Yes No Postpone/cancel surgery if necessary Hospitalist/APN/Medical Subspecialist Consult Postoperatively -active co-management of medical issues -active use of EMR -communication with PCP, specialists as necessary Nuts and Bolts • What is the medically complex team? – Consult (comanagement) service for patients identified as “medically complex” – Began in 2005, fully staffed in mid-2006 – About 90% are orthopedics patients • Also neurosurgery/general surgery/urology, etc – Work closely with nurse practitioner – Consults are different than General peds consults • No routine involvement of Pediatrics residents Coverage Structure • Hours – – – – – – Hospitalists are in-house until midnight Mon-Fri Hospitalists are in-house until afternoon Sat-Sun On call 24-7 via a dedicated pager Weekdays: dedicated person to Medically complex Nights/weekends: covering General Peds too Daytime person is seeing preop visits, attending multidisciplinary meetings, seeing patients in PICU Delineation of Responsibility An Example • Surgeon – – – – – • Procedure consent Wound Drains Surgical hardware Post operative mobilization Medical Subspecialist – Procedures – Chronic outpatient management changes – Disease specific medication • Hospitalist – – – – – Medical subspecialist care coordination Chronic condition management Medication management Nutrition Managing acute clinical changes Challenges of Comanagement I • Delineation of responsibility – Who does what? – Do patients/families/nurses/physicians understand? – “Overlapping” medical-surgical issues • • • • • Fever evaluation, antibiotics Central lines Feeds, especially in patient with abdominal surgery Patient positioning Discharge planning Challenges of Comanagement II • Patient selection – Who gets comanaged? • Communication challenges – – – – • Over-reliance or under-reliance on the comanager – – – – • Who talks to whom? About what? Too many cooks in the kitchen? Who is “captain of the ship”? Different surgeons do things differently Rotating schedules (orthopedics, pediatrics, etc) means lots of handoffs Sometimes surgeon needs to see the patient Sometimes subspecialist needs to see the patient Hospitalists have limits to expertise as well—they are not specialists Differences in experience (community vs teaching hospitals) Financial concerns – Dedicated comanager is almost definitely a money-loser What We Do/Don’t Do • What we do – Discuss patients preoperatively with ortho, sometimes anesthesia and/or other specialists – Follow patients while in PICU before transfer – Try to round with orthopedics daily • What we don’t do – Make large-scale decisions without talking to primary service • Transfer to PICU, procedures, etc. unless emergency – Make decisions about surgical issues (eg, PT, wound care, etc.) unless emergent – Generally involve general pediatrics residents – Have final say about patient discharges Sample Breakdown: 3 Months (1853 surgeries) Figure 2. Elective Surgeries: Patient Breakdown Hospitalist consult Detailed eval (no hospitalist consult) 31% MCPs w ithout further eval 3% 1% Preop conference 4% 61% NonMCPs Comanaged Patients: Diagnoses Figure 4. Hospitalist Consults: Underlying Diagnoses Metabolic/genetic disease 16% Skeletal dysplasia Cerebral palsy 51% 6% Neuromuscular disease 10% Other 17% Preop Visits • 214 patients, 155 had recommendations preoperatively by hospitalist • More medications, more complexity, lack of ambulation all statistically significantly associated with a recommendation being made • 38% had a medication change • 21% had nutrition change • 19% had lab studies ordered • 36% contacted or referred to subspecialist Postop Comanagement • Implemented our program in phases (2003-5, 2005-6, 2006-present) • Post-PICU length of stay from 6 to 8 days (p=0.07) • Days on TPN, number of lab tests decreased significantly • Costs actually went up (might be PICU related) • $59K89K81K Impact on Nurses • Does having a pediatrician involved with medically complex patients improve nurse satisfaction? Pediatrician Involvement Improving RN Satisfaction 80% 70% 60% 50% 40% 30% 20% 10% 0% Never Rarely Sometimes Often Always Summary/Conclusions • A comanagement program can work but needs lots of time and resources • Initial outcomes/costs may go in the wrong direction • Nurses may be most supportive • Next step: protocols Hospital Medicine – Surgical Services The Cincinnati Children’s Co-Management Experience Spinal Fusion Surgery Cincinnati Co-Management Our Setting • Large tertiary care 500-bed medical center • Full service surgical services – ~200 spinal surgeries per year Cincinnati Co-Management Our Service • Staff – 11 providers – Most split time between surgical and other services • Two Sections – Orthopaedics, ENT, all other surgical consults – Neurosurgery, Epidermolysis Bullosa • No Clinic Time – See patients in post-operative phase only – Do not follow patients while in ICU Cincinnati Co-Management Our Service • Coverage – – – – – – Two providers on-site during day 7 days a week One provider on site until 10pm most weeknights 24/7 dedicated on-call coverage Attending/Fellow only No residents No nurse practitioners Cincinnati Co-Management Three Levels of Care • Consultation – Traditional – question asked and answered – No orders written, primary team makes final decision • Co-Management – All medical issues covered by hospitalist – Orders written, decisions made and communicated – Surgeon attending of record • Attending of Record – Patient is transferred to hospitalist service – Surgical team co-manages Cincinnati Co-Management Spinal Fusion Patients • Sentinel event 2010 – All spinal fusion patients co-managed by hospitalist – Regardless of medical complexity • Protocol – Initiated by Orthopaedics – Updated with others’ input Cincinnati Co-Management Challenges / Answers • Consistency • Communication – Sometimes you need to call the attending directly    Any outstanding questions? 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