U.S. News and World Report recently disclosed their Best Children’s Hospitals 2017-2018 annual rankings. Do children’s hospitals even matter? Is an academic center, community or other facility good enough?
In general, I advise not to swoon over institutions as they are only as strong as their weakest link. Being an admitted patient or having a loved one hospitalized —in even the most optimal of circumstances— warrants a family or otherwise invested advocate at the bedside throughout the stay. Not merely to be an effective communicator to ensure no avoidable medical errors arise, but also to provide support and be the patient’s voice when it is difficult for them to be their own. See 10 Ways to Save Your Life or the Life of a Loved One.
In the world of pediatrics, children’s hospitals do distinguish themselves profoundly for a number of reasons. Most importantly, every cog in the caregiving chain has dedicated pediatric training that was more than a weekend course or a solitary rotation in medical school. Not only are the wide array of staff members familiar, used to and typically prefer treating premature infants to toddlers to children on up to adolescents and young adults, but they also possess the expertise to dose adjust for body surface area with medications and radiation for imaging modalities, perform procedures on tiny vessels, recognize the needs of those with congenital disorders as they grow as well as grasp the psychosocial, behavioral and developmental dynamics—and how best to navigate them.
At these facilities, board-certified pediatric surgeons, pediatric radiologists, pediatric nurses, pediatric anesthesiologists, pediatric occupational therapists, pediatric physical therapists, pediatric cardiologists, pediatric emergency physicians, pediatric oncologists, pediatric intensivists, respiratory therapists, pathologists, researchers, pharmacists, genetic counselors and so on can compose the multi-disciplinary teams that abound. Child life divisions that create programs to enhance joy, laughter and assuage suffering play an integral role throughout the institution making the process for the patient and family more palatable when possible. These do exist in non-specific hospitals, but usually on a much smaller scale.
To appreciate the significance, it is important to understand what goes on elsewhere. In many more general facilities, a pediatric radiologist is not always—and more often than not isn’t— interpreting the films. Medical decision making is based in part on these determinations. It is not uncommon for a general hospital to only have a pediatrician, let alone a true pediatric radiologist on staff for a restricted number of hours. At other times, an adult radiologist is often pressured to review studies from this population. Many will be comfortable interpreting down to preteen patients, but not to early childhood and infancy. The technicians performing the imaging may not fully appreciate the importance of pediatric doses of radiation— and the litany of sometimes less than along with the stretching of resources to the so-called "top of their license" continues. This extends to plenty of the subspecialties.
Because community hospitals may not have the case load, pediatric surgeons might require running between 2-3 institutions to maintain their livelihoods and clinical skills. It is not uncommon for large academic centers to send the more junior member of the surgical team to these satellite locations. Given that the more complex cases tend to occur at the main campus, the turn over can be high for the more junior physicians. The post-operative care is crucial to the success of a surgery and the continuity of their support staff can be more variable or limited in skill set in the more remote setting. To surgeons, being supported by superior teams is essential to providing the highest quality of care. For patients, often this ancillary team is why going to a children's hospital for an elective surgery is as important as selecting the experienced surgeon.
Throughout my decade-plus term of practicing in New York City, pediatric patients— because they can be more labor intensive than adults— often reflected a financial loss for hospitals. So, throughout the years pediatric departments and floors in multiple venues kept getting more and more truncated in terms of equipment and staff until many were entirely closed. Pediatricians are not always staffed when kids come through emergency rooms and urgent care. Adult providers routinely provide their care. On many occasions, this can be sufficient but not all the time. In those scenarios, this lack of proper training can be detrimental.
Academic centers traditionally have the resources to manage complex disease states and higher risk conditions. They often have excellent pediatric floors and a diversity of sub specialists with appropriate training. This is not always so throughout the facility, like in the emergency room. Teaching hospitals have medical students and residents, so there is a premium placed on being current and up-to-date. The vast spectrum of patient from newborn to young adult can fare well. In certain hospitals, the neonatal or pediatric intensive care units can only provide a specific level of care sometimes necessitating transfer to a more comprehensive facility.
Anticipating the unique needs of the child and clinical situation is the best way to determine what facility is most ideal and feasible.
Excellent care can be provided at community hospitals, but the range can vary. These organizations traditionally manage the bread-and-butter better than the other (especially more specialized) places. When they exceed the scope of their capacity is when untoward events arise.
From a patient perspective, a children's hospital is the way to go when possible especially when clinical complexity is higher-- when in need of a pediatric-dedicated emergency room and if there is a greater likelihood of admission. In an urgent situation, the patient is taken to the closest hospital pediatric-specific or not. In these instances, delaying care to get to the children's hospital if much further away than the closest hospital can pose a greater risk. While at the nearer general hospital, an individual can be stabilized and transferred to a more comprehensive facility if need be and when possible-- obviously less ideal in certain situations.
Community facilities that regularly manage cookie cutter pediatric issues might very often be preferable in varying locales. Knowing your town or region and the individual institutions' levels of capability is in your best interest as this is crucial to understanding your best option---there is no wide brush, as some environments can be saturated with optimal care while others are at a deficit. Of course, pediatric-specific care givers will be the optimal choice and plenty of non-children's hospitals are very well-stocked. Appreciating your geographical reality is best determined with a little research along with a discussion with your doctor who knows the state of health care in your district.
