Background: The Pediatric Hospital Medicine (PHM) service at Medical College of Wisconsin/Children’s Hospital of Wisconsin has historically consisted of patient care teams with an attending pediatric hospitalist, pediatric residents, rotating family medicine residents and medical students. In 2017, the PHM service saw an unexpected increase in patient volumes with a 28% increase in the number of patient encounters compared to the previous year. The daily average census increased by 48.9%. Residents reported increased symptoms of burnout and difficulty balancing service vs. education.Given the urgent need to expand the PHM service, our section piloted a unique Advanced Practice Provider (APP) program drawn from within our institution. Nationally, the use of APPs on hospital medicine services has grown since changes to resident duty hours in 2003 and 2011. Per the 2016 State of Hospital Medicine Report, APPs are utilized in adult hospital medicine more commonly than in PHM. Anecdotally, it has been known to take a year to build an APP hospital medicine service line from conception to implementation. Our group needed an innovative solution to accommodate the increased volume of patients quickly.
Purpose: Due to an unanticipated increase in patient volumes in 2017, the Section of Hospital Medicine sought to rapidly expand the PHM service in the absence of existing hospital medicine trained APPs while preventing increasingly larger patient volumes on the resident teams.
Description: Inspired by shared physician models, in which physicians have concurrent appointments in two or more patient care arenas, the PHM group partnered with Pediatric Critical Care and Emergency Medicine to build an Advance Practice Provider (APP) team utilizing existing talent within those departments. Seven Pediatric Intensive Care Unit (PICU) Advance Practice Nurses (APNs) and one Emergency Medicine Physician Assistant (PA) volunteered to dedicate a portion of their clinical time to Hospital Medicine. These APPs are providers with several years of experience within the hospital system which allowed them to quickly adapt to the acute care floor.
A patient care team was built consisting of one experienced APP and one hospital medicine attending physician. Within 8 weeks of identifying the need for an APP team, the team was caring for a census of 5-8 pediatric patients admitted to the hospital medicine service. From June 2017 to August 2017, the team carried an average of 16.4% of the overall PHM morning census. The average length of stay for patients admitted to the hospital medicine APP service was 67 hours compared to 89.2 hours for patients admitted to other PHM teams despite similar acuity as confirmed by case-mixed index.
Due to the success of the pilot program, the Section of Hospital Medicine has since hired two APNs and two PAs who are currently being trained by the PICU and ED providers that participated in our pilot.
Conclusions: The Section of Hospital Medicine at MCW/CHW successfully instituted an APP service within a short timeframe by utilizing experienced pediatric APPs already employed within the hospital system. This allowed us to safely accommodate an unexpected increase in patient volumes without placing further strain on our residents in training. What’s more, it provided a framework for hiring and training APPs in pediatric hospital medicine. Other institutions that do not currently have a pediatric hospitalist APP team could replicate this program using existing talent within their institution.