Francisco Alvarez, MD

Introduction

Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.

Pediatric hospitalists should be able to:

• Discuss the pathophysiologic mechanisms that result in fever.
• List the different methods available for obtaining a temperature and explain common errors associated with each.
• Differentiate FUO from disorders known to present with serial or prolonged fevers.
• Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
• Identify the common infectious causes of FUO, particularly as they differ by geographic region.
• Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
• Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
• Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
• List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
• Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
• Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
• Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
• Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
• Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.

Pediatric hospitalists should be able to:

• Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
• Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
• Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
• Access and comprehensively review all relevant prior records.
• Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
• Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
• Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
• Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
• Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
• Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
• Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
• Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
• Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
• Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
• Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.

Introduction

Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.

Pediatric hospitalists should be able to:

• Discuss the pathophysiologic mechanisms that result in fever.
• List the different methods available for obtaining a temperature and explain common errors associated with each.
• Differentiate FUO from disorders known to present with serial or prolonged fevers.
• Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
• Identify the common infectious causes of FUO, particularly as they differ by geographic region.
• Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
• Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
• Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
• List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
• Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
• Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
• Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
• Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
• Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.

Pediatric hospitalists should be able to:

• Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
• Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
• Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
• Access and comprehensively review all relevant prior records.
• Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
• Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
• Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
• Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
• Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
• Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
• Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
• Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
• Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
• Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
• Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.

Introduction

Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.

Pediatric hospitalists should be able to:

• Discuss the pathophysiologic mechanisms that result in fever.
• List the different methods available for obtaining a temperature and explain common errors associated with each.
• Differentiate FUO from disorders known to present with serial or prolonged fevers.
• Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
• Identify the common infectious causes of FUO, particularly as they differ by geographic region.
• Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
• Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
• Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
• List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
• Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
• Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
• Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
• Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
• Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.

Pediatric hospitalists should be able to:

• Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
• Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
• Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
• Access and comprehensively review all relevant prior records.
• Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
• Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
• Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
• Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
• Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
• Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
• Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
• Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
• Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
• Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
• Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.

As a newly recognized specialty, pediatric hospital medicine (PHM) continues to expand and diversify.¹ Pediatric hospitalists care for children in hospitals ranging from small, rural community hospitals to large, free-standing quaternary children’s hospitals.^2-4 In addition, more than 10% of graduating pediatric residents are seeking future careers within PHM.⁵

In 2018, Fromme et al. published a study describing clinical workload for pediatric hospitalists within university-based settings.⁶ They characterized the diversity of work models and programmatic sustainability but limited the study to university-based programs. With over half of children receiving care within community hospitals,⁷ workforce patterns for community-based pediatric hospitalists should be characterized to maximize sustainability and minimize attrition across the field.

In this study, we describe programmatic variability in clinical work expectations of 70 community-based PHM programs. We aimed to describe existing work models and expectations of community-based program leaders as they relate to their unique clinical setting.

We conducted a cross-sectional survey of community-based PHM site directors through structured interviews. Community hospital programs were self-defined by the study participants, although typically defined as general hospitals that admit pediatric patients and are not free-standing or children’s hospitals within a general hospital. Survey respondents were asked to answer questions only reflecting expectations at their community hospital.

Survey Design and Content

Building from a tool used by Fromme et al.⁶ we created a 12-question structured interview questionnaire focused on three areas: (1) full-time employment (FTE) metrics including definitions of a 1.0 FTE, “typical” shifts, and weekend responsibilities; (2) work volume including census parameters, service-line coverage expectations, back-up systems, and overnight call responsibilities; and (3) programmatic model including sense of sustainability (eg, minimizing burnout and attrition), support for activities such as administrative or research time, and employer model (Appendix).

We modified the survey through research team consensus. After pilot-testing by research team members at their own sites, the survey was refined for item clarity, structural design, and length. We chose to administer surveys through phone interviews over a traditional distribution due to anticipated variability in work models. The research team discussed how each question should be asked, and responses were clarified to maintain consistency.

Survey Administration

Given the absence of a national registry or database for community-based PHM programs, study participation was solicited through an invitation posted on the American Academy of Pediatrics Section on Hospital Medicine (AAP SOHM) Listserv and the AAP SOHM Community Hospitalist Listserv in May 2018. Invitations were posted twice at two weeks apart. Each research team member completed 6-19 interviews. Responses to survey questions were recorded in REDCap, a secure, web-based data capture instrument.⁸

Participating in the study was considered implied consent, and participants did not receive a monetary incentive, although respondents were offered deidentified survey data for participation. The study was exempted through the University of Chicago Institutional Review Board.

