==Pediatrician Specific Practice: Description of How Pediatrics is Practiced Differently at YKHC==
YKHC is an unusual and wonderful place to practice medicine and especially pediatrics. Pediatricians at YKHC act as subspecialist extenders for all pediatric specialties that are not available in Bethel and often not in Alaska. There are many unique and interesting challenges (and frustrations) with practicing medicine in a remote region with travel and communication issues that are unique to our area. It is a lot like practicing third world medicine with much better support and infrastructure. The medicine is interesting and spans from primary care to pediatric subspecialty management to critical care with NICU/PICU patient stabilization and transport. Pediatricians at YKHC are primarily responsible for Chronic Peds Patients or complex and chronically ill kids, but we also do a variety of other patient care activities as well.

Pediatricians manage approximately 1,200 chronically ill patients of mainly Yup’ik Alaskan descent with significant respiratory, genetic, metabolic, cardiac, endocrine, neuro and infectious disease issues. They act as pediatric subspecialty extenders and consultants for family medicine, emergency medicine and village health aide providers. Pediatricians manage ADHD, fetal alcohol syndrome, cerebral palsy, seizure disorders, congenital heart disease, congenital adrenal hyperplasia, asthma, aspiration syndrome, chronic lung disease, and issues related to prematurity. In clinic, we see complex-care pediatric patients, urgent, acute and well child care patients as well as ER follow up patients. The hospitalist pediatricians need to be able to stabilize, manage, and transport critical care and neonatal emergency patients. Occasionally the hospitalist pediatrician will fly on medevacs to villages for potential preterm or high-risk term infant deliveries. The pediatricians assist and collaborate with pediatric sub-specialists when they visit YKHC and via email, text and phone. Occasionally pediatricians make visits to village clinics or subregional centers.

At YKHC, our pediatric patients get more invasive disease than children in the lower 48. We have therefore modified standard lower 48 guidelines and created some of our own for more conservative evaluation and treatment of our patients. In most places you would not do as many labs and xrays as we do here, but many times pneumonia, bacteremia and serious infections are missed if we do not check. Kids can be running around the ER with a little cough and no significant lung exam findings and have a significant pleural effusion on CXR. Or a well-looking 2-month-old with a low grade temp will have 230 WBCs in their CSF. We also have invasive Hflu A infections with either indolent or aggressive presentations. It pays to be very, conservative, vigilant and to watch kids closely before sending them back to a village where they may get worse and not be able to return due to weather.
==Description of Pediatrician Services and Practice==
'''Outpatient''': Outpatient pediatricians work in clinics providing care for routine, acute and complex care pediatric patients. They also provide consultative services to family medicine clinic providers and liaison with sub specialists plus behavioral health, developmental, educational service providers.

'''Inpatient''': Hospitalist pediatricians work on the inpatient ward and manage hospitalized children with chronic and/or complicated issues. They are also responsible for providing consultation to family practitioners, emergency medicine physicians, midlevels and village health aides; attending all high-risk deliveries and pediatric codes; and providing intensive care while patients are awaiting transport.

'''ER''': Pediatricians assigned to work in the ER will see urgent care and emergency pediatric patients as needed. They will also provide consultation for family medicine, midlevel and ER providers as well. The ER pediatrician has a range of encounters including minor illnesses and care of lacerations, orthopedics, wounds, trauma patients and coordination of care between YKHC and higher level services in Anchorage.

==[[Job Duties#PEDIATRICS|Pediatric Job Duties]]==

==Definition of Chronic Peds Patient==
We are often asked what defines a Chronic Pediatric Patient.

There are a few absolute criteria and then some softer calls.

1. Premies delivered less than 36 wks. These patients are followed until they are 1-2 years of age or their prematurity related issues have resolved

2. Pediatric patients that are followed by a pediatric subspecialty such as neurology, cardiology, endocrinology, etc. (Peds does not need to follow patients seen by the regular ENT, ortho, Behavioral Health or surgery)

3. All pediatric patients that require close pediatric care management and village RMT follow up EX: a 2 month old with a first RSV infection admission will inevitably have recurrent lung issues and wheezing until they are 2-3 years old- these patients are usually that best managed by the pediatricians with the health aides in the village and when seen in Bethel.

4. Any patient that has had recent serious illness such as respiratory failure, meningitis with sequela, osteomyelitis or other pediatric orthopedic issues that require close follow up.

5. Any infant or child that a provider, in collaboration with a pediatrician, feels warrants peds only care and care management.

