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.