Data Analysis

Employers were dichotomized as community hospital employer (including primary community hospital employment/private organization) or noncommunity hospital employer (including children’s/university hospital employment or school of medicine). Descriptive statistics were reported to compare the demographics of two employer groups. P values were calculated using two-sample t-tests for the continuous variables and chi-square or Fisher-exact tests for the categorical variables. Mann–Whitney U-test was performed for continuous variables without normality. Analyses were performed using the R Statistical Programming Language (R Foundation for Statistical Computing, Vienna, Austria), version 3.4.3.

Participation and Program Characteristics

We interviewed 70 community-based PHM site directors representing programs across 29 states (Table 1) and five geographic regions: Midwest (34.3%), Northeast (11.4%), Southeast (15.7%), Southwest (4.3%), and West (34.3%). Employer models varied across groups, with more noncommunity hospital employers (57%) than community hospital employers (43%). The top three services covered by pediatric hospitalists were pediatric inpatient or observation bed admissions (97%), emergency department consults (89%), and general newborns (67%). PHM programs also provided coverage for other services, including newborn deliveries (43%), Special Care Nursery/Level II Neonatal Intensive Care Unit (41%), step-down unit (20%), and mental health units (13%). About 59% of programs provided education for family medicine residents, 36% were for pediatric residents, and 70% worked with advanced practice providers. The majority of programs (70%) provided in-house coverage overnight.

alvarez02250821e_t1.jpg

Clinical Work Expectations and Employer Model

Clinical work expectations varied broadly across programs (Table 2). The median expected hours for a 1.0 FTE was 1,882 hours per year (interquartile range [IQR] 1,805, 2,016), and the median expected weekend coverage/year (defined as covering two days or two nights of the weekend) was 21 (IQR 14, 24). Most programs did not expand staff coverage based on seasonality (73%), and less than 20% of programs operated with a census cap. Median support for nondirect patient care activities was 4% (IQR 0,10) of a program’s total FTE (ie, a 5.0 FTE program would have 0.20 FTE support). Programs with community hospital employers had an 8% higher expectation of 1.0 FTE hours/year (P = .01) and viewed an appropriate pediatric morning census as 20% higher (P = .01; Table 2).

Program Sustainability

jhm014110682_t2.jpg

To our knowledge, this study is the first to describe clinical work models exclusively for pediatric community hospitalist programs. We found that expectations for clinical FTE hours, weekend coverage, appropriate morning census, support for nondirect patient care activities, and perception of sustainability varied broadly across programs. The only variable affecting some of these differences was employer model, with those employed by a community hospital employer having a higher expectation for hours/year and appropriate morning pediatric census than those employed by noncommunity hospital employers.

With a growing emphasis on physician burnout and career satisfaction,^9-11 understanding the characteristics of community hospital work settings is critical for identifying and building sustainable employment models. Previous studies have identified that the balance of clinical and nonclinical responsibilities and the setting of community versus university-based programs are major contributors to burnout and career satisfaction.^9,11 Interestingly, although community hospital-based programs have limited FTE for nondirect patient care activities, we found that a higher percentage of program site directors perceived their program models as sustainable when compared with university-based programs in prior research (63% versus 50%).⁶ Elucidating why community hospital PHM programs are perceived as more sustainable provides an opportunity for future research. Potential reasons may include fewer academic requirements for promotion or an increased connection to a local community.

We also found that the employer model had a statistically significant impact on expected FTE hours per year but not on perception of sustainability. Programs employed by community hospitals worked 8% more hours per year than those employed by noncommunity hospital employers and accepted a higher morning pediatric census. This variation in hours and census level appropriateness is likely multifactorial, potentially from higher nonclinical expectations for promotion (eg, academic or scholarly production) at school of medicine or children’s hospital employed programs versus limited reimbursement for administrative responsibilities within community hospital employment models.

There are several potential next steps for our findings. As our data are the first attempt (to our knowledge) at describing the current practice and expectations exclusively within community hospital programs, this study can be used as a starting point for the development of workload expectation standards. Increasing transparency nationally for individual community programs potentially promotes discussions around burnout and attrition. Having objective data to compare program models may assist in advocating with local hospital leadership for restructuring that better aligns with national norms.

