ourselves and then we'll get started. My name is Bridget I'm the nurse practitioner that works at Boston Children's Hospital with Becky. Nathan Rosenberg Nationwide Children's Hospital. Elaine Tsao at Seattle Children's University Washington. Elise McClanahan Vanderbilt University and Elizabeth Martin Vanderbilt University. All right so we have nothing to disclose we just want to acknowledge APPMNR for having us here the pediatric rehab physicians who are seeing acute care consults many of you are here and then Dr. Dubon started really the consult service at Children's and a lot of the data from the adult world was compiled by her so just giving her a little bit of a shout out. So rehab medicine consults so we all know that consults are important we know that they do good things and there's a lot of adult data out there that they decrease length of stay and patient outcomes are better and disposition is better and patients are happier but there's really no data in the pediatric world for any of this. So from a terms of a length of stay you actually decrease length of stay by like 12 to 30 days it's you know 44 percent shorter length of stay on a medical floor 20 percent in the ICU. You're thinking about better outcomes in mobility for patients with brain injuries less complicated less frequent use of benzos and antipsychotics in level one trauma centers. You're seeing survival odds actually improve when there's early PM&R consults. You're seeing optimization of disposition where these kids are going is actually more appropriate and patients are happier because they're seeing us sooner. So something that I thought was really interesting is the trauma classification is that it actually says that all trauma centers have to determine the level of care required after trauma center discharge and that actually includes protocols to identify rehab services processes to determine rehab care ensuring that services are actually there in a timely manner. Early multidisciplinary assessment I love this verbiage but then it says physicians physiatry we're applicable and it's like well really aren't we actually more important to just be then when applicable. So like you can be a level one a level two or level three trauma center. This is actually the same verbiage for all trauma centers. So it says if there's a rehab doc that's great. They should be a part of this but it doesn't really say that we are an integral aspect of becoming a trauma center. So I just think that's interesting and kind of how they talk about this and but I do think that you know maybe we talk about to the trauma centers it's like maybe we should be required and maybe we should be a part of trauma center classification and how does that work. So today we're going to have a panel conversation. So this is confusing. So please use this QR code. It is not the QR code that is on your sheet. Your sheet QR code is a research project which we're going to talk about at the end. Also on the bottom of every single slide for today in the bottom right corner for all of these questions there's going to be my name and the number again. So if people are coming in late you can always log in a poll everywhere once we get to that aspect of the presentation. OK. If you have questions I can always come back to this. So I'm going to have Bridget be the person to talk and ask the questions. She is the brains behind our consult service and is going to kind of manage this and we want participation. So hopefully there are some other microphones that we can get out into the audience so they can also listen or they can use one of the ones at the top and we can run around and hand it to people. But I definitely want to hear your input. I we are not the only four institutions in the country that are doing this. You guys are all doing this as well and we want to hear that from you. Okay, so the first question is, describe your hospital system's consult service in three minutes or less. Who's first? You are first. No, I'm not. No, Vanderbilt. Okay, Vanderbilt is first. Vanderbilt is first. Hello. So, I'm at the Monroe Corral Junior Children's Hospital at Vanderbilt. It's a mouthful. It is a 343-bed tertiary care facility, including 119 NICU beds and 42 PICU beds. We do not have our own inpatient rehab unit at this point, but it is forthcoming. We have one consult service that sees any of the pediatric rehab consult patients. We're covered. We have 0.4 attending FTEs and an APRN who has 0.7 FTEs covering the consult service. Number of new consults, as you can see on the slide, it's rising from 2022 to 2023, both in terms of new consults and the number of follow-ups that we're able to cover. We have a number of services that are consulting ours, you know, all throughout NICU, PICU, oncology, ortho, trauma, neurosurgery. And then we don't have an automatic consult, but if you'll advance the slide. This is our early mobility order set. It's been a big initiative in our hospital to try to get overall physical occupational speech therapy more involved early on, and that usually triggers a consult to the pediatric rehab physicians. And then the next slide is just the amount of inpatient consults and numbers that have gone up per year. At the end of 2020, we added a nurse practitioner, so it was covered by Dr. Martin until that time, and then I started at the end of 2022. So you can see when we've added new people, the consult service has really grown, and then also that's our RVU measurements by annual year as well. Yeah. Okay. I'm next. Can I just add, too, that with those numbers, so I started at Vanderbilt in October 2019, so that 2019 is November and December of that year. The nurse practitioner joined the following year in November, so that's December, basically, for the time that she was there. And then Elise also joined at the end of the year, so we're seeing the numbers go up pretty significantly each time we add a person. Okay. Now it's my turn. So Boston Children's Hospital, it's 485 beds. We actually have two consult services. There's a general consult service and a cardiac consult service, so I run the general, and then Ana Ubeda's on cardiac. Bridget, we have full NP coverage, so 40 hours a week. She does four days a week of general, one day a week of cardiac. We have about one FTE between Dr. Ubeda and I, so maybe 50, 50.5 for each one, but it changes per week, but we do not have any coverage on the weekends, so we're only by phone through our pager. And then looking at the numbers, you can see the yellow is the number of consults per year, so in 2015, 2016, 2017, they're really minimal. Dr. Ubeda was hired, we increased. Dr. Dubon was hired, we increased even further, then COVID happened, and then Bridget and I were hired at the same time, and we went from 550 to 1,300 in a year. So more people work here, we do more things, and then the 1,000 is just from the end of September of this year in terms of billing, and so you can see that just number follow-ups are just exponentially increasing as we increase our coverage. Okay, Nationwide Children's Hospital. So we're three physicians at this exact moment, and I don't think we've ever had three that weren't postpartum all at the same time, and clearly I wasn't one of those, so we've never actually had three, but we're going to get there. Next month, we'll have all three. It ends up being about .5 FTE total, and so it's like a half day of consults, half day of clinic, and we do not staff the inpatient unit, and the inpatient docs don't staff the consults, so that requires really good communication between the two teams to say a lot of times what works well for each