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. 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.

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 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 an experienced pediatric provider

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 keeping 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 might 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 be helpful
    • Seen on 2/15/13. Start Pulmocort. PMD recheck 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 percentile
    • 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 or recurrent difficult-to-control seizures
    • Made CPP until FTT issue resolved and may then graduate from registry if gaining weight well
  • 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 Notes 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: 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 the Pediatric Hospitalist if you have a question about whether you should admit the patient or not.

  1. 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.
  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 tiger text 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 updated 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 blue.

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 native patient to a non-native facility you will need to obtain approval from contract health at ANMC.
  2. 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.
  3. 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.
  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

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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