Our study has several limitations. First, our sampling frame was based upon a self-selection of program directors. This may have led to a biased representation of programs with higher workloads motivated to develop a standard to compare with other programs, which may have potentially led to an overestimation of hours. Second, without a registry or database for community-based pediatric hospitalist programs, we do not know the percentage of community-based programs that our sample represents. Although our results cannot speak for all community PHM programs, we attempted to mitigate nonresponse bias through the breadth of programs represented, which spanned 29 states, five geographic regions, and teaching and nonteaching programs. The interview-based method for data collection allowed the research team to clarify questions and responses across sites, thereby improving the quality and consistency of the data for the represented study sample. Finally, other factors possibly contributed to sustainability that we did not address in this study, such as programs that are dependent on billable encounters as part of their salary support.

As a newly recognized subspecialty, creating a reference for community-based program leaders to determine and discuss individual models and expectations with hospital administrators may help address programmatic sustainability. It may also allow for the analysis of long-term career satisfaction and longevity within community PHM programs based on workload. Future studies should further explore root causes for workload discrepancies between community and university employed programs along with establishing potential standards for PHM program development.

Acknowledgments

We would like to thank the Stanford School of Medicine Quantitative Sciences Unit staff for their assistance in statistical analysis.

Disclosure

The authors have nothing to disclose.

As a newly recognized specialty, pediatric hospital medicine (PHM) continues to expand and diversify.¹ Pediatric hospitalists care for children in hospitals ranging from small, rural community hospitals to large, free-standing quaternary children’s hospitals.^2-4 In addition, more than 10% of graduating pediatric residents are seeking future careers within PHM.⁵

In 2018, Fromme et al. published a study describing clinical workload for pediatric hospitalists within university-based settings.⁶ They characterized the diversity of work models and programmatic sustainability but limited the study to university-based programs. With over half of children receiving care within community hospitals,⁷ workforce patterns for community-based pediatric hospitalists should be characterized to maximize sustainability and minimize attrition across the field.

In this study, we describe programmatic variability in clinical work expectations of 70 community-based PHM programs. We aimed to describe existing work models and expectations of community-based program leaders as they relate to their unique clinical setting.

We conducted a cross-sectional survey of community-based PHM site directors through structured interviews. Community hospital programs were self-defined by the study participants, although typically defined as general hospitals that admit pediatric patients and are not free-standing or children’s hospitals within a general hospital. Survey respondents were asked to answer questions only reflecting expectations at their community hospital.

Survey Design and Content

Building from a tool used by Fromme et al.⁶ we created a 12-question structured interview questionnaire focused on three areas: (1) full-time employment (FTE) metrics including definitions of a 1.0 FTE, “typical” shifts, and weekend responsibilities; (2) work volume including census parameters, service-line coverage expectations, back-up systems, and overnight call responsibilities; and (3) programmatic model including sense of sustainability (eg, minimizing burnout and attrition), support for activities such as administrative or research time, and employer model (Appendix).

We modified the survey through research team consensus. After pilot-testing by research team members at their own sites, the survey was refined for item clarity, structural design, and length. We chose to administer surveys through phone interviews over a traditional distribution due to anticipated variability in work models. The research team discussed how each question should be asked, and responses were clarified to maintain consistency.

Survey Administration

Given the absence of a national registry or database for community-based PHM programs, study participation was solicited through an invitation posted on the American Academy of Pediatrics Section on Hospital Medicine (AAP SOHM) Listserv and the AAP SOHM Community Hospitalist Listserv in May 2018. Invitations were posted twice at two weeks apart. Each research team member completed 6-19 interviews. Responses to survey questions were recorded in REDCap, a secure, web-based data capture instrument.⁸

Participating in the study was considered implied consent, and participants did not receive a monetary incentive, although respondents were offered deidentified survey data for participation. The study was exempted through the University of Chicago Institutional Review Board.

Data Analysis

Employers were dichotomized as community hospital employer (including primary community hospital employment/private organization) or noncommunity hospital employer (including children’s/university hospital employment or school of medicine). Descriptive statistics were reported to compare the demographics of two employer groups. P values were calculated using two-sample t-tests for the continuous variables and chi-square or Fisher-exact tests for the categorical variables. Mann–Whitney U-test was performed for continuous variables without normality. Analyses were performed using the R Statistical Programming Language (R Foundation for Statistical Computing, Vienna, Austria), version 3.4.3.

