Journal Information
Vol. 99. Issue 5.
Pages 293-294 (01 November 2023)
Vol. 99. Issue 5.
Pages 293-294 (01 November 2023)
Editorial
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Pediatric hospital medicine facing the new healthcare reality
La pediatría interna hospitalaria ante la nueva realidad asistencial
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Pedro J. Alcalá Minagorrea,b,
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alcala_ped@gva.es

Corresponding author.
, Juan Ignacio Montiano Jorgea,c, Juan José García Garcíaa,d
a Sociedad Española de Pediatría Interna Hospitalaria (SEPIH), Spain
b Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
c Hospital Universitario Txagorritxu, Vitoria-Gasteiz, Spain
d Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
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In recent times, paediatric inpatient care has been confronted with significant challenges, such as super-specialization and the risk of care fragmentation, the exponential increase in chronic disease and medical complexity, and growing concerns about the sustainability of the health care system. The hospital-based or “hospitalist” model of care, widely developed in recent decades, emerged in response to these phenomena and encompasses paediatric internal medicine as the specific field of paediatric practice devoted to the comprehensive inpatient care of paediatric patients.

Paediatric hospital medicine is a field with its own organizational structure, capable of delivering advanced and comprehensive care for the most common acute and chronic diseases of paediatric patients admitted to hospital at different levels of care or to hospital at home units. Paediatric hospitalists also collaborate in the care of patients who require surgery or inpatient care in different paediatric subspecialities, whether routine or urgent.

The favourable outcomes of specialised paediatric hospital-based internal medicine programmes in terms of efficiency, care quality and patient and family satisfaction explain to a great extent the considerable growth of this speciality. Paediatric hospital medicine, as it came to be known in the United States, was formally recognised by the American Academy of Pediatrics (AAP) in 1999, with the subsequent development of a specific section on hospital medicine that established the core competencies for developing training curricula in different hospitals. The American Board of Medical Specialties officially recognised paediatric hospital medicine as a medical subspeciality in December 2016, and at present there are more than 6000 accredited paediatricians in the field.

Although the figure of the chief paediatrician as the head of a ward exists in nearly every paediatric inpatient care department in Spain,1 there is substantial variability in the training and professional background of chief paediatricians in general inpatient wards, as is the case in all other paediatric specialities. In this regard, from its foundation, the Sociedad Española de Pediatría Interna Hospitalaria (SEPIH, Spanish Society of Paediatric Hospital Medicine) has been engaging in significant efforts to lead and coordinate the development of this field.2 All these initiatives have been endorsed by the Asociación Española de Pediatría (AEP, Spanish Association of Pediatrics), a powerful driver of the necessary development of paediatric subspecialities, and through the White Book on Paediatric Subspecialities as the essential source on paediatric care delivery in Spain. The steps taken in the development of paediatric hospital medicine in Spain have been described in a special article published in the Hospital Paediatrics journal of the AAP.3

As is the case of all other paediatric subspecialities, we await the official recognition of our particular field by the public health authorities. This is an essential step toward standardising the educational requirements, skills and attitudes that must be achieved by a specialist to be able to deliver comprehensive general paediatrics inpatient care within the established standards of care.

Clearly, the main challenges facing paediatric hospital medicine concern the management of children and adolescents admitted to hospital under a variety of circumstances. The broad scope of the field requires continuous education, and it is important to reduce variability in clinical practice, to seek constant improvement and to address the reasonable demands of patients and families, who are increasingly involved in the care process. To this end, the priorities in the field include the management of health care-associated disease, improving patient safety and care quality and strategies for the humanization of paediatric inpatient care in the framework of a child- and family-centred care model. Paediatric hospital medicine focuses on the comprehensive care of ill children, with supervision of every aspect of their management, and is particularly valuable in patients with multiple diseases or with disease of unknown aetiology after the initial investigation of the presenting signs and symptoms and with a broad differential diagnosis.

Paediatric hospitalists are responsible for coordinating the care of chronically ill and medically complex paediatric patients, who are sometimes dependent on technology, from a holistic patient- and family-centred approach. They also play a key role in ensuring continuity of care through transitions to primary care services. In recent years, specific units have been developed for the management of patients with chronic illness and medical complexity4 to manage not only conventional inpatient care but also the delivery of hospital-level care at home, thereby avoiding long stays in hospital and helping children and families have more normal lives.

Still, hospital at home should not be a resource restricted to the management of chronic disease. It is estimated that up to 5% of paediatric patients with acute diseases or exacerbations of chronic disease could benefit from early transfer home, or even direct admission to hospital at home, to receive hospital-level care. Different studies have demonstrated that the care and treatments administered (or self-care and self-administered treatment) at home are as effective and safe as those receive through conventional hospitalization. The hospital at home model also facilitates a greater participation and involvement of the patient and the family in care delivery, humanizes health care and improves the experience of patients and families. Any form of hospital at home service contributes to the optimization of health care resources, both through the reduction of direct costs and through the freeing of hospital beds. This can reduce the burden on inpatient care settings when they are experiencing significant pressure and reduces the risk of nosocomial infection. Lastly, advances in information and communication technologies and the ever-growing possibility of remote monitoring and follow-up can provide the definitive push to the development of paediatric hospital at home services.

In a special article in the current issue of ANALES DE PEDIATRÍA, Batlle et al.,5 on behalf of the Working Group on Hospital at Home of the SEPIH, offer a comprehensive perspective on the characteristics and requirements for the delivery of hospital-level care at home to paediatric patients with acute disease. As the authors noted, the success of this inpatient care model depends on different aspects, such as the adequate selection of eligible patients, the creation and training of interdisciplinary care teams and the education and training of family members. But there are also important organizational challenges that involve the hospital itself. In this regard, the health care authorities must provide the necessary institutional support to consolidate and expand paediatric hospital at home programmes for the paediatric population and ensure equal access to this resource.

From within the field of paediatric hospital medicine, we are aware of the structural changes that have been taking place in health care organization in recent times. The numerous challenges facing health care call for a proactive and innovative approach to ensure the delivery of care of the highest quality to all hospitalised paediatric patients. The COVID-19 pandemic and post-pandemic situations have facilitated the debunking of many deep-seated paradigms, such as the notion that hospitals are indispensable and fixed structures. In many cases, the home is the best possible hospital setting. And we would probably make that choice as patients. Receiving adequate home care of any kind should not be contingent on geographical factors or any other factors that could result in inequality in care delivery, but should be a resource available to any child in need of it, and a right guaranteed by public institutions.

As stated by the US senator Daniel Patrick Moynihan (1927–2003), the future of a society may be forecast by how it cares for its young. This is even more true when it comes to how it cares for its ill young.

Funding

This research did not receive any funding.

References
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J.M. Ramos Fernández, J.I. Montiano Jorge, R. Hernández Marco, J.J. García García.
Situación de la Pediatría Hospitalaria en España: informe de la Sociedad Española de Pediatría Hospitalaria (SEPHO).
An Pediatr (Barc)., 81 (2014), pp. 326
[2]
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Creation of a pediatric hospital medicine subspecialty in Spain.
Hosp Pediatr., 13 (2023), pp. e43-e46
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F.J. Climent Alcalá, M. García Fernández de Villalta, L. Escosa García, A. Aroa Rodríguez, L.A. Albajara Velasco.
Unidad de niños con patología crónica compleja. Un modelo necesario en nuestros hospitales.
An Pediatr (Barc)., 88 (2018), pp. 12-18
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An Pediatr (Barc), 99 (2023), pp. 321-326
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