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Complete Summary

GUIDELINE TITLE

Physicians' roles in coordinating care of hospitalized children.

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

AAP Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

COMPLETE SUMMARY CONTENT

 
SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 QUALIFYING STATEMENTS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

  • Acute illnesses or injuries
  • Exacerbations of chronic illnesses or conditions

GUIDELINE CATEGORY

Evaluation
Management

CLINICAL SPECIALTY

Family Practice
Pediatrics

INTENDED USERS

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Social Workers

GUIDELINE OBJECTIVE(S)

To summarize the responsibilities of the primary care physician, attending physician, and other physicians involved in the care of hospitalized children in order to ensure that these children receive appropriate, coordinated, and comprehensive inpatient care that is delivered within the context of their medical home and is appropriately continued on an outpatient basis

TARGET POPULATION

Hospitalized children

INTERVENTIONS AND PRACTICES CONSIDERED

  1. Initial assessment, including medical history, physical examination, psychosocial assessment
  2. Obtaining history and other pertinent information from the primary care physician
  3. Referral and consultation with adult subspecialists and surgeons, as appropriate
  4. Discharge planning and coordination

MAJOR OUTCOMES CONSIDERED

Not stated

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

METHODS USED TO ANALYZE THE EVIDENCE

Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

A formal cost analysis was not performed and published cost analyses were not reviewed.

METHOD OF GUIDELINE VALIDATION

Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Initial Assessment

For any child requiring hospital admission, an initial assessment made before or at the time of hospitalization allows for the child to be admitted to the inpatient setting that is best suited to his or her specific problem(s). If the inpatient or hospital setting best suited to the child's needs is not on the approved list of the child's insurance carrier, the physicians caring for the child must advocate for the best interest of the child and seek approval for admission to the appropriate setting.

A complete evaluation includes a history of the present illness; past medical history; pain assessment; review of systems; review of immunizations; assessment of growth, developmental, educational, and emotional status; review of family and social history, including review of behavioral and environmental risk factors; and a physical examination. The effects of the child's condition on his or her family and the effects of the family on the child's condition need to be evaluated to initiate family-centered care. These assessments may be performed just before or concurrent with hospitalization and routinely involve collaboration with other nonphysician health care professionals, such as nursing staff, child life specialists, social workers, etc.

Obtaining History from the Primary Care Physician

It is especially important that the child's medical history be obtained when the primary care physician is not the primary attending physician. Hospital-based attending physicians, surgeons, and subspecialists who hospitalize children with complex or multiple problems must communicate with the child's primary care physician for overall coordination of care. If necessary, this may include obtaining authorization for specific services. For children with new onset of acute problems, preexisting illness, chronic disease, and/or past hospitalizations, hospital and outpatient information must be available on admission for the inpatient health care team to review. Access to this information prevents unnecessary duplication of previous diagnostic and therapeutic measures, allows primary care and hospital-based physicians to update the status of past conditions that may not be obvious on the current admission, provides insight into psychosocial issues facing the patient and family, and facilitates monitoring the child's growth and development. Additionally, this information may indicate that a condition initially considered appropriate for a short-stay unit actually requires formal inpatient hospitalization. Inpatient and outpatient facilities must be able to provide and receive necessary medical records in a reliable, timely, safe, and confidential manner.

Ongoing Role of the Primary Care Physician

When physicians other than the primary care physician participate in the care of the child, the primary care physician can help ensure continuity of care and help the family develop trust in providers who have no preexisting relationship with the family. When the primary care physician does not directly participate in hospital-based care, regular communication with the attending physician enables the primary care physician to remain actively involved in the patient's care. As the hospitalization progresses, the primary care physician can provide valuable insight into the patient's changing medical condition and the patient's and family's psychosocial status and response. The primary care physician can help integrate and coordinate the input of various physicians when multiple consultants are involved in the patient's care. The continued involvement of the primary care physician ensures discharge planning is proceeding effectively. It improves the primary care physician's understanding of the patient's hospital course to facilitate optimal transitional and ongoing outpatient care. For patients and families facing end-of-life issues, the involvement of the primary care physician is particularly valuable.

Pediatric Consultation for Adult Subspecialists and Surgeons

When the attending physician does not routinely care for pediatric patients, pediatric consultation can help with the physiologic, pharmacologic, and psychosocial issues unique to younger and smaller patients. The patient's primary care physician may fill this clinical role. Alternatively, another general pediatrician, or family practitioner with demonstrated consistent experience in the inpatient care of children may serve as a consultant. Such formal consultation is particularly recommended for any hospitalized child with complex medical or psychosocial problems and all patients who are younger than 14 years or less than 40 kg in body weight.

Discharge Plans and Coordination

Before discharge, an assessment of the child's needs should be made, plans should be formulated, treatment should be provided, and necessary information should be supplied to family members. Treatment plans must be made in accordance with the child's developmental, educational, and emotional level. Family members or guardians must be involved with formulation of the treatment plan, because they are ultimately responsible for decisions about the care their child receives.

If treatment is not completed during hospitalization, appropriate outpatient management must be arranged. The child's social, developmental, and family status are particularly important, because most children will receive part of their treatment on an outpatient basis. The attending physician, together with other members of the health care team and the family, is responsible for evaluating whether the outpatient treatment plan appears feasible for the child's family to undertake and modifying the plan if needed. At the time of discharge, a written summary and recommendations for outpatient care must be available to all personnel and institutions involved in the future care of the child. Timely dictation services should be available to ensure a complete and legible record of events is provided. Laboratory, imaging, and consultative reports pending at the time of discharge should be specifically identified. Referrals must be provided for all needed outpatient services, including a source of primary care if the child does not have a primary care physician. In such instances or when the primary care physician was not directly involved in the child's hospitalization, the provider responsible for ongoing care should be contacted directly by the inpatient team before the day of discharge to ensure continuity of care. All referrals for outpatient services should be arranged with providers familiar with the special needs of children.

Occasionally the child's physicians, when determining the need for inpatient care, may not be in agreement with decisions made by external organizations (e.g., review organizations or health maintenance organizations or insurance companies). Standards of medical care established by peer groups should be used as guidelines when controversy exists with the understanding that the guidelines may not be applicable to each child's situation. In such instances, as in all instances, treatment and discharge decisions must be made with the best interest of the child as the primary motivation.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically stated.

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Appropriate care of hospitalized children from admission through discharge

POTENTIAL HARMS

Not stated

QUALIFYING STATEMENTS

QUALIFYING STATEMENTS

None provided

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Getting Better
Living with Illness

IOM DOMAIN

Effectiveness
Patient-centeredness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

DATE RELEASED

2003 Mar

GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

SOURCE(S) OF FUNDING

American Academy of Pediatrics

GUIDELINE COMMITTEE

Committee on Hospital Care

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Primary Author: Jack M. Percelay, MD, MPH

Committee on Hospital Care, 2002-2003: John M. Neff, MD, Chairperson; Jerrold M. Eichner, MD; David R. Hardy, MD; Michael Klein, MD; Jack M. Percelay, MD, MPH; Ted D. Sigrest, MD; Erin R. Stucky, MD

Liaisons: Mary T. Perkins, RN, DNSc; Susan Dull, RN, MSN, MBA; Jerriann M. Wilson, CCLS, Med

Consultant: Timothy E. Corden, MD

Staff: Stephanie M. Mucha, MPH

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

AAP Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Pediatrics (AAP) Policy Web site.

Print copies: Available from AAP, 141 Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on August 18, 2003. The information was verified by the guideline developer on September 8, 2003.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.

DISCLAIMER

NGC DISCLAIMER

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