In this Issue.... 9/26/07

Pediatric Services Expansion - Growth of our Inpatient Unit
Who are we?
Clinical Corner
Scope of Pediatric Inpatient Unit Services
Availability of Standard Admission Order Sets
Pediatric Emergency Admissions
Direct Pediatric Admissions or Transfers from another Hospital
Calendar of Pediatric Meetings and Events in 2007
ED Update
Sign up for PediPulse

Pediatric Services Expansion - Growth of our Inpatient Unit

We opened our inpatient unit nearly a year ago, and the unit has already served more than 750 pediatric patients. Consistent with the planned scope of this service, the children stayed for an average of 1.8 days. They covered all ages in the pediatric population - from the 1-day-old newborn born at home to the almost-18-year-old. More facts about our inpatient pediatric cases follow:

• 60 percent of patients were admitted with primary medical diagnoses.

• 52 percent were admitted from the Emergency Department at Providence St. Vincent and a few from other local emergency departments, including those within Providence Health & Services.

• Almost 20 percent of children were directly admitted from home or private practice offices, and 3 percent were transferred from the Perinatal Unit at Providence St. Vincent.

• The pediatric hospitalists at Providence St. Vincent were the primary care providers for half of our patients. Pediatric/adult general surgeons provided primary care for another 30 percent. Private pediatricians or sub-specialists attended to the remaining 20 percent.

• We transferred 16 patients (2 percent) to other facilities because of insurance preference or for care that we do not provide. This care included evaluation of complex genetic disorders, treatment of psychological/behavioral diagnoses and intensive care.

This first year has witnessed the development of several new programs in collaboration with providers of pediatric specialties. In addition to providing care for newborns with hyperbilirubinemia and evaluation of sepsis and for children with various primary medical, respiratory and surgical diagnoses, we have developed programs for children with new onset Type I diabetes, eating disorders, behavioral health, and orthopedic surgery/injuries. The children with eating disorders and behavioral health diagnoses have medical diagnoses as their primary admitting diagnosis.

We are very pleased with our progress over this first year. Our patient/parent satisfaction evaluations have been outstanding. We look forward to continuing to provide this outstanding family-centered care to the patients admitted to the Inpatient Pediatric Unit.

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Who are we?

Pediatric Hospitalists
We are proud to introduce our seven pediatric hospitalists at Providence St. Vincent Medical Center. Click here. Our pediatric hospitalists are available in-house for all patients who require primary hospital coverage or consultation: 

 
Hours: 24/7
Phone: 503-216-6338, ext. 6246
Inpatient pediatric unit phone: 503-216-4400
Matthew Gadbaw, M.D., FAAP (Medical Director)
Cynthia Chan-Lazarra, M.D., FAAP
Cynthia Cristofani, M.D.
Yolanda Domond, M.D.
Elroy Jan, M.D.     
Kathleen Lewis, M.D.       
Nicole Perdue, M.D.              
 

Inpatient pediatric nursing
The Inpatient Pediatric Unit at Providence St. Vincent has a full staff of experienced pediatric nurses. Each of our nurses brought several years of nursing experience and a burning desire to care for children to our unit when it opened last September. Our  patients benefit from the team’s combined experience, which exceeds 150 years, in a variety of pediatric settings.

Many of the nurses worked in adult units at Providence St. Vincent waiting for the opening of our pediatric unit. During this time they accumulated experience in many areas, including orthopedics, general surgery, neurology/neurosurgery, obstetrics, cardiology and emergency care. Others came from pediatric hospitals in Oregon, California, Michigan and Florida.  All nurses participated in a unit orientation to build teamwork and their pediatric expertise. Monthly inservices focused on our expanding patient populations also help us to grow in our expertise.

As our unit has been full on several occasions, we have planned to accommodate more patients with the same level of pediatric nursing expertise in a safe, family-centered environment. To accomplish this, we have cross-trained nurses with the NICU and perinatal areas. We have also cross-trained staff with the pediatric surgical staff. With this cross training, the same nurse can care for a patient before, during and after surgery.

As we look forward to our second year, we are very excited about our new challenges and the opportunity to provide outstanding, family-centered care to our special pediatric patients.

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Clinical Corner

What's your diagnosis?
The patient was a 17-year-old male with a history of eczema and migraines, as well as  chickenpox at age 8. He presented to the Providence St. Vincent pediatric unit with a three-week history of generalized headache then later developed neck stiffness over the three days prior to admission. He complained of mild photophobia and nausea. He was seen in ED two days prior to admission. An MRI/A of the brain was normal, and an LP was performed revealing nine WBC’s with a lymphocytic predominance, TP 40 and glucose 53. CSF GS/culture were negative. The patient was believed to have a viral meningitis, and he was sent home with Vicodin for pain control.