Participation and Program Characteristics

We interviewed 70 community-based PHM site directors representing programs across 29 states (Table 1) and five geographic regions: Midwest (34.3%), Northeast (11.4%), Southeast (15.7%), Southwest (4.3%), and West (34.3%). Employer models varied across groups, with more noncommunity hospital employers (57%) than community hospital employers (43%). The top three services covered by pediatric hospitalists were pediatric inpatient or observation bed admissions (97%), emergency department consults (89%), and general newborns (67%). PHM programs also provided coverage for other services, including newborn deliveries (43%), Special Care Nursery/Level II Neonatal Intensive Care Unit (41%), step-down unit (20%), and mental health units (13%). About 59% of programs provided education for family medicine residents, 36% were for pediatric residents, and 70% worked with advanced practice providers. The majority of programs (70%) provided in-house coverage overnight.

alvarez02250821e_t1.jpg

Clinical Work Expectations and Employer Model

Clinical work expectations varied broadly across programs (Table 2). The median expected hours for a 1.0 FTE was 1,882 hours per year (interquartile range [IQR] 1,805, 2,016), and the median expected weekend coverage/year (defined as covering two days or two nights of the weekend) was 21 (IQR 14, 24). Most programs did not expand staff coverage based on seasonality (73%), and less than 20% of programs operated with a census cap. Median support for nondirect patient care activities was 4% (IQR 0,10) of a program’s total FTE (ie, a 5.0 FTE program would have 0.20 FTE support). Programs with community hospital employers had an 8% higher expectation of 1.0 FTE hours/year (P = .01) and viewed an appropriate pediatric morning census as 20% higher (P = .01; Table 2).

Program Sustainability

jhm014110682_t2.jpg

To our knowledge, this study is the first to describe clinical work models exclusively for pediatric community hospitalist programs. We found that expectations for clinical FTE hours, weekend coverage, appropriate morning census, support for nondirect patient care activities, and perception of sustainability varied broadly across programs. The only variable affecting some of these differences was employer model, with those employed by a community hospital employer having a higher expectation for hours/year and appropriate morning pediatric census than those employed by noncommunity hospital employers.

With a growing emphasis on physician burnout and career satisfaction,^9-11 understanding the characteristics of community hospital work settings is critical for identifying and building sustainable employment models. Previous studies have identified that the balance of clinical and nonclinical responsibilities and the setting of community versus university-based programs are major contributors to burnout and career satisfaction.^9,11 Interestingly, although community hospital-based programs have limited FTE for nondirect patient care activities, we found that a higher percentage of program site directors perceived their program models as sustainable when compared with university-based programs in prior research (63% versus 50%).⁶ Elucidating why community hospital PHM programs are perceived as more sustainable provides an opportunity for future research. Potential reasons may include fewer academic requirements for promotion or an increased connection to a local community.

We also found that the employer model had a statistically significant impact on expected FTE hours per year but not on perception of sustainability. Programs employed by community hospitals worked 8% more hours per year than those employed by noncommunity hospital employers and accepted a higher morning pediatric census. This variation in hours and census level appropriateness is likely multifactorial, potentially from higher nonclinical expectations for promotion (eg, academic or scholarly production) at school of medicine or children’s hospital employed programs versus limited reimbursement for administrative responsibilities within community hospital employment models.

There are several potential next steps for our findings. As our data are the first attempt (to our knowledge) at describing the current practice and expectations exclusively within community hospital programs, this study can be used as a starting point for the development of workload expectation standards. Increasing transparency nationally for individual community programs potentially promotes discussions around burnout and attrition. Having objective data to compare program models may assist in advocating with local hospital leadership for restructuring that better aligns with national norms.

Our study has several limitations. First, our sampling frame was based upon a self-selection of program directors. This may have led to a biased representation of programs with higher workloads motivated to develop a standard to compare with other programs, which may have potentially led to an overestimation of hours. Second, without a registry or database for community-based pediatric hospitalist programs, we do not know the percentage of community-based programs that our sample represents. Although our results cannot speak for all community PHM programs, we attempted to mitigate nonresponse bias through the breadth of programs represented, which spanned 29 states, five geographic regions, and teaching and nonteaching programs. The interview-based method for data collection allowed the research team to clarify questions and responses across sites, thereby improving the quality and consistency of the data for the represented study sample. Finally, other factors possibly contributed to sustainability that we did not address in this study, such as programs that are dependent on billable encounters as part of their salary support.

