These posters have been presented at 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.
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Global Health Elective: Swaziland, Africa
Jane Duong
Describes her learning experience providing care with the Baylor International Pediatric AIDS Initiative (BIPAI) in September 2017.
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Global Health Experience in Swaziland
Anik Patel
Describes a global health learning experience at the Baylor Center of Excellence in Swaziland, where diagnosis and treatment of HIV/AIDS and TB, along with maternal health, women's health, and adolescent care are provided.
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Hematuria Without Microalbuminuria
Angela Ferguson, Vimal Chadha, Amy Wiebold, and Uttam Garg
Background
Microabubiminuria is a condition in which small amounts of albumin are excreted in the urine without overt nephropathy. Based on the
American Diabetic Association classification, microalbuminuria is defined as urinary excretion of albumin of 30–300 mg per 24 hours or 20–200 mcg/min or 30–300 mcg/mg creatinine. Various conditions such as diabetes, hypertension, and impaired renal tubular reabsorption can lead to microalbuminuria. Microalbuminuria is an indicator and predictor of the development of overt nephropathy. If identified and treated early, overt nephropathy can be prevented and averted. Proteinuria and hematuria are the two most common urinary abnormalities encountered during routine urinalysis. In renal dysfunction, it is common to encounter isolated proteinuria without hematuria. Also, when using a dipstick, it is not uncommon to encounter mild isolated hematuria without proteinuria. Since dipstick and protein precipitation methods lack sensitivity for trace proteinuria, immunoassays are used for the measurement of trace amounts of albumin in urine. It is commonly believed that hematuria is always associated with proteinuria or microalbuminuria. Based on this belief, many laboratories cancel microalbuminuria testing if the urine dipstick is positive for blood. We encountered several urine samples that were dipstick positive for blood but negative for microalbuminuria based on the American Diabetic Association definition.
Materials and MethodsTo study this aspect more objectively, urine samples with a typical creatinine concentration were spiked with 5, 10, 20 and 50 uL of whole blood (total volume 10 mL). Using a dipstick, these aliquots were tested for blood and protein, and then analyzed for creatinine and microalbumin on a chemistry analyzer. The urine dipstick analysis was performed on the Clinitek 500 Urine Chemistry Analyzer, while the urine creatinine and microalbumin were performed on the Ortho Vitros 5600 using the Vitros CREA slides and Randox microalbumin reagent.
ResultsFigure 1. Visual analysis of urine specimens
Urine specimen A (Fig. 1 A and B) and urine specimen B (Fig. 1 C and D) were aliquoted and spiked with 0 (Blank), 5,10, 20 and 50 uL of whole blood. Total volume of 10 mL. Aliquots of each were also spun down to visualize the red blood cells present (Fig. 1 B and D).
Table 1. Urine characteristics
Color, clarity, blood and protein were assessed by dipstick and read by the Clinitek analyzer. Creatinine and microalbumin were measured by the Ortho Vitros 5600.Conclusions
•These findings suggest that samples with hematuria may be negative for microalbumin, and therefore, laboratories should not automatically cancel microalbumin testing if a sample is dipstick positive for blood. •A better strategy may be to test the sample for protein using a dipstick and cancel the test for microalbumin only if the sample is positive for greater than trace protein.
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Investigating Program Directors' Milestone Assessment Practices in Graduate Medical Education
Kadriye O. Lewis, Susan B. Hathaway, J F. Knapp, Denise Bratcher, and Douglas Blowey
The purpose of this study is to investigate the current assessment practices as well as identify the needs and challenges of the Program Directors in implementing ACGME's Milestones for assessment in graduate medical education at a pediatric hospital. The ultimate outcome of this study will be to fairly deliver our support and services to all programs equally providing expertise/consulting, guiding, mentoring/advising, and distributing resources.
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Pre-Implementation of a Fontan Post-Operative Clinical Pathway: Summary of 2016 PDSA Cycles
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.
