by Dr. Erin Stucky Fisher, MD, MHM
I am a career pediatric hospitalist. Not one of my days is the same because as a hospitalist I have the opportunity to serve in numerous capacities within my hospital medicine group, my hospital and the fields of pediatrics and hospital medicine. I am one of the senior attendings on the pediatric hospital medicine service coordinating care teams, I serve on committees at my hospital and university, and I am involved in national work affecting the care of pediatric inpatients.
So here’s a day in the life of me, Erin Stucky Fisher, pediatric hospitalist:
I start at 6:45 AM, reviewing all teams’ patient list. As the “first call” PHM, I am responsible for assuring all ICU transfers and surgical consults were correctly added in our EMR. I scan the “admits-24hrs-allsites” list – I am responsible for assuring not only our site but all ward sites (three total) have correct attending information that matches the night pediatric hospital medicine signouts for the three sites. This way patients in route from an outside facility are on our forefront. I contact the Nursing Supervisor to run the list of pending admissions and transports and nurse staffing for the day.
We three on service for this holiday weekend talk about our newly admitted patients from the night prior with some discussion about patients with diagnostic dilemmas. We all comment, quickly check e-literature, and review more critical patients to be seen first before any Resident or Nurse Practitioner rounds.
I am first call today and also covering inpatient physiatry, I get simultaneous calls for emergency transport and from the nurse of a physiatry patient who tells me she is speaking with a concerned father. I know this father. He does not get concerned easily. I triage the transport call and get the team activated. I call the Registered Nurse to ask her to tell Dad I will be there in 10 minutes. The residents flex to see a nephrology patient, waiting for me to attend to these critical issues.
We start FCR – family centered rounds. I help the resident notice the mother’s frustrated body language. I gently interject, “It looks like we are not giving you time to speak, Mom. We want to hear your concerns now. Can you help us better understand what is top in your mind for your daughter today?” I later ask the med student to show mother how the gastro-tracheal surgical site is healing well , and basics on how the tube feedings will work. I reviewed this with him yesterday, and want to see if he retained this and can present it to the parent in a clear manner, with teach-back. He does well.
Outside the room we debrief as we walk to the next room. I give feedback privately to the resident regarding watching body language; I give feedback to the student in front of the team to validate his good work with specific comments on what he did well. We finish rounds. I have received 7 pages since this time – 1 more transport, 2 from outside emergency departments to admit children, 4 from our emergency department, 1 going to the operating room so can you please see him now for his pre-op?
I tell my resident team I am off to an adjacent building for a meeting. I will be only a 2 minute’s walk away. It is a holiday but a group of us review our hypertonic saline policy. We discuss safety, monitoring, sodium levels for which an ICU consult are indicated. We talk about the evidence based medicine and get input from an ICU colleague and a nursing educator for the medical/monitored sites and come up with our hospitalist summary of how to best implement the policy. We agree the policy needs to return to Pharmacy & Therapeutics (P&T) Committee for revision and contact the P&T Committee Chair to effect this.
I return and re-visit some patients. FCR does not allow time for a full exam as much as I would like on some of my patients. My subI pages me to review data on one of her patients who had a sepsis evaluation and has a rash. We discuss how does this impact our treatment plan? How will you tell the parents the results? What are you most worried about now? What are the new discharge criteria? How will the nurse know what you are thinking? We meet at the bedside to talk with the nurse.
I spent time at the computer. Documentation. I read and edit notes. I page interns and residents with changes. Tell me why I changed this? Describe for me why it is important to always include X in your note about Y patient type. They need to know that the medical record is a communication tool, a validation of billing tool, and yes, if you do not document it, it did not happen. People reading the EMR are not mind readers. You need to learn to document concisely yet include pertinent details. It is an art form. I get through about half of my patients, answering pages in between. I message my 2 partners on service to see who has seen which newly admitted patients. Are we on target? Any issues? The nursing supervisor calls me to run the afternoon and night staffing. We have pending in the ED….in the PACU…current census at our community sites is….at our NICU satellites is….We are staffed well for the night. Should be no problem admitting patients. ED staffing is secure. This means we can meet the needs of the kids in the community, and that is good.
I meet my team to review management of our teen with electrolyte imbalance. What are we worried about? What will you have on your sign-out tonight? Why? We review also status asthmaticus. How does Magnesium work? When can you tell you need ICU care? How do you discuss this with a scared family? We talk about child protection issues and our role. This is a topic that can’t be taught didactically. (Un)fortunately we have had a number of times this month where trainees experienced why our advocacy role has to be with a big “A” in these cases. The (), as I tell the team, is that they must learn this. That is the only part of this that warrants a parenthesis.
I sign out to my colleague on call. One transport out for severe asthma with saturations in the high 80’s. ICU aware. Two pending patients not yet here. I review what I discussed with the admitting residents. We discuss other known patients with ongoing or potential issues.
I finish editing notes and write my own on my attending-only patients. I finish my billing and make sure the Problem Lists are up-to-date, as I know these are key for billing and good patient care communication. As we are partners in care with our hospital, I know that my documentation drives severity of index scoring and ability for the hospital to get properly reimbursed for the needs of these acute and complex patients. As my hospital system is a non for profit that is a safety net for children, this is very important. I re-check pending studies for my patients, and revisit two of my attending-only patients who were more unstable today. All is well. The nurses are comfortable with the plans and parents have no new questions.
I spend another few hours working on a few projects, preparing for tomorrow. I re-read my latest edits to our Solutions for Patient Safety (SPS) summary presentation for physician leaders, edit a paper my ex-fellow is writing on the importance of parents’ ability to identify their treatment team, provide comments to a resident who has just started her quality project for residency, and scan the most recent financial statement from my clinical research trial. My first meeting when off service tomorrow is for the SPS group, followed by a conference call with a national group identifying metrics for pediatric surgical imaging and another for quality improvement best practices for discharge with the Society of Hospital Medicine (SHM).
It is good to be a hospitalist. Caring for patients. Caring about families. Caring to improve healthcare systems.
Dr. Erin Stucky Fisher MD, MHM is a pediatric hospitalist at Rady Children’s Hospital-San Diego and a professor of clinical pediatrics at UC San Diego School of Medicine. She is the UC San Diego pediatric hospital medicine fellowship director and the Department of Pediatrics vice chair for clinical affairs, as well as Rady Children’s medical director for quality.
Dr. Stucky Fisher attended medical school at the University of California, San Francisco and completed her pediatric residency at UC San Diego, where she was chief resident. She went on to complete advanced training in quality and safety through various groups.
She serves on many national healthcare quality committees for the American Academy of Pediatrics, Society of Hospital Medicine (SHM), and Children’s Hospital Association, and has served as a content expert for the Institute for Healthcare Improvement and Emergency Medical Services for Children on pediatric safety issues.
Her research interests include bronchiolitis, healthcare systems and quality improvement.
Dr. Stucky Fisher created the Innovative Quality Improvement Research in Residency (INQUIRY) Program for residents and fellows and trains QI teachers at the national level through the Quality and Safety Educators Academy of SHM and the Alliance for Academic Internal Medicine.
She is also the lead developer of PediBOOST, a pediatric discharge transitions toolkit, through a University of California five- medical campus Quality and Innovations Center grant.
Bio source: http://www.rchsd.org/doctors/erin-fisher-md/