As a newly recognized subspecialty, creating a reference for community-based program leaders to determine and discuss individual models and expectations with hospital administrators may help address programmatic sustainability. It may also allow for the analysis of long-term career satisfaction and longevity within community PHM programs based on workload. Future studies should further explore root causes for workload discrepancies between community and university employed programs along with establishing potential standards for PHM program development.

Acknowledgments

We would like to thank the Stanford School of Medicine Quantitative Sciences Unit staff for their assistance in statistical analysis.

Disclosure

The authors have nothing to disclose.

As a newly recognized specialty, pediatric hospital medicine (PHM) continues to expand and diversify.¹ Pediatric hospitalists care for children in hospitals ranging from small, rural community hospitals to large, free-standing quaternary children’s hospitals.^2-4 In addition, more than 10% of graduating pediatric residents are seeking future careers within PHM.⁵

In 2018, Fromme et al. published a study describing clinical workload for pediatric hospitalists within university-based settings.⁶ They characterized the diversity of work models and programmatic sustainability but limited the study to university-based programs. With over half of children receiving care within community hospitals,⁷ workforce patterns for community-based pediatric hospitalists should be characterized to maximize sustainability and minimize attrition across the field.

In this study, we describe programmatic variability in clinical work expectations of 70 community-based PHM programs. We aimed to describe existing work models and expectations of community-based program leaders as they relate to their unique clinical setting.

We conducted a cross-sectional survey of community-based PHM site directors through structured interviews. Community hospital programs were self-defined by the study participants, although typically defined as general hospitals that admit pediatric patients and are not free-standing or children’s hospitals within a general hospital. Survey respondents were asked to answer questions only reflecting expectations at their community hospital.

Survey Design and Content

Building from a tool used by Fromme et al.⁶ we created a 12-question structured interview questionnaire focused on three areas: (1) full-time employment (FTE) metrics including definitions of a 1.0 FTE, “typical” shifts, and weekend responsibilities; (2) work volume including census parameters, service-line coverage expectations, back-up systems, and overnight call responsibilities; and (3) programmatic model including sense of sustainability (eg, minimizing burnout and attrition), support for activities such as administrative or research time, and employer model (Appendix).

We modified the survey through research team consensus. After pilot-testing by research team members at their own sites, the survey was refined for item clarity, structural design, and length. We chose to administer surveys through phone interviews over a traditional distribution due to anticipated variability in work models. The research team discussed how each question should be asked, and responses were clarified to maintain consistency.

Survey Administration

Given the absence of a national registry or database for community-based PHM programs, study participation was solicited through an invitation posted on the American Academy of Pediatrics Section on Hospital Medicine (AAP SOHM) Listserv and the AAP SOHM Community Hospitalist Listserv in May 2018. Invitations were posted twice at two weeks apart. Each research team member completed 6-19 interviews. Responses to survey questions were recorded in REDCap, a secure, web-based data capture instrument.⁸

Participating in the study was considered implied consent, and participants did not receive a monetary incentive, although respondents were offered deidentified survey data for participation. The study was exempted through the University of Chicago Institutional Review Board.

Data Analysis

Employers were dichotomized as community hospital employer (including primary community hospital employment/private organization) or noncommunity hospital employer (including children’s/university hospital employment or school of medicine). Descriptive statistics were reported to compare the demographics of two employer groups. P values were calculated using two-sample t-tests for the continuous variables and chi-square or Fisher-exact tests for the categorical variables. Mann–Whitney U-test was performed for continuous variables without normality. Analyses were performed using the R Statistical Programming Language (R Foundation for Statistical Computing, Vienna, Austria), version 3.4.3.

Participation and Program Characteristics

We interviewed 70 community-based PHM site directors representing programs across 29 states (Table 1) and five geographic regions: Midwest (34.3%), Northeast (11.4%), Southeast (15.7%), Southwest (4.3%), and West (34.3%). Employer models varied across groups, with more noncommunity hospital employers (57%) than community hospital employers (43%). The top three services covered by pediatric hospitalists were pediatric inpatient or observation bed admissions (97%), emergency department consults (89%), and general newborns (67%). PHM programs also provided coverage for other services, including newborn deliveries (43%), Special Care Nursery/Level II Neonatal Intensive Care Unit (41%), step-down unit (20%), and mental health units (13%). About 59% of programs provided education for family medicine residents, 36% were for pediatric residents, and 70% worked with advanced practice providers. The majority of programs (70%) provided in-house coverage overnight.

