The Pediatric Hospital Medicine Core Competencies Supplement: a Framework for Curriculum Development by the Society of Hospital Medicine with acknowledgement to pediatric hospitalists from the American Academy of Pediatrics and the Academic Pediatric Association

Caring for Hospitalized Children in Foster Care: Provider Training, Preparedness, and Practice

BACKGROUND AND OBJECTIVES

Children and youth in foster care (CYFC) have high rates of health care utilization, including inpatient care. The objective of this study was to explore the inpatient provider experience caring for CYFC.

METHODS

Semistructured interviews were conducted with inpatient pediatric providers from Mid-Atlantic hospitals. Interview questions focused on 3 domains: provider training and preparedness, practice challenges, and strategies to improve care for CYFC. Conventional content analysis was applied to interview transcripts.

RESULTS

Thirty-eight interviews were completed with providers from 6 hospitals, including 14 hospitalists, 1 advanced practice provider, 11 registered nurses, 10 social workers (SWs), and 2 case managers. Nearly all (90%) reported at least monthly interactions with CYFC. Themes related to training and preparedness to care for CYFC included: medical providers' lack of formal training, limited foster care knowledge, and feeling of preparedness contingent on access to SWs. Themes related to unique practice challenges included: identifying CYFC, obtaining consent, documenting foster care status, complex team communication, and navigating interpersonal stress. Participants' suggestions for improving their ability to care for CYFC included increasing SW capacity, expanding provider training, standardizing electronic medical record documentation and order sets, and improving team communication and information sharing.

CONCLUSIONS

There are unique medical, social, and legal aspects of caring for hospitalized CYFC; pediatric medical providers receive limited training on these topics and rely heavily on SWs to navigate associated practice challenges. Targeted educational and health information technology interventions are needed to help inpatient providers feel better prepared to effectively meet the needs of CYFC.

Development, implementation, and evaluation of a simulation-based educational curriculum for pediatric hospitalists

BACKGROUND AND OBJECTIVES

Minimal published simulation-based educational training exists for practicing pediatric hospitalists. Our aim was to determine specific pediatric hospital medicine (PHM) knowledge, skill, and competency needs aligned with our scope of practice and evaluate the impact of a simulation-based training curriculum.

DESIGN AND METHODS

Baseline and post-training surveys were administered to 48 physicians providing self-ratings on a 5-point scale from Novice to Expert on published PHM competencies. Results were used to develop a targeted simulation curriculum. Participants were considered competent in a domain if their mean score was 3 or greater. We categorized participant responses to individual questions into nine domain scores on survey self-assessments. Score analysis was performed using the signed-rank test and McNemar's test. Post-training evaluations solicited curriculum acceptance and perceived clinical value.

RESULTS

The baseline response rate was 98% and the post-training response rate was 85%. Areas with the lowest competency on baseline self-assessment included advanced airway management (38%), vascular access and emergency medications (38%), code cart skills (19%), team communication (51%), and medically complex care (49%). Post-training scores improved significantly for five of nine domains, with the largest gains in the "not competent" at baseline group. Percent competent (% with mean score >3) increased significantly in three domains (advanced airway management, code cart skills, and complex care). Participants rated educational sessions favorably (98%) and most (95%) reported using knowledge/skills learned for patient care.

CONCLUSION

Baseline self-assessment results were instrumental in curriculum design. Post-training analysis revealed gains in multiple domains and identified opportunities for future interventions. Most hospitalists reported participation positively impacted patient care with high learner satisfaction.

Technology-Dependent Pediatric Inpatients at Children's Versus Nonchildren's Hospitals

BACKGROUND AND OBJECTIVE

Technology-dependent children (TDC) are admitted to both children's hospitals (CHs) and nonchildren's hospitals (NCHs), where there may be fewer pediatric-specific specialists or resources. Our objective was to compare the characteristics of TDC admitted to CHs versus NCHs.

METHODS

This was a multicenter, retrospective study using the 2012 Kids' Inpatient Database. We included patients aged 0 to 18 years with a tracheostomy, gastrostomy, and/or ventricular shunt. We excluded those who died, were transferred into or out of the hospital, had a length of stay (LOS) that was an extreme outlier, or had missing data for key variables. We compared patient and hospital characteristics across CH versus NCH using χ² tests and LOS and cost using generalized linear models.