person. Our volumes are there per month, which you can put that together to figure out in a year, it's about 700 to 800. We did a QI with the PICU, it was about eight or nine years ago, and it increased by 20%, and sustained that increase for a while, and then it's been eight or nine years, and so we need to go back to it. My suspicion is that if we go back and do a little bit more hospital outreach, we're going to get back up to 1,000 a year or so, somewhere around there. We do see weekend consults, the on-call physician does, and we get calls 24-7, about 25 to 40%. That's a rough estimate. It depends on the month. During trauma season, there's a lot that's IPR related, and then I think that there's a whole lot that's not IPR related, and I think we appreciate that as an opportunity for medical management. All right. I'm representing Seattle Children's. Seattle Children's is part of the University of Washington, and we serve patients in the WAMI region. WAMI stands for Washington, Wyoming, Alaska, Montana, and Idaho, so it's a huge catchment area. The hospital currently has 407 beds. That was just increased earlier this year. We do have an inpatient rehab unit of 12 beds, and I found some of these stats from our hospital website in 2022, our top five reasons for inpatient admission. Seizures was number one, chemotherapy's number two. It's not totally representative of why rehab is consulted, but interesting facts. What was also nice to see was, at least on the outpatient side, rehab has the highest volume of visits, but I think that includes all the therapy visits. So I started as an attending in 2014, and that was also the first year that we had a designated consult service, and now we have an attending covering consults every day of the week. We do have a nurse practitioner that covers three days of those weeks as well. The number of patients on our consult list actively are anywhere from 30 to 40. I just got some fresh work RVU numbers, and this is just based on my own, probably 0.5, 0.6 FTE on consult service. Last year it was around 15, 60, and this year it's projected around 1,800 or 2,000. And so it's growing. We do have three therapy teams, just one physician consult team, but three therapy consult teams, that was not eloquent, acute care, cancer care, and infant therapies. We do get consults from basically every service in the hospital, including psychiatry. And the rehab consults questions for us, lots of pumps. Anybody who has a pump, we could consult it, but we're also, aside from placing the actual pumps or explanting pumps, we're it for all of pump management beginning to end, including a very extensive sort of education for the families, any sort of workup, site for access. We're in the IR suites doing DICE studies. So we're in there, we get consulted on pumps. Lots of tone management, lots of just general rehab assessment, which turns into a lot of medical questions, and that invariably turns into discharge planning, lots of questions about inpatient rehab. We're partnering with our infant therapists, particularly for those who clearly have CP, to start those early diagnoses, those early education and conversations with families. And Sprint. Sprint is a program that we developed several years ago. It's a two-week intensive rehab program for those who are hospitalized on our cancer care or bone marrow transplant units. And these are people who otherwise would be coming to inpatient rehab but can't because of various medical reasons or they're getting chemotherapy. And so that was sort of developed out of our consult service. Can I ask you a question? Yes. Is Sprint on the medical floor or is it on the rehab floor? On the medical floor. Yeah. Awesome. Well, thank you, guys. The next section of questions, we want your help as well. If you guys go on the poll everywhere, we're having a little bit of difficulty, so the answers will not show up here, but they will show up on Becky's computer, so we'll be able to tell the results of the polls after everyone has done their particular answers. So the first question is, what percent of your consults are related to disposition or appropriateness for inpatient rehab? Oh, yeah, so it's at the bottom of the screen. So it's Becky Siegel 327, S-I-E-G-E-L, and then it's two, three, three, three. No, two, two, three, three, three. I'm dyslexic, sorry. Did it work? Thank you for letting us know. Siegel 327. So from our perspective, I don't actually have this information from Boston Children's. I would say a lot of times we're getting consulted for inpatient rehab. In reality, it's a medical question and we're answering other things than just should this kid go to inpatient rehab. I think anybody else want to answer? You guys kind of are. Everybody else kind of put this on their slide. So some people are saying 30, 40, one person said 70%. 30%, 45%. So it sounds like a lot of what we're doing is getting consulted for this. Somebody knows that it's 45.7%. I think whoever you are, that's really impressive. Is everybody seeing a lot of just like, hey, this kid needs to go to rehab? Or like we already put in the referrals for rehab. Like we need your documentation. Raise your hand if that's like a typical consult. Yeah, we definitely get that one too where they're like the therapists have recommended it. We just need you to make it formal. Yeah, but I don't even know if this patient's appropriate for rehab. So I will come and do my evaluation. So a question for a crowd out there on that topic. If that's your situation, do you have a relationship with your therapist where that's what you prefer that they'd be doing? Is that like, I see a lot of people saying that's what they do, they recommend inpatient rehab. Would you rather that they do it, they recommend it to the team and then get a consult or talk to you first? I can come for microphones in the group too. I would rather they talk to me first, personally. Sometimes I think with like a busy consult service though, it can be hard to have that. Sometimes it's nice to have that gatekeeper almost where they're recommending that and then you can throw in your lot as well. I mean, obviously I think we'd rather them come and speak with us so that the referral is actually appropriate. Sometimes it's just to discharge a difficult patient and that's not appropriate. And a lot of times I get consulted, we referred them, but we got denied. So can you come and fix this? And my answer is, why didn't you call me a week ago and we could have written something that you wouldn't get denied because now I have a lot of extra work to do. Anyone else? I'm glad I'm wearing tennis shoes today. When I set up the consult service at my hospital, I got the dedicated time, about 50%, and then I asked to have my office with the therapist. So I actually sit with them. A lot of them have my cell phone. So we come up with a lot of the plans together and most my consults do come from the therapist. They recommend me and a lot of them, we come up with everything collaboratively. I'll go see the patients with them during therapy sessions, stuff like that. So it's usually a team decision. All right, next question. What percent of your consults are related to medical questions? So on a similar realm, but opposite. Good question. It can be bracing. Bracing and equipment, sure. But how do you deal with that, right? Because can you really get equipment started while kids are, how much education are you doing to your team to be like, hey, this kid needs a new wheelchair. Can you come and do it? And I'm like, I had this conversation with you last week. That's not how it works. I cannot get