Once a pediatric patient has been added to the CPP registry, they are seen in clinic only by the pediatricians (unless none is available), the health aides report all of their encounters to the pediatric hospitalist and they are managed by the pediatricians and our peds care manager. CPP kids can and should be graduated as they get older and their lung disease or other problems improve or resolve. The chronic kids will stay with peds until they are 18 or they stop seeing a pediatric specialist at YKHC and must be formally transitioned to the family medicine service when they are 18 or it is appropriate ie pregnancy etc.

CPP patients have a primary pediatrician who is designated by village assignment. In the best of all worlds, the assigned pediatrician is responsible for adding and taking CPP patients off the registry as appropriate, they try to see their own CPP patient’s in clinic when able and appropriate and they are responsible for medication refills, specialty care follow up, updating problem lists etc. In reality, we all do all of this (with the CM help) with all the patients as we see them or do RMT.

'''Making a patient CPP''': This should only be done by experienced YK pediatric providers. To add a patient to the CPP registry create a CPP Raven banner, update the problem list with pertinent information as to why the patient is CPP, pertinent follow up and plans and how long the patient will be CPP…ie CPP until hip dysplasia is resolved or ECHO is complete or ???. Send a patient communication to the care manager and the primary pediatrician assigned to the patient’s village letting them know you added the patient to the CPP list and why…plus follow up info they need to know. There is a patient education handout in RAVEN for a child who becomes CPP.

'''Removing a patient from CPP Registry''': This can and should be done by anyone with time to review a chart and make this determination. When CPP patient’s have outgrown their reason to be CPP ie no longer have a need for specialty care, close peds care management or are now relatively well—they can be graduated ☺. You can tell the family of ask the CHA to let the family know that on review of their recent history that they are well enough to be graduated from the CPP list. It is a good idea to message the case managers about graduating a patient in case they know of more specialty care or needs that was not apparent on review.

===[[How to Add and Remove CPP RAVEN banners]]===

''This should only be done by experienced pediatric provider only''

==[[media:chronic peds village pods.pdf|CPP Village Assignments]]==

==Problem List: A quick method of communicating to other providers taking care of patient==
When you make a patient a CPP, put the reason/diagnoses for adding the patient and any pertinent notes. It is difficult and time consuming to look for and locate important patient documentation in encounter, RMT, multimedia and communication attachments when time is limited or in an emergency.

Looking at the Problem list and notes is MUCH faster. Comments can be added in the notes section of a problem to convey brief important care management information as things listed below.

If we work on keep our problem lists updated by adding, modifying, resolving and inactivating problems we will improve continuity of care and save each other a lot of time trying to piece together care plans etc.

NOTE: For longer Care Plans and Individual Patient Protocols, put an alert note in RAVEN. Reference that note or any updated/new alert notes, by date, in the appropriate problem's comments. Writing a good note is great, but it is difficult to take the time to look through all the documentation to find a note that has the good details that you night need in a hurry.

===Updating Problem Lists===
*Enter any new problem that will need ongoing follow up and care management ie seizures /status epilepticus; VSD; respiratory failure; Chronic Kidney Disease etc, Congenital Adrenal Hyperplasia etc

*Only add problems that require ongoing management or might impact future health status…Do not add non-serious issues like strep throat/chronic Otitis media/mild anemia or other issues that do not require ongoing evaluation and management

*Update problem lists regularly with new or additional information noted on chart reviews, specialty notes reviews, and patient encounters in ER, OP clinic, village clinic and NW. Put in things that another provider would want to know if they were providing acute care, doing a care management review or in an emergency.

*Consolidate like problems and comments into as few problems as possible

*Cancel old problems (this lines them out) that are no longer important and resolve problems that are not active but would be good to know about --this leaves them visible on regular RAVEN and removes them from RMT problem lists.

