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Section on Hospital Medicine News Section on Hospital Medicine News Document Transcript

  • Section on Hospital Medicine News Dedicated to the Health of All Children in the Hospital Issue No. 1 2007
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 2 Issue No. 1 2007 Newsletter Editor-in-Chief Jennifer A Daru, MD IN THIS ISSUE Page jadaru@gmail.com Making the Rounds: A Letter from the Chair 3 Section Manager Letter from the Editor 4 S Niccole Alexander, MPP Subcommittee Updates 5 nalexander@aap.org You are the Consultant 6 Newsletter Designer Practice Profile 8 Ruth Podjasek, BGS Pediatric Critical Care & Sedation 10 rpodjasek@aap.org Spotlight on Research 11 Neonatal Medicine Update 12 Hospitalists On–Line 14 Join an SOHM Subcommittee: Billing and Coding Corner 15 • Coding and Billing Pediatric Hospital Morbidity & Mortality 16 Contact: Yong Han, MD Executive Committee Roster 20 yshan@texaschildrenshospital.org • Community Hospitalists Contact: Jack Percelay, MD jpercelaymd@yahoo.com • Palliative Care Contact: Maggie Hood, MD Maggie.hood@multicare.org • Critical Care Contact: Kimberly Boland, MD k.boland@louisville.ed or Ben Alexander, MD balexander@wakemed.org • Early Careerists and Pediatric Residents Contact: Julia Aquino, MD jaquino3@jhmi.edu • Medical Informatics and Technology Contact: Timothy Hartzog, MD tim@hartzoghealth.com Mark your calendar for future AAP National Conference & Exhibitions. Oct. 27-30, 2007 in San Francisco, CA Oct. 11-14, 2008 in Boston, MA Oct. 17-20, 2009 in Washington, DC Oct. 2-5, 2010 in San Francisco, CA If you couldn't attend the 2006 NCE, you can visit us online at http://www.aap.org/nce/ for post - conference details and see and hear what you missed... the many wonderful educational and net working experiences!
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 3 Issue No. 1 2007 Making the Rounds: A Letter from the Chair Laura J Mirkinson, MD, FAAP Chair, Section on Hospital Medicine I have just returned from the AAP’s Na- the AAP. Our long-term goal is to provide our membership tional Conference & Exhibition in Atlanta with a coding and billing guide specific to inpatient pediat- excited and energized! We had a full ric services. Look for a future newsletter devoted solely to house at our Section meet ing – my thanks this topic. to Dan Rauch, our program chair, and eve- ryone who presented posters. The great attendance at our Sec- There is still so much to do. The AAP SOHM is the home for tion meeting and the dedication (and determination) of our ex- pediatric hospitalists and it can only achieve its goals if it is ecutive committee are both indicators of the energy and forward meet ing the needs of the membership. So let us know what you motion of the Section. need and what you think this Section should be doing with all its energy. The big question for all of us now is where and how will all this energy be directed? That’s where you, the membership of the Here are some ways to become more involved: Section, come in. You are needed to participate in the Section activities and help us achieve our goals. What I hear from indi- 1. Join PRIS (Pediatric Research in the Inpatient Setting) and vidual members and what I read from the AAP SOHM help develop evidence-based research for pediatric inpatient LISTSERV® is that many of us are facing the same difficulties medicine. Contact Christopher Landrigan at and trying to find answers to the same problems. Some of these clandrigan@rics.bwh.harvard.edu. are clinical, some are administrative and some speak to the basic 2. Give us suggestions for educational topics and speakers for problems facing hospitalist medicine. We are all looking for the National Conference & Exhibition. Contact Dan Rauch evidence-based indicators to help us clinically, to define and at Daniel.rauch@med.nyu.edu prove our value to hospital systems, and to help us establish and 3. Contribute to our “Speakers Bureau” if you have heard a maintain healthy, sustainable pediatric hospitalist programs. I top-notch speaker. Contact Laura Mirkinson at am hopeful that the work of the Section will help provide the mirkil@holycrosshealth.org answers. 4. Contribute to our newsletter as a writer or editor. Contact Jennifer Daru at jadaru@gmail.com For those of you who missed our meeting, let me briefly bring 5. Help develop our medical informatics, enhance our website, you up to date. The AAP SOHM has been busy this year! contribute your clinical guidelines and order sets, and de- velop PodCasts. Contact Tim Hartzog at 1. The AAP SOHM has taken on the responsibility for the tim@hartzoghealth.com planning of the next Pediatric Hospital Medicine Meeting, 6. Join a subcommittee and help set the goals and the direction August 2-5, 2007. As some of you know, this is a tri- for the Section. Contact our section manager Niccole sponsored meeting involving the AAP, the Ambulatory Pe- Alexander at nalexander@aap.org diatric Association (APA) and the Society for Hospital Medicine (SHM). This is going to be a fantastic meeting Active membership in the Section is rewarding personally and with sessions on clinical medicine, education, research, and advantageous professionally. Thanks to all you who make this practice management. Look for the official brochure in Feb- section exciting and strong! ruary 2007 for registration details. 