your kid a new wheelchair tomorrow. What we were whispering up here is, I think it's really hard to tease out, do we do this or do we do that? I feel like most of us do it all. You know, we're a field that's all about sort of this comprehensive daily function and it will include orthotics, it will include DME. So I feel like, and if eventually the question is, are they inpatient rehab candidate or not, then sure, that's one question. But I don't know, I feel like we kind of do it all. Is that right? Yeah. So in the answers here, we're getting a range of 30 to 80 with what looks like a mean and a median of about 50%. And I think when we started, almost all of our consult questions were about inpatient rehab because that's the only thing that people knew that we did. And as we were there and we provided more education and they started to associate, oh, PM&R, you help with Tone, this is Tone. Oh, you help with this thing called PSH. We can call you for that. Or, oh, we don't call neurology, we call you for this. And obviously the therapists are the frontline and they provide a lot of education and they're often the first ones to see the patients and help direct it. But having that presence and having that continual education for the services has been really helpful. Okay. Yeah. The next one is, does your institution have auto consults? So the next question to this is, if they do, yes, what are they? And the question after that is, do you think we should? And for what diagnoses? Who here has auto consults? Yes. What are they for? Level one trauma. I'm looking at Carl because I'm like, for some reason that my brain went black. I'm just trying to try to answer this. Level one trauma. Logistic consciousness. GCS Lesson 15. There we go. Does that mean it's built in? It's in the order set. It's in the order set. Yeah, it's part of the order set. And the trauma program, if those consults don't go in every month, they come and find the person that didn't do it and make sure they know. The cracks are not falling through often at all. Is it part of your accreditation requirements? Yeah. So there's a question of, is that part of the accreditation requirement? For us it's yes. So we work closely with trauma on that. Anybody else have auto consults? It looks like from the crowd, it's about 45% yes, 55% no. Anyone that's not related to TBI, GCS. Any spinal cord injury auto consults? Spina bifida babies? All brain tumors? Yeah. Cardiac arrest? And stem cell transplant. Stem cell transplant, pre-stem cell transplant. Anything else that we're missing? Hopefully we're writing these down, but not, hopefully we'll remember them. Anything else that you think we should be doing that we're not? Amputation. What about a new spinal cord injury? What about like a loss of signal in the OR when a kid's getting a fusion? Neuromuscular. What do you mean by neuromuscular? Baby with SMA. What if they're gonna get gene therapy, though? Do they really need us? We hope we get to discharge them at 18 months. See? Pre-surgical assessments. There's like brain tumor out there, there's epilepsy surgery out there. I wondered about saying either outpatient or inpatient, depending on where you are, if you're gonna do surgery on structures that we rehab, why not just have it be an auto consult? Because we often find ourselves behind it. Would you guys like to hear a talk just about pre-surgical assessments at one of these conferences? You'll see us here next year. What about like epilepsy surgery? Post that, post hemispherectomy. Seen that. So I think there's a lot out there, and I think it's just important to know what are other institutions doing, and how are they incorporating it into their EMR, and how are they communicating that that's helpful and important? You can put your diagnoses in here for what you think an automatic consult would be beneficial for if you want to. We already talked about it though. Are we missing anything? Yeah. So every patient that's admitted that has CP and a GMFCS four or five, like they're in the hospital. So we get a lot of those. Yeah, what's going on? Burns, good, yes. We don't see burns at our institution. Who here has seen burns where they are? Are you guys getting consulted a lot or no? Not really, but yeah. Okay, Alyssa. We have heart transplant, heart and lung pre-transplant. Heart, lung, pre-transplant. It's good, okay. I was gonna say we don't have any auto consults, but we have these epic alerts attached to certain diagnoses. So if somebody comes in with a spinal cord injury, we get an alert in our box, and that's an occasion for us to check to see if they have an AD protocol. Somebody with a back of a pump that comes through, if they're in the hospital and we're not consulted and they have a pump and the alarm date is coming up, then we better know. And so it doesn't trigger an automatic consult, but it triggers your eyes to take a look. And like goes to the urine basket to be like, hey, you should see this kid, you should reach out to the team. Yeah. Cool. And is that just generated through the EMR? Yeah. Is that an epic module that does that? We have epic, so yes. Can we steal it? Yeah. Can you send that around, please? Is that the whole world? I'll make a note. Thanks. What's the, oh, sorry. The next question is, what is the general timing of consults for TBI or SCI patients at your institution? So the options are on admission within 24 hours, within 72 hours, within a week, when they are ready for rehab or no set timeframe where they're not seen. I would say for us, it's usually within the first 24 to 48 hours, often when they're still pretty, very acutely ill, especially the, but I think it's been pretty fast. And I think part of it, for anything that falls in the early mobility, that makes things happen very quickly. But we also have some really great neurocritical care docs who are very pro PM&R. And so we have a lot of people who are very pro-PM&R, and so we have a regular monthly meeting with them and they tend to facilitate that too. So we don't have auto consults, but we do meet with the trauma team for their rounds three days a week. So it's not usually, it's usually when they're definitely not herniating or going palliative, we get consulted. Okay. Oh no, just, oh. And also the poll everywhere isn't working. I don't know what's going on. It's okay. Some people answered it and some people can't get it, but that's okay. This one's not working, yeah. I'll pull, we'll try to, we'll see. Who here has APC assistance? And who doesn't? Yeah. APC assistance? Only a couple. Only a few. What institutions? There's Children's Mercy over there and that's Houston over there, yeah. Who else? What institutions? Like an APRN. Either a PA or an APRN. Children's, we're all children's. Children's. DC, yeah. Seattle does too. UNC. Minnesota Children's, yeah. Okay. So a lot of people. I see another hand. Anybody want to, so the next question is. So the next question is open-ended, but it's if you have APC assistance, how do they add to your workflow? So I can talk while I'm walking over to Clarice. So I don't think our service would exist without Bridget. She is the gamekeeper and the gatekeeper of all of the new consults. She's the one who is updating charts. She's the one who's making sure that we're consulted on the kids that we should be. She's the one communicating with teams when I'm in clinic. She's the one chart reviewing when I'm in clinic. So when I get out of clinic, I can run to the floor and see kids right away. So I'm not waiting two hours to kind of look at everybody's chart and talk to all the teams. She kind of holds the page or two when