This is Chris Sosa with the Becker's Healthcare
podcast.
And today, we'll be joined by doctor Scott
Krugman, director of pediatric operations at Herman and
Walter Samuelson Children's Hospital at Sinai. Doctor Krugman,
thank you for joining us today.
Thanks for having me. Excellent, doctor. Would you
please introduce yourself and give us a bit
about your background?
Yeah. So I am a, general pediatrician,
and I have been in, pediatric leadership positions
for many years.
I ran a department of pediatrics
at a community hospital in Baltimore County for
20 years,
and did that with,
I thought great success until they decided to
close pediatrics in, 2018.
And since then, I've been at the Children's
Hospital at Sinai in Baltimore where I've been
vice chair of pediatrics and now,
the director of pediatric operations because I hold
another hat, which is a a senior associate
dean for the George Washington University School of
Medicine where we're now a regional medical campus
for that school.
Thank you for laying all that out for
us, doctor. And you touched on briefly the
subject that we wanna touch today. And the
question I have for you, just to get
things started, is from your perspective, could you
please detail the challenges that pediatric inpatient units
are facing and why some are closing?
Yeah. So this has been going on for
a couple decades sort of under the radar.
But over the past 5 to 7 years,
if you're paying attention to the, Becker's Weekly
notifications that a lot of us get,
more and more often you're seeing that pediatric
units are closing. And the reason is that
community hospitals really have a hard time,
supporting
a money losing venture, which is inpatient pediatrics.
It costs a lot of money to
staff
units with pediatricians,
with pediatric specific nurses,
and most pediatric units in community settings will
have very variable volume. So at one point
in the middle of winter, there might be
10 kids on their unit and they're overflowing.
In the summer, there might be one child.
Sometimes, the variation goes from day to day,
whereas one day it's full, the next day
it's empty. And to staff that kind of
unit is very, very challenging because
nothing in pediatric works on a average daily
census.
Whereas, if you have a hospital that has
multiple adult units,
usually, the average doesn't vary that much that
you can predictably
staff with nursing and doctors
how to run those units, or you can
flex people from one to another. But, typically,
in community hospitals,
there's only 1 pediatric unit, and there's nowhere
to flex people to. So
the costs are
higher than expected.
And, of course, we're dealing with hospital based
revenue. And depending on what state you're on,
things vary a lot. But for the most
part, pediatrics is not high end
money making
procedures like neurosurgery and orthopedic surgery. So for
when the hospital is looking at their bottom
line, the easiest thing to cut off in
is inpatient pediatrics.
Thank you so much for laying out all
those challenges, and, clearly, there are many.
Doctor, the next thing I wanna ask you
is given those challenges,
what are the ripple effects of pediatric inpatient
units closing
respectful
respective to both the children and the communities
where they live?
Yeah. And this is where things are starting
to,
come to a head, and they really came
to a head during COVID time when
we had the initial lockdown and pediatric volumes
plummeted, and a lot of units
closed, shut down, some temporarily, some not. But
the year after, we had a huge respiratory
viral surge in pediatrics, and kids were being
sent all over,
all from state to state and all over
the world you know, all over farther away
to get care because there were not enough
beds in the area anymore. So what we're
seeing is,
especially in rural areas but also in many
suburban areas, that the local hospital that closes,
children have to go farther to seek definitive
care. So we're seeing an increase in number
of kids who are being transferred from one
hospital to another,
increasing number of kids who are being cared
for at children's hospitals,
and that consolidation
is really having an effect that it takes,
the the care that was once able to
be delivered in the community out of the
community.
And because those hospitals are doing less children,
less pediatric care in general, we're finding that
most emergency departments in community settings are not
prepared
to take care of kids. So the most
recent data is that 80% of hospitals are
not
have do not have the guidelines and the
procedures and the equipment
to successfully care for kids, and that's causing
potentially bad effects of kids not getting the
care they need or having bad outcomes like,
worse morbidity or mortality because they're not ending
up in a place initially who has is
the bill has the ability to care for
them.
At this point in time, doctor, what are
the steps that you think health care leaders
and others, whether it be legislators or other
leaders in
certain positions, what can they do to improve
this situation?
So we haven't really had very large conversations
as a society about how we wanna care
for kids.
It's always an afterthought. Most of
the models that have been put in place
to reduce costs around hospital
care have been done so around the Medicare
population for good reason because they cost a
lot of money.
So we need to decide if we wanna
care for kids or not and what
what number of hospitals and what sort of
distances are we is acceptable for kids to
get care. And
if we went from it from a
standpoint of what's in the best interest of
kids, we could design a completely different system
in this whole in our whole country. And
the problem is unless we have better payment
mechanisms
for pediatric care, there is not gonna be
any impetus to change, and pediatrics is gonna
have to end up being a community benefit
or,
a loss leader that a hospital might tolerate.
And my recommendation to local hospitals is decide
if you're in or not. And if you're
not in, what are the mechanisms you're gonna
put in place to make sure kids are
getting safe care? And I I don't know
how often those conversations are happening, but the
more that those can happen, I think we're
gonna be in a much better place. And
we really need to have a a structure
in place that puts the kids first and
puts the payment for those services first so
that we can assure that, you know, in
a certain
rural area, kids have a point access to
care, and then there might be a, like,
a a, like, a spoke part, and then
there's a hub where they need to go
if they actually need to go there. But
if it's something simple, they can stay in
their community, which is better for the family
and better for the child.
Doctor, thank you so much for sharing your
time and insights with us today. We're gonna
get them out to our audience as soon
as possible, and we look forward to connecting
with you again soon. Thank you so much
for having me.