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Sanibonani! A Global Health View of the HIV/AIDS Epidemic in Swaziland
Angie Schmidt
Describes a global health learning experience with the Baylor International Pediatric AIDS Initiative in Swaziland.
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South Africa: Combatting the Rise of HIV in Adolescents
Ryan Northrup
Describes a global health learning experience in South Africa in 2017, focused on educating teenagers in schools about sexual health and AIDS prevention.
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Swaziland: A Journey into Culture and Health Care
Claire Hickey
Describes a global health learning experience with Baylor International Pediatrics AIDS Initiative in Swaziland in 2017.
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Tender Loving Care at The Lake Clinic, Cambodia
Shubra Srinivas
Describes a global health learning experience at The Lake Clinic in Cambodia caring for children and adults in a low resource setting in 2017.
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Therapeutic Plasma Exchange (TPE) Performed in Tandem with CRRT and/or ECMO: Experience of One Pediatric Center
Lejla Music Aplenc, Cindy George, and Kimberly Marriott
SUMMARY
The most common indications for starting tandem procedures were ASFA Category III indications, followed by un-categorized indications.
Similar to other reports in literature, hypocalcemia and hypotension were the most common complications. Transfusion reactions were rare, despite the use of large volumes of plasma.
Tandem procedures in critically ill pediatric patients require close monitoring and excellent communication between staff members.
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The Scope of Social Work Practice in Transition to Adulthood Care
Teresa Hickam
This is a study of roles executed by social workers and nurses to address common transition planning needs in a pediatric hospital. Duties were stratified based upon tasks assigned only to social work versus those shared with nursing or other team members.
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Use of Personalized Patient Heart Diagrams at the Bedside to Improve Quality of Care
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.
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A Quality Improvement Project for the Evaluation and Management of Possible Necrotizing Enterocolitis in Single Ventricle Patients
Laura Miller-Smith, Jennifer Flint, and Lisa Laddish
Background:
Infants with single ventricle (SV) physiology are at high risk for interstage complications, including necrotizing enterocolitis (NEC). The underlying pathophysiology and age at presentation differs from NEC literature described in premature infants, making NEC in SV patients challenging to diagnose and treat. We perceive significant variability in the approach to possible NEC in SV patients at our institution.
Aims:
To identify variability & standardize the approach to management of NEC
To create a management algorithm for diagnosing and treating NEC
Methods:
After review of current practice and review of medical literature, an algorithm to guide medical decision making specific to SV patients was developed. Modified Bell’s Staging Criteria was considered, clinical and lab data was evaluated, and current choice/duration of antimicrobial therapy was examined.
Results:
-72 patients who underwent palliation for SV physiology July 2012 – August 2016 were included.
-10 patients met Bell’s Criteria for NEC, Ib or higher
-Mean NPO 10.6 days
-Mean duration of antimicrobial 7.6 days
-11 patients did not meet criteria but were NPO >24 hours for bloody stools (2 received antimicrobials)
-9 out of 12 received a nephrotoxic antibiotic
-Lab tests and frequency of KUBs varied
Conclusion:
• Variability in approach to possible NEC has potential to impact long term outcome • QI project identified hospital variability & designed algorithm more specific to the physiology of the SV population in effort to standardize care
• Minimizing variability will help identify specific areas of intervention to improve patient outcomes
• We have developed a management algorithm that is currently in use in our institution
• We hope to use the findings from this project to further investigate diagnostic criteria and treatment guidelines to take the place of Bell’s Staging Criteria for infants with CHD and to standardize radiographic imaging for suspected NEC
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Obstacles to Introducing a Post-operative Feeding Protocol in the Single Ventricle Population
Lisa Laddish, Laura Miller-Smith, and Jennifer Flint
Objective:
To decrease the morbidity associated with feeding complications by implementing a post-operative feeding protocol for infants with single ventricle physiology
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Library Transformation through Collaborative Innovation
Keri Swaggart, Courtney Butler MLS, and Linda Taloney
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Passport to the PICU: A Quality Improvement Project for Resident Critical Care Education
Laura Miller-Smith, Tara Benton, Jennifer Flint, Jenna Miller, and Kelly S. Tieves
The Pediatric Intensive Care Unit (PICU) has significant variability in patient numbers, acuity and disease processes represented throughout the year. This variability leads to differences in educational exposure for our residents. Prior attempts at standardizing education through a scheduled didactic program were limited by the time constraints of this high intensity and unpredictable environment. In 2015, the pediatric critical care rotation evaluation had the lowest scores for provision of didactic education. On a Likert scale of 1-5 (with 5 being excellent), the didactic scores were 3.41 (Jan - June 2015) and 3.79 (July - Dec. 2015.), lower than other rotations (mean S.D. 0.98, 1.14, respectively). Adult learners require diverse educational methods for optimal learning, and hands-on learning through patient care should be augmented through other educational experiences.
