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Defining the Role of Pediatric Hospitalists In the PICU - A Survey of Pediatric Hospitalists, Hospitalist Directors and PICU Directors

Sunday, October 21, 2012
Room 281-282 (Morial Convention Center)
Ryan S. Bode, M.D., Dustin Rayhorn, Heidi Dalton and Murray Pollack, Department of Hospital Medicine, Phoenix Children's Hospital, Phoenix, AZ

Purpose

The expansion of pediatric Hospitalists' clinical roles has included the care of critically ill children, including patients within the pediatric intensive care unit (PICU) and code and rapid response teams (RRTs).  Driving forces include: Hospitalist skill set development, anticipated shortfalls in the availability of Intensivists, further restrictions in resident work hours, potential cost advantages, and quality of Hospitalist versus resident coverage.  It is not known how many Hospitalists practice in the PICU, training guidelines/requirements, or scope of practice.   The aim of this study is to outline and define the current roles of pediatric Hospitalists in the PICU.

Methods

The American Academy of Pediatrics Section on Hospital Medicine maintains an active list serve with an estimated 2000 pediatric Hospitalists.  A cross sectional on-line survey was sent to the listserve with separate links to "Hospitalists" and "Hospitalist Directors."  In addition, a database was purchased thru the American Hospital Association.  Hospitals with PICUs and PICU Directors were identified, an email database created, and an on-line survey was sent. 

Results

150 Hospitalists, 65 Hospitalist Directors and 42 PICU Directors completed the survey.  20% of Hospitalists, 21% of Hospitalist Directors, and 29% of PICU Directors indicated Hospitalists functioned within the PICU.  Hospitalists' clinical roles identified included: "actively admit and manage patients under supervision of intensivist" (68%) and "admit and manage patients independently of intensivist" (20%).  Patients cared for included: 68% "all patients regardless of severity" with 23% indicating only "intermediate or step-down patients".  Hospitalists perform the following procedures/management on a regular basis: 63% intubation, 25% central line placement, 38% arterial line placement, 25% chest tube placement, 75% conventional ventilation, 31% advanced ventilation, 56% moderate-deep sedation and 69% vasoactive medications.  90% of Hospitalists with a clinical role in the PICU indicated no additional preparatory training or credentialing.  PICU Directors using Hospitalists answered: 56% no additional training, 22% Pediatric Fundamentals of Critical Care Medicine, and 11% other formal training.  13% of PICU Directors not using Hospitalists indicated they planned to use Hospitalists in the future.  Those not planning on using Hospitalists site the reasons: 33% insufficient training, 29% credentialing/medical staff issues, 19% no precedent or model.  37% of Hospitalists are on their code team and 41% are on their RRT with 25% serving as the physician lead.

Conclusion

Pediatric Hospitalists have an evolving role in the care of critically ill children in the PICU.  This includes the active management of ventilated patients, patients on vasoactive medications and procedures such as intubation, line placement and sedation.  There is a lack of additional or formal training, credentialing and shared precedent.  Successful practice models need to be explored and shared as well as recommendations regarding additional and ongoing training, and scope of practice as the trend of Hospitalists' in the PICU is anticipated to continue and expand.