2. Several subcommittees of the AAP SOHM (Critical Care, Laura Coding and Billing, Palliative Care and Medical Technol- mirkil@holycrosshealth.org ogy and Informatics) presented posters at the Section Meet- ing reflecting their work this year. (For details, see the sub- committee reports in this newsletter). 3. The Section has developed several brochures for the parents of hospitalized children. These are the first AAP brochures that are specific for the inpatient pediatric service. They cover the topics of Gastroenteritis, Croup, and Pain manage- ment. They are on their way to the AAP’s marketing depart- ment this fall. 4. The Section has purchased new software to upgrade our website with the goal of having an archive of the LISTSERV® topics and greater interactive capability of the website. We are looking forward to developing PodCasts in the future (and suggestions for topics are welcome). 5. The initial data from the Coding and Billing survey will now be presented to other committees and sections within
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 4 Issue No. 1 2007 Letter from the Editor Jennifer Daru, MD, FAAP, Editor -in-Chief MEMBER CENTER Welcome to the January 2007 Section on Hospital Medicine Section on Newsletter. A special welcome as well to our new editorial board! With six new me mbers on the editorial team from pro- Hospital Medicine grams large and small across the nation, we expect to be bring- ing you the information that is most relevant to the care of chil- Be sure to visit the dren in the hospital and your practice. We’re still looking for a Billing and Coding Corner editor and an editor for the new Politics and Ethics col- Members Only Center umn, so if you are interested, please contact me at jadaru@gmail.com . for a wealth of resources Including We hope that this issue makes you think about your patients and your contract a little differently. The article from Hospitalists On-line expands on a conversation from the LISTSERV® by exploring the pros and cons of restrictive covenants. It’s something • Busine ss/Coding we all need to think about as we sign contracts. Also, there is a wonderfully thought • Informatics out piece on how maternal use of SSRIs may be affecting our youngest patients. Our • Job/Educational Opportunities critical care art icle touches on the use of simulation in teaching and for the first time • Improving and Developing we outline a Canadian Hospitalist program. You Are the Consultant will help you Pediatric Hospitalist Programs think about what you might do at a community hospital to work up a complicated case • AND MORE! before transferring. And then, of course, there are plenty of other care and policy up- dates in our other sections. http://www.aap.org/moc/ Give us your feedback, write an article or join our editorial staff. There’s plenty more to say! Jennifer jadaru@gmail.com Section on Hospital Medicine News Editorial Board: Editor -in-Chief Jennifer Daru, MD jadaru@gmail.com General Editor Sheldon Berkowitz, MD Sheldon.Berkowitz@childrensmn.org On the Wards Julie Lipps Kim, MD jlipps@stanford.edu You are the Consultant Lisa Zaoutis, MD zaoutisl@email.chop.edu Be Informed!! Practice Profile Susan Wu, MD Get Involved!! suwu@chla.usc.edu Pediatric Critical Care & Sedation Linda Snelling, MD Linda_Snelling@brown.edu Join the SOHM Politics and Ethics OPEN LISTSERV® today! Neonatal Medicine Ursula Kneissel, MD ukneissl@crhc.org Send an email to Niccole Alexander Hospitalists On-Line Jennifer Maniscalco, MD JManisca@cnmc.org nalexander@aap.org Pediatric Hospital Morbidity Mary Ellen Valletta, MD, JD for more info. & Mortality valleme@peds.ufl.edu LISTSERV® Editor Billing & Coding Corner OPEN Kevin Powell, MD PhD kpowell@pol.net
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 5 Issue No. 1 2007 Subcommittee Updates Advanced Modules 17. Management of the Child with Congenital Heart Disease 18. Oncologic Emergencies Critical Care Subcommittee 19. Diagnosis and Management of the Child with Acute Renal The Society of Critical Care Medicine (SCCM) has decided to Failure develop a Pediatric Fundamentals of Critical Care Support (P- 20. Post Operative Management FCCS) course for Pediatrics that will mimic the course SCCM 21. Sedatives, Analgesics and Neuromuscular Blockers currently offers for non-intensivist “adult” physicians who pro- 22. Tubes, Lines and Shunts vide critical care services. This course will be used nationally 23. Hospitalists and the Critically Ill Child and internationally to improve the skills of physicians other than 24. Medical Emergency Rapid Intervention Teams pediatric intensivists who care for critically ill children. 