The patient returned to the ED two days later because of persistent symptoms as well as onset of a pruritic, vesiculopapular rash over the right side of his neck and chin, and overlying erythema with some pus from the chin lesions. The patient also had right cervical lymphadenopathy. He denied fever/chills but had a temperature of 38.5 C. He denied visual changes, dysarthria, swallowing difficulties, weakness, numbness or balance difficulties. There was no change in mental status.

What is your next step?

What happened to the patient?

By: Elroy Jan, M.D.
Medical Pediatric Hospitalist,
Providence St. Vincent Medical Center

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Scope of Pediatric Inpatient Unit Services  

The Pediatric Inpatient Unit at Providence St. Vincent is a 12-bed medical-surgical unit.  We specialize in the care of acutely ill patients from birth to the 18^th birthday. Ages 18 years and older may be cared for in the pediatric unit if deemed appropriate by the admitting physician, pediatric charge nurse, patient and family. Admission criteria includes patients who have medical and surgical diagnoses requiring a mild to moderate level of care with the expectation for a brief and uncomplicated hospitalization. 

 Private pediatricians and pediatric surgeons who have active privileges at Providence St. Vincent may admit patients to this unit in collaboration with the unit charge nurse. Admission and discharge criteria will be guided by Admission Scope of Practice. Prior to admission, a courtesy call from the pediatric unit charge nurse or admitting physician will be made to the pediatric hospitalist covering the unit in order to verify that the admission meets the Admission Scope of Practice.  Our in-house, pediatric hospitalist team is available to care for patients 24-hours a day, seven days a week.

 Patients who require care beyond the sub-specialists at Providence St. Vincent, or who have the potential risk of progressive cardiorespiratory or neurologic compromise will be transferred to a facility that provides this care. Patients 14 or older who require ICU services may be considered for admission to the intensive care unit at Providence St. Vincent.

General guidelines for appropriate pediatric patient admission at Providence St. Vincent Medical Center

1. Respiratory disease
   1. Patients with mild or moderate pulmonary (lower or upper airway) disease with stable oxygen requirements and minimal risk of progression to respiratory failure or airway obstruction.
   2. Patients who require intermittent (every one or more hours) nebulized medications while on the pediatric unit. Children will be evaluated for transfer to a facility that provides intensive pediatric care if their condition does not improve after receiving two initial hourly nebs, or if they require increased frequency of nebulized therapy or continuous nebulized therapy during their hospitalization.
   3. Patients with chronic respiratory disease and/or who have artificial airways and may require respiratory support will be referred to a facility that provides intermediate and intensive pediatric care.
    
2. Gastrointestinal disease
   1. Patients with stable gastrointestinal disease that requires intravenous rehydration.
   2. Patients with a gastrointestinal problem requiring urgent endoscopy or surgery, but who do not have cardiorespiratory compromise or acute GI bleeding.
   3. Patients with a stable, chronic gastrointestinal diagnosis who require inpatient care for another non-life-threatening condition.
    
3. Neurologic disease
   1. Post-operative neurosurgical patients who have had non-life-threatening neurosurgical procedures and do not require cardiorespiratory monitoring.
   2. Patients with non-life-threatening neurologic disease who require admission for non-life-threatening interventions.
   3. Patients with acute inflammation of the central nervous system with low risk for neurologic deficiency or other complications.
   4. Patients with acute or known neurologic disease who may progress to moderate to severe neurologic compromise will be referred to a facility that provides intermediate and intensive pediatric care.
    
4. Cardiovascular disease
   1. Patients with known congenital heart disease who have had surgical correction admitted for a non-life-threatening, non-cardiac intervention.
   2. Patients with acute or known cardiac disease who may progress to moderate to severe cardiovascular compromise will be referred to a facility that provides intermediate and intensive pediatric care.
    
5. Hematologic/Oncologic, Renal and Metabolic Disease
   1. Patients with known, chronic disease admitted for intermittent therapeutic intervention.
   2. Patients with known, chronic disease who are potentially unstable or have severe hematologic or metabolic derangements will be referred to a facility that provides intermediate and intensive pediatric care.
    
6. Endocrine
   1. Patients with known or new-onset diabetes.
   2. Diabetic patients with ketoacidosis requiring intermittent subcutaneous insulin. Patients who are not ketoacidotic but may require continuous insulin infusion will be evaluated by the pediatric hospitalist, pediatric endocrinologist and pediatric charge nurse before admission to the inpatient pediatric unit.
   3. Patients with known, chronic disease who are potentially unstable or have uncontrolled disease will be referred to a facility that provides intermediate and intensive pediatric care.
    
