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Bearings - Winter 2010

Children’s National Manages Influx of Patients with H1N1 Flu

Children’s National Medical Center has been leading the greater Washington, DC region in the treatment of children with H1N1 flu. Children’s National also is engaged in community education to help families in Maryland understand how to care for children at home, when to call a doctor, and how to make an informed decision about vaccinations.

Not surprisingly, Children’s Emergency Department (ED) treated an extraordinary number of children for flu-like symptoms in 2009. As of December 28, the peak caseload occurred on October 26, when 429 patients visited the ED in one day, including 232 with flu-like symptoms.  

Leading into the peak and coming out of it, Children’s National declared itself in pandemic mode. This meant more staffing, triaging patients according to symptom severity, and protecting staff and other patients with increased use of protective gear, including surgical masks and rubber gloves. To streamline assessment, treatment, and discharge, the ED staff used a pre-printed prescription pad for Tamiflu™, which accounts for age, weight, and underlying conditions.

On October 30, a few days after the ED peak, the inpatient side of the hospital experienced its peak with 39 children in hospital beds for overnight observation and/or longer hospitalization with confirmed H1N1. While 39 represents a large number of patients with one diagnosis, percentages of H1N1 flu admissions compared to H1N1 flu ED visits were not surprising. These percentages – about 12 percent – are comparable to percentages found during a regular seasonal flu season. ED visits and hospital admissions were high, because of the high numbers of people, especially children, infected with this novel virus.

To address these higher numbers, Children’s National’s ED transformed its department to meet the caseload surge. ED staffing was increased, with 20 to 25 percent more doctors and nurses assigned to each shift. A one-time billing office was converted to a flu rapid screening unit for patients with less severe symptoms. Overflow ED patients with serious flu symptoms were seen in the ED hallways, which at times were lined with extra chairs. To prevent the spread of illness while continuing to see non-flu patients, the ED waiting room was divided in two by a large curtain to separate out patients and families with flu symptoms. Additionally, patients and families with flu symptoms were given masks to wear.

Children’s National developed a resource center on its web site where healthcare providers, patients, and families found information about H1N1 and seasonal flu, including tips about recognizing symptoms, treating children at home, and talking to children about illness. Direct links to other organizations, such as the Centers for Disease Control and Prevention, assured that information was timely, and expanded resources available to patients and families.

Additionally, Children’s specialists, including Peter R. Holbrook, MD, executive vice president and chief medical officer, proactively reached out to media to get out the word through regional and national media to provide expertise on the treatment of H1N1 flu in pediatric populations.  Children’s resource center contains links to these reports, including a Washington Post feature that profiled children from Maryland who had been treated in the ED.

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Children’s National Works to Reduce Traumatic Brain Injuries

With the recent news regarding the rise of concussions in athletes at both the amateur level and in the National Football League (NFL), Children’s specialists are using their clinical expertise to take a leading role in the treatment and prevention of traumatic brain injuries (TBI) in children and adolescents. Children’s concussion expert Gerard Gioia, PhD, has given a number of interviews, most recently to the New York Times regarding the impact the NFL’s new policies are having on how TBI is regarded among coaches and parents of children and adolescents.

The number of traumatic brain injuries (TBI) that occur to children annually in Maryland continues to be significant. In 2000, according to the Brain Injury Association of Maryland:

  • Eleven percent of all injuries to children 14 years and under were TBI-related injuries;
  • More than 16 percent of all injuries in the 15 to 24 year age group were TBI-related injuries;
  • More than 18 percent of all injury-related deaths in children 14 years and under were TBI-related injuries; and
  • Twenty-five percent of all injury-deaths in the 15 to 24 year age group were TBI-related injuries.
Children’s Safe Concussion Outcome Recovery & Education (SCORE) Program evaluates, monitors, and manages the care of children and adolescents with concussions (mild TBI’s). The SCORE program is the only program in the greater Washington metropolitan region that specializes in the evaluation and management of concussions in children. Of the total patient population served in the SCORE Program, more than 55 percent of the children treated have been Maryland residents. In 2008, Children’s National treated 792 children in its concussion clinic, of which 458 were from Maryland. Children from Bethesda, Rockville, Potomac, and Silver Spring constitute a significant number of the patients seen at the clinic.

When it comes to concussions, children and teens require different treatment, according to international experts who recently published consensus recommendations. The British Journal of Sports Medicine’s new guidelines recommend that children and teens be strictly monitored and activities restricted until the child or teen is fully healed. These restrictions include no return to the field of play, no return to school, and no cognitive activity.

This new consensus is from the International Conference on Concussion in Sports. Children’s pediatric concussion expert and neuropsychologist Dr. Gioia participated in the panel, and played a key role in delineating the differences between children, adolescents and teens, and adult athletes.

"These consensus recommendations mark the first time that international experts have focused on specialized treatment for kids," said Dr. Gioia, chief of Neuropsychology at Children’s National. "This conference of experts has led the way in developing protocols for adult athletes, and now international protocols take into consideration that the developing brain of the child and adolescent requires special consideration. The guidelines also point to the important role parents, coaches, and teachers play in assessing and treating young athletes."

