These posters have been presented at a meetings in Children's Mercy and around the world. They represent research that was done at the time they were created, and may not represent medical knowledge or practice as it exists at the time viewers access these posters.>
Review of Karyotypic Data from Low Grade Glial Brain Tumors, Specifically Pilocytic Astrocytomas, and Correlation of Genetic Aberrations with Tumor Recurrence.
Linda D. Cooley, Scott C. Smith, Lisa Warren, Melissa Gener, Kevin Ginn, and John Herriges
Abstract: Brain tumors are the most common solid tumor of childhood. Approximately 50% of pediatric CNS tumors are low grade gliomas (WHO grade I or II) and Pilocytic astrocytoma (PA) is the most common accounting for 33% of all gliomas in children 0-14 years and ~18% of all childhood brain tumors. Prognosis with this slow-growing tumor is excellent; 10 year overall survival of ~95%. However, event free survival averages ~50%. Patient age and extent of tumor resection are key prognostic factors; tumor location and size impact resection and outcome. Histopathological features indicate PA is a benign tumor and rarely are anaplastic features of malignancy present. This study sought to determine if chromosomal aberrations correlate with increased risk of tumor recurrence. Observation shows that while the majority of PA have a normal karyotype, a portion have highly abnormal karyotypes; the clinical significance of which is unclear. Methods: Pathology archives were queried for PA between mid-2008 and mid- 2017. Review included chromosome, FISH, microarray, molecular results, cytogenetic methods, histopathology, tumor location, patient age, extent of surgical resection, chemotherapy, radiotherapy, and outcome. Karyotypes were defined as “aberrant” if there were multiple bizarre chromosome abnormalities, multiple telomeric association (tas) figures or translocations, or multiple dicentric chromosomes. Routine cell culture methods were used with mechanical +/- enzymatic disaggregation, alpha-MEM medium, and monolayer coverslip cultures with harvest as soon as feasible to capture metaphase cells. Results: Of 64 cultured PA, 4 failed to grow. Karyotypes were normal (n=32), simple (n=3), hyperdiploid (n=12), or aberrant (n=13). Four patients had a second tumor resection; 2 had aberrant and 2 had normal karyotypes on the initial and repeat studies. Of the 13 patient tumors with aberrant karyotypes, 6 tumors (CMH cases 1-5) demonstrated tas, dicentrics, subclones, etc., and two (CMH cases 6, 7) had multiple cells with an excess of aberrant chromosomes. Four tumors (CMH cases 8-13 – not shown) had a normal karyotype with one or two highly aberrant cells; of these, one patient with two resections (CMH cases 11 & 12) showed two highly aberrant cells on both the initial and second study. Discussion: Highly aberrant karyotypes are unexpected in benign tumors. PA, is a histologically benign tumor with ~95% 10 year overall survival. Repeatedly finding highly aberrant karyotypes in some of these tumors begs the question of clinical significance. How should these karyotypes be interpreted? Finding the abnormalities in tumors resected twice suggests an ongoing cellular/biologic process specific to that tumor tissue. The repeat finding of tas and dicentrics suggests a role for telomere dysfunction in these tumors. This is consistent with up-regulation of TRF1 and TRF2 (TTAGGG repeat-binding factors) occurring in the early stages of LGG carcinogenesis, which is characterized by short telomeres, genomic instability, low proliferative rate and prolonged life span (1). Limitations of the study: Data are limited – few patients, inconsistent FISH, microarray and molecular studies were done; no sequence analysis. Multiple factors play a role in patient outcome including tumor location and resectability. Conclusions: Additional cases, additional follow-up, additional genomic analyses are needed. Next step: WES of rearranged cases is planned.
Facilitating the everyday steward: Impact of mandatory antimicrobial indication/duration and a 48 hour time out
Ann L. Wirtz, Alaina N. Burns, Brian R. Lee, Tammy Frank, Laura Fitzmaurice, Richard Ogden, Brian O'Neal, and Jennifer Goldman
Introduction: Required indication, duration, and a 48-hour antimicrobial timeout are an integral part of antimicrobial stewardship standards; however, limited data are available to demonstrate an effect on antimicrobial utilization and antimicrobial stewardship practice. Therefore, we evaluated the impact of mandatory declared indication/duration along with a pharmacy-driven 48-hour timeout on antimicrobial utilization and antimicrobial stewardship interventions.
