Background:
Many pediatric hospitalist programs in community hospitals around the country function with a 24-hour shift model for 24/7 coverage. This creates significant discontinuity and daily inefficiencies in patient care. Furthermore, there is a robust amount of adult literature that points to the benefits of both inpatient and outpatient continuity of care. When our community hospital expanded and nearly tripled our total pediatric beds, it was felt that a Pediatric Hospitalist Continuity Model (PHCM) was needed to improve patient continuity.
Methods:
Without additional hiring to our 6.5 FTE hospitalist group, a PHCM was created. This included a week of 6-7 daytime service shifts that were 9 hours long and were double covered with a 24-hour shift physician. In the morning, patients were divided up between the service physician and 24-hour physician based on complexity and expected length of stay (LOS). More complex, chronic and longer (expected) LOS patients were directed to the service MD. Simple observation patients and inpatient procedural sedations were directed to the 24 hour MD. Continuity was measured for both groups before and after the PHCM was introduced, using the same months of the year. Continuity was measured by the number of notes written (H&P, progress note, discharge notes) written by each physician. Higher continuity was noted by lower number of physicians caring for each patient. Target (Goal) continuity ratios were developed using the number of physicians in relation to LOS and was decided based on our 6 -7day service week model.
Results:
Introduction of the PHCM improved overall continuity by 62%. When patients had an LOS of 8 days, the PHCM improved continuity by 50%. Similarly, for LOS of 4 days there was 20% improvement in continuity. In addition, with the PHCM we reached or exceeded our goal ratios for LOS days 1,2,6,8 and 15.
Conclusions:
The PHCM provides a feasible and effective framework to improve physician-patient continuity. In addition, overall physician satisfaction with work flow was felt to be much better given that they did not encounter a large number of new complex and chronic patients every morning at the beginning of each 24-hour shift. Physicians also felt they were able to visualize patient improvement or deterioration far better while on service week than on 24 hour shifts alone. Future investigations may include impact of similar PHCM on LOS and costs for the medically complex pediatric patient as they generally tend to disproportionally utilize medical dollars.