I'm in clinic. So I'm not sitting in clinic with eight pages that I have to get back to. It allows me to kind of actually focus my work very nicely. Our APP, she doesn't need us to like sign off on her. So that's helpful. And then when we're really busy, she's only one day a week with me, but she'll see like the more chronic kids, the GMFCS5 kids who were admitted with pneumonia and we were consulted for storming or spasticity. So she helps a lot with those. Yeah. When we're doing more of the neurotrauma, the cardiac kids, stuff like that. And then she'll also do the NICU babies to help kind of check in. If I did the initial consult and I recommended starting a med or whatnot, she'll do kind of the followups for me. Anyone else want to answer? How do your NPs, or how do you want your NPs to add to your workflow? What's your like ideal? I would say our NP usually we kind of have see a lot of the newer ones and kind of handle the new consults. Anyone else? Okay. This is the next question. So for those of us that don't have NPs doing it, how do you find that that works in terms of the humanity side of it? And not saying that they don't necessarily grasp humanity the same way, but I think a lot of people right or wrong or potentially wrong grasp towards physicians for that humanity. Did you ever find that you're lacking that? I don't think so for us. I think she does a great job of connecting and spending a lot of time with our families. And I think there was something in another talk that was said that I think was very accurate that it's a lot about the person and not just the credentials. And so finding the appropriate person that you're training. Our nurse practitioner worked for 10 years in pediatrics, but specifically in our, what we call our care team, which is our non-accidental trauma assessment team. So coming in while she had no PM&R experience, had a lot of experience with non-accidental trauma and brain injury. And so that was incredibly useful. We started from scratch in teaching the neuro exam and things like that, but I think having that background was very valuable. So Bridget, before we stole her from one of our patients, she was a private duty nurse for one of our kids with a high cervical spinal cord injury. And then we kind of plucked her from that to be our NP. So she has, from a spinal cord injury perspective, more knowledge than I do about the day-to-day of actually taking care of patients with AD, right? Like I talk about it all the time, but have I had a patient have AD 20 times in the day and what you actually do from a functional perspective, from a caregiver? No, Bridget has that experience and can speak to that with families. And I think that adds a lot to interactions with patients and understanding that in a very different way than I do. So what are the parameters and how does Bridget identify? Does she want to answer that question? Sure. During lunch, I stock all of the floors and look at the diagnoses that are on the sides. And then I will just go through and kind of with what we had come up with, the auto consults, if any of those patients fit those what we thought could be auto consults, I'll dig through their chart more and see if they have any identifiable rehab needs that we could be a part of, or I'll kind of put them on my watcher list if I think that they could be someone that maybe we would be helpful for, or I'll reach out directly to the primary teams to see if they think that we would be helpful. Sometimes they say no, sometimes they say not right now. Sometimes they're like, what is PM&R? Not very long. I would say about 10 minutes, 10, 15 minutes. If you do it every single day, you kind of can, how our floors work is you can actually link it by time. So you can just look at the patients that have been there for a certain amount of time. We also, the frequent flyers that are always in, you kind of know their names and they pop up and you're like, hey I know this kid so we'll see them. And I kind of mostly look on the ICUs, our ninth floor which is neurology, neurosurgery, neuro-onc, our orthopedics floor. Those are kind of the main ones that I start with and if I have more downtime, which is not usually, I'll kind of spread out a little bit more to our other floors. Quick question, when you are stalking the patients, as you said, what are the legalities around that? I know, that is a good question and I don't know. I don't, I don't open the money charts. I'll just look on the sides and then if I think that it would be something, I would reach out to the team. It's more of like a cursory glance, like oh this patient had a diagnosis of a brain tumor, like oh maybe we should reach out to the team, reach out to the therapist who's following this kid would be helpful. So it's more of like a diagnostic screen, but also that's hard because sometimes they get in for RSV and it's not RSV, right? It's not perfect. Another thing that we do is we do a weekly consult rounds with all the therapists and the case managers because the therapists are getting a lot more consults than we are and so as we're running through these patients and their discharge plans and what they're thinking about, we identify a number that have not had PM&R consults that are appropriate for PM&R consults. Do all of the case managers go to that and do all the therapists go to that and how long does that take? So we have lead therapists that go, so there's a lead PT and a lead OT and a lead speech therapist, so they're kind of representing all of therapy, but the therapists kind of have a list together. Most of the case managers come, it's not consistent every week, some come more than others. It usually takes, we have an hour slotted out, usually it doesn't take the whole hour. So we do something similar but we cannot get people to show up and we're running our list and then they're like oh who else needs to be seen and it's we've really struggled with how to get consults that way. We've really struggled on like how do we actually get the therapists involved because the lead therapists come but they don't communicate with the rest of the therapists. We actually don't, like very, there's very limited communication to get that stuff. Is yours in person or virtual? Virtual. Yeah, that's helped us a lot too. Yeah, we do ours in person. Ours is Wednesdays every day over the lunch, over the lunch hour, so all of the acute care therapists come and it's the rehab team case managers, if they feel appropriate, our rehab liaison and all the acute care therapists and we run through like any pertinent patients that, one, that our consult team is following and that any other therapists think that we should be involved with. And then the other thing I'll say is we have a phenomenal nurse practitioner who, she is full-time consults and so she's kind of our gatekeeper. So similarly when we were talking about disposition planning and communication with the therapy team, like she is kind of our gatekeeper and like our acute care therapists know that she is a primary point of contact, so that helps us a lot in terms of when we're in clinic and things like that. Similar to what you said, Becky, that she is kind of their go-to contact and then reaches out to us for any further discussions that she feels we need to be involved in with families. Anything else? Clarice, you should have sat in the front. Yeah, I just want to say one thing. That's illegal, going through patients charts, if you're not actually consulted on them, so I would be very careful what you're doing. But it's still a little touchy, but what I do is I attend multiple rounds. So I do the therapy