Methods: We performed a retrospective evaluation of ASP interventions and antimicrobial use following implementation of mandatory antimicrobial indication/duration at the point of computerized physician order entry (CPOE). A pharmacist-driven 48-hour antimicrobial timeout was introduced on the same date. This study was conducted at Children’s Mercy Kansas City, a 367-bed freestanding pediatric hospital servicing the Kansas City Metro Area and beyond. Data were collected from February 1, 2016 to January 31, 2018. A pre and post comparison was performed; interventions were implemented hospital-wide on February 14, 2017. ASP intervention rates were measured. Days of therapy (DOT) per 1000 patient days of antibiotics were also evaluated. Poisson models were utilized to compare DOT rates pre- and post-implementation, and seasonal decomposition analyses were performed to account for seasonal variability.
Results: A significant decrease in DOT rates was observed in non-ASP monitored antibiotics post-implementation, including cefazolin (39.7 to 36.9; p
Conclusions: Implementation of additional stewardship practices, including mandatory antimicrobial indication/ duration and a pharmacist-driven 48-hour timeout, resulted in a decrease in the use of antimicrobials, including those not monitored by our ASP. These efforts augmented, but did not replace existing stewardship efforts. These results support initiatives highlighted by national organizations to minimize unnecessary antimicrobial use through ASP.
Implementing Daily Management System Huddle Boards to Improve Communication Across Satellite Laboratories
In a laboratory setting with fast-paced changes and heavy demands on staff, day-to-day communication across departments is challenging, yet paramount to resource sharing and real-time problem solving. Children’s Mercy Hospital Kansas City (CMH) has implemented system-wide lean practices focused on clinical and operational excellence. Our laboratory mission, or True North, is to produce clinically relevant laboratory results and information to assist in the diagnosis, treatment and prognosis of patients in a timely manner, by: Reducing Errors – Pre-analytical, Analytical & Post-analytical Making encounters with the laboratory extraordinary Reducing turnaround times Maximizing employee engagement and productivity Reducing waste The first phase of the CMH Daily Management System (DMS) was to implement daily huddle and metrics boards. Each individual department would align unit-level readiness and quality metrics to the institution’s True North foundational elements and report on the following daily readiness objectives: 1. MESS: Methods, Equipment, Supplies, and Staffing (displayed as green or red) 2. Situation Awareness Notifications (abnormalities that need special attention that day) 3. Recognition (employees who go above and beyond contributions from previous day) 4. Announcements (department or institutional changes taking place that day) 5. Daily Workload (reported in patient volumes and previous day test volume) 6. Quick Hits and Big Issues (problem solving: QH completed within 3 days/check-in dates for each) A multi-tiered system would include huddle boards from individual department levels (i.e. Chemistry, Microbiology, or satellite department), one overall for the lab (pictured below), and the hospital as a whole. Each tier would report up to the next tier daily at the same time. Huddles are kept to five minutes or less.
DMS allows departments to identify MESS red/green thresholds that affect patient care. All information should be displayed in a simple, clear format where any employee walking by would understand how patient care is being delivered for that day. All huddle boards are dry erase for easy documentation and use red/green magnets to identify abnormalities “at a glance.” Huddles take place at the beginning of each shift with all stakeholders present to ensure clear communication between staffing changes. Departments are required to first determine what MESS levels would be considered abnormal (red). This requires breaking down testing platforms, staffing matrices and supply and inventory par volumes to ensure continual and efficient patient care. Any downtime, critical staffing level, or backorder that can cause delays in testing should be reported red for the day. Methods are department goals that are critical for care management and can be measured as they progress. This can include mandatory education for staffing or employee vaccination compliance. Problem solving is a daily occurrence. These issues are documented as “Quick Hits” (being completed within the department in three days or less) or “Big Issues” (taking additional time, resources, and possibly external departments). Each problem is assigned to a lead and given a due date to report back. Progress is reviewed during huddles and documented using Harvey Balls showing progress. These sheets can be used to show inspectors documentation of issues resolved in the department. Every department is required to identify situations that could cause delays in patient care. This can include, but is not limited to, IT downtime, courier delays, weather concerns, construction, or surges in patient volume. This information is followed up with Announcements and Employee Recognition. Metrics provide visual content to continual improvement. Metrics are also included in daily reporting, focusing on Safety, Employees, Quality, Delivery of Services, and Stewardship or Resources. These metrics must be measurable, contribute to improved patient care, employee engagement, operational and clinical excellence. These metrics should be department specific, timely, and patient centered.