RESULTS

In the final sample of 64 521 discharges, 55% of discharges of TDC were from NCHs. A larger proportion of those from CHs had higher disease severity (55% vs 49%; P < .001) and a major surgical procedure during hospitalization (28% vs 24%; P < .001). In an adjusted generalized linear model, the mean LOS was 4 days at both hospital types, but discharge from a CH was associated with a higher adjusted mean cost ($16 754 vs $12 023; P < .001).

CONCLUSIONS

Because the majority of TDC are hospitalized at NCHs, future research on TDC should incorporate NCH settings. Further studies should investigate if some may benefit from regionalization of care or earlier transfer to a CH.

Developing Content for Pediatric Hospital Medicine Certification Examination Using Practice Analysis

OBJECTIVES

The American Board of Pediatrics (ABP) and the Pediatric Hospital Medicine (PHM) subboard developed a content outline to serve as a blueprint for the inaugural certification examination through practice analysis. The systematic approach of practice analyses process is described in the study.

METHODS

A diverse, representative panel of 12 pediatric hospitalists developed the draft content outline using multiple resources (publications, textbooks, PHM Core Competencies, PHM fellow's curriculum, etc). The panel categorized practice knowledge into 13 domains and 202 subdomains. By using the ABP database self-defined practicing pediatric hospitalists were identified. Participants rated the frequency and criticality of content domains and subdomains along with providing open-ended comments.

RESULTS

In total, 1449 (12.1%) generalists in the ABP database self-identified as pediatric hospitalists, and 800 full-time pediatric hospitalists responded. The content domains that were rated as highly critical and frequently required in practice were weighted more heavily (ie, the percentage of examination questions associated with a domain) than the less critical and less frequently rated. Both community and noncommunity pediatric hospitalists rated domains similarly (P = .943). Subdomain and preliminary weights were rated with similar means and SDs in the majority of topics.

CONCLUSIONS

There was concordance in the rating of domain and universal tasks among both community and noncommunity hospitalists. The areas of significant differences, although minor, could be explained by difference in practice settings. The practice analysis approach was structured, engaged the PHM community, reflected the breadth and depth of knowledge required for PHM practice, and used an iterative process to refine the final product.

Medical Student Training in Pediatric Hospital Medicine: A National Survey of Pediatric Clerkships

BACKGROUND AND OBJECTIVES

Medical student electives offer opportunities for career exploration; it is unknown if electives exist for the newest pediatric subspecialty, pediatric hospital medicine (PHM), or how PHM competencies are already addressed in required medical student training. Our objectives for this study were (1) to determine the prevalence of exposure to PHM competencies in medical school and (2) to inform a needs assessment for a PHM elective.

METHODS

A 5-item survey was distributed to members of the Council on Medical Student Education in Pediatrics as part of a larger survey in 2018. Descriptive statistics were used to report responses as proportions. Responses to 1 open-ended question were coded and grouped into categories.

RESULTS

Of 152 total respondents, 118 (77.6%) answered at least 1 question. Respondents felt that quality improvement was addressed in preclinical years (40.4%), whereas systems-based practice was incorporated into core clerkships (32.1%). Although most indicated that leadership and education should be taught at the subinternship level (29.6% and 25%, respectively), those competencies are not currently integrated into subinternship rotations (7.4% and 4.8%, respectively). Approximately half (n = 58; 49.5% each) reported that their institution offers a PHM elective. Lack of a standardized curriculum (16%) was seen as a barrier, and in free-text responses (n = 33), respondents also noted concerns regarding saturation of inpatient settings and redundancy with required rotations.

CONCLUSIONS

How to become a good leader and how to become a good educator were identified as PHM competencies that should be, but are not currently, taught at the fourth-year medical student level. A standardized curriculum and strategies to mitigate redundancy with existing rotations may increase satisfaction of students.

Current Perspectives on Transport Medicine in Pediatric Hospital Medicine Fellowships

Transport medicine (TM) is a Pediatric Hospital Medicine (PHM) Core Competency and part of the proposed PHM fellowship curricular framework. No published TM curricula are available. This cross-sectional study was designed to determine attitudes toward TM training among PHM fellowship stakeholders and conduct a TM curriculum needs assessment. Unique, web-based, anonymous surveys for PHM fellows, graduates, and program directors (PDs) were administered, with response rates of 57%, 37%, and 44%, respectively. Fellows' interest in completing a TM rotation is greater than their perceived interest by PDs (P = .06). Graduates who completed a TM rotation were more likely to recommend a TM rotation than those who did not (P = .001). Perceived barriers included lack of a formal TM curriculum and time constraints. Stabilizing patients and triage of referrals were deemed important learning objectives, and active learning strategies were prioritized. Curriculum design should focus on topics specific to the transport process and environment.

Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships

Pediatric Hospital Medicine (PHM) is an emerging field in pediatrics and one that has experienced immense growth and maturation in a short period of time. Evolution and rapid expansion of the field invigorated the goal of standardizing PHM fellowship curricula, which naturally aligned with the field's evolving pursuit of a defined identity and consideration of certification options. The national group of PHM fellowship program directors sought to establish curricular standards that would more accurately reflect the competencies needed to practice pediatric hospital medicine and meet future board certification needs. In this manuscript, we describe the method by which we reached consensus on a 2-year curricular framework for PHM fellowship programs, detail the current model for this framework, and provide examples of how this curricular framework may be applied to meet the needs of a variety of fellows and fellowship programs. The 2-year PHM fellowship curricular framework was developed over a number of years through an iterative process and with the input of PHM fellowship program directors (PDs), PHM fellowship graduates, PHM leaders, pediatric hospitalists practicing in a variety of clinical settings, and other educators outside the field. We have developed a curricular framework for PHM Fellowships that consists of 8 education units (defined as 4 weeks each) in 3 areas: clinical care, systems and scholarship, and individualized curriculum.

Pediatric Hospital Medicine: A Proposed New Subspecialty

Over the past 20 years, hospitalists have emerged as a distinct group of pediatric practitioners. In August of 2014, the American Board of Pediatrics (ABP) received a petition to consider recommending that pediatric hospital medicine (PHM) be recognized as a distinct new subspecialty. PHM as a formal subspecialty raises important considerations related to: (1) quality, cost, and access to pediatric health care; (2) current pediatric residency training; (3) the evolving body of knowledge in pediatrics; and (4) the impact on both primary care generalists and existing subspecialists. After a comprehensive and iterative review process, the ABP recommended that the American Board of Medical Specialties approve PHM as a new subspecialty. This article describes the broad array of challenges and certain unique opportunities that were considered by the ABP in supporting PHM as a new pediatric subspecialty.

Developing Validity Evidence for the Written Pediatric History and Physical Exam Evaluation Rubric

OBJECTIVE

The written history and physical examination (H&P) is an underutilized source of medical trainee assessment. The authors describe development and validity evidence for the Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric: a novel tool for evaluating written H&Ps.

METHODS

Using an iterative process, the authors drafted, revised, and implemented the 10-item rubric at 3 academic institutions in 2014. Eighteen attending physicians and 5 senior residents each scored 10 third-year medical student H&Ps. Inter-rater reliability (IRR) was determined using intraclass correlation coefficients. Cronbach α was used to report consistency and Spearman rank-order correlations to determine relationships between rubric items. Raters provided a global assessment, recorded time to review and score each H&P, and completed a rubric utility survey.

RESULTS

Overall intraclass correlation was 0.85, indicating adequate IRR. Global assessment IRR was 0.89. IRR for low- and high-quality H&Ps was significantly greater than for medium-quality ones but did not differ on the basis of rater category (attending physician vs. senior resident), note format (electronic health record vs nonelectronic), or student diagnostic accuracy. Cronbach α was 0.93. The highest correlation between an individual item and total score was for assessments was 0.84; the highest interitem correlation was between assessment and differential diagnosis (0.78). Mean time to review and score an H&P was 16.3 minutes; residents took significantly longer than attending physicians. All raters described rubric utility as "good" or "very good" and endorsed continued use.

CONCLUSIONS

The P-HAPEE rubric offers a novel, practical, reliable, and valid method for supervising physicians to assess pediatric written H&Ps.

Children with medical complexity: creating a framework for care based on the International Classification of Functioning, Disability and Health

Children with medical complexity (CMC) comprise a growing sector of the pediatric population. They are characterized by having severe chronic multiple system conditions, functional limitations, and family needs. While CMC comprise 0.4% to 0.7% of children, they have high healthcare costs and resource utilization, and are thus a key population of interest in health reform efforts. Despite the growth in the development of complex care delivery models, there is little available information to guide the training of diverse professionals in the provision of care that CMC and their families need. We propose a new framework for analysis and discussion based on the components of the International Classification of Function, Disability and Health, with augmentation of further areas of common need identified in this unique population of children. This framework can be used to delineate necessary professional team areas of expertise, guide improvement in care and provider training, and, potentially, to reduce cost as best practices for care are developed and researched.

