Framing the Issue

  • In 2012, there were nearly 5.9 million hospital stays for children 17 and younger in the United States.
  • Of those stays, 3.9 million were for the child’s birth, 1.9 million were for non-maternal/non-birth reasons, and 104,700 were maternal stays for pregnant teens.
  • For most major diagnostic categories, the rate of hospitalization for children decreased over time or remained relatively unchanged between 2000 and 2012.
  • In 2010, there were more than 25.5 million emergency department visits for children younger than 18.
  • The vast majority (96 percent) of those ED visits resulted in children being treated and released.

pediatrics hospital clinical managementFive years ago, Anne Arundel Medical Center’s inpatient pediatric unit was a financial drain on the hospital. At the same time, recognition was growing that, although the emergency physicians did a good job treating children brought to the emergency department, it wasn’t the ideal environment for them.

“The potential to be next door to an old lady dying of a stroke or an intoxicated 25-year-old who’s in handcuffs and cussing meant it was not the place to bring your beautiful little 2-year-old with a 104 fever,” explains Michael Clemmens, M.D., director of pediatrics at the Annapolis, Md., medical center. “We decided the kids needed better and they needed their own space.”

In looking for solutions, hospital leaders settled on a model that had worked in other Maryland hospitals — a combined pediatric ED and inpatient unit with one shared medical staff.

The blended unit, opened in April 2011, consists of two parallel hallways. One side houses an eight-bed pediatric ED and the other an eight-bed inpatient unit. A central nursing corridor runs between them. If patient demand on the ED side of the unit is too great, inpatient beds can be used for emergency patients and vice versa, Clemmens notes.

In its first year, the combined unit handled about 14,000 emergency visits. Within three years, pediatric emergency visits grew to 18,000 annually and plateaued at that level. The inpatient side has stayed steady at about 1,000 admissions annually.

The unit comes very close to breaking even. “The hospital still has to pay a bit of a supplement because of the inpatient care that’s required,” Clemmens says. “But the dollars spent to supplement the program dropped dramatically once the pediatricians started seeing emergency patients.”

The biggest benefit is that the hospital is able to keep children who need inpatient care in the community. “You shouldn’t have to go to the big city if you have pneumonia and need to be in the hospital for a couple of days,” Clemmens says.

Anne Arundel’s model is just one example of how community hospitals are addressing pediatric patients’ needs in a time when hospitals are being pressured to cut costs and improve care quality.

Better at keeping kids out of this hospital

Nationwide, hospitals with pediatric units are assessing the level of services they can provide given their patient volumes, says Scott Ransom, M.D., a managing director in Navigant Consulting’s health care practice. “If you have very low volumes, it could have a real financial impact on your facility if you don’t have enough revenue offsetting whatever it costs to maintain those services,” he says.

Pediatric hospital admissions have gone down over the years, thanks in part to antibiotics, vaccines and better control of asthma. “We’re just better at keeping kids out of the hospital,” Clemmens says.

Between 2008 and 2012, the rate of hospitalization decreased by 0.6 percent per year among infants and 0.9 percent per year among children ages 1 to 17, according to the Agency for Healthcare Research and Quality.

Despite the challenges, some community hospitals are maintaining or even bolstering pediatric offerings, often by partnering with prominent children’s hospitals, Ransom notes.

Pediatric hospitalists tackle emergency care

At Anne Arundel Medical Center, leaders had the advantage of proximity to the hospital that founded a combined pediatric ED/inpatient approach. Clemmens credits David Monroe, M.D., with creating the model in 1997 at Howard County General Hospital in Columbia, Md. Other hospitals followed suit, including Baltimore’s MedStar Franklin Square Medical Center and Greater Baltimore Medical Center in 2004.

“Most of the rest of us in Maryland have learned from them and generally modeled our programs after Monroe’s pioneering efforts,” Clemmens says.

The Maryland model relies on pediatric hospitalists to provide inpatient and emergency care. Although, at Anne Arundel that meant the existing ED lost 20 percent of its pediatric volume, it was able to commensurately increase its adult emergency volume by becoming more efficient and shortening wait times, Clemmens says.

The medical center’s combined unit is staffed by 10 pediatric hospitalists — five full time and five heavy part time. From 8 a.m. to midnight, two pediatric hospitalists work the unit. One physician works in the ED in the slow morning hours, while the other handles inpatient cases. As emergency volume picks up later in the day, both physicians staff the ED.

“The same doctors take care of the child emergently, and they either fix them up and send them home or, if they need to be admitted, we admit them to ourselves,” Clemmens says. “So there is one less handoff, and there is more continuity of care.”

About 85 percent of the unit’s work is emergency care and 15 percent is inpatient care, Clemmens says. The pediatric ED sees a lot of minor trauma — cuts and broken bones, but also serious illness — everything from pneumonia and respiratory failure to meningitis and sepsis.

Common reasons for admissions include appendicitis; such respiratory conditions as asthma and pneumonia; dehydration; and skin and soft tissue infections. The average pediatric length of stay is 1.7 days.

