The medical ecosystem (Figure 2)
During the hospitalization reviewed, each patient encountered a mean of 6.2 medical specialties, 1.9 surgical specialties, and 8.5 non-physician specialties. The most frequent medical consult services were pulmonology (25/29), critical care (23/29) and palliative care (22/29). Pediatric surgery was the most consulted surgical service (20/29), followed by otolaryngology, (13/29). Every patient in this cohort received inpatient services from nursing, care management, and respiratory therapy. Other commonly used services included: physical therapy (27/29), chaplaincy (26/29), and Child Life (24/29).
Although pulmonary and palliative care were the most common medical consults, timing of consultation was highly variable. Palliative care consult timing ranged from 0 to 268 days post admission (median 9.5 days). In cases where tracheostomy occurred, palliative care consult timing ranged from 50 days prior to tracheostomy to one day after (median 7 days prior). Similarly, pulmonary consult ranged from 1 to 130 days post admission (median of 3 days) and from 198 days before to 10 days after tracheostomy placement (median 9 days prior).