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Clinical Work Expectations and Employer Model

Clinical work expectations varied broadly across programs (Table 2). The median expected hours for a 1.0 FTE was 1,882 hours per year (interquartile range [IQR] 1,805, 2,016), and the median expected weekend coverage/year (defined as covering two days or two nights of the weekend) was 21 (IQR 14, 24). Most programs did not expand staff coverage based on seasonality (73%), and less than 20% of programs operated with a census cap. Median support for nondirect patient care activities was 4% (IQR 0,10) of a program’s total FTE (ie, a 5.0 FTE program would have 0.20 FTE support). Programs with community hospital employers had an 8% higher expectation of 1.0 FTE hours/year (P = .01) and viewed an appropriate pediatric morning census as 20% higher (P = .01; Table 2).

Program Sustainability

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To our knowledge, this study is the first to describe clinical work models exclusively for pediatric community hospitalist programs. We found that expectations for clinical FTE hours, weekend coverage, appropriate morning census, support for nondirect patient care activities, and perception of sustainability varied broadly across programs. The only variable affecting some of these differences was employer model, with those employed by a community hospital employer having a higher expectation for hours/year and appropriate morning pediatric census than those employed by noncommunity hospital employers.

With a growing emphasis on physician burnout and career satisfaction,^9-11 understanding the characteristics of community hospital work settings is critical for identifying and building sustainable employment models. Previous studies have identified that the balance of clinical and nonclinical responsibilities and the setting of community versus university-based programs are major contributors to burnout and career satisfaction.^9,11 Interestingly, although community hospital-based programs have limited FTE for nondirect patient care activities, we found that a higher percentage of program site directors perceived their program models as sustainable when compared with university-based programs in prior research (63% versus 50%).⁶ Elucidating why community hospital PHM programs are perceived as more sustainable provides an opportunity for future research. Potential reasons may include fewer academic requirements for promotion or an increased connection to a local community.

We also found that the employer model had a statistically significant impact on expected FTE hours per year but not on perception of sustainability. Programs employed by community hospitals worked 8% more hours per year than those employed by noncommunity hospital employers and accepted a higher morning pediatric census. This variation in hours and census level appropriateness is likely multifactorial, potentially from higher nonclinical expectations for promotion (eg, academic or scholarly production) at school of medicine or children’s hospital employed programs versus limited reimbursement for administrative responsibilities within community hospital employment models.

There are several potential next steps for our findings. As our data are the first attempt (to our knowledge) at describing the current practice and expectations exclusively within community hospital programs, this study can be used as a starting point for the development of workload expectation standards. Increasing transparency nationally for individual community programs potentially promotes discussions around burnout and attrition. Having objective data to compare program models may assist in advocating with local hospital leadership for restructuring that better aligns with national norms.

Our study has several limitations. First, our sampling frame was based upon a self-selection of program directors. This may have led to a biased representation of programs with higher workloads motivated to develop a standard to compare with other programs, which may have potentially led to an overestimation of hours. Second, without a registry or database for community-based pediatric hospitalist programs, we do not know the percentage of community-based programs that our sample represents. Although our results cannot speak for all community PHM programs, we attempted to mitigate nonresponse bias through the breadth of programs represented, which spanned 29 states, five geographic regions, and teaching and nonteaching programs. The interview-based method for data collection allowed the research team to clarify questions and responses across sites, thereby improving the quality and consistency of the data for the represented study sample. Finally, other factors possibly contributed to sustainability that we did not address in this study, such as programs that are dependent on billable encounters as part of their salary support.

As a newly recognized subspecialty, creating a reference for community-based program leaders to determine and discuss individual models and expectations with hospital administrators may help address programmatic sustainability. It may also allow for the analysis of long-term career satisfaction and longevity within community PHM programs based on workload. Future studies should further explore root causes for workload discrepancies between community and university employed programs along with establishing potential standards for PHM program development.

Acknowledgments

We would like to thank the Stanford School of Medicine Quantitative Sciences Unit staff for their assistance in statistical analysis.

Disclosure

The authors have nothing to disclose.

Facilitators: Christopher Russo, MD, FAAP, Laura Hodo, MD, and Lauren Wilson, MD

This session discussed ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool that can be used beyond the session. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.

