In this Issue.... 8/29/06

Clinical Corner
Child Life Update
Nursing Update
Pediatric Hospitalist Development
Topic of the Month
From our Consultants
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Clinical Corner

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Child Life Update

Did you know Providence St. Vincent Medical Center is the only primarily adult facility in the state to employ a certified child life specialist to address the emotional and developmental needs of our youngest patients? Barbara Blair, CCLS, provides preparation opportunities and supportive interventions to children before surgical and radiological procedures in the new Gerry Frank Center for Children's Care as well as to siblings of NICU babies and children of adult patients. She is also available via pager to assist with pediatric patients in the Emergency Department and is involved in training new employees on topics such as preparation and positioning children for comfort for medical procedures.

The new 12-bed pediatric inpatient unit scheduled to open later this year will employ the services of a Child Life Specialist as an integral team member, providing supportive interventions and play opportunities daily for children of all ages.

The goal of the Child Life program at Providence St. Vincent is to provide children with the tools and support they need to cope with the health care experience and leave with an enhanced ability to meet future life challenges. Thank you to all the community physicians, surgeons and specialists who have supported this valuable program!

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Nursing Update: Inpatient Pediatrics Becomes a Reality

When the new pediatric inpatient unit will open, more than 35 specialists and department leaders will have come together to plan for this inpatient care area. This unit is designed for all pediatric patients, from the select newborn who needs to return to the hospital after being home to the teenager who has not yet reached his or her 18th birthday. The new unit will have 12 private patient care rooms with in-room accommodations for parents. The rooms will feature the latest technology necessary to provide care to this diverse age group. In addition to the patient care rooms, the unit will have special areas for family-centered care, including an activity room and family/visitor areas.

Around-the-clock medical coverage will be provided by Providence St. Vincent hospitalists, pediatricians, or by pediatricians and/or pediatric surgeons wishing to admit children who need community hospital pediatric care. Registered nurses who have pediatric acute care experience and have been oriented to pediatrics and Providence Health System will provide nursing care. Plans are also in process for a dedicated pediatric pharmacist. Providence St. Vincent currently has respiratory care practitioners with pediatric experience who are providing pediatric care in the Emergency Department and NICU.

Policies and procedures have been updated. New emergency carts and equipment, including Broselow carts and a Broselow/Hinkle bag in the Emergency Department and pediatric equipment on all hospital code carts, have been purchased. The Providence St. Vincent version of a Rapid Response Team, DART, will respond to pediatric calls. Education sessions on special emergency and developmental needs of children are planned for nursing, respiratory therapy and support staff.

Many community members have been involved in the planning of this unit. If you have any questions or would like to discuss your ideas with the planning team, please contact me. Our goal is to meet the needs of the community that is served by St. Vincent. An open house, to view the new unit and meet the staff, is planned for the end of October. Watch for the announcement of the time and date. We hope to hear from you and see you in October.
Mary Rummell, RN

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Pediatric Hospitalist Development

An exciting advancement in pediatric care is taking place at Providence St. Vincent. We have prepared extensively during the past year to expand our services into the inpatient arena, and through a culmination of effort from many people, we will be ready to open our doors in the fourth quarter of this year.

Our planned development of a pediatric inpatient unit represents a natural progression of the medical center's rapidly growing pediatric services. Recent growth is highlighted by the increased volume of our pediatric emergency room visits (15,000 kids seen in 2005) and the addition of the Gerry Frank Center for Children's Care, which encompasses pediatric day surgery and neurodevelopmental rehabilitation. Our planned expansion also is in response to the growing demand for pediatric services in Washington County, which currently has among the highest penetration of young families in the area with nearly 30 percent of its population under 18 years of age.

Our guiding principle has been to design a space for pediatric care that will provide safe, family-oriented services for infants and children. The level of care delivered will be at the community hospital level – we are not a full-fledged children's hospital. Portland already has two spectacular children's hospitals. Accordingly, we have worked diligently to design a scope of practice that strictly dictates the type of admissions that are appropriate for Providence St. Vincent.

The scope of practice for the inpatient pediatric unit is based on an American Academy of Pediatrics policy statement written in 2004, which defines pediatric patients who need step-down or pre-intensive unit level of care. Recognizing the extra limitations of our hospital (e.g., no pediatric ICU, limited specialty support for pediatrics), we have further narrowed our scope to avoid any adverse outcomes. With these principles in mind, the basic tenet of our scope is that patients admitted to our inpatient unit will have medical and surgical diagnoses requiring a mild to moderate level of care, with the expectation for a brief and uncomplicated hospitalization.

With safety as our utmost concern, we have also developed a pediatric rapid response team to immediately address the rare instance where a patient becomes sicker than initially expected. This team will quickly address patient status in order to ensure patient stability or to arrange expedient transfer to a facility that can provide necessary services. Also, we are forming a committee of physicians to continually monitor pediatric admissions to ensure that patients are being admitted in accordance with our scope of practice.

Any physician with privileges to care for children at Providence St. Vincent may admit patients to the pediatric unit. An in-patient pediatric hospitalist will be available 24-hours a day for primary hospital coverage or consultation.

We have utilized an innovative approach to staffing our pediatric hospitalist group. Since we expect the initial pediatric in-patient census to be relatively low, we have incorporated physicians who have dual training in internal medicine and pediatrics. These "medpeds" physicians have completed dual residencies and carry separate board certifications/eligibility in both internal medicine and pediatrics. The primary responsibility of these providers will be to see all hospitalized pediatric patients on our service. If the pediatric census is low, they will also follow patients admitted to the adult hospitalist service. As the pediatric census grows, those hospitalists will cover solely the pediatric service.

