EXECUTIVE SUMMARY

Some community hospitals that struggle to maintain a financially viable pediatric inpatient service have found success with a model that combines their pediatric inpatient unit with a pediatric ED. The approach was developed first at Howard County General Hospital in Columbia, MD, nearly two decades ago, and has been duplicated at other community hospitals in the state. Now, community hospitals elsewhere are taking a look. In addition to the financial benefits, users of this approach say that it can improve throughput while also boosting patient and provider satisfaction.

  • The concept involves placing the pediatric inpatient unit adjacent to the pediatric ED so that pediatric physicians and nurses can float between the two sides of the unit as needed, maximizing resources.
  • Although the approach initially takes volume away from the adult ED, administrators say hospitals generally replace this volume within two years.
  • Pioneers of the combined model note community hospitals must engage in at least 10,000-12,000 pediatric encounters in the ED every year for the combined pediatric inpatient unit/pediatric ED model to be successful.

Some community hospitals struggle to maintain service to pediatric inpatients, even as there may be a plentiful supply of pediatric visits to the ED. Part of the problem is that there often isn’t enough inpatient volume to financially sustain 24/7 coverage.

However, a hybrid pediatric inpatient unit/ED model has proven to be the solution for a number of hospitals in Maryland, and now some medical centers in other regions are taking a similar path.

Administrators who have implemented this type of combination pediatric inpatient/ED unit acknowledge that it requires high-level buy-in and initial investments in staffing as well as facility modifications in most instances. However, they also note that with patience, the model can deliver quicker door-to-provider times and enhanced satisfaction among both patients and unit staff.

Maximize Pediatric Resources

David Monroe, MD, an assistant professor of pediatrics at Johns Hopkins University School of Medicine in Baltimore and director of the Children’s Care Center at Howard County General Hospital in Columbia, MD, originally came up with the idea for the combined unit nearly two decades ago as a way to enable his community hospital to offer easily accessible, pediatric-focused inpatient and emergency care.

“Pediatric patients do have some very special needs compared with adult patients,” he explains. “While mixing [adults and children] has worked for a long time [in EDs] all across the country, it is not the ideal situation that parents and patients prefer.”

Monroe acknowledges that the extended region surrounding Howard County General Hospital does not suffer from a lack of pediatric resources. He notes, for example, that there are three large, academic medical centers that offer a range of pediatric inpatient and emergency services, but to access these services families must drive 40 minutes. Monroe wanted to offer good inpatient and emergency pediatric care to families in their own communities.

Today, the combination unit at Howard County General Hospital consists of 12 emergency beds and six inpatient beds, and staff treat roughly 18,000 patients in the ED every year.

Most of the providers are pediatricians, although roughly 20% are pediatricians with emergency training as well. The nurses all specialize in pediatrics. The staff can float between the inpatient and emergency sides of the unit as needed, maximizing resources, Monroe explains.

“Since it is the same staff taking care of the admitted patients and the emergency patients, the transition to inpatient care is very smooth and time delays are much shorter,” Monroe observes. “One of the things that everyone who works in emergency medicine knows is that one of the potential pitfalls has to do with handoffs, and this eliminates the very first, critical handoff from emergency care to the first several hours of inpatient care.”

Now in place for nearly 20 years, the combination pediatric inpatient unit/pediatric ED has demonstrated that it is financially viable. Indeed, Monroe and colleagues have published findings on this aspect, showing that the approach offers a cost-effective way to maintain pediatric emergency and inpatient services in community hospitals with lower inpatient volumes.1

However, Monroe notes that the model is not necessarily a good fit for all community hospitals.

“You have to be able to estimate that you have at least 10,000 to 12,000 annual pediatric ED visits,” he says. “If you aren’t getting to those numbers, then you are probably going to have a hard time making your budget.”

Minimize Testing, Unnecessary Treatment

Since Monroe established the first combination unit of this type at Howard County General Hospital in 1997, several other community hospitals in Maryland have adopted the model as well. For instance, Anne Arundel Medical Center, a 380-bed hospital in Annapolis, MD, implemented the model in 2011.

