Winter 2005

Hospitalists Knit Together Inpatient Care

When a child is checked into a hospital for a complex disorder, the patient is likely to be seen by a steady stream of specialists, each one focusing on a particular area of expertise. On any given day, the child might see a neurologist, a pulmonologist, a nephrologist, a physical therapist and any variety of other health care workers.

Using a model that has proven successful for adult hospital patients, pediatricians specializing in hospital-based care — pediatric hospitalists — have an increasingly important role in coordinating all aspects of a child's care at UCSF Benioff Children's Hospital. "We are a natural extension of the primary care pediatrician while his or her patient is in the hospital. As generalists, we share the same global, holistic approach to children," says pediatrician Stephen Wilson, M.D., Ph.D., who co-leads the pediatric hospitalist program with pediatrician Timothy Kelly, M.D. "We also act like team captains, helping facilitate the complex interaction of specialists and hospital systems to provide the highest level of coordinated care."

The term "hospitalist" was introduced into the medical literature in 1996 by UCSF physicians Robert Wachter, M.D., and Lee Goldman, M.D. They pointed out that patients were increasingly cared for by teams of specialists who tended to focus solely on their areas of expertise. This team approach is becoming more and more common as care has become more complex and as financial pressures have pushed all but the sickest patients into the outpatient setting. Hospitalists bring a generalist back into the picture, not as just one more member of the team, but as the coordinator whose role is to see the forest along with the trees.

In addition to taking an overall, holistic view of the child's care, hospitalists are familiar with the roles of hospital personnel and how hospital systems are integrated. Children need hospitalists even more than adult patients, says Wilson. "In pediatric patients, the difference between inpatients and outpatients is even more distinct than for adults," he says. "Hospitalized children tend to have acute conditions that are rare for outpatient doctors to see, and the issues involved in mobilizing all aspects of hospital-based care have become harder for pediatricians to oversee from their offices."

Pediatric hospitalists at UCSF Benioff Children's Hospital are responsible for a substantial proportion of patients in the pediatric acute care units. They also serve as a central point of access and consultation for physicians calling to admit patients. Another important role is to provide procedural sedation to make tests and procedures less painful or frightening for children. "We work with anxiolytics and pain medications, and we work with Child Life services, who provide non-drug solutions like guided imagery or self hypnosis," Wilson says.

When it's time for a child to be discharged, the hospitalists help with the transition back to the primary doctor and coordinate post-discharge care. "We set up home nursing, provide education regarding new equipment and medications, and make ourselves available to patients and primary physicians to deal with questions that come up after discharge," Wilson says. "We also dictate a summary and transmit it to the primary physician within 48 hours for every discharged patient, and make it a point to call the primary physician, when indicated, to make sure that the transition of care is smooth for both the patient and the doctor."

In the future, says Kelly, hospitalists will likely move from being coordinators to being the central figures in a hospitalized child's care. "We would become the primary source of care, with specialists consulting," Kelly says. "That's what the adult model looks like already."

For more information, contact Dr. Wilson or Dr. Kelly at (415) 476-5943.

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