In this Issue....

May 23, 2008
Important Pediatric Links
Pediatric IV Starts: Commitment to Quality and Safety
Pediatric Medical Students Are Coming to Providence St. Vincent Medical Center
Pediatric ED Update
March Pediatric In-Service
Calendar of Neonatal and Pediatric Educational Events, 2008
Providence St. Vincent Eating Disorder Treatment Program
Clinical Corner

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Important Pediatric Links

Please take advantage of our "Important Pediatric Links" section. It has been updated to include important neonatal and pediatric documents. You will now find admission policies and contact information for pediatric patient admission; general information about our pediatric unit and pediatric hospitalists; a list of our subspecialists and their contact information; pediatric admission order sets; a calendar of educational offerings in pediatrics and neonatology; and a calendar of PALS and NRP classes. We hope that this section provides a central repository of information for those who are interested in and refer patients to Children at Providence St. Vincent services.

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Pediatric IV Starts: Commitment to Quality and Safety

Marie Curley, R.N.
Nurse Manager, Inpatient Pediatrics and Pediatric Surgery

Pediatric nurses are aware that IV placement is rated as the second-most common source of "worst pain" experienced during a child's hospital stay. In a recent study by Walsh, 89 percent of parents said they might consider a painless IV for their child. Of these parents, 93 percent were willing to spend extra time in the ED so that their child could have a painless IV; 78 percent were willing to spend extra money for a painless IV experience.

In our pediatric surgery and inpatient departments, we follow the recommendations of the American Academy of Pediatrics (www.aap.org) and the American Pain Society (www.ampainsoc.org) relating to needle-stick procedures:

* It is the responsibility of those who care for children to eliminate or assuage pain and suffering whenever possible.

* Treatment approach should be multimodal and tailored to the child’s needs. Local anesthetics and strategies should be used to soothe and minimize distress.

This year, we have been auditing the care of patients receiving needle-stick procedures. For each child, a survey is completed that includes the following information: number of IV sticks, location of IV sticks, comfort measures, and who started the IV. Our goal is to assure our patients of minimal IV attempts and minimal discomfort during the course of their procedure. Thus far, our accomplishments include:

* Staffs are aware of and are using comfort measures. Topical anesthetic (LMX/emla) and hot packs are used for the majority of cases, depending upon the child’s age and the time when ethel chloride spray may have been administered. Age-appropriate distraction and caregiver's involvement are used. All children receive age-appropriate preparation.

* The majority of patients have successful IV starts upon first attempt.

* If child has had two attempts, the situation is evaluated to assure that the most skilled person is involved. We collaborate with NICU, IV team and emergency department.

* We call the physician if we have attempted several times (> 4 attempts), and if we believe that other options to IV therapy exist, such as oral fluid challenge.

With these measures, we continue to strive for patient safety and comfort while ensuring effective pediatric care.

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Pediatric Medical Students Are Coming to Providence St. Vincent Medical Center

Elroy Jan, M.D., and Yolanda Domond, M.D.
Site directors for Oregon Health & Science University Medical Student Clerkship

Beginning June 30, third-year medical students from OHSU will rotate through Providence St. Vincent on their pediatric clerkship. They will spend their days primarily on the Pediatric Inpatient Unit with pediatric hospitalists, but they will also spend time in other departments and clinics that treat children, including the Gerry Frank Center, the radiology center and several pediatric subspecialty clinics. Thanks to all those who have volunteered to be involved in teaching these students. Please greet them in the hallways and on the different units throughout the hospital. These students may turn out to be our future pediatricians!

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Pediatric ED Update

Gina Craven, RN

Since last year, several nurses with extensive pediatric and neonatal nursing experience have joined the emergency department staff. These nurses have worked closely with the entire staff to identify and respond to needs for pediatric training, additional pediatric equipment, and updated pediatric policies and procedures. The existing staff have enthusiastically welcomed their new co-workers and have recognized the benefits that enhanced pediatric capabilities will provide for all the pediatric/neonatal patients and families who seek care at the Providence St Vincent Pediatric Emergency Department.

As noted previously in PediPulse, extensive pediatric in-service education was provided last fall for emergency nurses. The in-service occurred in the form of a two-day pediatric skills session. In April, a second two-day session was held for Providence Health & Services emergency techs. Essential skills covered included "identifying the sick child,” taking accurate vital signs, proper holding and splinting techniques and reviewing code cart contents. Thanks to all the nurses and techs who participated in these sessions. Their commitment to pediatric care will assure that we provide the highest quality care for our young patients.

On a different note, commendations are due to the emergency nurses who developed the pediatric acetaminophen fever packs for families in need. Their results have just been published, bringing them well-deserved recognition and encouraging other institutions to emulate this worthy program.

