Category:Pediatrics

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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. 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.

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.

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: 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.

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 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

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)

3. All pediatric patients that require close pediatric care manage¬ment and village RMT follow up

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

5. Any infant or child that a provider, in collaboration with a pedia¬trician, 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 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.

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 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.

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.

How to Add and Remove CPP RAVEN banners

This should only be done by experienced regular pediatricians only

To add a CPP Banner

  • Go to AdHoc Charting (a button at the top of the screen) in PowerChart.
  • Click Patient Registries
  • Click CPP
  • Click the green check mark at the top left of the screen

To remove a CPP Banner

  • 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
  • Click the green check mark at the top left of the screen

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.

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

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,

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.

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 well

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.

Outpatient: 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 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

  1. 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.
  2. 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.
  3. Alert the office assistant and Charge nurse of your plan for admission so they can obtain a preadmission FIN #.
  4. Have nurse or office assistant page the admitting provider with FIN # so orders can be written.
  5. Clinic charge nurse will contact charge nurse on NW for a “ heads up”
  6. Complete your clinic documentation and interventions as needed. Please keep patient and family updates on status of transfer.
  7. Once bed has been assigned, provider on NW completes admission orders; clinic nurse will provide sign out to admitting nurse on Northwing.
  8. 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

  1. Call ED physician to obtain an accepting physician. Inform clinic charge nurse and ED charge nurse of transfer to ER.
  2. Complete clinic documentation with important transfer information.
  3. Nurse will give report to ER and transfer patient to ER when room available.
  4. Always keep parent/patient informed of status of situation
  5. IF you have an emergent patient take them directly to ER trauma bay and call for help.
  6. 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

  1. 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.
  2. 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.
  3. 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.
  4. Complete Raven note / transfer summary with pertinent details.
  5. Obtain all radiological images on disk from radiology department.
  6. Complete Transfer form (PTOS) with all appropriate signatures.
  7. Remind clerk to print out all Raven documents and labs and place in transfer packet.
  8. 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

See Village trip section

Prior to your trip

  1. Obtain list of chronic pediatric patients who need follow up in the village.
  2. 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 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

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