#93: Complex Care – Making Medical Care Less Complex for Patients and Families

September 13, 2023 | By Sam Masur

Audio

Summary:

Here, we make complex care a little less complex by reviewing the key elements of history-taking for patients with medical technology. We discuss management of acute clinical presentations and the role of the complex care physician in providing excellent care for this unique patient population.

Complex Care Pearls

1. Elicit concerns from the parent and/or caregiver, making note of the patient’s baseline status
2. Use a thorough review of systems, including medical technology, to maintain a comprehensive differential diagnosis
3. The complex care physician plays a central role  in providing a medical home and as partner with the patient’s medical team

Complex Care Notes 

General

1. Care of patients with complex medical needs which typically involves the use of a multidisciplinary team to provide comprehensive medical care both in the inpatient and outpatient settings. 
2. Complex care physicians come from diverse training backgrounds, such as general pediatrics, pediatric hospital medicine, and pediatric critical care medicine.
3. Dr. Hogan notes that it is important to understand the complex care physician does not replace other subspecialists, but serves as the patient’s medical home and coordinates care among subspecialists. 

H&P of a patient with complex medical needs

1. Maintaining a delicate homeostasis is important in patients with complex medical needs as simple illnesses are rarely simple in this patient population. 
2. Elicit concerns from the parent and/or caregiver, but avoid anchoring on a diagnosis. Ask if the patient has had a similar problem before. Dr. Hogan says that asking the question may help you dial into the main concern more efficiently as it may take a long time to read through the patient’s long chart. 
3. Determine changes from the patient’s baseline medical status.
4. Complete a thorough review of systems, including assessment of feeding tolerance and medical technologies:

1. • VP shunt: 
     • Note the type of shunt, date of shunt placement or any shunt revisions
     • Is the patient vomiting, encephalopathic, or having increased seizure frequency? These may be signs of a shunt malfunction.
     • Dr. Hogan reminds us that a shunt series can confirm placement of the shunt, but does not tell us about its function. We must complete a thorough H&P to determine if further imaging is needed. 
   • Trach/vent/airway clearance
     • What is the patient’s baseline airway clearance plan and which specialist put this plan in place? (check out our “Clear the Air on Airway Clearance” episode on 8/16/23 for more information).
     • Have there been any changes to the abundance or appearance of secretions? This may suggest a respiratory infection.
     • Has the patient increased airway clearance frequency or intensity during the illness and, if so, did they see improvement?
     • When was the last tracheostomy change and who manages trach care?
     • Evaluate the patient for increased work of breathing, tachypnea, and changes on auscultation. 
   • G-tube
     • Confirm the type of tube: Is it a G-tube, GJ-tube, or NG tube?
     • Check the site of the tube for any signs of infection (erythema, drainage, skin breakdown) or leakage. 
     • Assess for abdominal distention or tenderness. 
   • Bladder cath
     • What is the schedule for clean intermittent catheterization?
     • Have there been any recent changes to urine appearance or output?
     • Does the patient have any prior history of urinary tract infections? If so, which organisms? These questions may be helpful in guiding potential future antibiotic therapy. 
   • Baclofen pump
     • Assess for signs of baclofen withdrawal (can mimic increased intracranial pressure): vomiting, lethargy, seizure activity
     • When was the pump placed and when was it last interrogated? 

Management a patient with complex medical needs

1. Depending on the clinical scenario and resources at home, can sometimes use shared decision making in disposition for patients with complex medical needs; however, one should maintain a low threshold to transfer patients to an acute care setting for further workup. 
2. Strict return precautions are critically important.
3. “Private duty nursing” or “Home shift nursing:” nurses that provide care to the patient at home for a set number of hours. There is a national shortage of home care nurses and inequities in access to this care across the complex care community.
4. Medical professionals can help by involving social workers and care coordinators as part of the multidisciplinary team. 

Goal

Listeners will explain the role of the complex care physician, key aspects of the history and physical exam for a patient with complex medical needs, and general management of an acute clinical presentation.

Learning objectives

After listening to this episode listeners will…  

1. Explain the role of the complex care physician. 
2. Be able to take a thorough and pertinent medical history for a patient with medical complexity.
3. Account for key aspects of medical technology when formulating a differential diagnosis. 
4. Advocate for patients with medical complexity to have equitable access to medical services at home.

Disclosures

Dr Hogan reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Iness AN, Hogan A, Masur S, Chiu C, Berk J. “#93: Complex Care – Making Medical Care Less Complex for Patients and Families”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ September 13, 2023.