*Add brief pertinent information in the problem list comments if needed.
*Examples of Problem List Communications Notes that might helpful
**Seen by 2/15/13. Start Pulmocort. PMD reck in 2 months. pulm f/u 6 months. Needs chest CT in one year with pulm f/u
**Atypical febrile seizures. EEG referral made. Diastat prescribed. No anti-epileptics for now
**Weight check q week in village and monthly with Bethel peds until patient reaches 10th percent
**Work with and allow family to make decisions about treatment and coming to Bethel by regular plane or medevac.
**A specific plan for emergencies like SVT, recurrent difficult to control seizures
**Made CPP until FTT issue resolved and may then graduate from registry if doing
*You can modify the name of the problem list to add limited information… ie Premature Infant can be changed to read ‘33 6/7 week Premie’ and no further comments are needed if they are uncomplicated
*Alert Note’s are created for longer and evolving individual care plans Make a note in the comments of a problem with the date of the latest note/s. Make sure your filters are set to see all alert notes
*Put a date in the body of your problem list comments. The date of a comment is seen on regular RAVEN, but not in the RMT problem list comments. On RMT comments there is no time frame reference. EX: Put date the specialist was seen and the month and year the follow up is due
*Keep Problem Lists updated with
**Specialty visits and f/u or management changes and when next appointment is due
**Therapeutic pearls for really sick and difficult patients
**Meds and lab result with therapeutic goals and plans
**Important things that might affect future care
**The date of last/most updated alert note detailing longer and more complex individual care plans
*If you make a patient CPP, please put a problem in for why this patient is made CPP.
'''Example:''' Patient is made CPP for Severe Breath Holding with seizure like movements. Referred for an EEG etc. Note the EEG referral has been made so the next person can check on the status of the EEG. Also note that the patient was made CPP for this issue.
*Put procedures in histories section. PE tubes, T&As, appys etc are easy to enter there.
*Try to combine issues into one problem where it makes sense. When we get a ‘simple’ discharge from NICU, A summary problem could look like 36 week premie: transient hypoglycemia, hyperbli treated with lights and poor feeding that resolved. This makes it so you don’t’ have three separate problems to put on the list.

==[[Outpatient Pediatric Detailed Information]]==

==[[Preparing For and Navigating Clinic]]==
==[[Specific Types of Appointments and Procedural Processes]]==
==Admitting a Patient from Clinic to Inpatient==
Pediatric patients can be admitted to family medicine or the pediatric service depending on acuity of patient. If you have a child that is not a Chronic Peds Patient (CPP), which you can tell by looking at the Alerts on the banner bar, he or she can be admitted to the Family Medicine Ward doctor. If it is a complicated child and /or is a CPP, the child should be admitted to the Pediatric Hospitalist. You can call Pediatric Hospitalist if you have a question about whether you should admit the patient or not.
#Contact provider on Northwing for admission--the Pediatric Hospitalist or the Kusko or Yukon Family Physician. The village the patient is from determines which family medicine provider you contact. Your clinic unit clerk can assist you in figuring out which family physician to contact for an admission from your patient's village or you can call the unit clerk at x6330. Bethel admissions will go to the least busy family physician, so you can contact either one and might be bounced to the other physician.
#Determine if admitting provider will be seeing the patient in clinic before going to the floor or if patient may be transferred directly to inpatient unit.
#Alert the office assistant and Charge nurse of your plan for admission so they can obtain a preadmission FIN #.
#Have nurse or office assistant tiger text the admitting provider with FIN # so orders can be written.
#Clinic charge nurse will contact charge nurse on NW for a “ heads up”
#Complete your clinic documentation and interventions as needed. Please keep patient and family updated on status of transfer.
#Once bed has been assigned, provider on NW completes admission orders; clinic nurse will provide sign out to admitting nurse on Northwing.
#Patient will be transferred to the inpatient unit.

'''Some points to Remember'''

Talk with the ward doctor about which antibiotics to start fluids etc. so those can be started in the outpatient side and get the admission process initiated more quickly. The types of admissions for our hospital are mainly enlarging abscess and/or cellulitis that have failed outpatient treatment, large lower extremity cellulitis/abscesses that have not yet had outpatient treatment, pneumonia, bronchiolitis, suicidal ideation, fever in a neonate and labor.

===Transferring a patient from Clinic to Emergency Dept===

#Call ED physician to obtain an accepting physician. Inform clinic charge nurse and ED charge nurse of transfer to ER.
#Complete clinic documentation with important transfer information.
#Nurse will give report to ER and transfer patient to ER when room available.
#Always keep parent/patient informed of status of situation
#IF you have an emergent patient take them directly to ER trauma bay and call for help.
#IF you have an unstable, unresponsive patient in clinic have the clerk call a code.

===Transferring a Patient from clinic to Anchorage via Commercial Flight or Medevac===

#Contact accepting facility. ANMC/Providence contact appropriate on call service. Once you have obtained an accepting physician initiate transport. Remember if you are transferring a native patient to a non-native facility you will need to obtain approval from contract health at ANMC.
#If patient is stable contact our travel office and complete a patient transport order form. Have parent sign a consent to transfer patient and discuss risk/benefit.
#If patient is unstable initiate transfer via Medevac. See Medevac Section. Patient will need to be transferred to ER until transport arrives. See transfer to ER section.
#Complete Raven note / transfer summary with pertinent details.
#Obtain all radiological images on disk from radiology department.
#Complete Transfer form (PTOS) with all appropriate signatures.
#Remind clerk to print out all Raven documents and labs and place in transfer packet.
#Always keep patient/caregiver informed of status of situation.