7. Surgery
   1. Patients who have had surgical or radiological procedures, are hemodynamically and neurologically stable, and are not expected to have progressive problems with airway and bleeding. Examples include but are not limited to:

   • gastrointestinal procedures
   • neurosurgical procedures
   • craniofacial procedures
   • orthopedic procedures
   • ENT procedures
   • urologic procedures

   2. Post-operative patients who require cardiorespiratory monitoring, intravenous fluids, intravenous medications and/or intermittent (every three or more hours) respiratory treatments.
    
8. Psychiatric
   1. Patients with a medical diagnosis necessitating inpatient stabilization with a co-existent psychiatric diagnosis with low to moderate risk for self-harm.
   2. Patients with unknown ingestions, ‘detoxing’ from recreational/street drugs, or risk of harm to others will be referred to our intensive care unit or other facility that provides intermediate and intensive pediatric care.
   3. Patients with a new or chronic diagnosis of an eating disorder (e.g., anorexia nervosa, bulimia) who are hemodynamically stable.
   4. Eating disorder patients with heart rates consistently < 30, symptomatic hypotension (i.e., SBP < 70 with altered mental status), or cardiac arrhythmias (i.e. heart block) will be referred to our intensive care unit or other facility that provides intermediate and intensive pediatric care.
    
9. Multisystem and other diseases
   1. Patients who have complex multisystem disease requiring multidisciplinary intervention and consultation will be referred to a facility that provides intermediate and intensive pediatric care.
   2. Patients who have multisystem trauma, burns, abuse and/or dangerous ingestion will be referred to a facility that provides intermediate and intensive pediatric care.

Patient care will be provided in collaboration with the patient, family, primary physician, hospitalist, surgeon, nurse, pharmacist, nutritionist, child life therapist and appropriate additional disciplines. Interventions are performed based on physician orders and nursing assessment. Nursing activities include: assessing the physical, pain, safety, psychosocial, growth and developmental, and educational needs of the patient (including family/caretaker); implementing and coordinating the care plan and necessary referrals; and evaluating the effectiveness and results of interventions. Discharge criteria and planning will be initiated upon admission. Daily multidisciplinary rounds, including the child and family, will support patient care management.

 The registered nurse assumes responsibility for coordination of care as directed through physician orders and Basic Practice Guidelines for Pediatric Care and Providence St. Vincent policies and procedures. All care guidelines are presented for the approval process by the hospital-wide, interdisciplinary Quality Practice Council.

 Registered nurses on the Pediatric Inpatient Unit are highly skilled in pediatric care, including physical assessment, fluid management, medication administration and management, and advanced interventional skills. Competencies are defined through knowledge and specific skills applicable to this clinical practice area. Knowledge and skills are measured during orientation through the Performance Based Development System.

 An all-R.N. staff operates the unit utilizing the assistance of a health unit coordinator.  The unit has controlled access and provides the environmental safety guidelines as identified in PSVMC Nursing Practice Guideline #2: Environmental Safety for Pediatric Patients.  The child’s room and playroom are safe areas. Treatments are done in the treatment room. Oral medications for anxiolysis and oral/IV medications for procedural sedation may be used. The registered nurse administering the sedation and the physician ordering the sedation must be credentialed and follow the PSVMC Procedure # 14.46 Moderate/deep sedation. Deep sedation will not be done on this unit.

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Availability of Standard Admission Order Sets

This updated and expanded collection of orders can help you admit your pediatric patients more efficiently and effectively, and help us enhance the quality and convenience of our patient care. These orders are intended only as a framework to aid physicians as they begin the work-up and treatment of patients. We do not require physicians to use standard orders, but most choose to do so. Please use them as you deem necessary.