Specific aim: Develop a PICU resident curriculum and a)have trainees receive >90% education on 12 core critical care topics each rotation and b) improve our resident evaluation in the area for provision of didactics to a score of >4.0 by January 1, 2017.
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Autism screening in primary care: Community providers incorrectly report adherence to AAP autism screening guidelines
Jose Lopez-Lizarranga MD, Kimberly J. Reid, Sarah Nyp, and Cy Nadler
Purpose: To compare community provider reports of adherence to current American Academy of Pediatrics (AAP) autism screening guidelines with their self-reported practices, including implementation of the Modified Checklist for Autism in Toddlers (M-CHAT).
Methods: An online survey was distributed to primary care providers from Kansas, Oklahoma, and North Dakota. The survey collected demographics and self-reported ASD screening practices (including M-CHAT implementation procedures) and knowledge questions.
Results: 133 providers completed the survey (50% pediatricians, 32% int. med/fam. physicians, 18% physician assistants). Of the 96 who reported routinely screening for ASD; 78% reported adhering to AAP guidelines. However, no providers correctly answered all of the knowledge questions that would confirm an ability to follow the guidelines. Only 35% of providers who use the M-CHAT could identify the correct procedures for responding to a positive screen. Knowledge of AAP guidelines and M-CHAT procedures was not significantly correlated with provider profession, years in practice, or frequency of conducting relevant well visits.
Conclusion: Providers who report adherence with AAP guidelines appear at substantial risk for having gaps in knowledge that may negate the benefits of screening. Resident education programs, policy decisions in response to the USPSTF, and research on early autism identification must consider these gaps in knowledge that likely impact the effectiveness of community-based screening. Future research on community screening should focus on direct measurement of provider practices rather than relying on self report.
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Knowledge Base of Adolescents with Congenital Heart Disease
Mark Gelatt, Julie Martin, Jennifer A. Marshall, Jennifer Panuco, Jenea Schmidt, and Pamela Finn
Introduction:
Most congenital heart disease [CHD] is diagnosed and treated in early childhood with parents responsible for decision-making. The adolescent assumes this role in preparation for transition to an adult congenital heart program. We studied the knowledge base of our adolescent CHD patients and their parents.
Methods:
Established CHD patients, >11 y.o. and their parents, were independently surveyed in the outpatient clinic. Participation was voluntary. Cardiomyopathy, electrophysiology and transplant patients were excluded. Scores were assessed as full, partial or incomplete.
Results:
Most (98% parents; 83% adolescents) reported that their cardiologist had provided education. Adolescents provided a full (49%) and partial (15%) medical name and full (32%) and partial (35%) description of their condition. Older adolescents performed better (p<0.005). Parents scored better, regardless of patient age (p<0.005). Presence of prior surgery/intervention made no difference. Patients undergoing last surgery >11 y.o. scored better than those with surgery only when younger or without surgery (p<0.05) [data not shown]. Patients with mild unrepaired or surgically repaired shunt lesions (ASD, VSD, PDA), and their parents, were much less able to name their lesion than those with left heart lesions (aortic stenosis, coarctation, mitral valve disease), tetralogy of Fallot, TGA/TAPVR or palliated single ventricles, but similar in ability to at least partially describe the defect (p<0.005). In this more affected population, the ability to fully name the defect (81/134; 60%) far exceeded the ability to fully describe it (37/134; 28%; p<0.005).
