When Mark Attiah was a medical student at the University of Pennsylvania’s Perelman School of Medicine, he completed rotations in both pediatric and adult hospital settings. One of the patients he met was diagnosed with a severe chronic illness at the age of 17; upon turning 18, she had to transition from receiving care at a pediatric hospital to receiving care at an adult hospital, and her comments about the difference in the two environments reinforced Dr. Attiah’s observations. He published his thoughts in the Journal of the American Medical Association in 2013, summed up by his statement, “We are all children in the face of illness—scared, ignorant, and impulsive—and we should be treated as such.” Dr. Attiah proposed that modeling adult hospitals after pediatric hospitals has the potential to improve quality of care, patient satisfaction, and health outcomes, which, in turn, can positively impact reimbursement and readmission rates.
Perhaps the most obvious area in which children’s hospitals differ from adult hospitals is their physical environment. Striving to not be intimidating, children’s hospitals tend to feature single-patient rooms that are designed for comfort, bright lighting and lots of color, an abundance of art and plants, and family-centered spaces. They are designed with recognition that ensuring a good night’s sleep is important to recovery, that color impacts mood, and that play can reduce stress and help patients heal. Children’s hospitals include recreation and indoor/outdoor spaces, offer opportunities for patients to connect with one another, and are often set up for patients to have procedures done outside of their rooms so that the rooms remain a “safe space.” Daily activities such as arts and crafts, games, concerts, visits from celebrities, and even “proms” lend an aura of fun and a distraction from pain. The 18-year-old patient with whom Dr. Attiah spoke commented that without these distractions in the adult hospital, the only thing left for her to focus on was her illness and pain.
Another difference between pediatric and adult hospitals is found in the emphasis on family involvement in patient care. Children’s hospitals tend to have longer/more flexible visiting hours, including allowing families to remain in patients’ rooms overnight. They also allow family members to be present in patient rooms during treatment – even emergency procedures – and to accompany patients to the operating room, remaining with them until anesthesia takes over, to be present in the recovery room, and even to call codes for their child. This reinforces the importance of family as part of the treatment team and of making a priority of family members’ peace of mind about their child’s care. Increased family involvement helps boost patient morale, which can positively impact recovery time, and family members can be a good resource for the creation of care plans, providing important information to staff and supporting patients’ medical, physical, emotional, and social needs. Their involvement throughout the hospital stay – including on family-centered rounds – helps prepare them for post-discharge care, as well. (Interestingly, a study published in 2013 in the New England Journal of Medicine reported that having family members present during the administration of CPR for adult patients “was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the healthcare team, or result in medicolegal conflicts,” as is the traditionally held assumption.)
In a broader, but related, area, the approach to care in a pediatric hospital is not the same as it is in an adult hospital. The above-referenced 18-year-old patient found that the medical team in the adult hospital was “not as happy to be there.” Indeed, the staff in children’s hospitals tend to put particular effort into minimizing patients’ stress and lifting their spirits, generally demonstrating a good bedside manner. It is a visceral reaction to feel and show compassion to a sick or hurt child, and children’s fear is understood and accepted more than fear in an adult. Recognizing this fear, in turn, impacts care; for example, interventions (e.g. blood draws, vital checks, and medication administration) are more often grouped together, procedures are designed to be less threatening, etc. Although there is, according to Dr. Attiah, “a tacit assumption that adult patients have developed a certain hardiness – a stiff upper lip that renders a reasonably pleasant environment, or even sometimes a complete patient-physician trust, unnecessary…without help, most people, regardless of their age, aren’t naturally good at being patients.” Physicians approach adult patients as “seasoned veterans who are able to cope with the hardships of being ill in an alien environment with relative ease, even though this is often untrue.” Adults may be more difficult and less “cute” than kids, and their presence in the hospital setting more expected, but it is still a very emotional experience, and it is just as necessary for staff to connect with them and support a patient-centered culture for them.
In 2015, a group of doctors from Yale published an article in the Annals of Internal Medicine entitled “Balloon Animals, Guitars, and Fewer Blood Draws: Applying Strategies from Pediatrics to the Treatment of Hospitalized Adults.” One topic addressed in the article was the presence of child life specialists in pediatric hospitals, whose goal is to guide children and their families through the “psychosocial and developmental concerns” of hospitalization, including preparation for medical procedures, pain management, coping strategies, and encouragement of self-expression. In fact, the American Academy of Pediatrics has stated: “Child life services should be delivered as part of an integrated patient- and family-centered model of care and included as a quality indicator in the delivery of services for children and families in healthcare settings.” At the other end of the spectrum, there are over 200 sites in 32 states and 11 countries participating in the Hospital Elder Life Program (HELP), which similarly guides older adults through their hospital stay in an effort to prevent them from developing delirium, which can affect up to 25% of elderly hospital patients. In the middle, however, there are no such programs designed for adults.
Making practices and settings more patient- and family-friendly is not necessarily more convenient for care providers, who may be in the mindset of doing things the way they have always been done. However, all patients, regardless of age, deserve care that is focused on best meeting their needs in a human, caring manner that has the potential to inspire better results.
Contributed by Holly Valovick – QLK