“One of the motivators is to find a more cost-effective way to keep the pediatric inpatient unit open, and the way you do that is you use the same pediatrician to not only take care of those inpatients, but also to see emergency patients,” explains Michael Clemmens, MD, the director of pediatrics at Anne Arundel Medical Center. “I think the genius of David Monroe is that he said we just need to put everything geographically together and have the pediatric ED contiguous with the pediatric inpatient, and then we can just use the same physician on both sides of the road.”

However, Clemmens notes that the financial case for the combination unit was not the only reason his hospital made the change. For instance, he explains that while emergency medicine clinicians in the hospital’s main ED were doing a fine job taking care of children, the thinking was that clinicians with child-specific training could bring added value to the table.

“The vast majority of what comes into an ED from a pediatric standpoint isn’t necessarily a true medical emergency. There are a lot of urgent care [cases] and a lot of worried well,” Clemmens observes. “What we saw was that when kids came in critically ill, the emergency medicine doctors were superb at resuscitating them and caring for them. There were, however, lots of kids who came in not so sick who got lots and lots of testing and treatment. And our experience was that pediatricians tended to do less, both from a diagnostic and therapeutic standpoint.”

For example, Clemmens notes that a 1-year-old child exhibiting very fussy behavior might present with a fever of 105. In one instance, the child might undergo a blood test and a spinal tap, and in another instance the child might just receive a pain reliever and a chance to take a nap, after which the fever subsides and the fussiness dissipates, he says. Ultimately, the child is diagnosed with a nasty virus.

“Our hope [in implementing this combination unit] was to minimize testing and unneeded treatment, and we thought pediatricians were in the best position to do that,” notes Clemmens, although he adds that most of the providers staffing the unit are pediatricians with experience in emergency care. “The vast majority of pediatric EDs in the state of Maryland where this combined model is most prevalent are not double-boarded [in pediatrics and emergency medicine], but they are pediatricians with an interest and experience in emergency care, and that is who we staff with.”

The unit uses both inpatient and emergency nurses, but they are “first and foremost” pediatric nurses, Clemmens notes.

“Many have experience in critical care or pediatric emergency medicine at tertiary care centers, and some are pediatric inpatient nurses who receive some extra training to be able to take care of kids in the pediatric ED,” he says.

While implementing the combined unit, hospital administrators wanted to provide a child-friendly environment for young patients so that that they would not have to share the same space with older patients experiencing heart attacks, strokes, or substance use problems.

“We didn’t think that was the right environment for little kids. We felt like they deserved their own space,” Clemmens explains.

Crosstrain Staff

Today, all patients under 18 years of age are treated in the pediatric ED, including patients who are brought in by ambulance and those who are critically ill.

“We stabilize them, and if they need pediatric intensive care, then — because we don’t have that at our hospital — we transfer them to [a larger facility] in Baltimore or Washington, DC,” Clemmens says.

The combined unit is able to offer 24-hour coverage, including 16 hours per day of double coverage.

“At 8:00 in the morning, two physicians come in and relieve the night crew, and one of those physicians handles the eight inpatient beds and does inpatient rounding, and the other physician handles the eight emergency beds,” Clemmens shares. “When the first physician is finished with his inpatient duties, he will join the emergency physician in caring for kids on the emergency side, usually as we get into the noon hour when traffic in the ED picks up.”

This double coverage typically remains until midnight, when the two physicians sign out patients on both the inpatient and ED side to a single physician who will cover the combined unit until 8 a.m.

On a given shift, nurses will be assigned to work on either the inpatient or emergency side of the unit, but Clemmens notes that they are all cross-trained and fully capable of pitching in on the other side, if needed.

“If things fall apart on the ED side and it is all quiet on the inpatient side, then that inpatient nurse can just step across the hall and start doing emergency work,” he says. “Likewise, if the inpatient side is extremely heavy, an emergency nurse could help out on that side.”

There is both a triage nurse and a charge nurse in the unit for 16 hours a day; in the overnight hours, there is usually a combined triage/charge nurse, Clemmens explains. “The majority of pediatric patients come in between noon and midnight, with evenings being particularly busy after pediatric offices are closed and parents pick their kids up from day care and school,” he says. “The period between 3:00 in the afternoon until 11:00 in the evening is particularly busy.”

