Background: The care of surgical patients is becoming more complex as patients with increasing comorbidities require surgical procedures. In adult hospital medicine, co-management of complex medical patients by hospital medicine and surgery has been shown to decrease length of stay and readmission for many procedures. It remains unclear, however, which patients are most likely to benefit from co-management. In particular, few analyses of co-management exist in the pediatric literature despite 65% of Pediatric Hospital Medicine (PHM) providers reporting working with co-management models. Many of these institutions do not currently monitor metrics or evaluate performance of these co-management programs. There is currently a need for identification of the populations best served by co-management, measurement of outcomes, and establishment of best practices in pediatric surgical co-management.
Purpose: Development of a PHM and orthopedic co-management program database to improve the care of complex medical patients undergoing posterior spinal fusions (PSF) and decrease length of stay and readmission rate while better understanding which patients benefit from co-management.
Description: In our institution, we identified medically complex patients undergoing PSF for scoliosis. We compared patients undergoing PSF for secondary scoliosis compared to those undergoing PSF for idiopathic scoliosis and found the median length of stay (LOS) is longer (129 verses 106 hours) and readmission rates are higher (17% verses 0%). The increased LOS and readmission rate for complex patients undergoing PSF reveals opportunity for improved care.Beginning in July of 2016, the PHM group conducted a pilot of co-management with a single orthopedic surgeon. Inclusion criteria included medically complex patients defined has having at least one medical co-morbidity undergoing PSF. Eligible patients were identified preoperatively by the surgeon and our institution’s Special Needs clinic.
Based on our experience with our pilot program, we undertook the development of a database in order to track metrics for co-managed patients in order to evaluate the effects of co-management on patient care, to aide in future quality improvement work, and to identify the cohort patients who benefit the most from co-management services. Metrics include readmissions, transfers to the intensive care unit, rapid responses, surgical complications, hospital charges and cost, patient satisfaction, and time in pediatric intensive care unit.
Preliminary data suggests our co-management model reduces readmissions compared to a historical control. Data collection is ongoing in order to further evaluate this co-management program, develop best practices, and identify patients who are most likely to benefit from surgical co-management.
Conclusions: Complex medical patients undergoing PSF are at increased risk for longer LOS and readmissions. Designing co-management models to leverage the expertise of pediatric hospital medicine and orthopedic surgeons may improve care for these complex medical patients. Developing a database to track metrics in a co-managed population can help identify the impact of co-management programs on patient care as well as identify patients whose care is optimized by comanagement.