rounds, I sit with them, I do NICU rounds over at like a county hospital, I do trauma rounds, and one that was one way to get your face known, this is who I am, and then the more as you go weekly or whatever, they'll be like, hey, is this somebody you guys should be seeing? And I'm like, absolutely. Or the therapist, when I talk to them, and they'll be like, hey, I've asked for a consult, I like, I really need to see him. I go, well, until they place that consult, I cannot go digging through that chart, but I'm very happy to see them. But yeah, I don't touch a patient's chart until I have been formally asked. So in our hospital, I would, actually this applies more to our adult and patient rehab unit where I was medical director there, and we had clinical liaisons who were a therapist or a nurse, and so the PTA clinical liaison could technically get into patients' charts because they had therapy orders. So right now, I'm working with the medical directors of the critical care units and our PD trauma unit to create auto orders for therapies for patients who have been admitted for a certain amount of time, and they're actually admitted beyond just kind of an observation type of stay. And that way, the therapist, I plan to work with that therapy manager, who's only one therapy lead, and have, I mean, so technically, legally, this is the loophole, is that because they have therapy orders, the therapist can actually look through the chart and tell me if they think that, oh, you know, maybe you can talk to the primary team about getting a consult for this patient because we think they will really benefit from having you on their case. And then, but also we're working on auto orders for certain diagnoses like TBI and spinal cord injury. Clarice, I think you make a solid point about legality and needing to find the boundary there. A suggestion, I think, if that's something that you guys are interested in doing, if you do it as QI, you can likely find a way to do it and access the charts if it's QI, and you are getting that approved as QI before you do it. I think the other benefit, if you do it as QI, is you get a whole bunch of data there, and as we talk about this more, I wonder if those data are something that we may actually want to share with this group specifically, if that works out. I was just going to suggest that I think if you want more involvement and attendance from the therapists, that, you know, they're going to have from their own department the number of hours FTE, you buy out their time, 0.05, 0.10, and convince the hospital that the return on investment of another person coming to get rehab care, or if you want value-based to avoid secondary complications of their condition, it's going to be worthwhile to the hospital. And we're doing it through a grant, but we hope in the future to prove that's going to be efficacious so they can free up the therapists. Next question. Great. The next one is, do you think that consult should be required for training, so for residents, fellows? 100% right now for yes for fellowship and residency. That's either one of you or 20. Yes, but only fellowship is 10%. Oh, no, you changed. Somebody changed their mind. So, are there any trainees in here you want to talk about? Do you think that it should be a part of your training? Did you find it beneficial? Thoughts? And then the follow-up question there is, should it be like a fixed set of your time? Should it be something you do PRM when the good stuff comes in? My amazing PD sitting right next to me. No, I honestly think as a trainee, having the ability to do consults as a resident and then grow from that in a fellowship has fine-tuned what I want to be doing as an attending. I do think there is a role for balancing the role of like how many consults we see is it during a fellowship though, like if there's an NP or a PA to be like, yes, I've seen them and this was the education that I took from this, but this is somebody if we continue to see as a follow-up, I don't necessarily know if I'm gonna grow more with this relationship. So, I do think there's a role of balance in that, but I think overall throughout my training it's been beneficial both as a resident Anyone else? I'll say that in our program the residents have said of all the pediatric rehab experience they have, they like consults the best. So, I think it's probably pretty variable like institution to institution, but during my residency I did, we did inpatient consults like for three months as part of like during PEDS and I thought it was hugely beneficial. I thought that was like one of the main ways I learned about pediatric rehab and like a lot of the, you know, jobs that are available aren't just inpatient, like there aren't just like, you know, inpatient rehab units everywhere. A lot of places you will be either like starting a consult program or building consults. So, I think doing consults and residency and definitely fellowship I think should be required, but my PD is also right behind me. My PD is not next to me right now, I just want to make that very clear. I think my perspective is there are hospitals out there where there are adult physiatrists who are doing PEDS consults, so having that as part of training that they've seen kids and have to make decisions is really important. That's kind of my perspective on it. I think from a continuity perspective as well, you're seeing these kids like initial stage and then they come to rehab and then you see them in follow-up, so I think it's a really good learning opportunity there. We have actually tried to now set up, our fellows have two months, one month each year of general consults and then they kind of do staggered cardiac and we actually try to set up their inpatient consults the month before their inpatient rehab, so they actually get to see the kids in the acute care and then maybe they're transferred and they see them while they're there at some point, so you actually get more of that continuity, which a lot of us don't do inpatient, but we do consults, so we don't get that continuity, but for our fellows and our trainees I think it's actually a really amazing way to kind of see that entire continuum of care. In my residency, I know consults was probably one of my biggest learning times and I really, really liked it and I wish I had more of that in my fellowship. I don't know if my PD is in here, but I also think just, not even just from the medical perspective, but from learning how to talk to other colleagues, from learning how to network yourself, that should be part of training, especially if we're gonna be trying to spread PD rehab out and you need to learn to talk to the neurosurgeons and the neurologists and the orthopedic surgeons and you're not gonna get that when you're just inpatient rehab and outpatient. No, I'm not a trainee, but I was. One thing I like about it is when the residents or fellows come through, I do family meetings and it's very different running a family meeting or doing a family meeting in an inpatient rehab unit versus the ICU, so if I can, even though they really suck, I'll have them come to the end-of-life talks. Do we withdraw care? Do we not? And a lot of times, neurology is usually the one doing the MRI and giving all the doom and gloom, but then they're like, well, if we choose to keep my child alive, what's the rest of our life look like? So it's almost like doing life care planning on the spot right there, so I feel like it's very valuable because if you get into your attending job and you get thrown in on day one and you have to do this very uncomfortable discussion, I think there's a lot of