In a typical day, 50-60 kids will visit the pediatric ED, although summers tend to be quiet, while traffic picks up considerably in the winter, Clemmens observes.

“We saw 18,000 kids last year,” he adds.

Consider Effect on Adult ED Volume

As with all EDs, there are plans in place to handle volume surges to the pediatric ED. For instance, Clemmens notes that one treatment room and one triage room can be converted into additional patient care rooms.

“[Also,] we have two rooms that can divide in half and be used as fast-track rooms, so basically we can turn two beds into four beds,” he says. “Then, we can also capture empty inpatient rooms and use those as emergency beds, if they are available.”

Another surge option involves sharing some of the patient volume with the adult ED at the hospital. With the adult ED’s approval, the pediatric ED can lower the age threshold for patients so that the adult ED sees kids from ages 14-18 while the pediatric ED sees all children under the age of 14.

“We will take care of the younger kids until the volume is acceptable, and then we will move the age threshold back up to 18 again,” Clemmens says.

Although Clemmens does not own an array of metrics to document the effects of the combined unit on patient care, it seems clear that the approach has been a winner with patients and families.

“Our pediatric volumes have gone up 40% [since the unit was instituted in 2011],” he says. “The community has embraced us, and we are seeing kids from farther geographic regions whose families are willing to make the drive to come see us.”

Clemmens acknowledges, however, that higher volume in the pediatric ED typically means lower volume in the adult ED — at least initially. In fact, that reality was a significant concern among the physicians and leaders in the adult ED when the idea for the unit was first discussed. Fortunately, such concerns eased soon after the combined pediatric ED/inpatient unit was implemented.

“We took 20% of the emergency medicine group’s business, but they were able to open up space, reduce wait times, and then backfill that 20%, so their patient volume actually stayed the same,” Clemmens says.

However, some of the emergency physicians had other concerns as well.

“The emergency physicians didn’t necessarily want to give up the opportunity to provide clinical care to kids,” Clemmens notes. “They had been trained to take care of emergently ill kids, and if they didn’t get to do it, [they were worried that] they would lose their skills.”

Clemmens was able to work through this problem by enabling emergency physicians to work in the pediatric ED during the hours when there is double coverage.

“Those who are interested come and work with us,” he says.

Concept Attracts Interest

While the combination pediatric inpatient unit/pediatric ED concept has proliferated at community hospitals in Maryland, there has been no large-scale move to adopt the model in other states. However, there has been interest. In fact, Nash UNC Health Care is in the process of implementing the concept at Nash General Hospital, a 232-bed hospital in Rocky Mount, NC.

Badie Clark, MD, the medical director of inpatient pediatrics and neonatology at Nash UNC Health Care, explains that many different factors contributed to the decision to adopt the concept, but it is an attempt to fill a void that became apparent when local pediatricians elected to give up their inpatient practice two or three years ago.

“The hospital did not have a dedicated pediatric service like most community hospitals, so the pediatricians would admit their patients to the hospital and round on them,” he says.

The hospital moved to bring in a hospitalist service to handle inpatient pediatrics, but it has not been financially self-sustaining.

“Some community hospitals have had this problem where the inpatient census is up and down, it is seasonal, and it is just really expensive, and it was pretty evident early on that it was not going to be cost-effective,” Clark observes. “Intake for pediatrics is a service to the community, and it is certainly difficult to even break even.”

At the same time, though, demand for emergency care at the hospital is robust. In fact, the hospital recently built a new ED facility along with an adjacent pediatric ED, although staffing at the pediatric ED has been a struggle, according to Clark.

Determined to find a better way to move forward, Clark learned about the combination pediatric inpatient unit/pediatric ED model used in Maryland, and was intrigued.

“We’ve got the perfect setup. We have a pediatric ED that is not staffed properly, and we are struggling on the inpatient side because it is just a big money pit ... and it has to be subsidized,” he explains. “It seemed like the community hospitals [using the combination model in Maryland] are comparable to our hospital.”