Larger health systems often have satellite facilities in different geographical locations than the main hospital. Timely communication of department readiness across a health system is vital to ensure continual patient care when distance can affect distribution of additional resources. Telecommunications allows for huddles to take place online where information can be shared in real time. This allows for administration to allocate additional resources quickly, when necessary. CMH uses Polycom RealPresence to video conference huddles at the Tier 2 Laboratory Management huddle, as well as the hospital Tier 3 level. WebEx and Skype are other options for teleconferencing.
The Daily Management System has allowed for improved communication between shift exchange and departments throughout the hospital. The standardized process empowers frontline employees to identify abnormalities in staffing and equipment, resolution of issues, and efficiencies in process improvement. This bottom-up approach aligns with the True North mission allowing employees to become engaged and more solution-driven. Health systems with multiple satellite locations are able to connect via telecommunication technology, allowing for real-time reporting and deployment of resources. This ensures optimal utilization of resources that can be reallocated based on volume drivers within the department. Aligning department readiness and metrics with patient outcomes daily helps build a highly reliable organization focused on continuous improvement. In this continuously changing healthcare environment, institutions must become more efficient with limited resources, focused on clinical improvement, and empowering staff to discourage burnout. DMS is an effective lean tool for organizations wanting to break down silos, improve communication between departments, and strive towards clinical and operational excellence.
P16-Ki67-HMB45 Immunohistochemical Profiling May Help Discriminate Between Spitzoid Melanoma and Atypical Spitz Nevi
Robert E. Garola and Vivekanand Singh
When Spitz nevi have increased vertical thickness (>1.5 MM), show ulceration and deep seated mitosis, the differential diagnostic considerations of atypical Spitz nevus (ASN) or a Spitzoid melanoma (SM) enter into consideration. While expert consultation from a dermatopathologist is most often sought to resolve the differential diagnosis, it could be expensive and time consuming. Recently, the use of molecular genetic testing has also been advocated in the work group up of atypical melanocytic proliferations. On the contrary, immunohistochemistry is a more routinely used technique in most pathology centers may be more simple to apply. A single immunohistochemical marker may not be accurate enough to differentiate benign from malignant melanocytic lesions. Recently, one study (Ref. 1) employed the combination of p16, Ki-67 and HMB45 (PKH) immunohistochemistry on adult melanomas and proposed a combination of the three markers with scoring in discriminating SM and ASN in children. In this study we applied the methodology of the published study to atypical Spitzoid lesions and Spitzoid melanomas.
Methods •Institutional review board approval was obtained for this HIPAA-compliant study. •We retrospectively reviewed 10 cases (4 SM and 6 ASN) from children (age range 1.5-12 years, 6 females and 4 males). •H&E stained slides and immunohistochemical stains for PKH were independently interpreted by two pathologists. •The extent of IHC expression in the lesional cells were scored following published criteria comprised as follows:
-P16 scored as 0; >50% stained cells, 1; 11-50%, 2; 1-10%, 3; 0%
-Ki-67 scored as 0; <2%, 1; 2-5%, 2; 6-10%, 3; 11-20%, 4; >20%
-HMB45 scored as 0; gradient present, 1, doubtful/inconclusive gradient, 2; gradient absent
-The total PKH score for the combination of the 3 antibodies for any case could vary from 0 to 9.