“We pride ourselves on knowing what our limitations are,” Clemmens says. Children who need a pediatric intensive care unit or simply more intensive nursing care than Anne Arundel is able to provide get transferred to Johns Hopkins Hospital in Baltimore or Children’s National Health System in Washington, D.C. Children with major trauma can be transported from the scene to Johns Hopkins or Children’s National — both five minutes by air from Annapolis.

Emotionally exhausting

The switch to a combined unit was a major undertaking. A critical task was making sure the pediatric hospitalists and nurses had the necessary skills to handle emergency cases. For a full year before the pediatric ED opened, the hospital held weekly or every-other-week training sessions with outside pediatric specialists. Training has continued for the five years since then with a monthly simulation program by physicians from Johns Hopkins.

“We don’t see as many critically ill patients as the adult ED does, and that makes our simulation training all that much more important,” Clemmens says. “We have to be ready for the infrequent, but critical situation.”

Pediatric physicians and nurses also had to become accustomed to the ED setting itself. “Pediatric emergency care is a very stressful environment because our patient is not just the child; it’s the family,” Clemmens says. “When the health of the thing that is most precious to you is threatened, parental anxiety is high. No matter what the complaint is, there is that fear that their child might not be OK. That is an emotionally exhausting challenge to deal with on an hourly basis.”

The pediatric team went from seeing 1,000 or so inpatients a year to seeing the same number of inpatients plus 18,000 emergency patients. “The pace of the work is significantly more challenging,” Clemmens says. As a result, pediatric hospitalist pay was raised to reflect the increased difficulty of the work.

The right clinicians, right administrators

The hospitalists maintain close ties with community pediatricians. “The best care of the child really dictates that there is close communication and continuity,” Clemmens says. Many of the pediatric emergency patients are sent to the ED by their pediatricians. The hospitalists notify the pediatricians when their patients are admitted from the ED and when they’re going to be discharged. A nurse navigator follows up on every discharged inpatient and high-risk emergency patient.

Getting a combined pediatric ED/inpatient unit off the ground requires up-front support from key players within the hospital. Those people include a pediatrician champion and a pediatric nurse manager who can be the pediatrician’s “partner in crime” because nurse-doctor collaboration in the endeavor is critical, Clemmens says.

“You need the support of administration and the commitment to providing the care despite some of the economic challenges,” he adds. Also necessary is buy-in from the emergency medical team. “The lead pediatrician has to have a good relationship with the lead emergency medicine physician so that they’re working in cahoots and not at cross-purposes.”

So far, the combined pediatric ED/inpatient unit model hasn’t caught on widely outside of Maryland, Clemmens notes. “Finding the right pediatrician who can get along with the right emergency physician who is supported by the right administrator who all want to do what’s right for the kids in the community even though it may mean a shift in income — that can be a tough get,” he says.

The Annapolis community has been very supportive of Anne Arundel’s combined unit, Clemmens says. The medical center’s three child-life specialist positions are funded by donations to its foundation.

“I like to think that we’ve earned the reputation that if your child is sick and you live somewhere in the vicinity, we’re the place to come,” Clemmens says.

Teaming up with a big name so everybody wins

In suburban Chicago, Northwest Community Healthcare was at the leading edge of the curve in partnering with a well-known children’s hospital to expand access to pediatric services in its community.

The Arlington Heights, Ill., institution’s relationship with Ann & Robert H. Lurie Children’s Hospital of Chicago started in 1991 with Lurie-employed physicians providing care in what was then a Level II neonatal intensive care unit. Since then, the partnership has grown to include a pediatric emergency department, opened in 2004; the upgrade to a Level III neonatal intensive care unit in 2010; and more recently, a Lurie outpatient subspecialty center on Northwest Community’s campus.

“It’s not a static relationship,” says Don Houchins, R.N., director of women and children’s services and the pediatric ED. “As children’s health care has changed, our relationship with them and our needs have changed.”

Pediatric hospital care at Northwest Community is provided by 20 employed Lurie doctors — pediatric emergency physicians, neonatologists and pediatric hospitalists. Northwest Community collects the facility fee and Lurie the physician fee.

Lurie physicians are well-integrated into the Northwest Community medical staff, Houchins says. They serve on various pediatric committees and take part in the hospital’s annual needs assessment. “It’s a seamless discussion that goes on,” he says. “You have Lurie physicians and Community physicians sharing issues, and the information goes both ways.”

The partnership benefits patients by providing local access to pediatric hospital care. “It wasn’t too long ago that most parents with a child with special needs wouldn’t think twice about taking them to the city,” says Kimberly Nagy, R.N., Northwest Community chief nursing officer and executive vice president, patient care services. “There is a lot of hardship in that — time and expense — that makes it very challenging for families. We’ve assisted in facilitating access for families to be able to stay within the community and not have to travel.”

Local access to the pediatric emergency physicians and the Level III NICU means fewer patient transfers, each of which poses some amount of patient risk, Nagy says.

In the 15-bed inpatient unit, 60 to 70 percent of patients are admitted from the ED, which is open daily from noon to midnight. Surgical cases and some direct admissions round out inpatient volume.