value from that. No, I totally agree. It's a very different conversation. Nathan. Hey, Carl. Hi. Hey, Carl, you're a fellowship program director, is that right? Yeah, that's right. Okay, cool. What do you think, so you've got the before and after of having a fellowship that had fixed consult time for your fellows and then that didn't have it and then we switched to having it. What feedback have you gotten from your fellows that the difference there? So the fellows have all been very positive in having it dedicated. We treat it as kind of a junior attending on the consult service, really have them take primary responsibilities and it's been a very positive. We did it kind of targeted for a couple of people who knew they were going to be starting a consult service as a part of their job, so we just kind of flexed some of their other time into a junior consult month and it was such a success that we've now integrated as a permanent part of the rotation schedule. Thanks, Kyle. The next one's an open-ended one. What has been the greatest struggle in growing your service? I think it's been especially when the services start to realize what you can add, there's an influx and we, you know, don't necessarily have the bandwidth to see all the patients and follow them up maybe as much as we'd like. I think it's more of a manpower once they realize the value that we can add. And I'm gonna say from my perspective, I think our department doesn't always see the financial value of the consult service in comparison to outpatient and procedures and so making sure that we can get the financial justification for people's time because we clearly see that as we add people and we add presence, we increase the number of consults and I think we're doing better for the kids, but we have to show that financial value to the department as well. I think it's just, it's hard growing something, right? It's hard getting face time with the stakeholders to get you in there, right? You have to have a really great patient experience and let's say you have at our institution, especially on the oncology floor, like they rotate for one week every six months and that's it. So if you have a great experience, they might not be on for six more months and they might not tell their colleagues. So when you have a huge institution, it's finding the people that know what you do and support you and building that relationship and like we have a great relationship with the NPs in the ICUs. A lot of them just have my cell phone number and like so we go to the, we go and sit down usually and I'm like, hey, do you guys have anyone for us right now? Like we go and hang out with our complex care team, like we walk by and we walk in like, hey, you guys got anybody on your unit that you have for us right now? And so some of it is just having the time, but financially like they're not paying me to go and sit in the room and have these conversations necessarily. So it's definitely hard. So in my experience, it's not having Dr. Clamar be the consult attending. So when I was running our consult service, I was trying to do it on about an hour and a half a day and it wasn't enough time to go introduce myself to the other services, communicate to them, educate them on what it was that we could provide for their patients. And we really, it was when administratively we decided to give somebody enough time to do that, that the consult service really ballooned. What do you guys do? How do you communicate with your colleagues for those people that are switching on like a daily basis of who's covering the consult service? How do you guys make sure that your colleagues know what's going on? Who should they be seeing the next day? How frequently do they think these kids should be seen? Yeah, that's a good question. So we use an epic handout, the handoff sheet, and just have to keep that really copacetic and updated. We also struggle with how do you communicate with all the services, right? So there's paging, but then it's clunky. So we were actually moving over to Volt and then Realtime. So, you know, we have two people on at any one time. So then it's just having all those services being able to contact us. Yeah, we have a encrypted, through our email, like a safe document that can have patient information that is accessible off-site that you can actually update. So then you can see, hey, this person should be seen on Tuesday, or this person should be on a weekly queue schedule. And like this is what we did. These were the rehab racks, or like this is what we're following up. These are the medical updates. So we alternate every day for our consult service. So for the outside teams, it's just a call schedule on our pager system. Between us, we actually have a meeting for half an hour on Mondays and Wednesdays, where we just run all the consults with our whole pediatric rehab division and actually our clinical liaisons and the resident, and just run through all the active consults on our list and what we're thinking for those patients. And then in between those two times, we tiger text, and we also have tiger text groups with neurosurgery and with trauma surgery for Okay. Next question. I was just going to say, I think another aspect of kind of the struggle with growing is who you're housed within. We do not have our own department. We're under the Department of Orthopedics. And as much as we try, we'll never be orthopedic surgeons, and we do not make the money of orthopedic surgeons. So going back, just kind of, I think our sky limit would be to be our own department sometime, but it will take a little bit to get there. Our I.D. said orthopedics for a really long time, and that was really confusing when we were walking into a patient room, and we're like, hey, we're the rehab team. Your I.D. says orthopedics. And you're like, so we got that changed, and that's actually been like, even though it's very simple, is actually we have notes in our own location, they're not under ortho anymore in there. Our I.D.s actually say rehab medicine, and that, those two little things actually make a big difference about where to find us and where to find our documentation, which is simple but complicated. I was going to answer part of that question of the struggle. It's not so much of a struggle, but sort of what I found, in addition to building those relationships that you were talking about, which I think is so important, I think having that continuity on our own end is also fairly important. If you start a new med and you want to follow up in a couple of days, then, gosh, wouldn't it be nice if it was the same person that saw them in the first place? And we already struggle so much with the primary team switching over week after week, and you're finding yourself repeating the same conversations week after week, because you're not reading your notes. And so on our end, when we have a lot of handing off of each other, I personally find it kind of hard to be that one person who's on just for the day, and you have a massive list of people you don't know. So I've got to be real about something about growth, because our greatest struggle with growing our service has actually been provider burnout, because volume was too high, and there was too much. And so this, you know, I'm not enjoying consults as much as I used to be. I'll say, if you're doing consults and you're not passionate about it, that's a hard job. And so somebody said, hey, can we not grow for a second? That was a real thing, and I'm wondering, I mean, I think that's a perspective to also consider that our greatest struggle with growth is actually just not having the man