==[[ER: Detailed Information]]==

==[[Inpatient: Detailed Information]]==
==[[OB/Newborn: Detailed Information]]==
==[[Call: Detailed Information]]==
==[[Pediatric Consults]]==
==[[Chronic Pediatric RMT]]==
==[[Peds Medevacs]]==
==[[Pediatric Care Management]]==
==[[Pediatric Specialty Services]]==
==[[Pediatric Psychiatry Services]]==
==Pediatric Village Trips==
[[Village Trips|See Village trip section]]

===Prior to your trip===
#Obtain list of chronic pediatric patients who need follow up in the village.
#Obtain a list of patients who require vaccines updated
==Peds SART==
We do not always have a pediatric certified SART team and the pediatricians cannot do SART exams on their own. Please see the [[Child/Adolescent Sexual Assault Flow|Pediatric SART Guideline]] for more details on who needs exams, how and where the patient gets the evaluation and care they need and who does it
==[[OR for Peds]]==
==[[Newborn Information Access on RAVEN]]==
==[[Pharmacy Things to Know]]==
==[[Emergency Stabilization Information]]==

Category:Pediatrics

2018-02-10T00:46:15Z

JaneM:

==Pediatrician Specific Practice: Description of How Pediatrics is Practiced Differently at YKHC==
YKHC is an unusual and wonderful place to practice medicine and especially pediatrics. Pediatricians at YKHC act as subspecialist extenders for all pediatric specialties that are not available in Bethel and often not in Alaska. There are many unique and interesting challenges (and frustrations) with practicing medicine in a remote region with travel and communication issues that are unique to our area. It is a lot like practicing third world medicine with much better support and infrastructure. The medicine is interesting and spans from primary care to pediatric subspecialty management to critical care with NICU/PICU patient stabilization and transport. Pediatricians at YKHC are primarily responsible for Chronic Peds Patients or complex and chronically ill kids, but we also do a variety of other patient care activities as well.

Pediatricians manage approximately 1,200 chronically ill patients of mainly Yup’ik Alaskan descent with significant respiratory, genetic, metabolic, cardiac, endocrine, neuro and infectious disease issues. They act as pediatric subspecialty extenders and consultants for family medicine, emergency medicine and village health aide providers. Pediatricians manage ADHD, fetal alcohol syndrome, cerebral palsy, seizure disorders, congenital heart disease, congenital adrenal hyperplasia, asthma, aspiration syndrome, chronic lung disease, and issues related to prematurity. In clinic, we see complex-care pediatric patients, urgent, acute and well child care patients as well as ER follow up patients. The hospitalist pediatricians need to be able to stabilize, manage, and transport critical care and neonatal emergency patients. Occasionally the hospitalist pediatrician will fly on medevacs to villages for potential preterm or high-risk term infant deliveries. The pediatricians assist and collaborate with pediatric sub-specialists when they visit YKHC and via email, text and phone. Occasionally pediatricians make visits to village clinics or subregional centers.

At YKHC, our pediatric patients get more invasive disease than children in the lower 48. We have therefore modified standard lower 48 guidelines and created some of our own for more conservative evaluation and treatment of our patients. In most places you would not do as many labs and xrays as we do here, but many times pneumonia, bacteremia and serious infections are missed if we do not check. Kids can be running around the ER with a little cough and no significant lung exam findings and have a significant pleural effusion on CXR. Or a well-looking 2-month-old with a low grade temp will have 230 WBCs in their CSF. We also have invasive Hflu A infections with either indolent or aggressive presentations. It pays to be very, conservative, vigilant and to watch kids closely before sending them back to a village where they may get worse and not be able to return due to weather.
==Description of Pediatrician Services and Practice==
'''Outpatient''': Outpatient pediatricians work in clinics providing care for routine, acute and complex care pediatric patients. They also provide consultative services to family medicine clinic providers and liaison with sub specialists plus behavioral health, developmental, educational service providers.

'''Inpatient''': Hospitalist pediatricians work on the inpatient ward and manage hospitalized children with chronic and/or complicated issues. They are also responsible for providing consultation to family practitioners, emergency medicine physicians, midlevels and village health aides; attending all high-risk deliveries and pediatric codes; and providing intensive care while patients are awaiting transport.