Results • Four cases of SM had total PKH scores: 7, 6, 7 and 5. • Six cases of ASN had PKH scores of 3, 2, 3, 2, 3 and 3. •In our study all cases of SM had a total score of >4 and all ASN scored <4. • HMB45 was completely negative in one case each of SM and ASN. • Where aCGH was done, heterozygous loss of 9p correlated well with low P16 immunostain positive cell numbers in one case. Conclusions 1)Our study replicates the findings of the published study of adult melanomas and nevi that showed a total PKH score of equal/or>4 is seen in melanoma. 2) A single immunostain could be misleading as Ki-67 labeling index tended to be higher in young children (<2 years of>age) and HMB45 was occasionally negative in both ASN and SM, and P16 could be completely lost in ASN.
3) We suggest routine use of PKH immunohistochemistry in the work up of atypical Spitzoid lesions in children.
1) Uguen, A., et al. A p16-Ki-HMB45 immunohistochemistry scoring system as an ancillary diagnostic tool in the diagnosis of melanoma. Diag Pathol 2015; 10: 195-1005.
Incredible Years (IY) Parents & Babies Well-Baby Program: Expanding the Reach through Cultural Adaptation
Ayanda Chakawa and Briana Woods-Jaeger
Kristi Gordon, Elizabeth Simpson, Sarah Forge, and Eileen Almon
•In 2012, our hospital expanded obstetrical services resulting in the delivery over 3700 infants per year.
•Approximately 35% of these infants had no relationship to a primary care physician with privileges at our hospital.
•These infants were either uninsured, Medicaid insured or privately insured but whose primary care physician did not have hospital privileges.
•Private Pediatricians “on call” were given these unassigned infants and were attempting to evaluate infants in the mornings, prior to seeing their scheduled office patients
•This resulted in an unmanageable daily census for them.
•This led to Pediatrician dissatisfaction, delayed medical evaluations of some infants, discharge planning dilemmas and financial burdens to both the hospital and the Pediatricians on staff.
•The existing affiliation with an Academic Children’s Hospital for Neonatology Professional and Neonatal Intensive Care Directorship services was expanded to include an Advanced Practice Registered Nurse (APRN) Newborn Hospitalist service to care for unassigned, routine newborns. Oversight was provided by physicians within the Division of Neonatology dedicated to coverage for this service.
Newborn Hospitalist Role
•Provide care to infants born at the delivery center whose primary care providers are not on staff.
•Dedicate 100% professional effort on newborns outside of intensive care setting. •Recent QI projects:
•Improving testing for drugs of abuse.
•Implementation of transcutaneous monitoring of bilirubin.
•Refining car seat testing guidelines.
•The team is currently preparing the first edition of a newsletter, Newborn Connections.
•Consistent, timely medical evaluation of all infants without consideration of insurance/Physician availability or limitations.
•Safe, comprehensive, quality care for all infants without need for Private Pediatrician oversight.
•High family satisfaction ratings on patient satisfaction survey. •Small number of dedicated APRN Providers led to standardized education and care for families. •Consistent availability of services improved communication with nursing staff and hospital administrative staff.
•Improved discharge coordination with scheduled PCP follow-up appointments prior to hospital discharge.
•Affiliation with local Academic Center/Neonatology, improved credibility with families and seamless transition between NICU and routine newborn services. •APRN job satisfaction/career growth opportunities with autonomy building hospitalist service and coordination with supervisory physicians
•In our state, development and growth of an APRN -led Newborn Hospitalist Service has permitted a population of infants to receive consistent, safe, quality care.
•This program could be duplicated at institutions with similar circumstances
Leslie Hueschen, Stephanie Burrus, Andrea Raymond, Charity Thompson, Lisa Carney, and Jay Rilinger
Early recognition of sepsis and designing a huddle process are key drivers of the Improving Pediatric Sepsis Outcomes (IPSO) collaborative. Our tertiary care, free-standing, pediatric hospital joined the IPSO collaboration in 2016. Our hospital began piloting Situation Awareness (SA) Escalation Huddles in 2016, to improve recognition of patients with clinical deterioration. The tool triggers if a patient has a high PEWS(> 5), requires initiation of hi-flow nasal cannula, or for staff/parental concern. The SA paper tool guides the communication process and steps of the huddle. Huddles include a nurse, provider, and respiratory therapist. One of the goals of the SA escalation huddle is to decrease the amount of Advanced Life Support code blue events and rapidly identify sepsis patients on the inpatient units. Prior to this study there was no formal screening process for sepsis in the inpatient units.
