AAMC Reporter: September 2007

Children's Hospitals Save Young Lives with Targeted Initiatives

Staff at UNC Children's Hospital are responding more quickly to patients in distress.

Her son's physician calls her "Dr. Wimberg." But Janet Wimberg has never received any formal medical training. What she has done is be a partner in her son's care for the past five years. Diagnosed on his first birthday in 2002 with tyrosinemia, an exceedingly rare condition that attacks the liver, her son Kyle has undergone two liver transplants, a bout of lymphoma, chemotherapy infusions, pneumonia, and a host of other problems. But Kyle is a fighter.

Now six, Kyle is doing well. His port was removed in July, and his infusions have given way to oral medications. He starts kindergarten this month.

Most parents with chronically ill children become medical "experts" of sorts, if only by virtue of being at their children's side during treatments and procedures. But Wimberg took it a step further by recommending changes in her son's treatment—changes with which Kyle's gastroenterologist John Bucuvalas, M.D., often agreed.

This collaboration results from a new initiative at Cincinnati Children's Hospital Medical Center, one of several children's hospitals to design programs for improving the quality of their patient care. A professor of pediatrics and the associate medical director of the hospital's liver care center, Bucuvalas wants families to be involved in making critical treatment decisions for their children. To that end, he helped develop what is popularly known among staff and patients as the liver portal, a tool that is helping parents like Wimberg gain more information about their children's treatments, which in turn paves the way for more informed and valuable parental input.

"It is a Web-based system that gives families access to information about their kids' medications and their lab studies and their procedures so that when they go see their local physician or go to the ER, they have access to it," Bucuvalas said.

Wimberg referred to herself as a "pre-portal" and a "post-portal" parent, with life looking very different after she began using the liver portal in 2003.

"Kyle would get his labs drawn at say 8 o'clock in the morning, and I would be sitting around literally all day waiting for his nurse coordinator to call me and tell me what those results were," Wimberg said. "I never knew what my next day was going to look like.... It was a stressful situation for the whole family."

The liver portal is helpful for doctors—and the entire hospital—as well. Bucuvalas said he no longer plays phone tag with many of his patients, and the nurses with whom he works no longer need to call patients with results.

According to Uma Kotagal, M.D., senior vice president for quality and transformation at Cincinnati Children's, the liver portal signals the beginning of what she said will be a "complete transformation of the system," so that medical errors, hospital-acquired infections, and other complications resulting from in-house care become a thing of the past. Already, Kotagal said, the percentage of liver transplant patients whose medication is in the right range has climbed from 30 percent to 80 percent.

The hospital is in the process of designing the portal for use by families of children with other chronic conditions that require constant monitoring, like diabetes.

Improving quality is also one of the goals of North Carolina Children's Hospital at the University of North Carolina (UNC) at Chapel Hill. At UNC, whenever a health care provider or patient family member believes a child may need immediate resuscitative medical attention, they can alert the hospital's Rapid Response Team (RRT).

Cherissa Hanson, M.D., assistant professor of pediatric critical care at UNC, said that before the RRT was developed, the typical response to a child in distress was to contact that child's primary care physician to begin treatment. If the child's condition worsened, a code team would be called to take the child to intensive care. The RRT, which consists of a respiratory therapist, a pediatric critical care nurse, and a critical care pediatric physician, saves time by making quick bedside assessments and initiating life-saving therapies if necessary. Between 2005 and 2006, incidents of cardiac arrest among hospital patients decreased from once every 41 days to once every 200 days, and mortality rates have dropped as well, Hanson said.

"Being here before we had it and after we had it, you can feel the difference," Hanson said.

Physicians and patients are feeling a difference as well at Children's Medical Center of Dayton (affiliated with the Wright State University Boonshoft School of Medicine). The center has taken deliberate steps to curb hospital acquired infections in its pediatric intensive care unit (PICU)—and it has virtually eliminated them. In fact, their PICU went nearly a year and a half without one hospital infection after instituting its "bundling" strategy in 2005.

What is bundling?

"It simply means you just bundle different steps together in the single process" of inserting central lines into critical patients, said Carol Wise, M.S., R.N., the hospital's director for corporate education, quality, and professional staff. "So it's paying careful attention to how you place a line, ensuring a sterile field is maintained, addressing how you change the dressing, maintaining the sterility of the line when it's in place, and then ensuring the line is taken out in a timely fashion."

And the effort is paying a bundle of dividends. In fiscal year 2005, the hospital's neonatal intensive care unit reported no central line infections. The previous year saw three infections.

Even in extremely low birthweight babies weighing less than 1,000 grams, the hospital's numbers were impressive after adapting the bundling program to this extremely high-risk patient population. Measured by the percentage of catheter infections per 1,000 catheter days, the infection rate dropped from 6.9 percent in fiscal year 2004 to 3.9 percent in fiscal year 2005, when the center instituted the bundling program.

—Barbara Gabriel, special to the Reporter

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