Continuity of Care
Care of the surgical patient begins with a referral to the surgical service. The majority of the patients are initially seen in the clinics at Children's Mercy Hospital and Clinics (CMH), which are conducted by the surgical staff and by the residents. Each staff surgeon has a weekly clinic at CMH. Residents participate in staff clinics as time allows and must be present at the time of the Residents' Clinic each Monday morning.
Many patients come to the Surgical Service as hospital consultations, all of whom are initially seen by a PSR, along with the junior rotating residents. Approximately 10% are initially evaluated by the surgical staff at a satellite office which is located 19 miles from the hospital. The majority of these patients have common pediatric surgical problems such as inguinal hernias, umbilical hernias, subcutaneous masses, etc. Many of those patients undergo their operation at Children's Mercy Kansas near the surgeons' satellite office and do not enter the system at Children's Mercy Hospital.
None of the CMH residents participate at Children's Mercy Kansas (this issue has been approved by the Residency Review Committee). This is due to the fact that the large volume of patients seen at the main campus is definitely sufficient to provide each of PSRs with adequate operative experience. All of the above-mentioned surgical conditions that are treated at the Kansas facility are seen on a much larger scale at the main campus. In addition, since Children's Mercy Kansas is located in Kansas, State of Kansas licensing and malpractice insurance would be required.
Evaluation of patients by the PSR in the CMH clinics or in hospital consultations results in the resident making decisions about further diagnostic tests and formulating a plan of action. Each patient that is seen at CMH is assigned to one of the surgical staff who is responsible for supervising the PSRs and implementing the management plan. For those few patients who enter the system through the satellite office and are scheduled for surgical procedures at CMH, a history and examination will have been performed by the attending physician and a chart notation should be made by the resident that he/she has examined the patient. These patients undergo the operation by one of the residents under the direct supervision of the attending surgeon.
Approximately 75% of the operations are performed as outpatient procedures. Those patients are generally followed in the clinic or office setting from which they came and follow-up is the responsibility of the operating surgeon. In the case of patients admitted after operation or who are inpatient at the time of operation, the residents are involved in their care, including all the critical care in the Neonatal Intensive Care Unit and the Pediatric Intensive Care Unit. This includes management of nutrition, monitoring, ventilation, etc. The exceptions to this rule is the "on bypass" management of ECMO patients, which is usually relegated to the neonatologist or intensivist. All postoperative care is the responsibility of the operating surgeon or his designated attending surgeon, including the supervision of residents involved in patient care.
The follow-up of patients after discharge from the hospital, again, is directed by the operating surgeon or responsible staff in the hospital clinic, the satellite office or in the Residents' Clinic. Patients who are initially seen in the CMH clinics and undergo operation at CMH are followed postoperatively at CMH for continuity of care and resident education.
Emergency Room Coverage
The junior surgical rotating residents are usually the first responders to a surgical consultation in the Emergency Room (ER). The PSR is responsible for confirming the findings of the junior resident and making a disposition. This disposition is discussed with the attending surgeon. Also, the PSR and attending decide how best to correspond with the referring physician, whether by phone call or by letter.
CMH is designated as a Level 1 Pediatric Trauma Center. To maintain Level 1 Trauma designation, the state of Missouri mandates that at least a PGY-4 resident must be in the hospital 24 hours a day. The evaluation, resuscitation and stabilization of trauma patients is therefore, under the direction of the PSRs, SCCR or senior pediatric surgical resident with supervision by the surgical staff. Multiple-system injury patients are admitted to the Pediatric Surgical Trauma Service and managed by the PSRs and SCCR. The transfer to a specialty service is accomplished when appropriate.
Rounds on the pediatric surgical service are expected to begin at 6 a.m. to allow complete evaluation of all of the patients on all of the units prior to the day's operating schedule. Early electronic order entry and progress notes for the day establish appropriate communication and clinical plan development with both the nursing staff as well as with other consulting services. These activities should be accomplished prior to either conferences or the start of scheduled operations during the day. The completion of the progress notes involves a team effort for the PSRs, the rotating junior general surgical residents and the nurse practitioners. These notes and orders are entered electronically except in the PICU. The PSRs are responsible for assigning the work on rounds, as well as for insuring completion of the work throughout the day and final review on evening rounds. The chief PSR is expected to have assigned individual operative cases to all the residents. History and physicals as well as consent forms must be completed in order to allow for efficient progress of care.
Within the course of the operation, the pediatric surgery resident is responsible for understanding the operation and having reviewed the indications for and basic techniques of any new procedure or any procedure that is begun with an attending whom they have not operated with before. This allows for efficient discussion of the operative case, as well as for patient safety and expeditious operative management. The pediatric surgery resident is responsible for writing post-operative orders on all patients as well as home discharge orders and home care for those patients whom he or she is managing directly. If the patient is transferred to the Neonatal Intensive Care Unit or the Pediatric Intensive Care Unit, the pediatric surgery resident is responsible for writing all post-operative orders and for arranging appropriate communication with the nursing staff in order to maintain post-operative care of that patient throughout the course of the patient's stay in the unit. The pediatric surgery service will assume primary care of those patients unless otherwise specified for any other reason. A clear short- and long-term care plan must be understood. For that reason, the PSR must establish appropriate lines of communication to take place between the general surgery residents and the attending staff. Any changes in the patient's condition must be communicated directly to the responsible attending or the covering attending in order to review the care plan and take the appropriate action.
The Neonatal Intensive Care Nursery and Pediatric Critical Care Unit require a special degree of interaction with the nursing service. There is an expectation that the intensive care nurses are integrally involved in morning surgical rounds.
The PSRs see patients in the Residents' Clinic, which is held every Monday in conjunction with Dr. Holcomb's clinic. This setting allows for independent preoperative evaluation of surgical conditions in children, exposure to scheduling operations and education in postoperative care in a continuous environment. Moreover, Dr. Holcomb is available to consult with or answer any questions that might arise.
The Residents' Clinic is staffed by the two PSRs. Both are expected to be present during this clinic and not in the operating room, as this setting represents their primary exposure to preoperative and postoperative decision-making (although they may also participate in clinics staffed by the pediatric surgical attendings).
Following the evaluation of each patient, the PSR formulates a letter to the referring physician indicating the nature of the patient's disease and recommended therapy. Each patient that is scheduled for an operation from this clinic is seen by Dr. Holcomb for resident education and confirmation of indications for surgery. These operations are scheduled on Tuesday and Thursday mornings under Dr. Holcomb's block time. One of the two residents usually participates in these cases, either as operating surgeon with Dr. Holcomb's assistance or occasionally as teaching assistant to a junior resident with Dr. Holcomb's supervision. The residents are also exposed to Dr. Holcomb's patients who are seen both preoperatively and postoperatively in this clinic setting.