During the didactic session a general background of importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy”, “exposure to different career paths”, and “transfer decision-making”.

Some of the challenges discussed in regards to developing an educational structure in community settings included:

1. Logistics

   • Making the case for education
   • Legal framework (i.e. Affiliation agreements, Liability)
   • Finances (i.e. GME funding)
   • Paperwork burden (ex. Licensing, Credentialing)

2. Learning Environment

   • Complementing clinical work with materials
   • Autonomy/Supervision balancing
   • Developing Clinical teachers

The didactic session also reviewed the 6 steps for curriculum development: General Needs Assessment, Targeted Needs Assessment, Goals and Objectives, Educational Strategies, Implementation, and Evaluation/Feedback. Each of these was described in further detail with relevant examples.

Groups were broken out into small groups based on four learner types: Medical Students, Family Medicine Residents, Pediatric Residents, and PHM Fellows. Within each group a “Program Development Matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.

A separate “Curriculum Development Matrix” was utilized during breakout groups that focused on curriculum development. This matrix was broken into 3 areas: Educational Strategies, Implementation, and Evaluation/Feedback. These were broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short and long term goals with action steps for both of these matrix subgroups.

Overall the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools to develop a needs assessment and planning to achieve the defined goals that can be readily used by sites who wish to develop or improve their current educational framework.

Facilitators: Christopher Russo, MD, FAAP, Laura Hodo, MD, and Lauren Wilson, MD

This session discussed ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool that can be used beyond the session. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.

During the didactic session a general background of importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy”, “exposure to different career paths”, and “transfer decision-making”.

Some of the challenges discussed in regards to developing an educational structure in community settings included:

1. Logistics

   • Making the case for education
   • Legal framework (i.e. Affiliation agreements, Liability)
   • Finances (i.e. GME funding)
   • Paperwork burden (ex. Licensing, Credentialing)

2. Learning Environment

   • Complementing clinical work with materials
   • Autonomy/Supervision balancing
   • Developing Clinical teachers

The didactic session also reviewed the 6 steps for curriculum development: General Needs Assessment, Targeted Needs Assessment, Goals and Objectives, Educational Strategies, Implementation, and Evaluation/Feedback. Each of these was described in further detail with relevant examples.

Groups were broken out into small groups based on four learner types: Medical Students, Family Medicine Residents, Pediatric Residents, and PHM Fellows. Within each group a “Program Development Matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.

A separate “Curriculum Development Matrix” was utilized during breakout groups that focused on curriculum development. This matrix was broken into 3 areas: Educational Strategies, Implementation, and Evaluation/Feedback. These were broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short and long term goals with action steps for both of these matrix subgroups.

Overall the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools to develop a needs assessment and planning to achieve the defined goals that can be readily used by sites who wish to develop or improve their current educational framework.

Facilitators: Christopher Russo, MD, FAAP, Laura Hodo, MD, and Lauren Wilson, MD

This session discussed ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool that can be used beyond the session. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.

During the didactic session a general background of importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy”, “exposure to different career paths”, and “transfer decision-making”.

Some of the challenges discussed in regards to developing an educational structure in community settings included:

1. Logistics

   • Making the case for education
   • Legal framework (i.e. Affiliation agreements, Liability)
   • Finances (i.e. GME funding)
   • Paperwork burden (ex. Licensing, Credentialing)

2. Learning Environment

   • Complementing clinical work with materials
   • Autonomy/Supervision balancing
   • Developing Clinical teachers

The didactic session also reviewed the 6 steps for curriculum development: General Needs Assessment, Targeted Needs Assessment, Goals and Objectives, Educational Strategies, Implementation, and Evaluation/Feedback. Each of these was described in further detail with relevant examples.

Groups were broken out into small groups based on four learner types: Medical Students, Family Medicine Residents, Pediatric Residents, and PHM Fellows. Within each group a “Program Development Matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.

A separate “Curriculum Development Matrix” was utilized during breakout groups that focused on curriculum development. This matrix was broken into 3 areas: Educational Strategies, Implementation, and Evaluation/Feedback. These were broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short and long term goals with action steps for both of these matrix subgroups.

Overall the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools to develop a needs assessment and planning to achieve the defined goals that can be readily used by sites who wish to develop or improve their current educational framework.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.