'''ER''': Pediatricians assigned to work in the ER will see urgent care and emergency pediatric patients as needed. They will also provide consultation for family medicine, midlevel and ER providers as well. The ER pediatrician has a range of encounters including minor illnesses and care of lacerations, orthopedics, wounds, trauma patients and coordination of care between YKHC and higher level services in Anchorage.

==[[Job Duties#PEDIATRICS|Pediatric Job Duties]]==

==Definition of Chronic Peds Patient==
We are often asked what defines a Chronic Pediatric Patient.

There are a few absolute criteria and then some softer calls.

1. Premies delivered less than 36 wks. These patients are followed until they are 1-2 years of age or their prematurity related issues have resolved

2. Pediatric patients that are followed by a pediatric subspecialty such as neurology, cardiology, endocrinology, etc. (Peds does not need to follow patients seen by the regular ENT, ortho, Behavioral Health or surgery)

3. All pediatric patients that require close pediatric care management and village RMT follow up EX: a 2 month old with a first RSV infection admission will inevitably have recurrent lung issues and wheezing until they are 2-3 years old- these patients are usually that best managed by the pediatricians with the health aides in the village and when seen in Bethel.

4. Any patient that has had recent serious illness such as respiratory failure, meningitis with sequela, osteomyelitis or other pediatric orthopedic issues that require close follow up.

5. Any infant or child that a provider, in collaboration with a pediatrician, feels warrants peds only care and care management.

Once a pediatric patient has been added to the CPP registry, they are seen in clinic only by the pediatricians (unless none is available), the health aides report all of their encounters to the pediatric hospitalist and they are managed by the pediatricians and our peds care manager. CPP kids can and should be graduated as they get older and their lung disease or other problems improve or resolve. The chronic kids will stay with peds until they are 18 or they stop seeing a pediatric specialist at YKHC and must be formally transitioned to the family medicine service when they are 18 or it is appropriate ie pregnancy etc.

CPP patients have a primary pediatrician who is designated by village assignment. In the best of all worlds, the assigned pediatrician is responsible for adding and taking CPP patients off the registry as appropriate, they try to see their own CPP patient’s in clinic when able and appropriate and they are responsible for medication refills, specialty care follow up, updating problem lists etc. In reality, we all do all of this (with the CM help) with all the patients as we see them or do RMT.

'''Making a patient CPP''': This should only be done by experienced YK pediatric providers. To add a patient to the CPP registry create a CPP Raven banner, update the problem list with pertinent information as to why the patient is CPP, pertinent follow up and plans and how long the patient will be CPP…ie CPP until hip dysplasia is resolved or ECHO is complete or ???. Send a patient communication to the care manager and the primary pediatrician assigned to the patient’s village letting them know you added the patient to the CPP list and why…plus follow up info they need to know. There is a patient education handout in RAVEN for a child who becomes CPP.

'''Removing a patient from CPP Registry''': This can and should be done by anyone with time to review a chart and make this determination. When CPP patient’s have outgrown their reason to be CPP ie no longer have a need for specialty care, close peds care management or are now relatively well—they can be graduated ☺. You can tell the family of ask the CHA to let the family know that on review of their recent history that they are well enough to be graduated from the CPP list. It is a good idea to message the case managers about graduating a patient in case they know of more specialty care or needs that was not apparent on review.

===[[How to Add and Remove CPP RAVEN banners]]===

''This should only be done by experienced pediatric provider only''

==[[media:chronic peds village pods.pdf|CPP Village Assignments]]==

==Problem List: A quick method of communicating to other providers taking care of patient==
When you make a patient a CPP, put the reason/diagnoses for adding the patient and any pertinent notes. It is difficult and time consuming to look for and locate important patient documentation in encounter, RMT, multimedia and communication attachments when time is limited or in an emergency.

Looking at the Problem list and notes is MUCH faster. Comments can be added in the notes section of a problem to convey brief important care management information as things listed below.

If we work on keep our problem lists updated by adding, modifying, resolving and inactivating problems we will improve continuity of care and save each other a lot of time trying to piece together care plans etc.

NOTE: For longer Care Plans and Individual Patient Protocols, put an alert note in RAVEN. Reference that note or any updated/new alert notes, by date, in the appropriate problem's comments. Writing a good note is great, but it is difficult to take the time to look through all the documentation to find a note that has the good details that you night need in a hurry.

