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| ==Pediatrician Specific Practice: Description of How Pediatrics is Practiced Differently at YKHC==
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| 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. | | 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. |
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| 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. On-call pediatricians need to be able to stabilize, manage, and transport critical care and neonatal emergency patients. Occasionally the pediatrician ‘on-call’ 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. Occasionally pediatricians make visits to village clinics or subregional centers.
| | {| class="wikitable" style="margin: auto; width: 75%" |
| | | !GENERAL INFORMATION |
| At YKHC, our pediatric patients get more invasive disease than children in the lower 48. We have therefore adapted 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 then 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 might get worse and not be able to return due to weather.
| | !SHARED PEDIATRIC RESOURCES |
| ==Description of Pediatrician Services and Practice==
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| '''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.
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| | | *[[General Introduction to Pediatrics]] |
| '''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.
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| | | *[[Chronic Pediatric Patient Definition]] |
| '''ER''': Both hospitalists and outpatient pediatrician ‘on call’ will provide consultative and emergent care to pediatric patients who present to the ED. Duties may involve laceration care, orthopedic care, wound care, care of trauma patients and coordination of care between YKHC and higher level services in Anchorage. There are also scheduled ER shifts where the pediatricians will be taking care of mostly acuity level two and three patients, but may be responsible for critical care stabilization of patients during their shift and can see urgent care patient as well.
| | *[[INTRA and INTERhospital Transfers|Admissions and Transfers]] |
| | | *[[Pediatric Consults]] |
| '''Call''': Call consists of consults, care of hospitalized pediatric patients, medevacs and care/stabilization/transport of pediatric patients in the ER and newborns as required. Some pediatricians do both clinic and hospitalist shifts and all pediatricians share night, emergency room coverage, weekend and holiday call.
| | *[[Pediatric Care Management|Pediatric Case Management]] |
| ==[[Pediatric Job Duties]]==
| | *[[Specialty Referrals#Pediatric Specialty Services|Pediatric Specialty Services]] |
| ==Definition of Chronic Peds Patient== | | *[[Newborn Information Access on RAVEN]] |
| We are often asked what defines a Chronic Pediatric Patient.
| | *[[SART|Sexual Abuse Response Team (SART)]] |
| | | *[[Pharmacy Things to Know]] |
| There are a few absolute criteria and then some softer calls.
| | *[[How to remove an allergy banner]] |
| | | *[[:Category:YKHC Guidelines|YKHC Clinical Guidelines]] |
| 1. Premies delivered less than 36 wks
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| | | !SPECIFIC PEDIATRIC DEPARTMENT INFORMATION |
| 2. Pediatric patients that are followed by a pediatric specialty such as neurology, cardiology, endocrinology, etc. (Peds does not need to follow patients seen by the adult ENT, ortho, Behavioral Health or surgery)
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| 3. All pediatric patients that require close pediatric care manage¬ment and village RMT follow up
| | *[[Outpatient: Detailed Information|Outpatient]] (''detailed introduction to Pediatric Outpatient job'') |
| | | **[[Pediatric Outpatient Job Description|Pediatric Outpatient Job Description]] |
| 4. Any young infants that have had recurrent lung infections or sig¬nificant/chronic lung disease less than 6 months of age as these have a tendency to be much sicker until they get older
| | **[[Preparing For and Navigating Clinic]] |
| | | **[[Specific Types of Appointments and Procedural Processes|Outpatient Pediatric Encounters]] |
| 5. Any infant or child that a provider, in collaboration with a pedia¬trician, feels warrants peds only care and care management.
| | **[[Village Trips|Pediatric Village Trips]] |
| | | **[[Bethel Regional High School Clinic]] |
| Once a pediatric patient has been added to the CPP registry, they are seen in clinic only by the pediatricians (unless none is avail¬able), the health aides report them to peds ‘on-call’ and they are managed by the pediatricians and our peds care manager. Some¬time the CPP kids get 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.
| | **[[Outpatient Clinic Introduction#Medication Refills|Medication Refills]] |
| | | *[[Inpatient: Detailed Information|Inpatient]] (''detailed introduction to YKHC Pediatric Hospitalist job'') |
| 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.
| | **[[Pediatric Hospitalist Job Description|Pediatric Hospitalist Job Description]] |
| | | **[[Hospitalist Workflow and Priorities]] |
| '''Making a patient CPP''': This should only be done by experienced YK pediatricians. 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 for a child who becomes CPP on RAVEN.
| | **[[Common Inpatient Admissions (Peds)]] |
| | | **[[:Category:Medevacs and Transport#Medevacs for Inpatient Pediatricians|Medevacs for Inpatient Pediatricians]] |
| '''Removing a patient from CPP Registry''': This is done by the primary care pediatrician. 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—the can be graduated ☺. You can let the CHA or family know that on review of their recent history that they are probably well enough to be graduated from the CPP list. A note suggesting that a patient be removed from the CPP registry should be sent to the primary pediatrician with a cc to the care manager. The primary pediatrician for that village is responsible for removing the patient’s banner if the care manager or they have no concerns about removing the patient.