After corresponding with Monroe from Howard County General Hospital, as well as administrators from some of the other community hospitals in Maryland that are utilizing the combination model, Clark organized a trip to Maryland to tour several of these hospitals and see the model firsthand. He brought with him the ED director, the nursing director, and chief medical officer from Nash General Hospital so that they could have a look as well.

“We spent two days [in Maryland], got a lot of good information, and came back thinking this was a good fit for us,” Clark says. “We haven’t converted [to the combination model] just yet, but we are in the planning stages.”

Initially, Clark notes there will be some geographic challenges.

“The pediatric ED is a new facility, and we didn’t build it as such to meet all the requirements of an inpatient facility, so there will have to be some modifications,” he explains. “We will probably function initially in two different areas — where the existing pediatric ward is and the existing pediatric ED, so it probably won’t be a true combined unit [just yet]; it will be a combined service.”

Reach Out to Referral Base

As the service grows, the required modifications to the pediatric ED will be made, Clark notes, but the model must show some results first.

“We will have to demonstrate some productivity and sustainability before we move to the construction to convert,” Clark explains

In addition to the financial benefits of operating a combined service, Clark also expects the approach to make a dent in nursing turnover.

“We have lost a lot of pediatric nurses because when our pediatric ward becomes an overflow space for adult medicine, they have to take care of a lot of adult patients, which causes job dissatisfaction,” he says. “When you have a core group of pediatric nurses who can work in either the pediatric ED or on the pediatric inpatient side, there should be better satisfaction and probably better retention.”

Currently, the pediatric ED averages 40-60 patients a day or about 15,000 per year, well within the threshold that Monroe considers necessary for the combined model to be successful, Clark notes.

“We are solid on our patient encounters, and if we can get our ED staffed 24/7 with pediatricians, we are actually going to get people who are now driving elsewhere for their care to come to our facility,” he says.

First, Clark is focused on winning back the support of local pediatricians, many of whom commonly admit patients to academic medical centers that are one or two hours away.

“I am hoping if we can get staffed with good pediatricians and then we provide good care, the local pediatricians will buy back into this,” he says.

Indeed, Monroe notes that community hospitals that are interested in pursuing the establishment of a combined pediatric inpatient unit/pediatric ED should make it a priority to win the support of their referral base early.

“Absolutely reach out to them before doing anything else, and continue that dialogue while you are open,” he says. “That is a large group of people that have specific needs, and that is your referral base. You need their input and support, so making sure there is really good community outreach and good community contact the whole time is critical.”

Monroe also stresses that hospitals should be prepared to commit adequate resources and staffing to the project from the very beginning, even if this requires some subsidization in the early stages.

“Patients and families have choices, and they will go to places that are delivering what they want,” he says. “Make sure the hospital administration is on board.”

Further, Monroe has found that nurturing a really good relationship with the most frequently used surgical subspecialists is critical, especially pediatric surgery and orthopedic surgery.

“If one doesn’t have that early, it makes caring for surgical emergencies much more difficult,” he says.

One new change coming to the combined unit at Howard General Hospital is the addition of four beds in the ED to accommodate pediatric mental health patients.

“There is an increase in the need for mental health services,” Monroe explains.

REFERENCE

1. Dudas RA, Monroe D, McColligan B. Community pediatric hospitalists providing care in the emergency department: An analysis of physician productivity and financial performance. Pediatr Emerg Care 2011;11:1099-1103.

SOURCES

  • Badie Clark, MD, Medical Director, Inpatient Pediatrics and Neonatology, Nash UNC Health Care, Rocky Mount, NC. Email: badie.clarkiii@unchealth.unc.edu.
  • Michael Clemmens, MD, Director of Pediatrics, Anne Arundel Medical Center, Annapolis, MD. Email: mclemmens@despamd.com.
  • David Monroe, MD, Assistant Professor of Pediatrics, Johns Hopkins University School of Medicine, Baltimore; Director, The Children’s Care Center, Howard County General Hospital, Columbia, MD. Email: davidmonroemd@gmail.com.