•Identify septic patients early on inpatient units by forcing consideration of sepsis during SA screening in high-risk patients. •Utilize existing SA screening tool without employing increased work demands on care providers. •Ultimately, improve timely treatment of septic patients (antibiotics, fluid resuscitation) and escalate to higher level of care earlier, if indicated.
In Fall 2017, a question “Sepsis Concern?” was added to the SA tool to better identify septic patients. Roll out of new SA tool was completed in a step-wise process throughout the hospital and completed January 2018 in all units. We collected the number of PICU transfers with + SA tool. We hypothesized this change should lead to timely identification of sepsis, care team huddle with bedside discussion, treatment, and escalation of care. Sepsis clinical practice guidelines and order-sets were developed in conjunction to aid in the decision making process.
There were 162 number of severe sepsis patients treated from September 2017 to March 2018 in our hospital. There were an average of 23 severe sepsis patients each month. 21% (34/162) of these patients were identified to have possible sepsis on the inpatient units.
From September 2017 to March 2018, 1,012 SA tools were triggered with a mean of 4.8 huddles/day. The average patient had an average 2.3 (1,012/445) SA huddles during their hospitalization. Of SA triggers, 49 huddles (over 34 patients) screened positive for “Sepsis Concern?”(4.8%,49/1,012). 71% of “+ Sepsis Concern” episodes were treated as possible severe sepsis (35/49). Of the “+ sepsis concern” patients, 29% (10/34) were transferred to the ICU. When completing the SA form 13.3% (135/1,012) skipped the “Sepsis Concern?” question.
During the study, 21% of PICU transfers for possible severe sepsis had the SA tool used (3/14) prior to transfer.
The majority of sepsis patients identified with the SA tool had severe sepsis and required ICU care. Ideally the “concern for sepsis” question would generate a shared mental model in the diagnosis and treatment of sepsis, however even questioning the possibility of sepsis and discussion about sepsis remains challenging.
David G. Ingram MD, Gaylyn Perry MD, Zarmina Ehsan MD, and Baha Al-Shawwa MD
•Iron status is an important aspect of the evaluation of children with excessive limb movements during sleep. •While there is clear data in adults to support this relationship, the data in children is less well established. •We evaluated the association between iron status and limb movements during sleep in a large pediatric sample. Methods •This is a retrospective analysis of a single institution sleep program looking at all patients who underwent overnight polysomnogram and ferritin test within 24 hours of doing the sleep study between January 2015 and October 2017. •Those with sleep apnea (Central Apnea Index >5/hr or Obstructive Apnea Hypopnea Index >2/hr) were excluded. Results •There were a total of 418 patients who qualified for inclusion. Mean age was 5.6 years (range 0–19 years). •Overall, higher ferritin level was significantly associated with increasing age, increasing N2 sleep, lower REM sleep and lower single limb movement index but did not correlate with periodic limb movements of sleep. •It appears that ferritin level at 30 nanograms per milliliter is the cutoff to make a difference in improving single limb movements (7.2+/-2.7 vs 7.9 +/- 3.6 for above and below 30 ng/ml, respectively). •In multivariate regression modelling including single limb movement index and age, the association between ferritin and limb movements was no longer significant. Conclusions •Overall, there is a weak correlation between ferritin and single limb movements during sleep. •However, it appears that age is an important possible confounding factor in the complex relationship between and iron status and limb movements in children.
David G. Ingram MD, Gaylyn Perry MD, Zarmina Ehsan MD, and Baha Al-Shawwa MD
•Vitamin D deficiency has recently been posited as an important factor in the pathogenesis of restless leg syndrome.
