The “Surgeon on Service” Model for Timely, Economically Viable Inpatient Care of Tracheostomy Patients in Academic Pediatric Otolaryngology

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Abstract

Importance

The traditional practice model for pediatric otolaryngologists at high-volume academic centers is to simultaneously balance outpatient care responsibilities with those of the inpatient service, emergency department, and ambulatory care clinics. This model leads to challenges with care coordination, timeliness of nonemergency operative care, and consistent participation in care and consultation at the attending surgeon level. The “surgeon on service” (SOS) model—where faculty members rotate to manage the inpatient service in lieu of outpatient responsibilities—has been described as one method to address this conundrum. The operational and economic feasibility of the SOS model has been demonstrated; however, its impact on care coordination, time from consultation to surgical care, and length of stay (LOS) have not been evaluated.

Objective

To determine the impact of the SOS model on the quality principles of timeliness and efficiency of tracheostomy tube placement and to determine if the SOS model is fiscally feasible in an academic pediatric otolaryngology practice.

Design, Setting, and Participants

Medical record review of patients undergoing tracheostomy in a pediatric academic medical center and survey of their treating physician trainees, comparing the 6-month SOS pilot phase (postimplementation, January-June 2016) with the 6-month preimplementation period (January-June 2015).

Intervention

Implementation of the SOS model.

Main Outcomes and Measures

Time to tracheostomy, frequency of successful coordination of tracheostomy with gastrostomy tube placement, total LOS, productivity measured in work relative value units, and responses to trainee surveys.

Results

Of the 41 patients included in the study (24 boys and 17 girls; mean age, 3 years; range, 3 months to 17 years), 15 were treated before SOS implementation, and 26 after. Also included were 21 trainees. Before SOS implementation, median time to tracheostomy was 7 days (range, 2-20 days); after SOS implementation, it was 4 days (range, 1-10 days) (difference between the medians, before to after, −3 days; 95% CI, −5 to 0 days). There was no significant difference in overall LOS or ability to coordinate tracheostomy with gastrostomy tube placement. Preimplementation trainee surveys cited dissatisfaction with the communication channels to the primary team when the consulting surgeon was not immediately available to perform tracheostomy. No challenges were reported after implementation. Productivity was comparable to that in the outpatient setting.

Conclusions and Relevance

In this study, the presence of a rotating inpatient pediatric otolaryngologist was a productive approach to patient care associated with more timely performance of tracheostomy. Other benefits were an improved balance of service with education to trainees and a better perception of communication with consulting services.

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