For children and adolescents, the guidance strongly reiterates several key points for coaches, parents, and physicians:
  • Injury to the developing brain, especially repeat concussions, may increase the risk of long term effects in children, so no return-to-play until completely symptom free.
  • No child or adolescent athlete should ever return to play on the same day of an injury, regardless of level of athletic performance.
  • Children and adolescents may need a longer period of full rest and then gradual return to normal activities than adults.
  • For children, "cognitive rest" is a key to recovery. While restrictions on physical activity restrictions are also important, cognitive rest must be carefully adhered to, including limits on cognitive stressors such as academic activities and at-home/social activities including text messaging, video games, and television watching.
Dr. Gioia also was involved with efforts at the Centers for Disease Control and Prevention (CDC) to develop resources for physicians, coaches, and parents to better understand and treat TBI-related injuries.

In May 2009, the Washington State Legislature became the first state to enact legislation regarding youth concussions and returning to athletic competition. The new law, known as the Zackery Lystedt Law, prohibits youth athletes suspected of sustaining a concussion from returning to play without a licensed healthcare provider’s approval. The law is named for Zackery Lystedt, who is a teenager from Seattle who suffered second impact syndrome and a severe brain injury while playing football in 2006.

The bill, which is the most comprehensive return-to-play law in the United States for athletes under 18, also directs school districts to develop information and policies on educating coaches, youth athletes and parents about the nature and risk of concussions, including the dangers of returning to practice or competition after a concussion or head injury. All student athletes and their parents/guardians in Washington also are required to sign an information sheet about concussion and head injury prior to the start of each season.

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Study Confirms the Importance of Pediatric Emergency Departments

In a joint policy statement published in Pediatrics entitled, "Guidelines for Care of Children in the Emergency Department," pediatric emergency medicine specialists and other pediatric specialists provide recommendations for appropriate equipment, training, medications, and policies for pediatric emergency care. The need for detailed pediatric emergency care guidelines comes in part as a result of a recent report issued by the Institute of Medicine (IOM), which states that only 6 percent of US hospital emergency departments are fully equipped to properly care for children.

"Children account for 20 percent of all emergency department visits, yet most hospitals are unprepared to provide appropriate care," said Joseph L. Wright, MD, MPH, senior vice president of the Child Health Advocacy Institute at Children’s National. "The potential widespread impact of the novel H1N1 strain of influenza underscores the urgency to ensure that our kids receive the best care when they come to their community hospital’s emergency department."

Dr. Wright is trained as a pediatric emergency medicine physician and helped write the revised policy statement from Pediatrics.  Dr. Wright was on the IOM committee that wrote the 2006 report, "Emergency Care for Children: Growing Pains."  Dr. Wright also serves as the Emergency Medical Services medical director for Pediatrics within the Maryland Institute for Emergency Medical Services Systems (MIEMSS).

Examples of appropriate care include having equipment to meet the various sizes of children from infants to adolescents, such as tubes for intubation, as well as ready access to specialists, such as pediatric anesthesiologists. The existence of specific policies and procedures to address the needs of children and families, particularly in times of surge, are also critically important.

This policy statement was funded in part by the federal Emergency Medical Services for Children (EMSC) program, which, along with 21 other professional organizations, has endorsed the statement. Children’s National is the federal grantee organization for the EMSC National Resource Center, which was established in 1991 to help improve the pediatric emergency care infrastructure throughout the United States and its territories.

Children’s National serves as one of only two designated Level I Pediatric Trauma Centers in Maryland. In fact, Children’s National was recently recertified as a Level I Pediatric Trauma Center by the American College of Surgeons. This requires that pediatric anesthesiologists, pediatric neurosurgeons, pediatric orthopedists, and pediatric general surgeons to be on-site 24 hours per day, seven days a week. In addition, Children’s National is required to have on-call other specialty surgeons and non-surgeons.

According to MIEMSS, Children’s National consistently treats approximately 50 percent of the total annual pediatric trauma center cases for children who reside in and/or were injured in Maryland. In its most recent annual report, MIEMSS reports that Children’s National treated the most pediatric trauma cases in the state in each of the last two years: 849 (June 2008-May 2009) and 889 (June 2007-May 2008).

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Children's National Named to the 2009 Leapfrog Group Best Hospitals List

Children’s National Medical Center is one of only eight children’s hospitals in the country named to the Leapfrog Group’s 2009 Top Hospitals List. The list is based on results from the Leapfrog Hospital survey, which focuses on objective measures and processes that ensure quality and safety. Children’s National is the only pediatric hospital selected from the Mid-Atlantic region to receive this designation.

"Once again, we are proud to be recognized as one of the top children’s hospitals in the country as recognized by the prestigious Leapfrog Group," said Edwin K. Zechman, Jr., president and CEO of Children’s National Medical Center. "Recognition by this group of demanding healthcare payers and thought leaders validates the measures we take at Children’s National to assure quality care in a safe environment for families in our region, across the country, and around the world."   

Among the criteria that the Leapfrog Group uses to select top performing hospitals are processes proven to reduce errors and enhance quality:

Computerized ordering of medicines, tests, and procedures
  • Staffing with appropriately trained professionals in intensive care units
  • Comprehensive systems, including training all staff, to prevent, detect and manage serious errors
  • Focused efforts on preventing infections
"While Congress debates healthcare reform, Children’s National Medical Center, along with all the hospitals recognized by the Leapfrog Group, demonstrates that we can deliver high-quality care in a safe environment, and that we can do it efficiently," said Peter R. Holbrook, MD, executive vice president and chief medical officer, Children’s National Medical Center. "We are encouraged that those who pay for health care – both private payers and government agencies – increasingly appreciate the importance of this recognition."

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