Pediatrics Preoperative Evaluation

Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]

One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]

Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]

In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.

In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.

METHODS

RESULTS

Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.

Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.

Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.

DISCUSSION

This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.

The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.

We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.

We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.

Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]

CONCLUSIONS

A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.

Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]

One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]

Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]

In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.

In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.

METHODS

RESULTS

Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.

Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.

Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.

DISCUSSION

This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.

The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.

We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.

We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.

Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]

CONCLUSIONS

A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.

Pediatric hospitalists are increasingly following their adult counterparts' lead in participating in comanagement programs with surgeons. In the 20112012 Society of Hospital Medicine survey of hospitalist practice models, 94% of adult hospitalists and 72% of pediatric hospitalists reported comanaging surgical patients.[1] Adult patients comanaged postoperatively have shown equivalent clinical outcomes with strong endorsement from nurses and surgeons in 1 study[2] and reduced morbidity, mortality, and length of stay in other studies.[3, 4]

One of the drivers of pediatric hospitalists comanaging surgical patients may be the increased complexity of hospitalized children.[5, 6, 7, 8] Two pediatric studies have assessed hospitalistsurgeon comanagement of medically complex children in the postoperative period. One study evaluating 14 patients undergoing spinal fusion surgery for neuromuscular scoliosis showed an association between pediatric hospitalist comanagement and a decreased length of stay, with decreased variability in postoperative length of stay.[9] A study of 207 medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis suggested an association between comanagement and reduced laboratory studies and parenteral nutrition but an initial increase in costs.[10]

Pediatric hospitalist programs have also followed adult programs' lead in evaluating surgical patients preoperatively. Studies of preoperative medical evaluations for adult surgical patients have reported mixed results, with improved use of recommended medical therapies, length of stay, and mortality postoperatively in 1 study,[11] whereas other studies have reported longer lengths of stay and higher costs.[12, 13] One adult study described a protocol‐based approach in which hospitalists coordinated pulmonary and cardiac evaluations for high‐risk spine patients but did not report any outcomes.[14] A pediatric study from the Netherlands described a multidisciplinary team approach to these patients, including both preoperative and postoperative evaluation, but did not include a hospitalist or general pediatrician nor present data on outcomes.[15]

In 2009, we began a hospitalist preoperative evaluation program for patients with neuromuscular scoliosis in anticipation of spinal fusion surgery. This program was established by the hospital administration in response to 2 sentinel events. Hospitalists, who had already begun comanaging surgical patients postoperatively, were required to see patients with neuromuscular scoliosis preoperatively. Hospitalists were felt to be knowledgeable about postoperative complications of spinal fusion surgery and were thought to perhaps be able to prevent certain postoperative complications.

In the current study, we sought to evaluate certain outcomes associated with this preoperative program. We hypothesized that evaluations for more complex patients would be more likely to be associated with preoperative changes. We evaluated how frequently hospitalists make recommendations for changes in patients' medical regimens or request further diagnostic evaluations and if any clinical characteristics were associated with hospitalists making these recommendations.

METHODS

RESULTS

Overall, 214 patients were included in our study. Typical patients included those with cerebral palsy scheduled to undergo posterior spinal fusion surgery. Many had significant comorbidities, including seizures and gastrointestinal (GI) disease, and were dependent on medical technology.

Regarding hospitalist recommendations, overall 155 patients (72%) received at least 1 recommendation. Types of recommendations are listed in Table 1. The most common type of recommendation regarding the patient's current regimen was medication change (82 patients, 38%). Recommendations for changes in nutrition were made in 46 patients (21%). Subspecialist input was elicited in 76 patients (36%); a subspecialist appointment was suggested most commonly (36 patients, 17%), whereas a telephone consultation occurred in 15 patients (7%). Hospitalists also frequently requested further diagnostic evaluation, especially laboratory studies (41 patients, 19%). Imaging studies were requested less frequently (11 patients, 5.1%) as were other studies such as electrocardiograms and pulmonary function tests (6 patients, 2.8%, each). No patient received a preoperative hospitalist recommendation to cancel or postpone surgery.