•We evaluated the association between vitamin D deficiency and limb movements and sleep architecture in a pediatric sample.
•This is a retrospective analysis of a single institution sleep program looking at all patients who underwent overnight polysomnogram and 25-OH vitamin D within 60 days of doing the sleep study between January 2015 and October 2017. •Those with sleep apnea (Central Apnea Index >5/hr or Obstructive Apnea Hypopnea Index >2/ hr) were excluded. Results •There were a total of 83 children who qualified for inclusion. Mean age was 7.0 years (range 1–17 years). •Overall, higher Vitamin D level was significantly associated with increasing N3 sleep (r=0.267, p=0.015), but was not significantly associated with other sleep parameters including limb movements. •In multivariate regression modelling including Vitamin D and age, the association between vitamin D and N3 sleep percentage remained significant (B=0.212, SE=0.102, p=0.04). Conclusions •Overall, there is a weak positive correlation between vitamin D and N3 sleep, even independent of age. •In contrast, there was no association between any limb movement parameter and Vitamin D status. •Further investigation is needed to better define the role of Vitamin D in sleep physiology.
Libby Milkovich, Meredith Dreyer, Brooke Sweeney, Sarah Nyp, and Ben Black
Problematic mealtime behaviors (PMB) (externalizing behavior at mealtime) have been seen anthropologically when adult caregivers are absorbed in their mobile phones. Parents with mobile phone problematic use (MPPU) are more likely to be absorbed in a mobile device. Neither the correlation of MPPU to PMB, nor the frequency of PMB to perceived impairment of problem behavior have been quantitatively studied.
Evaluate correlation of caregiver MPPU and child PMB to improve understanding of the possible implications of caregiver MPPU
Participants included caregivers of children ages 2-8 years being seen in a pediatric hospital clinic. Participants completed a survey on an iPad via REDCAP. The survey included demographics (caregiver/child age, gender, race/ethnicity; child BMI; caregiver level of education), a validated measure for caregiver MPPU (Mobile Phone Problematic Use Scale; MMPUS) and a validated measure for perception of child PMB (Meals in our Household; MIOH). MIOH includes frequency of PMB and perceived impairment from PMB. Measures are continuous variables. Spearman correlation was used for the studied variables and possible confounding variables. Significant confounding variables were evaluated in a regression model.
100 caregivers (mean age 32.9 years, 65% white, 20% ≤ high school completion) participated. Correlation of MIOH problematic behavior total with MMPUS was significant (p=.004, r=0.289). MIOH perceived impairment from PMB had stronger correlation with MMPU (p=M (p=.005). No significant caregiver variables noted for PMB. Younger child age was significantly correlated with PMB (p=.007, r=-.274). No significant differences in child variables for MPPU. Significant variables were evaluated in regression model, and MPPU and PMB remained significant.
Correlation was found between MPPU and PMB. Correlation was stronger when measure of perceived impairment was evaluated. This suggests that caregivers with increased MPPU perceive behavior as more problematic. Understanding the potential relationship between caregiver MPPU and child PMB, strengthens pediatricians’ ability to counsel about the implications of caregiver MPPU when discussing child PMB. Objective coding during mealtimes of caregiver mobile phone use and child mealtime behaviors will further evaluate this relationship.
Irina G. Trifonova, Troy E. Richardson, Jessica L. Bettenhausen, and Matthew B. Johnson
The increasing complexity of pediatric inpatients requires that all providers understand a comprehensive child’s medical and social needs. A survey administered to Children’s Mercy Hospital inpatient providers identified gaps in knowledge regarding the daily plan of care and discharge planning needs among Complex Chronic Care (CCC) patients. Multidisciplinary rounds (MDRs) create a shared decision model among all team members to ensure that all aspects of care for CCC patients are addressed.
To improve provider knowledge of the plan of care and discharge planning needs for CCC patients admitted to the Hospitalist service, from 40% to 75% of providers by implementation of MDRs.
