Background: Nationally, the number of adult patients (18+ years of age) with chronic congenital and childhood conditions being admitted to children’s hospitals has been increasing, and in some cases outpacing the rate of increase in pediatric admissions. This is secondary to advances in treatment of once-fatal conditions. Our institution is a quaternary referral center with over 600 beds and an average daily census of 15 patients aged 21 years or older admitted to a variety of medical and surgical services. Given that pediatric institutions are designed to care for children, the presence of adult patients presents unique challenges for providers such as unfamiliar medical comorbidities and how to transition to adult providers.
Purpose: In response to these challenges our Hospital Medicine division sought to build an internal medicine consult service staffed by Internal Medicine-Pediatric (Med-Peds) hospitalists called the Hospital Medicine Adult Care (HMAC) service. With the initial goal of improving access to adult providers for the care of adult-type clinical conditions such as VTE prophylaxis and hypertension management, the role of the HMAC service has expanded to include the development of a safety infrastructure and evidence-based clinical protocols for these special populations of adult patients. For example, acute care protocols were designed for management of life-threatening events, such as acute coronary syndrome and stroke, that are not commonly seen in a pediatric setting and may require transfer of care to an adult facility. Serving as part of the infrastructure to care for adult patients in a children’s hospital, HMAC continually addresses the new challenges and issues that arise in this understudied and vulnerable population including streamlining consultative care when adult subspecialty input is required from an affiliated adult institution.
Description: The HMAC service is staffed by a group of Med-Peds hospitalists and transition medicine physicians that have affiliated appointments within our Departments of internal medicine and pediatrics. Providers spend a one-week block on service and provide 24/7 consultative and co-management care for adult patients, with approximately three to five patients seen on a daily basis. Other duties include attending daily institution-wide safety huddles and responding to all adult medical response team and code activations. The HMAC service has also worked in a number of ways to improve patient safety and clinical care. In adult patients, the National Early Warning Score (NEWS) system has been instituted to detect early clinical deterioration. Hospital-wide simulation training involving the acute care protocols is regularly performed in order to ensure a multidisciplinary group of providers is ready to care for adults in these emergent situations.
Conclusions: Previously, there was no standardization of the care of adult patients in pediatric hospitals with high levels of variability both locally and nationally. Our HMAC service was developed in order to address these issues and has been very well-received by our institution providing niche consultative and co-management care as evidenced by a consistent increase in utilization of the service. Ongoing and future endeavors of the HMAC service include developing a quality metric dashboard for the care of adult patients in the pediatric setting to both identify opportunities for quality improvement and to assess the value added by our consultative service.