Conclusion:
Only one-half of adolescents are able to name their cardiac defect, and one-third are able to adequately describe the anatomy. Older adolescents, those with a more recent history of surgery and those with more complex defects perform better. Parents are much more knowledgeable than their children. A strong emphasis should be made on educating adolescents with CHD as they transition to adulthood.
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Application of the Many Facet Rasch Model to Validate a Survey for the Selection of Chief Residents
Kadriye O. Lewis and Haiqin Chen
The literature does not show any established guidelines, methods, or psychometric instruments for selecting Chief Residents in academic programs. This study validates a newly designed instrument based on the characteristics and leadership qualities from the residents' perspectives. Our newly developed survey can differentiate Chief Resident candidates' performance as well as identify why a specific candidate is selected or not through MFRM. This tool can be applied to other residency programs.
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Investigating Program Directors' Milestones Assessment Practices in Graduate Medical Education: Preliminary Results
Kadriye O. Lewis, Susan B. Hathaway, J F. Knapp, Denise Bratcher, and Douglas Blowey
ACGME's Milestones assessment requirement placed new demands on Program Directors. This study investigates current assessment practices as well as identifies the needs and challenges of the program directors in implement Milestones for assessment in Graduate Medical Education at Children's Mercy Kansas City.
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Knowledge Base of Adolescents with Congenital Heart Disease
Mark Gelatt, Julie Martin, Jennifer A. Marshall, Jennifer Panuco, Jenea Schmidt, and Pamela Finn
Introduction:
Most congenital heart disease [CHD] is diagnosed and treated in early childhood with parents responsible for decision-making. The adolescent assumes this role in preparation for transition to an adult congenital heart program. We studied the knowledge base of our adolescent CHD patients and their parents.
Methods:
Established CHD patients, >11 y.o. and their parents, were independently surveyed in the outpatient clinic. Participation was voluntary. Cardiomyopathy, electrophysiology and transplant patients were excluded. Scores were assessed as full, partial or incomplete.
Results:
Most (98% parents; 83% adolescents) reported that their cardiologist had provided education. Adolescents provided a full (49%) and partial (15%) medical name and full (32%) and partial (35%) description of their condition. Older adolescents performed better (p<0.005). Parents scored better, regardless of patient age (p<0.005). Presence of prior surgery/intervention made no difference. Patients undergoing last surgery >11 y.o. scored better than those with surgery only when younger or without surgery (p<0.05) [data not shown]. Patients with mild unrepaired or surgically repaired shunt lesions (ASD, VSD, PDA), and their parents, were much less able to name their lesion than those with left heart lesions (aortic stenosis, coarctation, mitral valve disease), tetralogy of Fallot, TGA/TAPVR or palliated single ventricles, but similar in ability to at least partially describe the defect (p<0.005). In this more affected population, the ability to fully name the defect (81/134; 60%) far exceeded the ability to fully describe it (37/134; 28%; p<0.005).
Conclusion:
Only one-half of adolescents are able to name their cardiac defect, and one-third are able to adequately describe the anatomy. Older adolescents, those with a more recent history of surgery and those with more complex defects perform better. Parents are much more knowledgeable than their children. A strong emphasis should be made on educating adolescents with CHD as they transition to adulthood.
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Knowledge Gap in Adolescent Heart Transplant Recipients
Pamela Finn, Brian Birnbaum, Audrey R. Kennedy, Jennifer A. Marshall, and Mark Gelatt
Background:
Studies have reported a knowledge gap Studies have reported a knowledge gap among adolescent and young adult heart heart transplant patients upon transitioning to adult cardiology practices.