===Updating Problem Lists===
*Enter any new problem that will need ongoing follow up and care management ie seizures /status epilepticus; VSD; respiratory failure; Chronic Kidney Disease etc, Congenital Adrenal Hyperplasia etc

*Only add problems that require ongoing management or might impact future health status…Do not add non-serious issues like strep throat/chronic Otitis media/mild anemia or other issues that do not require ongoing evaluation and management

*Update problem lists regularly with new or additional information noted on chart reviews, specialty notes reviews, and patient encounters in ER, OP clinic, village clinic and NW. Put in things that another provider would want to know if they were providing acute care, doing a care management review or in an emergency.

*Consolidate like problems and comments into as few problems as possible

*Cancel old problems (this lines them out) that are no longer important and resolve problems that are not active but would be good to know about --this leaves them visible on regular RAVEN and removes them from RMT problem lists.

*Add brief pertinent information in the problem list comments if needed.
*Examples of Problem List Communications Notes that might helpful
**Seen by 2/15/13. Start Pulmocort. PMD reck in 2 months. pulm f/u 6 months. Needs chest CT in one year with pulm f/u
**Atypical febrile seizures. EEG referral made. Diastat prescribed. No anti-epileptics for now
**Weight check q week in village and monthly with Bethel peds until patient reaches 10th percent
**Work with and allow family to make decisions about treatment and coming to Bethel by regular plane or medevac.
**A specific plan for emergencies like SVT, recurrent difficult to control seizures
**Made CPP until FTT issue resolved and may then graduate from registry if doing
*You can modify the name of the problem list to add limited information… ie Premature Infant can be changed to read ‘33 6/7 week Premie’ and no further comments are needed if they are uncomplicated
*Alert Note’s are created for longer and evolving individual care plans Make a note in the comments of a problem with the date of the latest note/s. Make sure your filters are set to see all alert notes
*Put a date in the body of your problem list comments. The date of a comment is seen on regular RAVEN, but not in the RMT problem list comments. On RMT comments there is no time frame reference. EX: Put date the specialist was seen and the month and year the follow up is due
*Keep Problem Lists updated with
**Specialty visits and f/u or management changes and when next appointment is due
**Therapeutic pearls for really sick and difficult patients
**Meds and lab result with therapeutic goals and plans
**Important things that might affect future care
**The date of last/most updated alert note detailing longer and more complex individual care plans
*If you make a patient CPP, please put a problem in for why this patient is made CPP.
'''Example:''' Patient is made CPP for Severe Breath Holding with seizure like movements. Referred for an EEG etc. Note the EEG referral has been made so the next person can check on the status of the EEG. Also note that the patient was made CPP for this issue.
*Put procedures in histories section. PE tubes, T&As, appys etc are easy to enter there.
*Try to combine issues into one problem where it makes sense. When we get a ‘simple’ discharge from NICU, A summary problem could look like 36 week premie: transient hypoglycemia, hyperbli treated with lights and poor feeding that resolved. This makes it so you don’t’ have three separate problems to put on the list.

==[[Outpatient Pediatric Detailed Information]]==

==[[Preparing For and Navigating Clinic]]==
==[[Specific Types of Appointments and Procedural Processes]]==
==Admitting a Patient from Clinic to Inpatient==
Pediatric patients can be admitted to family medicine or the pediatric service depending on acuity of patient. If you have a child that is not a Chronic Peds Patient (CPP), which you can tell by looking at the Alerts on the banner bar, he or she can be admitted to the Family Medicine Ward doctor. If it is a complicated child and /or is a CPP, the child should be admitted to the Pediatric Hospitalist. You can call Pediatric Hospitalist if you have a question about whether you should admit the patient or not.
#Contact provider on Northwing for admission--the Pediatric Hospitalist or the Kusko or Yukon Family Physician. The village the patient is from determines which family medicine provider you contact. Your clinic unit clerk can assist you in figuring out which family physician to contact for an admission from your patient's village or you can call the unit clerk at x6330. Bethel admissions will go to the least busy family physician, so you can contact either one and might be bounced to the other physician.
#Determine if admitting provider will be seeing the patient in clinic before going to the floor or if patient may be transferred directly to inpatient unit.
#Alert the office assistant and Charge nurse of your plan for admission so they can obtain a preadmission FIN #.
#Have nurse or office assistant tiger text the admitting provider with FIN # so orders can be written.
#Clinic charge nurse will contact charge nurse on NW for a “ heads up”
#Complete your clinic documentation and interventions as needed. Please keep patient and family updated on status of transfer.
#Once bed has been assigned, provider on NW completes admission orders; clinic nurse will provide sign out to admitting nurse on Northwing.
#Patient will be transferred to the inpatient unit.