Patients with major trauma or who need complex procedures still get that care at Lurie Children’s, about an hour from Arlington Heights. But often their post-acute care can be managed at Northwest Community by Lurie physicians who practice locally. “The patients are closer to their families, so the mom and dad have family and support structures around them in a community they know,” Houchins says.

The partnership gives physicians at Northwest Community direct access via phone consults to Lurie subspecialists that they otherwise wouldn’t have, Houchins says. “It really does bring a new level of care.”

Lurie Children’s shares its pediatric care protocols and pathways with Northwest Community. The local Lurie physicians sit on the quality committee along with Community physicians, hospital leaders and nurses, Houchins says. “It’s under NCH management, but it’s influenced by them and they’re a big part of where we go with our quality program.”

Sitting on the same committees helps to foster relationships and communication between the Lurie physicians and Community pediatricians. “If a pediatrician sends a sick patient to the ED, the Lurie physician would see that child and would call back the Community pediatrician to discuss the case and make sure follow-up care is coordinated,” Houchins says.

Northwest Community’s Busse Center for Specialty Medicine enables children who need subspecialty care to get it locally from Lurie physicians. This is particularly helpful for children who need regular, ongoing subspecialty care.

The two institutions work together on an annual basis to assess the community’s pediatric subspecialty care needs and to determine whether any services need to be added, expanded or reduced, Nagy says. Outpatient services offered at the center include pediatric cardiology, endocrinology, hematology/oncology, neurology, orthopedics and rheumatology.

The relationship boosts Northwest Community’s reputation in its market, Nagy says. “Over 25 years of partnership, the community sees Lurie and Northwest Community as one.”

Expanding reach

The benefits of community hospital and children’s hospital partnerships run both ways. “It’s keeping kids in the community, supporting our community hospitals and elevating care across the community,” says Jill E. Keats, Lurie Children’s vice president, program development. “But when a high level of care is needed, we have those relationships … with patients’ families and referring physicians in the community outreach hospital. It will make sure they’re getting [tertiary or quaternary] care and access here at Lurie.”

In 2009, Lurie had 10 partner hospitals. It now has 15 community hospital partnerships. Depending on the relationship, Lurie provides pediatric hospitalists, pediatric emergency physicians, neonatal specialists, or a combination thereof. In seven of the partnerships, Lurie physicians provide outpatient subspecialty care.

Often, Lurie physicians work full time at the partner hospital. “We think it’s important to have a team of dedicated physicians who are wedded to a site, who know the staff, who know the OBs and the primary care doctors, and it doesn’t feel like a revolving door of doctors coming in and out,” Keats says.

To ensure that standards of care provided by Lurie physicians don’t vary across partner hospitals, Lurie employs a medical director for quality who works with each institution through its infrastructure to establish and implement best practices.

Getting buy-in for the partnerships from local pediatricians hasn’t been difficult. “It’s typically more the case that the pediatricians in the community are going to the hospital saying, ‘Please put a pediatric hospitalist model in place,’ ” Keats says. For pediatricians to leave their offices for a chunk of time to round on maybe one inpatient is not efficient, she explains.

Strong relationships between local pediatricians and Lurie physicians is essential. “We recognize that these are their patients,” Keats says. “We want to be an extension of their practice and make sure there is really good communication upon decision to admit, updates during admission and at discharge. That’s how you build bilateral trust.”

Each partner hospital has its own personality, Keats notes. “When we recruit new physicians or start a new site, we want to make sure we recruit for a fit,” she says. Lurie physicians typically live close to where the partner hospital is, so they’re part of that community.

Having the Lurie brand for pediatric care gives community hospitals an edge when competing for patients. “They can promote and market to their communities that right here in their community hospital, they have access to Lurie Children’s,” Keats says. When a woman’s obstetrician is on staff at more than one facility, a hospital’s partnership with Lurie could sway her to deliver there. That decision could form a lasting relationship with the community hospital, Keats notes.

The partnerships also help Lurie Children’s remain competitive in a tough market. “It expands our regional reputation,” Keats says. “We continue to grow in market share year after year. That helps to make sure it’s not as fragmented of a market and that kids who really need specialty care are going to where the specialists are.”

Executive Corner

Cost and quality considerations in their pediatric service lines are spurring some community hospitals to develop partnerships with well-known children’s hospitals, says Scott Ransom, M.D., managing director in Navigant Consulting’s health care practice.

Community hospital advantages

Physician access: The children’s hospital either directly or via telemedicine provides patient access to pediatric specialists and subspecialists that the community hospital normally wouldn’t be able to recruit.

Scope of services: In some partnerships, the presence of children’s hospital physicians allows the community hospital to expand services to include needed offerings, such as pediatric emergency or advanced neonatal care.

Quality: The partnership elevates the quality of care through use of the children’s hospital’s clinical protocols and care pathways.

Patient volume: The reputation boost and expanded services brought by the partnership increase the community hospital’s patient volume, which helps to cover the cost of frequently money-losing inpatient pediatric services.