Pediatric inpatient hospital care

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ABSTRACT

Pediatrics is a field of medical specialty that focuses on children and their potential to successfully grow and develop into healthy adults. The articles in this special edition of Hospital Practice span a range of issues that affect children and their health care in the inpatient hospital setting, including equity and bias mitigation in health care, efficiency in patient rounding, using patient and family complaints to drive improvement efforts, the diagnostic process and avoiding fundamental diagnostic errors, pediatric palliative care, rapidly identifying and treating sepsis in children, the care and management of children on home ventilation, instituting a rapid response team in the pediatric environment, and quality rating systems for children’s hospitals.

KEYWORDS:

• Pediatrics
• children’s hospitals
• pediatric inpatient health care
• pediatric hospital medicine
• children’s health

According to the American Academy of Pediatrics (AAP), Pediatrics is the specialty of medical science concerned with the physical, mental, and social health of children from birth to young adulthood. Pediatric care encompasses a broad spectrum of health services ranging from preventive health care to the diagnosis and treatment of acute and chronic diseases [1],[p.780].

With the focus on children and their potential to grow and develop, pediatrics is fundamentally an optimistic field of medical practice. On the wall of the AAP’s national office is a quote that captures this sense of promise and potential: ‘Children are one-third of our population and all of our future’ [2, p.xviii]. If we do our work well with children in managing their health and healthcare, then those serving the pediatric population will have helped those children grow and develop into the young adults of tomorrow. The work to help children grow into healthy adults is defined in a 2004 Institute of Medicine report [3] where children’s health is described as the extent to which children are able or enabled to realize their full potential through ever increasingly complex interactions by the child with their physical, emotional, and social environments occurring over time.

The articles in this special edition of Hospital Practice span a range of issues that affect children and their health care, especially pertaining to inpatient hospital care. In a 2018 study examining changes in pediatric clinical practice that focused on trends in pediatric hospitalization, Bucholz et al. [4] identified that while pediatric admissions decreased from 2010 to 2016, there was an increase in complexity for the pediatric patients that did get admitted. The findings from the Bucholz et al study highlight the ongoing need for collaborative efforts to identify and share best practices aimed at improving pediatric patient outcomes [4]. The topics in this special edition address a number of pediatric clinical practice issues as they relate to what can be described as the increasingly complex pediatric patients who are admitted for inpatient hospital care. The topics are broad and reflect a range of subjects of potential interest to those physicians who primarily deliver inpatient care to pediatric patients and help inform Bucholz et al.’s call for ongoing collaborations to identify best practices that may improve pediatric patient outcomes among hospitalized patients [4]. For example, delivering equitable care is among the six quality domains defined in the seminal report on healthcare quality entitled Crossing the Quality Chasm [5]. The issue of equity impacts children on a number of levels, and Purtell et al. address adopting an anti-racism approach toward health care delivery. The authors recognize that the health systems we work in can be both part of the problem and part of the solution. Recommendations are made on how best to position the hospital systems in which we work to provide anti-racist, equitable care by centering the organization around cultural humility, bias mitigation, language inclusion, awareness of social determinants of health, nonviolent methods, and community partnerships.

Patient centeredness and efficiency are also two of the six main domains of healthcare quality [5]. Van Blarcom et al. provide insights into moving inpatient services toward more efficiency in morning rounding while incorporating a patient- and family-centered approach. Structured communication using the Patient-Family Centered I-PASS tool, scheduled rounding times, visual aids such as whiteboards and facecards identifying team members, and sitting while rounding improve patient safety and stakeholder satisfaction. Strategies to overcome barriers, such as trainee anxiety, and ensure medical education during rounds are discussed. In line with being responsive to patients and their families, Pearce et al. discussed how to use patient and family complaints to drive improvement efforts. The authors conclude that complaints should be addressed not as a ‘one-off’ but as thematically focused improvement initiatives, and failure to systematically respond to patient and family complaints suppress their voice.

Effectiveness is also one of the six quality domains [5], and Sawicki et al. reviewed the diagnostic process and discuss avoiding fundamental diagnostic errors to drive toward ideal patient outcomes. Diagnostic error is a relatively new academic field in quality and patient safety. This state-of-the-art narrative review is foundational for future research, identifying knowledge gaps specific to pediatric diagnostic error that can be the underpinning for future research.

Moresco et al. provide insights into the now well-established field of Pediatric Palliative Care which has become an expected clinical service essential to best practice in the pediatric inpatient setting. Unique aspects of the pediatric experience of serious illness include prognostic uncertainty, concurrent hospice and ongoing medical intervention, symptom management across a developmental spectrum, supporting hope in a family experience of illness, and caregiver/sibling support through bereavement. Shortages of trained Pediatric Palliative Care specialty providers are bridged by training pediatric professionals in pain and symptom management, communication, and care coordination. This paper highlights the evolution of Pediatric Palliative Care from a supportive service into an interdisciplinary specialty that improves outcomes for the patient, family, and caregiver.

A set of articles also addresses condition-specific topics. Workman et al. detail the improvement effort focused on ensuring optimal care for those children who develop sepsis. Providing specific data, the authors deliver an overview of how sepsis is identified and rapidly addressed, beginning when the patient enters the hospital and throughout their hospital stay. Despite this being a decades-long project, the team has implemented a continuous improvement process and has continued to fine-tune this process in order to more effectively identify and rapidly treat pediatric sepsis and reduce its morbidity and mortality. Kalm et al. walk us through the complexities required to render care for those children and adolescents who are technology dependent and whose health is maintained in the context of a home ventilation program that spans the inpatient setting to the home and community. When the child’s condition in the inpatient setting deteriorates and extra support is necessary, Troy et al. give us an overview of their experience with the rapid response team and how to make this valuable resource part of the standard of care with an algorithmic approach, which can be applied in any inpatient pediatric setting.

Finally, in an effort to inform professionals as well as patients and their families about the measured quality in healthcare facilities, publicly reported rating systems are an established element to the healthcare landscape. Chaulk et al. provide a topical review of the ranking systems that are now common-place in the pediatric health care environment and provide an overview of these consumer-oriented reporting systems. The authors conclude that pediatric rating systems lack the rigor of their ‘adult’ equivalents. This may result in caregivers being misled and providers focusing on misguided improvement strategies. Chaulk et al. review these shortcomings and offer strategies for improvement.

In summary, the articles in this special issue focus on pediatric inpatient care and address a wide-ranging set of topics that span various quality domains, several condition-specific areas, and publicly reported rating systems for children’s hospitals. While the list of topics covered in this special issue is not exhaustive, the range of subject matter is broad and provides a window into the complex patient care environment that increasingly defines pediatric inpatient care.

Disclosure of financial/other conflicts of interest

The authors have no relevant conflicts of interest to disclose. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

No funding was received for the preparation of this manuscript.