While the pediatric service grows, the hospitalists plan to be quite busy. Since they will be in-house 24 hours per day, the hospitalists will provide pediatric consultation for surgical services and the emergency department. They will staff our pediatric rapid response team, responding to any urgent medical issue involving any pediatric patient in the hospital. They will also co-lead the pediatric code team along with an emergency physician.

We are very excited about our group of medpeds hospitalists. They are dynamic, accomplished physicians that have been recruited from tertiary care centers across the country. Having completed residency training in the past few years, all have recent experience with pediatric and neonatal intensive care, as well as current demonstrated skills in pediatric inpatient medicine. On top of their clinical abilities, they have served in teaching roles and have other individual accolades, which include membership in Alpha Omega Alpha, chief residency, various pediatric publications and presentations, and fellowship experience. All are committed to pediatric inpatient care, and they will provide a strong foundation for the inpatient pediatric program.

It is our great pleasure to announce that Cindy Cristofani, M.D., has joined our team. Dr. Cristofani has more than 17 years of pediatric intensive care experience. She is a regional course director and instructor for pediatric advanced life support. She will join in the development of our pediatric in-patient program and will provide night coverage.

With a committed and competent staff focusing on safe, community-level pediatrics, we look forward to opening our in-patient pediatric unit. We encourage all interested physicians in the pediatric community to explore and participate in our current endeavor. It is an exciting time indeed for pediatrics at Providence St. Vincent Medical Center, and I hope that it is an enjoyable experience in which we can all share.


Best Wishes,
Matt Gadbaw, MD, FAAP
Internal Medicine and Pediatrics
St. Vincent Medical Center
Matthew.Gadbaw@Providence.org

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Topic of the Month: Hypoglycemia and Pediatric Care

This month's column will focus on hypoglycemia in pediatrics. We will discuss primarily which patients are at risk and what to do about it. Hypoglycemia definitions vary, but usually it is accepted as blood glucose <50mg/dl. Common clinical manifestations include altered level of consciousness, seizures, vomiting, lethargy, jitteriness, apnea, grunting and diaphoresis among other symptoms. Hypoglycemic infants may not always be symptomatic, so monitoring of at-risk infants is mandatory.

The pediatric populations I would like to focus on, in the context of hypoglycemia include neonates, ill infants, diabetics and children with inborn errors of metabolism. Neonates and infants have high glucose requirements and low glycogen stores and develop hypoglycemia when energy requirements rise. Therefore sepsis, respiratory distress, poor feeding, hyperthermia or hypothermia, asphyxia, and shock among other stressors can contribute to hypoglycemia. Neonates with prematurity or IUGR are especially at risk secondary to poor glycogen stores. Neonates born to diabetic mothers are at risk due to hyperinsulinism. This occurs because the fetal pancreas produces insulin to levels that correspond with maternal glucose. When the newborn is deprived of the mother's glucose, the pancreas continues to produce insulin at the same fetal level, and newborn glucose is rapidly depleted. This most commonly occurs in the first one to three hours of life and is typically transient.

The next population to briefly discuss is children with diabetes. For diabetics, maintaining euglycemia during any illness can be quite challenging. For example, a child does not eat, so parents cut back on the insulin, and the child goes into DKA. Conversely the child gets his insulin and doesn't eat and becomes hypoglycemic. The most important thing for these children in an outpatient setting is frequent glucose monitoring with insulin doses adjusted accordingly (usually in conjunction with a pediatric endocrinologist). In the inpatient setting, patients with DKA who are on an insulin drip are at risk for hypoglycemia. Glucose levels should fall no faster than 100mg/dl/h. We often need to add D5 or D10 to the fluids in order to keep patients glucose at a level adequate enough (usually 150-250) to be able to continue the insulin drip without causing hypoglycemia. Insulin is needed to clear the ketones and correct the acidosis.

Lastly we should discuss children with inborn errors of metabolism. Luckily we live in a state where we have excellent newborn screening. Many inborn errors of metabolism (IEM) are picked up in the newborn period. Parents with these children will usually come in with information about their disease and how to manage it. The most important thing to know about these children is that they should be seen immediately. If they have been feeding poorly or are ill, they need immediate dextrose administration!

Children who have been diagnosed early in life are often normal children. If they are allowed to get in a catabolic state, they can become neurologically impaired. It is critical that they be treated quickly and carefully. In any infant or child who presents with profound hypoglycemia, keep inborn errors of metabolism on your differential. They are less rare than you think: 1/5000 births. In one study, 28 percent of children who presented to an ED with hypoglycemia later were found to have a fatty acid oxidation disorder. Suspect inborn errors of metabolism in any child with neurological deterioration, metabolic acidosis, hypoglycemia, inappropriate ketosis, hypotonia, cardiomyopathy, failure to thrive and/or liver disfunction.

Well, that's about it. Many other hypoglycemia causes exist: toxic ingestions, endocrine deficiencies, and tumors among other etiologies. When hypoglycemia is suspected, draw extra blood and send it for lactate, insulin level, growth hormone, c-peptide, and cortisol levels. Check for ketones and talk to somebody who remembers the Krebs cycle. I'm getting hypoglycemic myself.
Alex Kitzis, MD

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From Our Consultants: Range of Pediatric Anesthesia Services Available

Providence St. Vincent Medical Center will soon be opening a pediatric inpatient ward. Currently, outpatient pediatric surgical procedures are performed in the Gerry Frank Center for Children's Care. The new inpatient ward will likely lead to increased surgical volume; some uncomplicated inpatient procedures are now being scheduled. Our anesthesiology department currently has five pediatric fellowship-trained physicians, and our plan is to add a sixth. We provide a wide range of services including anesthetics for radiology exams, surgical procedures, acute pain management, and anesthetic care for sick neonates in the NICU. For more information, please call 503-216-2716.
Greg Nadol, MD
 

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