Overview
Definition:
Resident-run after-hours pediatric clinics are settings where pediatric residents provide clinical care outside of regular business hours, often with direct or indirect supervision by attending physicians
These clinics aim to improve access to care, provide timely management for acute but non-emergent conditions, and offer a valuable training experience for residents.
Epidemiology:
The prevalence of resident-run after-hours clinics varies widely by institution and residency program structure
They are increasingly implemented to address the growing need for accessible pediatric care and to supplement traditional clinic models
Data on patient volume and acuity are program-specific.
Clinical Significance:
These clinics are crucial for managing common pediatric ailments like fever, minor infections, and exanthem, preventing unnecessary emergency department visits
They also serve as a vital educational tool, enhancing residents' diagnostic and management skills in a supervised, yet independent, setting
Ensuring patient safety and appropriate supervision is paramount to the success and ethical operation of these clinics.
Safety And Supervision Framework
Supervision Models:
Direct supervision where an attending is physically present
Indirect supervision with readily available attending consultation via phone or pager
Graduated supervision, where residents gain autonomy as their competency increases
Regular case reviews and feedback sessions are integral to all models.
Patient Selection Criteria:
Clearly defined criteria for patients suitable for after-hours clinics, focusing on stable conditions that do not require immediate specialist intervention or emergency services
Patients with high-acuity needs, chronic unstable conditions, or those requiring immediate hospital admission should be triaged to the ED or appropriate urgent care.
Risk Management Strategies:
Protocols for managing medical emergencies, including immediate transfer protocols to the ED
Robust charting and documentation standards
A system for follow-up on patients seen in the after-hours clinic
Regular audits of care quality and patient outcomes.
Staffing And Resources:
Adequate nursing and administrative support staff trained in triage and clinic flow
Availability of essential diagnostic equipment (e.g., otoscopes, thermometers, pulse oximeters) and basic medications
Clear communication channels with the hospital and other care providers.
Resident Roles And Responsibilities
Clinical Duties:
Performing comprehensive histories and physical examinations
Developing differential diagnoses and management plans
Prescribing appropriate medications and treatments
Educating patients and families
Documenting all encounters thoroughly.
Escalation Protocols:
Knowing when and how to escalate care to the supervising attending physician
Understanding criteria for patient transfer to the emergency department
Recognizing signs of clinical deterioration requiring immediate intervention.
Professionalism And Ethics:
Maintaining professional conduct at all times
Upholding patient confidentiality
Demonstrating accountability for clinical decisions
Adhering to institutional policies and ethical guidelines.
Attending Physician Oversight
Role Of The Attending:
Providing direct or indirect supervision based on resident competency
Reviewing patient charts and management plans
Offering real-time guidance and consultation
Serving as a resource for complex cases
Ensuring adherence to safety protocols.
Frequency Of Review:
Daily chart review for all patients seen by residents
Immediate consultation availability for urgent issues
Scheduled case discussions and feedback sessions
Periodic assessment of resident performance and clinical judgment.
Delegation Of Tasks:
Appropriate delegation of clinical responsibilities based on resident experience level
Empowering residents to make decisions within their scope of practice while ensuring a safety net
Clearly defined boundaries for resident autonomy.
Patient Safety And Quality Improvement
Adverse Event Reporting:
A transparent system for reporting near misses and adverse events without fear of retribution
Root cause analysis of reported events to identify systemic issues
Implementation of corrective actions to prevent recurrence.
Performance Monitoring:
Tracking key performance indicators such as readmission rates, patient satisfaction scores, appropriate antibiotic prescribing, and appropriate use of diagnostic tests
Regular quality improvement meetings to discuss trends and implement changes.
Patient Education And Communication:
Ensuring clear communication with families regarding the nature of the clinic, limitations of after-hours care, and the importance of follow-up
Providing written instructions and discharge summaries
Educating families on when to seek further medical attention.
Legal And Ethical Considerations
Informed Consent:
Ensuring patients and families understand they are being seen by a resident physician, with the level of supervision provided
Obtaining informed consent for treatment and procedures, as appropriate.
Scope Of Practice And Liability:
Understanding the legal framework governing resident practice
Adhering to institutional policies on scope of practice
Awareness of potential liabilities and institutional malpractice coverage.
Documentation Standards:
Meticulous and timely documentation of all patient encounters is critical for patient care continuity, legal protection, and educational assessment
This includes history, physical exam, assessment, plan, and any consultations or referrals.
Key Points
Exam Focus:
Understand the core principles of supervision in resident-run clinics
Be prepared to discuss scenarios involving patient selection, escalation of care, and attending oversight
Differentiate between appropriate and inappropriate use of after-hours clinics.
Clinical Pearls:
Always err on the side of caution when triaging patients for after-hours care
Maintain open and constant communication with your supervising physician
Document thoroughly – it protects you and the patient
Recognize the educational value and the responsibility that comes with independent patient management.
Common Mistakes:
Overestimating resident autonomy without adequate supervision
Failing to establish clear patient selection criteria
Inadequate triage leading to inappropriate patient visits or missed diagnoses
Poor communication between residents and attending physicians
Insufficient documentation of clinical decisions and rationale.