P0605 - Pediatric Hospitalist Co-management of Neurosurgery Patients Reduces Readmissions

Background: A pediatric neurosurgery and hospitalist co-management program cooperates as one team to care for complex pediatric neurosurgery patients in the ward setting. Surgical co-management, or shared responsibility for patients between hospitalists and surgeons, has shown potential to improve quality of care metrics including cost, length of stay, readmissions, and complication rates. Most pediatric hospitalists engage in co-management with surgeons, yet pediatric neurosurgical co-management has not been studied as an improvement strategy.
Methodology: We aimed to develop and implement a novel pediatric neurosurgery and hospitalist co-management program by October 31, 2019. Our program covers all pediatric neurosurgery patients admitted in a non-ICU setting, and not actively co-managed by another service, using the prior year of neurosurgical admissions to establish baseline data. Using improvement science methodology, an A3 that outlined standard work and program goals was created in collaboration between pediatric hospital medicine, neurosurgery, and front-line care providers. The program was studied using plan-do-study-act (P-D-S-A) methodology, with further aims in the first 6 months of the program to decrease 30-day unplanned readmissions to a goal of 10%, and decrease intensive care unit (ICU) length of stay, while not increasing length of stay or cost.

Results: In the first six months of the program, 156 pediatric neurosurgical patients were admitted to a non-ICU unit, and 50% of them were actively co-managed by a pediatric hospitalist, an increase from only 4% consults to pediatric hospitalists the prior year. Readmissions were reduced from 13.1% to 8.3%, with a special cause shift in frequency. As readmissions cost more than index admissions, this represented a projected savings of 5% of the total program cost. Length of stay was unchanged (4.0 to 4.1 days). ICU length of stay was also relatively unchanged (39 hours to 36 hours). Mean patient cost increased from $15,504 to $17,150, without a significant baseline shift.

Discussion: Strategies used to achieve successful readmission reduction included primary care doctor discharge contact, post-discharge phone calls, increased discharge teaching on pediatric issues, and awareness of pediatric discharge criteria. We anticipated that length of stay might increase as we worked to identify appropriate discharges, but it was relatively unchanged. Average patient cost may have increased due to increased patient complexity with a 6% reduction in observation admissions, and a 7% increase in ICU admissions. Despite more provider contact, provider costs did not increase. Through further tailoring of the program to target high impact patients for co-management, and further efforts to reduce ICU length of stay, we may be able to reduce cost.

Conclusion: Establishing a program for pediatric hospitalist co-management of neurosurgery patients is feasible. The program was highly successful in reducing readmissions, with associated projected savings of 5% of the total program cost.