more complex children in our hospitals

Those of us who provide inpatient care for children have been saying this over and over for the last decade or so: "children in our hospital are more complex to care for than ever before." However, most of the time, we were saying this based solely on our feeling, and the nature of the children we were seeing in the institutions in which we worked. 

This month's issue of the journal Pediatrics, published by the American Academy of Pediatrics presents two articles and a  commentary that address the issue of what types of children are being admitted to our hospitals.

The first article,  by Katherine Burns and colleagues from Arkansas Children's Hospital, looked at patients between 8 days and 4 years of age who had diagnoses consistent with congenital or complex and chronic problems, such as cerebral palsy, bronchopulmonary dysplasia (more commonly known as BPD--or chronic lung disease of prematurity), and  problems in 9 other organ systems. They found that hospitalization rates for children with more than one chronic problem rose  over the past 15 years much more rapidly than that for children with only a single chronic problem. Children with CP but no other chronic problems saw their admission rates actually decrease, while those who had CP plus another chronic problem saw a moderate amount of increase. Similarly, children with BPD alone  saw a small increase in their need for hospital services, but if they had other problems, their rate dramatically increased.

The second article, by Tamara Simon and colleagues from University of Utah, Children's Hospital of Boston and Children's Hospital of Philadelphia, took a somewhat different approach to arrive at a similar result. They demonstrated that children with complex chronic diseases made up a higher percentage of pediatric admissions in 2006, compared to 1997. These children now account for over 10% of all pediatric admissions, 26% of pediatric hospital days, and over 40% of all charges.  So,  more of these children are being admitted, they are staying longer in hospitals than other children, and it is costing our health care systems more to meet their needs.

So, what does all this mean?

Of what importance is this data for someone like myself, who has to plan appropriately to meet the needs of the children in our region? What does it mean for community hospitals, and primary care physicians?

The implications to me are clear: we (our community) needs to be prepared to meet the needs of children with special needs. This means that we have to have doctors available who are specially trained to care for their chronic conditions. That is where children's hospitals come in. By focusing pediatric subspecialists (doctors who are not only  trained to care for children, but who have spent additional years focused on a specific organ system or type of care) in a centralized location, these very rare physicians can provide life-saving and quality-of-life enhancing treatments needed by these children. By training other staff (nurses, respiratory therapists, child life specialists, nutritionists, physical-, occupational- and speech therapists, social workers, case managers, and others) to understand children's needs, we can give them the care they need in the hospital. This means more and more children will be admitted to specialty hospitals that have such services available, and fewer community hospitals will be able to meet the increasingly complex demands of children's health care over the next decade.

How will this trend affect the parents of special needs children in our region? It will mean that increasingly they will be coming for admission to a children's hospital such as Carilion Clinic Children's Hospital, where nearly every possible pediatric subspecialist is available.

It also means that they will be using our outpatient subspeicalty physicians increasingly, to help manage these children optimally in the community setting.  This is why we have some of our subspecialists running clinics in outlying locations.

It means that the pediatricians in the community will be increasingly called upon to coordinate care of these children, and to do that they will need to maintain open communication with the subspecialists who can help to guide care. It means that over time, we will need to augment services available in the home, and throughout the communities in which the patients reside. Methods to coordinate care, make sure it is provided in an evidence-based and cost-effective manner, will have to be developed.

I would love to hear comments from parents who have to find optimal ongoing care for their chronically ill children; from pediatricians and family docs in the community who struggle to provide a medical home for these children and their families, and from our subspecialists who see these children in and out of the hospital.

We are all in this together folks.

Recent Comments


I appreciate your thoughtful and well timed comments. I have been one of those physicians noting a clear increase of both complexity and numbers of chronically ill children in our region. This is a serious challenge for all of us in healthcare, specifically pediatrics. I anticipate resources to meet the needs of these children as the major issue to be addressed as they become more limited in years to come. We have our work cut out for us.

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About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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