power to keep up with it. And so we've been on growth pause for more than a year right now, and not, intentionally not making effort, which we don't love, but we're going to be a full crowd soon. I think the next question is a good segue of, do you feel respected in your hospital system, and do you feel like the primary teams generally follow your recommendations? Yes. Yeah, I think for the most part, and I think, one, most of the time they follow what you recommend, which is kind of nice, not all the time, and two, we get invited to so many care conferences that you feel that they respect what we're doing. I agree. I think for the most part, yes, respected. Follow recommendations for the most part. I don't know how many of you come across this where you get consulted for, especially maybe like rehab disposition, but then you see the patient and you realize there's other rehab needs that they have. And those can be the, at least in my experience, the recommendations that they're sometimes like, oh, we didn't really ask you for this. I'm like, I know, but I'm here now. So let's talk about it. And then I think it makes a big difference too, if you're able to speak with the teams about your recommendations versus if you're having to rely on them to read your note. I don't think I'm going to say just, yes, I'm going to say sometimes, and we're working on it. I think as a consult service that was here and there in the past five years, and now as somebody who is a dedicated person, people are still figuring out what we do and who we are, and that we're not just the person to come and do Botox, and we're not the person just for disposition. And I think a lot of teams are getting to the point of valuing our input, and I think most of our recommendations are followed. I think there's probably a slew of teams that even if you tell them on the phone, like, hey, this is what we recommend, it's not happening. I think that's just the lay of the land. Anybody else? I would just be curious to know if anyone else has run into a similar issue. I would say in terms of respect from our subspecialty colleagues, absolutely. I think carrying out our recommendations, in theory, yes. Where we've run into some challenges is in the setting of the pandemic with the nursing shortage and staff turnover, the education to carry out those recommendations, in particular like with our spinal cord injury population, bowel bladder management. I think it's, from our perspective, it's more of that conceptual learning model and staff being able to carry out those recommendations. It's not occurring because of lack of communication or buy-in from our subspecialty colleagues, but almost like a lack of knowledge from staff. Just to add to that, we have definitely seen similar issues. One of the things that we did, we have some pretty amazing nurse leaders, and with especially the high turnover that was happening during the pandemic and the infrequency that we would see spinal cord injury, we definitely saw that being missed. We actually put a protocol in place in collaboration with trauma and neurosurgery and gave it to the nurse leaders who then, they are actually the ones responsible for training and following up on the nursing staff. It doesn't fix the nursing staffing shortages, but it has given them something to follow and they're very good at their protocols. I think by giving it to them and putting it in their hands, we've at least seen some progress that way. I guess on a similar, what are ways that you guys have fostered connections with other teams and how have you done any education within your hospital system so that they know what you're doing? I've given different presentations, you know, when I first started. I met with the ICU. I met with the trauma team I've done Grand Rounds for trauma team. I've done Grand Rounds for pediatrics. I just did that last month I just made sure I'm always available A lot of the hospitalists have my cell phone number the trauma team has my cell phone number And I'm like if you ever have a question just ask, you know, you can curbside me Oh, I may be able to just answer the phone and I never turn down a consult unless I think I'm PT Then I say you need to consult PT, but that happens, but you know, I always take every consult, you know Sometimes they may ask me for something that was inappropriate But I get in there and I go actually I can help with X Y & Z and then they're like Oh, you know, so I just make being being available if you are constantly switching a different person every day I guess it gets a little harder, but I am the service. So it's always me So it makes it pretty easy and so I have good relationships with pretty much every service within our hospital When I'm not there Yeah right now. Somebody's holding down the fort No I usually try to give a good sign out like if they're covering for like a conference or something long and I let the therapy team know that I'm out But like I said, I'm still getting texts from the trauma team and stuff like that In the neuro ICU and stuff, but I just let him know, you know, hey, these are the people that need to be Close follow-up. Hey, you just follow up with this on Tuesday But if I'm only gone a day or two, I'm like just focus on the new ones I covered everybody before you left. I did as many follow-ups the day before Luckily the fellows there now too. So he knows the patients so he can help out with it. I Don't usually get too burned out because I like you said you have to be passionate about it and I love consults I Do outpatient I do outpatient Consults I do Nick you and the surrounding hospitals as well. So I I like seeing new people You never know what you're gonna get day to day. It can be a day old patient or a 36 year old, you know congenital heart patient But the only time is when I do a bunch of the like end-of-life talks like back to back to back or you know Do we withdraw care that can kind of suck the life out of you, but but we see so many great things, too You know the great outcomes and now that our inpatient rehab units in the hospital I actually get to see you know, they leave me max assist and they walk out of rehab So but now that they're in our system, I can actually still Thank you. Sorry I feel bad making you run everywhere. Kind of related to the answer to the previous question about getting people to follow recommendations, I've really just learning from experience made as a policy to go find a human resident, a tenant, whatever, on the team and go talk to them. One is my own. I don't sometimes get to writing up my note till later from home after kids go to bed. So if you want your meds started or your recommendations followed, then they don't always read the notes. Sometimes it takes a full 24-hour cycle till the following afternoon. So part of that is selfish. And then I think related to the current question, it's just a teaching opportunity. The lecture about top issues for inpatient rehab to residents is good. But the sort of one-on-one interaction, seek out the team room, find them, identify yourself because they don't rotate with us or know who we are at my hospital and make the rec. And there's other residents in the room. And it ends up, I think, paying dividends just to sort of be present. I came back in person to give my recs. Here's the med dose because I'm not going to write it up till six hours from now. And I think it pays dividends. Haven't done it any kind of official QI way. But I think if I ran the stats, they are followed sooner and more frequently when you make direct contact because we all assume that every primary team reads every note dropped