On the Front Lines of Pediatric Complex Care: Are We Preparing Emergency Medicine Residents?

On another typical call night at the hospital, I open up the emergency department (ED) board and recognize a familiar name: “Emma, 4-year-old female in respiratory distress.” A moment later, my pager buzzes: “Please call back regarding a consultation and potential admission.” Emma, well-known to our institution, is a 4-year-old girl with methylmalonic acidemia who is tracheostomy-dependent, ventilator-dependent, and gastrostomy tube–dependent, and nights like tonight are all too familiar for her and her mother. Emma’s story began not here with us, but rather, 4 years ago and 50 miles away in a community hospital ED, as 2 frightened first-time parents stood in the waiting room holding their four-day-old infant girl. All had been well during the pregnancy and nursery stay, but by her third day of life, Emma had become more and more difficult to rouse to feed. Her breathing had begun to appear labored, and her body seemed limp. This family, who had never had occasion to visit their local ED, found themselves suddenly surrounded by a team of physicians and nurses with worried expressions. The team had worked earnestly to stabilize her, first treating her glucose level of 24 mg/dL and bicarbonate level of 5 mmol/L and ultimately intubating her when her breathing became too rapid to support oxygenation. After she failed to improve despite the initial resuscitation, the ED physicians had consulted the in-house pediatric hospitalist, who had requested an ammonia level, which returned at 480 μg/dL. The hospitalist had recommended changing the fluids to include dextrose 10%, increasing the rate to suppress catabolism, and finally transferring Emma to the quaternary care pediatric center where I work and where Emma now gets most of her care.

Tonight, Emma’s mother had had to make a difficult decision, should she call 9-1-1 and be brought back to that nearby ED where her story began, or should she drive the 50 miles to our center and hope Emma’s breathing does not get worse along the way? She knows that the community ED likely will not have access to her full medical record or to subspecialty consultants, but she would be able to get care for her medically fragile child right away. Community ED physicians like the ones in Emma’s neighborhood will care for complex pediatric patients every day, both before and after their diagnoses are made, in the face of limited resources. Access to nearby and prompt emergency care is vital for children who are medically complex. It is incumbent on emergency medicine (EM) training programs to ensure that their graduates are appropriately prepared to care for this growing patient population in all clinical contexts. The field of pediatric hospital medicine (PHM) is in a time of growth and redefinition of our role within the health care system. Hospitalists are well poised to aid not only in the acute care of these patients in community and quaternary care EDs but also in the education of our EM trainees.

Children with medical complexity (CMC) are defined as having at least 1 chronic and severe clinical diagnosis that leads to functional impairment, significant family-identified health care service needs, and high health care use.¹ These patients compose up to one-third of all pediatric health care spending.² Chronic illness accounts for the majority of all pediatric inpatient days, and the proportion of inpatient care provided to children who are medically complex is increasing over time.^3,4,5 Pediatric hospitalists play an ever-growing role in the care of CMC, often serving as the leader and coordinator of a team of physicians and other care providers.⁶ Fittingly, the topic of CMC has been emphasized as an Accreditation Council for Graduate Medical Education program requirement in training PHM fellows and is 1 of the 13 core content domains represented on the PHM board certification examination.^7,8

With the rise of medical home–based comprehensive care models, the care of CMC is frequently centralized within tertiary and quaternary care centers.^9–12 However, many children do not live near these centers.¹³ Even children who receive much of their care at specialty centers may, at times, present to community EDs first because of the severity of their illness or the geographic distance from a pediatric hospital. In 1 study, the absolute number of pediatric visits by children with at least 1 complex condition was almost 6 times higher in general EDs compared with pediatric EDs (2 711 289 vs 465 137 visits).¹⁴ These encounters may present opportunities for CMC to receive more aspects of the care they need within their own communities, but the resources available to care for CMC at community and general EDs are highly variable. Some of these EDs have access to experienced community pediatric hospitalists, whereas others lack dedicated 24-hour pediatric support, much less the availability of pediatric subspecialists. When available, pediatric emergency medicine (PEM) faculties are ideally suited to care for CMC because their board certification requires knowledge of pertinent topics, such as transplant medicine, chronic illnesses, and technology dependence.¹⁵ However, there are only an estimated 1.6 PEM-trained physicians per 100 000 people in the United States, and their geographic distribution is heavily concentrated in urban settings.¹⁶ Only 23% of EDs in the United States have PEM coverage, and 40% of EDs have pediatric coverage. Even among children’s hospitals, not all ED providers have PEM training, so CMC arriving in the ED may be triaged and stabilized by EM physicians first.¹⁶

Because of fragmented care, parents report taking on the burden of coordinating their child’s care to bridge the informational discontinuity between systems.¹⁷ One existing means of aiding EM physicians in the care of CMC is with emergency information forms (EIFs), which summarize the patient’s medical history and recommend management strategies.¹⁸ EIFs can serve as an educational tool for EM residents as well as a management tool for all ED physicians and have been shown to improve performance in simulated ED scenarios of CMC by trainees and attending physicians.¹⁹ However, EIFs have limitations: they may not be available in emergent situations if the medical record has a different platform or if families do not have copies with them, they may not be updated regularly, and although they include many likely emergencies, they do not include all possible clinical scenarios for which a patient may present to the ED. Thus, competency in the care of CMC in the acute setting is a necessity for all EM trainees. Although all EM residency programs require training in the care of pediatric patients, the training dedicated specifically to the care of CMC is variable because there is no standardized curriculum.¹⁶ Furthermore, the care of CMC is not specifically addressed in the content specifications for the EM board certification examination.²⁰

To better assess this knowledge gap, we surveyed the ED residents at 2 local institutions that are nonfreestanding children’s hospitals. In both groups, ED residents overall described a lack of confidence in caring for CMC; on a 5-point Likert scale in which 1 represents not at all confident and 5 represents very confident, the mean confidence reported was 2.4 (SD = 1; n = 44). Specific clinical scenarios related to the care of CMC in which the mean confidence was <3 included the care of patients with transplanted organs, those at risk for adrenal suppression, those in metabolic crisis, and those dependent on technology. Importantly, we found ED residents’ interest in receiving more didactic education on CMC to be high; the mean score was 4.4 (SD = 0.7; n = 43), with 1 representing not at all interested and 5 representing very interested. This presents a valuable opportunity for PHM faculty to address this educational need.

At our institution, pediatric hospitalists have piloted a successful educational partnership with our EM program to implement a pediatric complex care curriculum, beginning with a lecture series dedicated to addressing the topics in which ED residents felt least confident. We have also expanded our pediatric hospitalist resident elective to include EM residents, which has been well received. As PHM enters a new era as a board-certified subspecialty, pediatric hospitalists should be recognized as an important resource to fill this critical knowledge gap, especially at institutions without dedicated pediatric EDs or PEM specialists. We would therefore advocate for a greater role of pediatric hospitalists in the education and training of EM residents to ensure they are equipped with the knowledge they need to care for children like Emma, regardless of where their careers take them.

• Copyright © 2020 by the American Academy of Pediatrics