Certain patient characteristics were associated with a statistically significant increase in likelihood of a preoperative intervention by the pediatric hospitalist (Table 2). These included type of surgery (OR: 2.70, 95% CI: 1.22‐5.97 for posterior spinal fusion), number of preoperative prescription medications (OR: 1.19, 95% CI: 1.06‐1.34), and nonambulatory status (OR: 2.02, 95% CI: 1.09‐3.74). Underlying disease also showed a statistically significant association with recommendations being made; patients were more likely to receive recommendations if they had cerebral palsy (OR: 2.01, 95% CI: 1.03‐3.92), spina bifida (OR: 2.33, 95% CI: 1.90‐3.48), and neuropathy (all had recommendations). An underlying diagnosis of skeletal dysplasia was statistically significantly associated with a decreased rate of recommendations being made (OR: 0.29, 95% CI: 0.14‐0.61). Patients with seizures (OR: 2.68, 95% CI: 1.29‐5.57) or GI comorbidity were more likely to receive a preoperative recommendation made by the hospitalist (OR: 3.35, 95% CI: 1.74‐6.45), but patients with cardiac and pulmonary comorbidities were not.

DISCUSSION

This is the first large study to examine the role of the pediatric hospitalist in preoperative evaluation of complex surgical patients. Our program developed as an evolution of a postoperative program that we have described previously.[10] The postoperative component of our comanagement program began in 2003, and the preoperative aspect was added in 2009. We believe that the preoperative component to our program contributed in some degree to the decrease in utilization of certain aspects of postoperative care over time such as parenteral nutrition. This change may have occurred because of improved bowel management perioperatively, for instance. Although the preoperative hospitalist evaluation program was instituted by our hospital administration, we felt a preoperative hospitalist evaluation represented a standardized, comprehensive way to evaluate patients before surgery. By 2009, the hospitalists at our hospital had already developed some expertise in managing patients after undergoing spinal fusion surgery.

The fact that hospitalists made recommendations for changes in medications, nutritional management, or diagnostic tests at such a high rate (72%) is interesting. We were not surprised by this finding based on anecdotal evidence because we feel that many of these patients may receive somewhat fragmented care because they often see multiple medical specialists. The high rate of interventions noted in our study may result from the fact that hospitalists who comanage these patients frequently after spinal fusion surgery were attempting to prevent postoperative complications that they see after this type of surgery. Many pediatric hospitalists have developed significant experience in caring for medically complex children and thus may feel more comfortable making preoperative recommendations than other general pediatricians.

We were not surprised to find that hospitalists made preoperative recommendations more frequently in children who had seizures, significant GI comorbidity, and who were nonambulatory. We also noted a statistically significant increased rate of recommendations when patients were on more preoperative medications. We believe that these variables suggest a population that is more medically complex. The importance of selecting medically complex patients for hospitalist comanagement has been noted previously.[16] Therefore, comanagement programs looking to maximize patient benefit for a preoperative hospitalist evaluation program might limit these visits to those who are most medically complex. We found a particularly low yield in evaluation of patients with skeletal dysplasia for example and may discontinue seeing these patients preoperatively.

We found the lack of statistically significant change in rate of hospitalist recommendations among patients with cardiac and pulmonary comorbidities interesting. Whether this was related to the mandatory preoperative pulmonology and cardiology visits is not certain. We hope to study the impact of these preoperative visits in the future as we continue to evaluate our perioperative program.

Several limitations of this study deserve note. This study was performed at 1 institution with 1 group of hospitalists and 1 group of orthopedic surgeons. Two of the study authors (D.R. and D.P.) were among the hospitalists involved with the clinical program. The study was retrospective and nonrandomized. We did not contact primary care physicians as a rule for further information about these patients. In this study, we did not specifically study the impact of hospitalist preoperative evaluations on postoperative outcomes, although the preoperative component represented an important aspect of the more systematic intervention described elsewhere.[10]

CONCLUSIONS

A preoperative program for pediatric hospitalists to see children in anticipation of spinal surgery for neuromuscular scoliosis leads to a high rate of recommendations for changes in medical management or diagnostic evaluation. Certain patient characteristics are more highly associated with hospitalists making these recommendations prior to surgery.