on their patient every day. And I think we also all know that does not always happen. Sometimes rehab notes are long. I think sometimes we make them long for our colleagues that are taking our patients when they're being admitted to inpatient rehab to kind of help that transition. Next, we're going to go through Becky's going to talk a little bit about her research project. OK, so in talking about consults, really important, we're all doing really great work. And I just kind of thought of this project to think about what are we doing, how many of us are doing this, and what does it look like just to get some baseline information of numbers. So you guys, Matt passed out my little QR code piece of paper. There are more of them if you guys came in late. So far, we only have five people that actually filled out the survey. And what it's asking for is what hospital are you at? What are the number of beds? Do you have an inpatient rehab? How many local inpatient rehab units are there? Some of the information that we presented at the beginning, what's your FTE coverage? What is your APC coverage? Are there automatic consults? There's a list of services of like, are you getting consults from these groups? Are you interacting with these groups? And then looking at, I started this a while ago, so looking at 2022. If you don't have this information, that's fine. When we ask our finance team, say, hey, these are the codes that we use with these attendings. Can you pull the data? It automatically comes with RVU and WorkRVU, so we put it in there. If you don't have it, that's fine. If it automatically populates, it's great. I think it's interesting to know kind of what actually are we generating in terms of RVU and WorkRVU for the work that we're doing. And I think this is a good question to end on, is do you think that the consult coverage that you have right now at your institution is enough to support the needs of your hospital? Anybody think the answer is yes? Anybody think the answer is no? Hey, Becky. We found that some folks have a really hard time getting their RVU data. If they don't have their RVU data, what do you want them to put on the survey? Just estimate it or don't fill it in. That's fine. Guess it or say nothing. But don't keep it from, don't have it keep you from finishing the survey so we can publish it. Yeah, that's fine. Matt, Matt, Matt, you're allowed. Just talk. Correct. One person from each institution. However, if you have a ton of people and I get two places from the same institution and they're one is, it asks if your number is quarried or an estimate. If I get two and they're both estimates from the same institution, we'll take the average of those or if three people fill it out by accident, we do want one per institution. And I think just like, where are the consult services, right? Like, where are we working? Where are we doing this? Where is this work happening? And then from here, having more conversations like this, having more ideas, this is just the baseline. But like, what could we have a consult? Hey, what are you guys doing for PSH? Plug for a paper that was just published about PSH. But like, we're all doing this. And so like, we need to support each other. So we actually have information. We have data. We can actually, once we just know where we are and what we're doing, then maybe we can do some of that adult research, looking at length of stay, looking at multi-disciplinary, multi-center studies, looking at some of this data, looking at some of this information. So then we can go to our institutions and say, hey, this work is really important. What we do is actually really important. And it's not black and white. It's gray, but it really helps patients. It's actually going to help costs. It's going to help satisfaction. It's going to help all of these amazing things. We don't have the data right now to go our institutions to say that those things exist. And what we need to do is just start. This is like the really, the little itty-bitty tip at the top of the iceberg of like, where are we? What are we doing? Is it enough? More to come. Are you looking for total capacity to prepare for having kids? Total capacity. How many beds are there in the institution? That's a good question. Any lasting questions? We have four minutes left. Any other thoughts, things about consults that you want to talk about? I'm going to give it to someone who hasn't talked yet. Well, not here yet. Just a quick thing that we learned from having the opportunity to do this for a total of two weeks relative to trainees was that we have a number of APPs who work with us. There are two or three on service at all times. And in the two weeks that we were able to separate the trainees who were on our service, which we have two or three of those at all times, from the APPs and have two different services, it was a much better experience for the trainees. I'm also a fellow, and my PD's right behind me. But I agree, yeah. So I mean, our consult service is pretty robust as well. We also have a running list of average 40, sometimes up to 50. And all those kids you could see pretty frequently throughout the week. And so we generally have the APPs and residents review all the patients every day. And it's split up who's in charge of which patients. And so for those two weeks that we had enough coverage to have two attendings, it was nice to have the time to be able to educate and learn and take interesting cases. Yeah, because I think what we found was, to Dinesh's point, that the APPs and the trainees have different jobs on the service. And the APPs are there to see the patients, to generate revenue, and to make sure that the job is done whereas the trainee's job is a combination of service and learning. And it was much more difficult to accommodate the learning needs of the trainees as well as the hurry up and get it done so we can move to the next patient needs of the APPs. So speaking on that, every time that we have a fellow on, Bridget actually does other stuff and is not on consult. So it is a fellow run month. Like, they are the primary person. They are on five days a week. This is what they do. This is their responsibility. And Bridget actually helps with other stuff. So we actually pull our NP from the service knowing that it is really that leadership. I am now an attending. I am now running the service. I now know all of these patients. And I think that's also important. I was going to bring the same thing. OK, good. We all talked about that. But I think it is. I think if we're talking about this being a part of training, then we need to be consistent. How many months is enough months? Like, how do we look at this? And I think this is something that can be talked about later. But I just thank all of you guys for all of your really hard work. And I think if you're doing something that really works, let everybody know, right? Like, I can put it on FizzForum. We can add it to the Facebook group. If you guys are using auto consults or if you're using something that has really worked for how you communicate with your team or how your setup is, like, I think there are a lot of people that we can learn from each other in what's working well. But we can also learn from each other what has not been successful and how we kind of grow or maintain or just provide this service for our kids. Any lasting thoughts from the panel? No? It is 5 o'clock. Thanks for coming, guys. Thanks, team.

pediatric rehab medicine consults

importance

challenges

patient outcomes

clear protocols

multidisciplinary collaboration

communication

experiences

manpower

research