'''Some points to Remember'''

Talk with the ward doctor about which antibiotics to start fluids etc. so those can be started in the outpatient side and get the admission process initiated more quickly. The types of admissions for our hospital are mainly enlarging abscess and/or cellulitis that have failed outpatient treatment, large lower extremity cellulitis/abscesses that have not yet had outpatient treatment, pneumonia, bronchiolitis, suicidal ideation, fever in a neonate and labor.

===Transferring a patient from Clinic to Emergency Dept===

#Call ED physician to obtain an accepting physician. Inform clinic charge nurse and ED charge nurse of transfer to ER.
#Complete clinic documentation with important transfer information.
#Nurse will give report to ER and transfer patient to ER when room available.
#Always keep parent/patient informed of status of situation
#IF you have an emergent patient take them directly to ER trauma bay and call for help.
#IF you have an unstable, unresponsive patient in clinic have the clerk call a code.

===Transferring a Patient from clinic to Anchorage via Commercial Flight or Medevac===

#Contact accepting facility. ANMC/Providence contact appropriate on call service. Once you have obtained an accepting physician initiate transport. Remember if you are transferring a native patient to a non-native facility you will need to obtain approval from contract health at ANMC.
#If patient is stable contact our travel office and complete a patient transport order form. Have parent sign a consent to transfer patient and discuss risk/benefit.
#If patient is unstable initiate transfer via Medevac. See Medevac Section. Patient will need to be transferred to ER until transport arrives. See transfer to ER section.
#Complete Raven note / transfer summary with pertinent details.
#Obtain all radiological images on disk from radiology department.
#Complete Transfer form (PTOS) with all appropriate signatures.
#Remind clerk to print out all Raven documents and labs and place in transfer packet.
#Always keep patient/caregiver informed of status of situation.

==[[ER: Pediatric Specific Information]]==

==[[Inpatient: Detailed Information]]==
==[[OB/Newborn: Detailed Information]]==
==[[Call: Detailed Information]]==
==[[Pediatric Consults]]==
==[[Chronic Pediatric RMT]]==
==[[Peds Medevacs]]==
==[[Pediatric Care Management]]==
==[[Pediatric Specialty Services]]==
==[[Pediatric Psychiatry Services]]==
==Pediatric Village Trips==
[[Village Trips|See Village trip section]]

===Prior to your trip===
#Obtain list of chronic pediatric patients who need follow up in the village.
#Obtain a list of patients who require vaccines updated
==Peds SART==
We do not always have a pediatric certified SART team and the pediatricians cannot do SART exams on their own. Please see the [[Child/Adolescent Sexual Assault Flow|Pediatric SART Guideline]] for more details on who needs exams, how and where the patient gets the evaluation and care they need and who does it
==[[OR for Peds]]==
==[[Newborn Information Access on RAVEN]]==
==[[Pharmacy Things to Know]]==
==[[Emergency Stabilization Information]]==

ER: Detailed Information

2018-02-10T00:44:18Z

JaneM:

Pediatric Hospitalist's encounters with critically ill patients in the ER will be more frequent at YKDRH than your usual small hospitals in the lower forty-eight. Maintain a higher index of suspicion for sepsis, meningitis, and other serious bacterial illnesses.

Respiratory illnesses ranging from pneumonia, empyema, and RSV WILL occur and you will learn to be very comfortable with stabilizing and transporting these infants. If a patient is identified as needing to be intubated, it is best do this earlier rather than later to allow for a smooth procedure. If you feel uncomfortable please ask for back up. All new providers should contact their assigned back up physician as soon as the decision to intubate is made. All patients on the floor should be transferred to the if possible) for intubation once that it is determined that this is necessary. The ER nurses are very used to dealing with pediatric intubations and will be very helpful during this process. We have a pediatric intubation guideline and weight based medication worksheets and orders in RAVEN for all intubations, resuscitations and stabilizations…please use them.

Pediatricians see patients in the ER as consultants, when they assume care of a sick patients in the ER when they are on call and during scheduled ER shifts.