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March Pediatric In-Service:

Kathleen Lewis, M.D., “Pediatric Palliative Care”

At our pediatric in-service lecture series in March, we were fortunate to have Dr. Lewis discuss pediatric palliative care. She explained the difference between palliative care and hospice care, and illuminated the special opportunities and challenges of providing palliative care to a pediatric population. She provided examples from her experiences with inpatient pediatric palliative care and discussed the possibilities of integrating a similar program with our inpatient services at Providence St. Vincent. It was an informative and stimulating discussion, and we look forward to future developments in our pediatric palliative care.

Click here to link to the slides from Dr. Lewis’ presentation

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Calendar of Neonatal and Pediatric Educational Events, 2008

Click here for calendar.

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Providence St. Vincent Eating Disorder Treatment Program

Jason Stone, MD

For more than 25 years, the Providence St. Vincent Eating Disorders Treatment Program has been helping adolescents and adults recover from eating disorders. The eating disorders program consists of structured, intensive, nine-and-a-half-hour treatment days, available five days per week. At the program, patients receive meal groups, nutritional counseling, health education, as well as individual, family, and group psychotherapy, all while being monitored medically and psychiatrically. Patients are able to return to their homes and families for nights and weekends, while learning to manage stressors and move past their eating disorder at the same time.

The program has recently benefited from the addition of the inpatient pediatric unit at St. Vincent, which has proved an incredible asset in caring for numerous medically unstable adolescents with eating disorders. With the addition of the pediatric unit, patients with eating disorders requiring inpatient medical stabilization are able to be treated in the supportive environment of the St. Vincent pediatric unit while simultaneously being followed by staff from the St. Vincent Eating Disorders Program. This has allowed for greater continuity in care and an exceptionally high level of satisfaction among family members and patients.

In recent years, the St. Vincent Eating Disorders Treatment Program has been expanding in order to reach an increasing number of patients struggling with eating disorders. We are proud and excited to announce that Linda Schmidt, MD, a board certified child and adolescent psychiatrist, will be joining Jason Stone, MD and the rest of the St. Vincent Eating Disorders Treatment Program in June. Dr. Schmidt, a compassionate and astute physician with eating disorders expertise, will be an outstanding addition to the program.

Eating disorder evaluations can be scheduled by contacting Access Triage at 503-574-9235 or 1-800-716-5325. Jason Stone, MD and Barbara Oyler, PMHNP welcome calls from providers with questions and can be reached at 503-216-2025. Further information on the program is available at the program's website.

Click here to visit the program's website.

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Clinical Corner

Andrew Zechnich, M.D.

CHIEF COMPLAINT: Altered Level of Consciousness
HPI: The patient is a 2 ½-year-old male who was playing at home with his sister. He complained to his mother of numbness in his feet (bilaterally) and abdominal pain. He was not acting quite right, and 9-1-1 was called. The paramedics noted the child to be confused, but responding appropriately, and he was transported to Providence St. Vincent. By the time he arrived to the ED, he had limited responsiveness and was having difficulty breathing. The paramedics had noted a strong chemical smell on the street where the family had walked home from the store earlier that day. They suspected recent spraying for weeds.

The child is previously well. There is no trauma, recent illness, ill contacts or travel. There has been no recent fever, headache, neuro symptoms, rash or other complaints.

PMH: none significant
Meds: none
Allergies: none

PHYSICAL EXAMINATION:

VITAL SIGNS: T 36.8, respiratory rate 15, pulse 109, blood pressure 155/86, O2 sat 71 percent, CBG normal

HEAD: Normocephalic. There is no external evidence of trauma. The pupils are equal, mid position, round, and both reactive to light. The conjunctivae are normal. EOMI. The face is symmetric. The oropharynx has considerable upper airway secretions but is otherwise normal. There are no oral lesions.

NECK: Supple. No evidence of meningeal irritation. There is no evidence of neck injury, tenderness, crepitance, or step-off. The anterior neck is non-tender without soft tissue swelling.

CHEST: Decreased breath sounds bilaterally.

CARDIOVASCULAR: Tachycardia without murmur. The periphery is well perfused. The peripheral pulses are symmetric.

ABDOMEN: Soft, non-tender, non-distended, normo-active bowel sounds.

EXTREMITIES: Without cyanosis, clubbing, or edema. There is no evidence of rash or petechiae. He has initially some spontaneous right upper extremity movement. He reaches up towards his mouth and nose. He does not follow any commands. He has decreased tone throughout. He is moving both legs.

INITIAL ED COURSE: The patient was brought to the Pediatric Emergency Department at Providence St. Vincent Medical Center. After assisting respirations and establishing IV access, the patient became weaker and continued to need airway and respiratory support. He was intubated with RSI technique, and his assisted respirations produced 100 percent sats. The CXR, head CT, CMP, CBC were all normal. Despite giving no further paralytics, after 30 minutes, the patient still had no spontaneous movements.

Further clinical history provided the diagnosis.

Click here for the diagnosis and case discussion

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