Electronic resources preferred by pediatric hospitalists for clinical care

OBJECTIVES

There is little research on pediatric hospitalists' use of evidence-based resources. The aim of this study was to determine the electronic resources that pediatric hospitalists prefer.

METHODS

Using a web-based survey, the authors determined hospitalists' preferred electronic resources, as well as their attitudes toward lifelong learning, practice, and experience characteristics.

RESULTS

One hundred sixteen hospitalists completed the survey. The most preferred resource for general information, patient handouts, and treatment was UpToDate. Online search engines were ranked second for general information and patient handouts.

CONCLUSIONS

Pediatric hospitalists tend to utilize less rigorous electronic resources such as UpToDate and Google. These results can set a platform for discussing the quality of resources that pediatric hospitalists use.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

IMPORTANCE

Optimal approaches to teaching bedside procedures are unknown.

OBJECTIVE

To identify effective instructional approaches in procedural training.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.

STUDY SELECTION

We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from full-text articles.

MAIN OUTCOMES AND MEASURES

We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as 'negative' or 'positive' based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes.

RESULTS

We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training.

CONCLUSIONS AND RELEVANCE

This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

Perceived core competency achievements of fellowship and non-fellowship-trained early career pediatric hospitalists

BACKGROUND

The pediatric hospital medicine (PHM) core competencies were established in 2010 to identify the specific knowledge base and skill set needed to provide the highest quality of care for hospitalized children. The objectives of this study were to examine the perceived core competency achievements of fellowship-trained and non-fellowship-trained early career pediatric hospitalists and identify perceived gaps in our current training models.

METHODS

An anonymous Web-based survey was distributed in November 2013. Hospitalists within 5 years of their residency graduation reported their perceived competency in select PHM core competencies. χ(2) and multiprobit regression analyses were utilized.

RESULTS

One hundred ninety-seven hospitalists completed the survey and were included; 147 were non-fellowship-trained and 50 were PHM fellowship graduates or current PHM fellows. Both groups reported feeling less than competent in sedation and aspects of business practice. Non-fellowship-trained hospitalists also reported mean scores in the less than competent range in intravenous access/phlebotomy, technology-dependent emergencies, performing Plan-Do-Study-Act process and root cause analysis, defining basic statistical terms, and identifying research resources. Non-fellowship-trained hospitalists reported mean competency scores greater than fellowship-trained hospitalists in pain management, newborn care, and transitions in care.

CONCLUSIONS

Early career pediatric hospitalists report deficits in several of the PHM core competencies, which should be considered when designing PHM-specific training in the future. Fellowship-trained hospitalists report higher levels of perceived competency in many core areas.

Pediatric hospitalists working in community hospitals

Pediatric hospitalists are increasingly common in community hospitals and are playing increasingly important roles. Scope of practice and staffing models vary significantly by program. Unique aspects of small pediatric hospital medicine programs in hospitals with limited pediatric subspecialty and surgical support are discussed, including clinical and logistic considerations, training needs, and advocacy roles.

Determinants of career satisfaction among pediatric hospitalists: a qualitative exploration

OBJECTIVE

To characterize determinants of career satisfaction among pediatric hospitalists working in diverse practice settings; to develop a framework to conceptualize factors influencing career satisfaction.

METHODS

Semistructured interviews were conducted with community and tertiary care hospitalists, using purposeful sampling to attain maximum response diversity. We used closed- and open-ended questions to assess levels of career satisfaction and its determinants. Interviews were conducted by telephone, recorded, and transcribed verbatim. Emergent themes were identified and analyzed using an inductive approach to qualitative analysis.

RESULTS

A total of 30 interviews were conducted with community and tertiary care hospitalists, representing 20 hospital medicine programs and 7 Northeastern states. Qualitative analysis yielded 657 excerpts, which were coded and categorized into 4 domains and associated determinants of career satisfaction: 1) professional responsibilities; 2) hospital medicine program administration; 3) hospital and health care systems; and 4) career development. Although community and tertiary care hospitalists reported similar levels of career satisfaction, they expressed variation in perspectives across these 4 domains. Although the role of hospital medicine program administration was consistently emphasized by all hospitalists, community hospitalists prioritized resource availability, work schedule, and clinical responsibilities, while tertiary care hospitalists prioritized diversity in nonclinical responsibilities and career development.

