Pediatric hospitalists in Canada and the United States: a survey of pediatric academic department chairs.

OBJECTIVES: To document the prevalence and practice patterns of pediatric hospitalists in academic centers in Canada and the United States; to characterize academic pediatric department chairs' definition of the term hospitalist; and to characterize pediatric department chairs' views of the training requirements for pediatric hospitalists. METHODS: A 14-item questionnaire was sent to all 145 pediatric department chairs from Canada and the United States during the fall of 1998. We defined hospitalists as physicians spending at least 25% of their time in inpatient care. RESULTS: Of the 145 eligible pediatric chairs, 128 (89%) responded (United States, 111/126; Canada, 14/16; Puerto Rico, 3/3). Ninety-nine (77%) of 128 pediatric chairs either have (64/128) or are planning to have (35/128) hospitalists in their institutions. Within academic programs with hospitalists, 82% of hospitalists currently work on general pediatric wards. Two thirds of hospitalists teach, 50% provide outpatient care, 50% have administrative duties, and 44% conduct research. One hundred eight (84%) of 128 believe that hospitalists should spend at least 50% of their time in inpatient care. Less than one third (30%) of pediatric chairs believe that hospitalists require training not currently provided in residency. CONCLUSIONS: A large proportion of academic pediatric centers either employed or planned to employ hospitalists in 1998. Pediatric academic department chairs do not see a need for training beyond residency for hospitalists. Further studies should address how pediatric hospitalists affect quality of care, cost, and patient satisfaction.

Effect of a reduced postpartum length of stay program on primary care services use by mothers and infants.

OBJECTIVE: To determine the impact of reduced postpartum length of stay (LOS) on primary care services use. METHODS. DESIGN: Retrospective quasiexperimental study, comparing 3 periods before and 1 period after introducing an intervention and adjusting for time trends. SETTING: A managed care plan. INTERVENTION: A reduced obstetrical LOS program (ROLOS), offering enhanced education and services. PARTICIPANTS: mother-infant dyads, delivered during 4 time periods: February through May 1992, 1993, and 1994, before ROLOS, and 1995, while ROLOS was in effect. INDEPENDENT MEASURES: Pre-ROLOS or the post-ROLOS year. OUTCOME MEASURES: Telephone calls, visits, and urgent care events during the first 3 weeks postpartum summed as total utilization events. RESULTS: Before ROLOS, LOS decreased gradually (from 51.6 to 44.3 hours) and after, sharply to 36.5 hours. Although primary care use did not increase before ROLOS, utilization for dyads increased during ROLOS. Before ROLOS, there were between 2.37 and 2.72 utilization events per day; after, there were 4.60. Well-child visits increased slightly to.98 visits per dyad, but urgent visits did not. CONCLUSION: This program resulted in shortened stays and more primary care use. There was no increase in infant urgent primary care utilization. Early discharge programs that incorporate and reimburse for enhanced ambulatory services may be safe for infants; these findings should not be extrapolated to mandatory reduced LOS initiatives without enhancement of care.

The challenges of automating a real-time clinical practice guideline.

OBJECTIVE: To elucidate the types of problems encountered during implementation of a World Wide Web-based clinical practice guideline to manage hyperbilirubinemia in newborn infants. DESIGN: Formative assessment of an automated clinical-practice guideline in a large-scale implementation. SETTING: Primary-care clinics and offices, inpatient clinics, and emergency department affiliated with an academic children's hospital. PARTICIPANTS: General pediatricians, neonatologists, pediatric nurses, and computer scientists. RESULTS: Existing guidelines for hyperbilirubinemia management could not be translated directly into web pages. Modifications of the original guidelines were required to represent the clinical intent of the guidelines accurately. In addition, the automated guideline was augmented to incorporate a mechanism for generating clinical encounter forms in order for the system to be accepted into the clinical work flow. Other clinical considerations that influenced the final form of the automated guideline included limitations of computer resources and time constraints during patient encounters. CONCLUSIONS: Many existing guidelines are not amenable to straightforward implementation in automated systems. Strategies to increase the efficacy of the automated guidelines included guideline modifications, as well as careful consideration of the flow of clinical work. Repeated cycles of development and pilot testing are needed to design methods to accommodate the constraints imposed by clinical use.

Linking multiple heterogeneous data sources to practice guidelines.

The BiliLIGHT system is a World Wide Web (Web) based system that integrates an interactive clinical practice guideline with real-time patient-data retrieval from remote heterogeneous data sources to help clinicians manage newborn jaundice at the point of care in three clinical settings. We briefly describe the system, how actual information exchange of medical data across institutional boundaries was achieved, and how the data were connected to a CPG. In particular, we examine the requirements for patient identification, exchange protocols, authentication, and a standard vocabulary.