All CCC patients (defined by ICD-10 code diagnosis; Fuedtner, et. al.) admitted to the Hospitalist service were candidates for MDRs. Patients with CCCs on resident teaching service were excluded. MDR team included a hospitalist, bedside nurse, nurse care manager, social worker, pharmacist and nutritionist. Providers were notified of qualified patients for MDRs three times a week prior to rounds. The MDR team members discuss the medical plan, address medication change, nutrition status, social and discharge needs. The process measure included the frequency of provider’s attendance at MDRs; the time spent rounding per patient was the balancing measure. Pre-round huddles were implemented 6/1/2017 to facilitate discussion of CCC patients among team members unable to attend bedside rounds (Figure 1). Statistical process control charts were used to assess the impact of pre-round huddles on percent provider attendance at MDRs. Following implementation of MDRs, providers completed subsequent surveys reflecting their knowledge on the plan of care for CCC patients.
MDRs were implemented 8/1/2016. Attendance remained unchanged until the introduction of pre-round huddles which significantly improved provider attendance (p
Implementation of the pre-round huddles had the most impact on providers’ attendance at MDRs, without increase the rounding time per patient. While providers reported some improvement in understanding of care for CCC patients, the impact of provider attendance at MDRs or pre-round huddles on readmission rate of CCC patients remains to be determined.
Courtney Wellman and Kristin Allender
Approximately 10% of school age children suffer from migraines, making migraines one of the top five health problems experienced by youth today
School nurses often are the first healthcare provider seen by youth with migraine; visits to the school nurse for headaches amounted to one-third of the enrolled student population in a large local school district. (see reference)
Empowering school nurses through education and resources to identify and manage migraines therefore may have significant benefits to children with migraines and their families.
To improve migraine care in the community through establishing a headache specialist mentorship program for select school nurses (the "Headache Champion Program")
Figure 1 provides an overview of the project model
Applications were accepted from interested, self-nominated school nurses within the region served by the headache specialist clinical program; those selected for the program demonstrated a commitment to learning and a passion for improving the lives of headache sufferers
The selected school nurses were matched with a headache specialist "mentor" for monthly telephone conversations aimed at increasing knowledge and empowering advocacy for youth with headaches; the headache specialist also provided additional resources for school and home use (e.g., www.headachereliefguide.com)
Nurses received a certificate of completion and a letter they could mail to families in the school district making them aware of the nurse's participation
RESULTS & CONCLUSIONS
Upon completion of the program, school nurse "Headache Champions" were empowered by knowledge to better care for school age children who suffer from migraines.
Feedback from school nurse participants was positive (e.g., "Being able to talk to a person is so much better than just receiving information. . . so educational")
Interest in the program has triipled since its roll out and continues in 2017-18 school year
Future efforts include an urgent access headache clinic, to which students may be directed, and continued growth of the mentorship program.
Brenda R. Pfannenstiel MALS, MA, AHIP; Courtney Butler MLS; Keri Swaggart MLIS, AHIP; and Megan Molinaro BA
Describes activities and resources provided by the Library Services department at Children's Mercy Kansas City.
Courtney R. Butler and Megan Molinaro
BACKGROUND: Children's Mercy is an independent, non-profit, 367-bed pediatric health system with multiple clinic locations and a strong focus on research. It offers a pediatric residency program and over 37 subspecialty fellowship programs.
New initiatives go through many steps from conception to implementation. The focus of this case study is to describe how gathering feedback from stakeholders during proposal development provided valuable insight, secured stakeholder collateral to support requests for administrative approval and funding, and marked the beginning of new productive institution-wide partnerships.
Conduct Focus Groups
Develop Fair Market Analysis/Executive Summary
Convene Task Forces for Implementation
GATHERING FEEDBACK: Gathering feedback is an important part of project development. Surveys can be a convenient and effective option, but they risk low response rates with stilted, fill-in-the-blank answers. Candid feedback was imperative for this initiative to ensure that all critical factors were being considered.
CONCLUSIONS: Using focus groups proved effectual in improving the project design. Feedback provided the opportunity to refine the proposal and highlighted issues that had not been sufficiently investigated such as interoperability with existing systems. It also revealed interest in additional use cases, such as the ability to host educational materials. Furthermore, the interactions resulted in stakeholders willing to advocate for the project and to participate in its development and implementation and better prepared Library Services to address administrative concerns. These newly built partnerships will allow future projects and service improvements to build off this project's success.