| | **[[Chronic Pediatric RMT]] |
| | | **[[Emergency RMT Scenarios and Responses]] |
| ===How to Add and Remove CPP RAVEN banners===
| | **[[Emergency Stabilization Information]] |
| | | **[[ER: Detailed Information|Emergency Department]] (''detailed introduction to Pediatric ED shift'') |
| ''This should only be done by experienced regular pediatricians only''
| | **[[OB/Newborn: Detailed Information|OB/Newborn]] (''detailed introduction to Pediatric newborn care'') |
| | | ***[[:Category:OB & Newborn#NEWBORN SPECIFIC INFORMATION|Newborn Resources on OB & Newborn Main Page]] |
| '''To add a CPP Banner'''
| | ***[[:Category:YKHC Guidelines#Neonatal References|Neonatal References/Resources on YKHC Guideline Page]] |
| *Go to AdHoc Charting (a button at the top of the screen) in PowerChart. | | **[[OR for Peds]] |
| *Click Patient Registries | | **[[Death Protocol]] |
| *Click CPP | | |} |
| *Click the green check mark at the top left of the screen | |
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| '''To remove a CPP Banner'''
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| *Go to AdHoc Charting (a button at the top of the screen) in PowerChart. | |
| *Click Patient Registries | |
| *Uncheck the CPP box and check the No Longer CPP box
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| *Click the green check mark at the top left of the screen | |
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| ==[[CPP Village Assignments]]==
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| ==Problem List: A quick method of communicating to other providers taking care of patient==
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| 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.
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| 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.
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| 1. Add brief pediatric subspecialty care and important follow up plans to the notes ...ie medication changes and therapeutic goals, treatment plans and goals, emergency care plans, specialty care follow up completed and due (these are especially important for seizure and cards kids), etc
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| 2. Add concise follow up plans to problem list notes for things like general problems ie FTT or HTN village/Bethel follow up expectations and next steps, terminal patient information on families wishes/DNI/DNR and do not medevac,
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| 3. Maintain the Problem List and keep it updated by inactivating or resolving problems as appropriate during each encounter or modify them to show a ‘history of’ that problem in case it is important in the future.
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| '''Examples of Problem List Communications/Notes that might helpful''':
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| *''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''
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| *''Atypical febrile seizures. EEG referral made. Diastat prescribed. No anti-epileptics for now''
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| *''Weight check q week in village and monthly with Bethel peds until patient reaches 10th percent''
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| *''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 well'' | |
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| 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.
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| ==[[Outpatient: Detailed Information]]==
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| ==[[Preparing For and Navigating Clinic]]==
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| ==[[Specific Types of Appointments and Procedural Processes]]==
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| ==Admitting a Patient from Clinic to Inpatient==
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| 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 Pediatrician on Call doctor. You can always call Peds or the FM Ward Docs if you have a question about whether you should admit the patient | |
| #Contact provider on Northwing for admission. Providers are divided into 2 sections: Yukon and Kusko depending on which village the patient is from will determine which provider you page. The clinic clerk can help assist you.
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| #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.
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| #Alert the office assistant and Charge nurse of your plan for admission so they can obtain a preadmission FIN #.
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| #Have nurse or office assistant page the admitting provider with FIN # so orders can be written.
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| #Clinic charge nurse will contact charge nurse on NW for a “ heads up”
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| #Complete your clinic documentation and interventions as needed. Please keep patient and family updates on status of transfer.
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| #Once bed has been assigned, provider on NW completes admission orders; clinic nurse will provide sign out to admitting nurse on Northwing.
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| #Patient will be transferred to the inpatient unit.
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| '''Some points to Remember'''
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| 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.
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| ===Transferring a patient from Clinic to Emergency Dept===
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| #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.
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| #Nurse will give report to ER and transfer patient to ER when room available.
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| #Always keep parent/patient informed of status of situation
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| #IF you have an emergent patient take them directly to ER trauma bay and call for help.
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| #IF you have an unstable, unresponsive patient in clinic have the clerk call a code.
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| ===Transferring a Patient from clinic to Anchorage via Commercial Flight or Medevac===
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| #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 patient to a non-native facility you will need to obtain approval from contract health at ANMC.
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| #If stable contact our travel office and complete a patient transport order form. Have parent sign a consent to transfer patient and discuss risk/benefit.
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| #If unstable initiate transfer via Medevac. See Medevac Section. Patient will need to be transferred to ER until transport arrives. See transfer to ER section.
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| #Complete Raven note / transfer summary with pertinent details.
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| #Obtain all radiological images on disk from radiology department.
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| #Complete Transfer form (PTOS) with all appropriate signatures.
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| #Remind clerk to print out all Raven documents and labs and place in transfer packet.
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| #Always keep patient/caregiver informed of status of situation.
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| ==[[ER: Detailed Information]]==
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| ==[[Inpatient: Detailed Information]]==
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| ==[[OB/Newborn: Detailed Information]]==
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| ==[[Call: Detailed Information]]==
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| ==[[Pediatric Consults]]==
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| ==[[Chronic Pediatric RMT]]==
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| ==[[Peds Medevacs]]==
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| ==[[Pediatric Care Management]]==
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| ==[[Pediatric Specialty Services]]==
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| ==[[Pediatric Psychiatry Services]]==
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| ==Pediatric Village Trips==
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| [[Village Trips|See Village trip section]] | |
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| ===Prior to your trip===
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| #Obtain list of chronic pediatric patients who need follow up in the village.
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| #Obtain a list of patients who require vaccines updated
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| ==Peds SART==
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| 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
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| ==[[OR for Peds]]==
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| ==[[Newborn Information Access on RAVEN]]==
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