If a patient is critically ill and requires PICU admission or if they require services that our hospital cannot provide, the patient must be transferred to Anchorage. If the patient is an IHS beneficiary (all Alaska Native patients), contact the ANMC peds on call to get an accepting physician. You are responsible for activating the transport team and the sooner this happens the better! You then obtain a transport packet and do the necessary paper work. This should include a PTO form, consent for transport, consent for transfer of records, relevant labs/documents, a CD of any relevant films, and a detailed transfer note. If the patient is particularly unstable this transfer note may need to be done after the transport team has left with the patient, as you may not have time prior to this. You can then fax the note to the receiving physician BUT THEY MUST RECEIVE A TRANSFER NOTE as soon as you can feasibly do one. If the patient is not an IHS beneficiary, s/he will be transferred to Providence. All non-PICU transfers to Providence must have a hospitalist-accepting physician and may be directly admitted to the inpatient unit or go through the ER depending on how the patient is doing and what they need. You can contact the pediatric hospitalist directly through Providence operators or through the PICU.

===Working and consulting in the ER===

If you see an ER patient from start to finish, you must complete the ER H&P and RAVEN discharge process. If you do a curbside consult in the ER, it is best to write a brief note as an addendum to the consulting physician’s ER H&P or on a separate RAVEN communication/consult note. If it is a telephone consult, the ER physician should be documenting their consult and the plan but it is always a good idea to make sure this has been done or add your own note in RAVEN. If a patient needs admission, the nurse must complete a Pediatric Early Warning Signs (PEWS) evaluation first to determine if the patient is an appropriate admission for our site. An accepting FM or pediatric physician must be obtained (and documented in your note), sign out given, an admit order placed and an admission FIN # requested. Once the admitting physician has a FIN # then they can write the admitting orders, add a diagnosis and complete medicine reconciliation.

Often the pediatricians on call are called stat to the ER for a pediatric emergency. It is best to determine what the ER physician needs from you—To assist them or assume as lead physician in the patient’s care. ER physicians all have differing levels of comfort in caring for pediatric emergencies. It is best for patient care to determine early on what roles the providers are going to assume and who is in charge. Often the ER docs are better with trauma and the pediatrician acts as an assistant/advisor. Some of the ER docs are comfortable with intubations and other procedures and just want help. Sometimes the ER is so busy that it makes sense for the pediatrician to assume full care of a critical patient. Pediatricians, Family Physicians and Emergency Physicians at YK are all good at pediatric medicine and we all collaborate and help each other to provide the best care possible for our patients.

'''NOTE''': No pediatric patients that require high flow can be admitted to YKHC.

'''NOTE''': If a pediatric patient you are caring for in the ER is stable while awaiting transport (does not need one to one physician care) and the RT, nurses, and ER physician feel comfortable with you leaving the floor or the hospital, then you can consider this as an option.

===Communication===
Good communication is critical in our care system. We encourage the ER physicians to call us with any pediatric questions. They also need to call us about any concerning or critical peds patients they are seeing. We need to know about any very sick, or potentially very sick patients, earlier rather than later, as we can provide advice and help. Even if a medevac and transport are already arranged, the pediatricians should be notified if there are any concerns about the patient. We may need to come in immediately or be ready to provide consultation and back up as needed. Any pediatric patient that is being admitted will have a Pediatric Early Warning Signs (PEWS) completed prior to admission. Any PEWS score of 6 or above will trigger a protocol for collaborative multidisciplinary evaluation and communication. It is important to determine if a patient is stable enough to be admitted at our facility or if they need to be transported to a higher level of care.

Not all ER physicians call the pediatricians on call for sicker patients. If a patient is concerning and the ER physician as not contacted the pediatrician on call, nursing has been encouraged to page peds on call. The on call pediatrician can then contact with the ER doc to discuss the patient further.

Communication between ER, wards and on call pediatricians is also very critical. ER peds providers should be talk with the inpatient or on call physicians about any potential admissions or very sick patients as early as possible. The on call and ward docs should also be letting the ER pediatrician know about any pediatric medevacs or sick kids coming in by commercial flight.

During a pediatric ER shift, the ER physicians should consult the scheduled ER pediatrician about any peds issues. If the ER pediatrician is tied up, the ER doc can call the ward pediatrician/peds on call. If a patient is going to be admitted, the provider admitting the patient must call the ward pediatrician/peds on call and document that they accepted the patient. The accepting pediatrician will write admission orders as soon as an admit FIN # is made. When the ER pediatrician goes off shift, they must sign out the care of any patients left in the ER to the ER physician with a plan of care established. If the patient is sick or could potentially be an issue, it is best to make the ward pediatrician/peds on call aware of the patient as well.

Please update problem lists and notes in patient charts as much as you are able. If a patient has a new onset of status epilepticus or is intubated for multi lobar pneumonia and respiratory failure etc—put this in the problem list for future reference. This is one of our best ways of clinical information sharing and improves continuity of care.

[[:category:Pediatrics]]