This population is vulnerable to life-threatening complications as they progress to adult care.
Framework/Methods:
We assess the current knowledge deficit of our adolescent and young adult patients and their caregivers in order to inform pediatric providers of their unique needs as they prepare to transition.
Heart transplant patients >10 yrs and their caregivers completed a written questionnaire prior to a clinic visit. 17 questions were asked including the need for transplant, medication names, purposes and adverse effects and the effects of living with a transplanted heart on exercise and work choices.
Patients were all transplanted in another facility and initial education occurred at that facility.
Conclusions:
Genetic factors and exercise/work limitations were the most misunderstood.
Our patients and caregivers also lacked a clear understanding of medications and common and/or serious adverse effects.
Areas that were well understood included: why the transplant was needed, meaning of immunosuppression, and the need for lifelong follow-up.
Recently our facility was granted permission to perform heart transplants and it will be our responsibility to initially and fully educate the patient and caregivers. A comprehensive team including a pharmacist, dietician, genetic counselor, and psychologist, in addition to nurses and physicians has been formed and they will be knowledgeable of ongoing needs with the intent to close the knowledge gap.
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B-Type Natriuretic Peptide (BNP) Levels During Extracorporeal Membrane Oxygenation (Ecmo) Weaning May Predict Survival To Hospital Discharge
John Graham, Jennifer Flint, and Erica Molitor-Kirsch
Background: Despite apparent clinical and echocardiographic evidence of adequate myocardial function and successful weaning towards decannulation, up to 33% of children who separate from cardiac ECMO do not survive to hospital discharge. Brain natriuretic peptide (BNP) is used as a marker of myocardial dysfunction in multiple clinical settings. We have anecdotally observed that during ECMO weaning, BNP levels remain stable or decreased in patients who survive after decannulation, but are elevated or rise in other children who die following decannulation.
Hypothesis: We hypothesized that trends in BNP levels during weaning from V-A ECMO may be useful to predict survival after decannulation from ECMO.
Methods Design: Retrospective cohort study Participants: Patients requiring V-A ECMO for cardiac failure admitted to Children’s Mercy Hospital PICU from May 2011-Feb 2014 who had BNP levels while on ECMO were included Measurements: The BNP level on full ECMO support and the BNP level on the lowest level of ECMO support prior to decannulation were recorded. Mann-Whitney U was used to compare BNP levels between those who died within 48 hours of decannulation, those who survived >48 hours off ECMO, and those who survived to hospital discharge.
Results: Twelve patients met inclusion criteria. Eleven had congenital heart disease, 7 had single ventricle physiology. Median age was 57.5 days (range 10-2237). Median weight was 3.85kg (range 2.7-28). Four patients survived >48hrs after decannulation (33.3%) and 2 patients survived to hospital discharge (16.7%). Among non survivors, median time to death after decannulation was 2.13 hours (range 0.13-1601). Survivors had a decrease or no change in their BNP level with weaning of ECMO support. Of non survivors, 57% had an increase BNP level or a BNP level that remained >5,000 pg/mL with ECMO weaning. At the time of minimal ECMO support, there was a trend towards lower median BNP levels in those who survived greater than 48 hours (314, 153-655) vs. those who died within 48 hours of decannulation (2671, 199-5001), p=0.088. There was a stronger trend towards lower BNP levels at the time of minimal ECMO support in those who survived to hospital discharge (190, 153-227) compared to all those who died (1174, 199-5001), p=0.059. STUDY LIMITATIONS: Our study was limited by the retrospective study design, small sample size, and the inability to quantify BNP levels >5,000 pg/mL.
Conclusion: BNP may be a useful biomarker to assess myocardial function while weaning ECMO support and warrants further study.
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Do the Best Hospitals Have Librarians?
Brenda R. Pfannenstiel
Objective: Determine how the presence of medical librarians correlates with hospital ranking on the U.S. News & World Report best hospitals list.
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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.