• Adolescent Eating Disorders Patient Orders
• Pediatric Anemia Admission Orders
• Pediatric Bronchiolitis Admission Orders
• Pediatric Croup Admission Orders
• Pediatric Admission Orders
• Pediatric Pneumonia Admission Orders
• Pediatric RAD Admission Orders
• Pediatric Seizure Admission Orders
• Pediatric Sepsis Admission Orders
• Pediatric Urinary Tract Infection / Pyelonephritis Admission Orders

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Pediatric Emergency Admissions

Once a patient has been evaluated in the Emergency Department and the assessment is made that the patient is within the scope of practice for the pediatric unit, the emergency physician should follow these steps:

1. Call the patient’s primary care physician (if the patient does not have one, then call the city call pediatrician) to discuss the case.
2. The patient’s primary care physician may decide to admit the patient to the Providence St. Vincent Medical Center inpatient pediatric unit or to another hospital. That decision is then discussed with the patient/family to determine final disposition.
3. If the patient is to be admitted to Providence St. Vincent and the primary care physician has pediatric privileges, the physician may either admit the patient personally or admit to the pediatric hospitalist.
4. If the patient is to be admitted to the hospitalist, the physician should call 216-6338, ext. 6246, to discuss the case. We strongly prefer to evaluate the patient in the Emergency Department and to write admission orders from there. Unless directed by the pediatric hospitalist, please do not send the patient to the pediatric inpatient unit before he/she is evaluated by the pediatric hospitalist.

Note: After the report is delivered by phone to the pediatric unit charge nurse, the charge nurse will call the pediatric hospitalist. This is to let the hospitalist review all admissions to the pediatric unit to ensure that they meet the scope of practice. It does NOT imply that the hospitalist will necessarily be consulting/following that patient. If the hospitalist does not feel that the admission meets scope of practice, then the hospitalist will call the Emergency Department or admitting physician to discuss.

 For patients < 28 days: Infants may be admitted directly to the pediatric unit if they meet admission criteria.  If there are questions regarding the appropriate unit for admission (NICU vs. pediatric unit), the referring physician (primary care physician, hospitalist, or emergency physician) will initiate discussion with the neonatologist to determine the appropriate placement.

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Direct Pediatric Admissions or Transfer from another Hospital

Patients may be directly admitted to our pediatric unit from home, clinic or an other hospital. We strongly prefer that the patient’s primary care physician evaluate any patient who is to be directly admitted on day of admission to ensure that the patient’s illness meets our scope of practice.

To admit a patient directly from home or clinic to be followed by the patient’s primary care physician:

1. Call 503-216-4080 to request a pediatric unit bed. You will need the patient’s name, date of birth, and admitting diagnosis.
2. Call the pediatric charge nurse at 503-216-4400 to discuss the admission and give admission orders, if necessary. We have pre-printed pediatric order sets that can be faxed to you. If necessary, request that the nursing staff alert you when the patient arrives on the pediatric unit.
3. Call the patient’s family. Direct them to come to the admitting desk in the main lobby of Providence St. Vincent.

To directly admit a patient to the pediatric hospitalist service:

1. Call 503-216-6338, ext. 6246, to discuss the case with the pediatric hospitalist. The hospitalist will need to know the patient’s name, date of birth, admitting diagnosis, and contact information before the patient can be admitted.
2. If the patient is being admitted from clinic or another hospital, the referring physician or nurse will need to report to the pediatric charge nurse, 503-216-4400.

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Calendar of Pediatric Meetings and Events in 2007

Pediatric in-service sessions – Monthly (first Wednesdays)
These informal teaching sessions are led by experts in their field. The sessions are held from noon to 1 p.m. and are located in the hospitalist conference room (first floor Providence St. Vincent, next to nursing administration)

 Pediatric fall conference – Sept. 26
An all-day conference highlighting pediatric infectious disease topics will be held in  Souther Auditorium at Providence St. Vincent Medical Center.

Pediatric quality meeting – Monthly
Issues related to the inpatient pediatric unit are discussed in this operational meeting.  Please e-mail Matthew.Gadbaw@providence.org if you wish to join this group.  All meetings are held from 7 to 8 a.m. in the Board Room (second floor, Providence St. Vincent Medical Center).

Pediatric department meeting and grand rounds – Quarterly This departmental meeting is held in Souther Auditorium at Providence St. Vincent Medical Center.

PALS recertification class – Ongoing
The next class will take place at Providence St. Vincent Medical Center. Please contact Cynthia.Cristofani@providence.org for registration information.

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ED Update

Pediatric Emergency Services at Providence St. Vincent continue to thrive. In only three years, volumes in our department have grown to more than 15,000 pediatric visits per year. Last year’s addition of the inpatient pediatric unit has been a boost, providing us with expert pediatric consultation and a streamlined admission process for our patients. 

In this update, I am pleased to report that we are increasing the use of lidocaine gel and ultrasound for our bladder catheterizations to minimize discomfort. We are also working on a pediatric-skills day for our nurses this fall, with the knowledge that continuing education for our staff is best for our patients’ care.

I am extremely pleased to take over for Dr. Seth Mehr as director of Pediatric Emergency Services.

By: Alejandro Kitzis M.D.
Alejandro.Kitzis@providence.org

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