Melissa D. Elliott
Title: Use of personalized patient heart diagrams at the bedside to improve quality of care
Background/Introduction: With congenital heart disease no two hearts are exactly the same. Even with the same lesion, the anatomy of the heart can be completely different. In response to a bedside nursing idea following a cardiac arrest, advanced practice nurses (APN) initiated a program to provide personalized cardiac anatomy diagrams at the bedside of every patient on the cardiology service.
Methods: When a cardiac patient is admitted to cardiology floor, the nurse will check the patients chart for an anatomy picture, then will place the patient’s initials on a worklist for the APN if no picture is available. The APN is responsible for creating a personalized cardiac anatomy picture, delivering it to the bedside, and providing education to the nurse and the patient’s caregiver. The diagram is saved in the patients chart.
Results: This project started on October 24, 2016. Initially data was tracked to ensure that nurses were requesting the pictures in a timely matter. This data was reviewed with nursing staff daily at the shift huddles. Additionally, anatomy picture at bedside was added to the nursing admission checklist. The team reached 100% compliance consistently by May 2017. A post implementation survey was completed by 60% of the nursing staff.
Conclusion: The value added from providing personalized patient heart diagrams at the bedside is improved care of cardiac patients through understanding of cardiac lesions and hemodynamics, increased education to the multidisciplinary care team and caregivers, and overall improved quality of care overall for this unique patient population.
The next goal is to expand this project to other units including the intensive care unit, fetal health, and preadmission testing.
Sarah M. Lagergren, Bryan Beaven, Suma Goudar, and Megan Jensen
Background/Introduction: Post-operative hospitalization for the Fontan procedure tends to have an extended hospital length of stay (LOS). From 2013-2014, the average LOS at Children’s Mercy for the Fontan procedure is 14 days, whereas the U.S. national reported average is 11 days. Post-operative management of this patient population is often caregiver dependent. It has been theorized that developing a more standardized post-operative management regimen tailored specifically toward the unique physiology of Fontan patients may be able to improve outcomes and decrease LOS.
Methods: A review of literature was performed and revealed three pediatric institutions have published their post-operative Fontan care guidelines. Common elements from these care guidelines were identified and then trialed in 2016 on our post-operative Fontan population. Three patients were included in four individual PDSA cycles. Adherence to each intervention was tracked and information gathered regarding potential issues.
Results: Use of supplemental oxygen prior to chest drainage tube removal had 100% adherence and no harm or negative side effects (such as nosebleeds, or impeding ability to ambulate) reported. Restriction of fluids had a 33% adherence rate with IV fluids started or IV fluid boluses administered over the 80% restriction in 2/3 patients. Following a standardized diuretic regimen had 100% adherence with no negative patient outcomes. Obtaining central access within 48 hours post-operatively via a PICC line had 100% adherence.
Conclusion: By performing individual PDSA cycles prior to full implementation of a post-operative clinical pathway, potential areas of concern were able to be identified and addressed or disproved. The Fontan clinical pathway was fully implemented for 2017 with plans to complete another full PDSA cycle.
Keri Swaggart, Courtney Butler MLS, and Linda Taloney
Ahead of Their Time: The Story of Alice Berry Graham and Katharine Berry Richardson, the Founders of Children's Mercy Hospital in Kansas City
Jane F. Knapp MD and Robert Schremmer
Describes the founding of Children's Mercy Hospital through the story of its founders, Katharine Berry Richardson and Alice Berry Graham.
Robert Schremmer and Jane F. Knapp MD
The Orphan Train Movement was responsible for relocating thousands of children from large eastern cities to rural areas and can be seen as the forerunner to today's foster care system.
Keri Swaggart and Nancy Allen
MCMLA 2012 Annual Meeting Presentation
Robert D. Schremmer MD and Jane F. Knapp MD
Describes the career of Arthur Emmanuel Hertzler, MD, 1870-1946, who practiced in Halstead, Kansas.