CONCLUSIONS

We illustrate how hospitalists in different organizational settings prioritize both consistent and unique determinants of career satisfaction. Given associations between physician satisfaction and health care quality, efforts to optimize modifiable factors within this framework, at both community and tertiary care hospitals, may have broad impacts.

Guiding principles for pediatric hospital medicine programs

Pediatric hospital medicine programs have an established place in pediatric medicine. This statement speaks to the expanded roles and responsibilities of pediatric hospitalists and their integrated role among the community of pediatricians who care for children within and outside of the hospital setting.

The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline

The field of pediatric hospital medicine (PHM) has experienced phenomenal growth over the past decade. Academic contributions by pediatric hospitalists include the creation of PHM core competencies, national collaborative PHM networks for both research (the Pediatric Research in Inpatient Settings network) and quality improvement (the Value in Inpatient Pediatrics network), a robust and well-attended annual scientific meeting, and an increasing number of divisions or sections of PHM in pediatric departments across the country. Many pediatricians are choosing to pursue careers in PHM,^, and several postgraduate training programs for PHM have emerged. Similar to other generalist pediatric fields,^- the question as to how best for PHM to evolve as a distinct discipline has arisen. Several training and/or certification options are feasible and have been examined by the pediatric hospitalists who constitute the Strategic Planning (STP) Committee. The objectives of this commentary are to (1) describe the work done to investigate these options to date, (2) provide a framework for evaluating them, and (3) describe next steps. This commentary will neither justify subspecialty status for PHM, which is currently still debated within the field, nor will it compare the development of PHM as a subspecialty with other generalist fields because such a comparison is premature.

Pediatric hospitalists' influences on education and career plans

BACKGROUND

Pediatric hospitalist (PH) presence is rapidly increasing, yet little is known about pediatric resident exposure to hospitalists, or how this affects resident education/career decisions.

OBJECTIVES

To determine resident exposure to pediatric hospitalists; examine resident opinions regarding hospitalists' roles; examine resident opinion of hospital medicine career training needs; explore how resident exposure to hospitalists affects career choices.

METHODS

Survey of random sample of 300 residents from the American Academy of Pediatrics Section on Residents database.

RESULTS

Two-hundred seventy-nine pediatric residents surveyed; 120(43%) responded with variance by question; 90% work with hospitalists during residency. Of this national sample, 82% cite hospitalists as enhancing education. A majority (64%) believe pediatric hospitalists are better than primary care physicians at caring for complex inpatients; 28% felt PH provided better care for routine admissions. Over one-third surveyed are considering a career in Pediatric Hospital Medicine (PHM); 7% plan to enter the field upon graduation. Residents cited opportunities to participate in education, flexible hours, and better salaries as the top 3 reasons to become a hospitalist. Ten percent felt there was no difference between resident and hospitalist positions; 21% see PHM as a short-term job without long-term potential. Of residents entering Primary Care, a majority (59%) stated that the availability of hospitalists would positively influence their choice of a practice position; 7% said they were "less likely to choose to practice Primary Care Pediatrics because of hospitalists."

CONCLUSIONS

PH have a role in physician training. While PHM has become a career consideration for trainees, more work needs to be done to improve the perception of PHM as a viable long-term career.

The hospitalist movement in general pediatrics

PURPOSE OF REVIEW

The present review focuses on the latest evidence from the past 18 months related to pediatric hospitalist medicine.

RECENT FINDINGS

The number of hospitalists continues to increase despite many programs not being financially self-supporting. Reports in the past have shown decreased length of stay, resource utilization, and costs with the hospitalist model. There are an increasing number of studies examining patient safety, quality initiatives, and communication issues such as 'handoffs' and family-centered rounds. The teaching role continues to broaden in scope and is highly valued by trainees. Pediatric hospitalist fellowship training programs are in an early stage of development. A list of core competencies as a framework for a pediatric hospital medicine curriculum has recently been published and should help to facilitate and standardize training. Recent publications suggest that there is still significant variation in the approach to and management of many common inpatient illnesses.

SUMMARY

In general, there continue to be reports of positive outcomes as a result of the introduction of the hospitalist model in pediatrics. Much of the current literature is geared toward reporting on alternative models of care, inpatient quality and safety initiatives, and hospitalist teaching. What is still somewhat lacking is multicenter collaborative prospective clinical trials for common inpatient general pediatric conditions. The variation reported in the management of common conditions presents an opportunity for improving the quality, safety, resource utilization, and appropriateness of care.