25. Hematology: Coagulation and Transfusions The AAP Section on Hospital Medicine can be proud of our P-FCCS STATIONS contribution to the development of this course. Our clamor for 1. Airway Management pediatric critical care CME for the non-intensivist was a major 2. Neonatal Resuscitation lobbying force behind the initial concept. Credit should be 3. Mechanical Ventilation given to the work we have done over the past several years as 4. Trauma hospitalists caring for children in the PICU in collaboration with 5. Pediatric Disaster our intensivist colleagues. Like PCPs, intensivists have come to 6. Vascular Access recognize the benefits of working collaboratively with hospital- 7. Invasive Procedures ists. We are now clearly perceived as a crucial part of the solu- 8. Case scenarios tion—no longer as a minor role player. Nothing definite yet, but hopes are high that SCCM will unveil Early Careerists and Residents Subcommittee P-FCCS with a two -day pre-course (August 1-2) at the AAP/ The field of pediatric hospital medicine is growing, as is the AAP APA/SHM Salt Lake City conference. This will be an opportu- Section on Hospital Medicine. Since its establishment in 2000, nity to reinforce your critical care skills in a friendly, collegial the Section has created a forum for pediatricians involved in hos- setting in an audience of peers, and from a systems standpoint, pital medicine to meet and exchange ideas. In the coming year, our feedback will improve the course for future audiences, na- the goal of this subcommittee is to involve more professionals in tional and international, hospitalist and non-hospitalist. The that forum, especially residents and young physicians. Our Win- draft outline for the course and textbook is listed below. ter 2006 newsletter was devoted to students, residents, and early careerists and proved to be an excellent source of information for Memb ership in the AAP SOHM subcommittee on critical (and those interested in the field. In the coming year, we plan to sur- intermediate) care is open to anyone interested in the field. To vey and publish residents' attitudes and their exposure to hospital join, contact subcommittee co-chairs Kimberly Boland at medicine and hospitalists. We also plan to be involved in resi- (k.boland@louisville.ed) or Ben Alexander at dency career panels and fairs to raise awareness of hospital medi- (balexander@wakemed.org). cine as a career option. Finally, we are very excited to have for- malized a resident liaison position to facilitate communication Basic Modules between physicians-in-training and the Section. The position, 1. Assessment of the Critically Ill Child: R Mejia, K Serrao which had been held by Dr. Alison Holmes for the past few 2. Airway Management years, will pass to Dr. Julia Aquino, a second year resident at 3. Cardiopulmonary/Cerebral Resuscitation Johns Hopkins. The leadership of the Section on Hospital Medi- 4. Diagnosis and Management of the Child with Acute Upper cine Early Careerists and Pediatric Residents Subcommittee is Airway Disease looking forward to a productive year. 5. Diagnosis and Management of the Child with Acute Lower Airway Disease If you are a resident or early careerist interested in joining the 6. Mechanical Ventilation subcommittee, please contact Julia Aquino at a. Non-invasive Ventilation jaquino3@jhmi.edu. b. Mechanical Ventilation 7. Diagnosis and Management of Shock 8. Acute Infections Palliative Care Subcommittee 9. Diagnosis and Management of the Child with Water, The Subcommittee on Palliative Care has had a quiet quarter. Electrolyte and Metabolic Disorders One of our members has shared her plan about furthering her ca- 10. Basic Trauma and Burn Management reer in Pediatric Palliative Care. Nadia Tremonti writes, "I am 11. Non Accidental Injuries Diagnosis and Management currently in the middle of my fellowship year and actually am 12. Pediatric Disaster Preparedness just finishing up a visiting rotation at Akron Children's Hospital 13. Poisoning with Dr. Sarah Friebert and the Pediatric Palliative Care Team. 14. Transport of the Critically Ill Child This is now only one of 2 hospitals in the country to offer a fel- 15. Neurologic Emergencies lowship in pediatric palliative care (the program in Wisconsin is 16. Ethical and Legal Issues cancelled for now), and I will be rotating at the other program, Boston Children's Hospital, in January. Continued on p. 15
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 6 Issue No. 1 2007 You Are the Consultant You review her vital signs: temperature 38.4°C, pulse of 160, An Eleven Year Old with Joint Pain respirations of 22, and blood pressure of 110/64. Her oxygen saturation is 99% on room air by pulse oximetry. Her weight is Laura Davidson, MD 62 kg (>95th percentile). She appears to be a well-developed and Children’s Medical Center of Dallas well-nourished girl who is nontoxic, completely cooperative, but Laura.Davidson@childrens.com quiet with slow movements. You note the following on physical examination: she has diffusely thinning hair and a faint viola - At the community hospital where you are a pediatric hospitalist, ceous rash over her forehead and cheeks with nasolabial sparing. a family practitioner asks you to see a patient that she has admit- She has scleral injection with dilation of the episcleral vessels ted for an inpatient work-up. The patient is an eleven year old bilaterally. She has a superficial ulcer on her hard palate with a Hispanic female with a long history of migratory joint pains, small area of surrounding erythema. She is unable to open her intermittent fevers, fatigue, and weight loss. mouth fully due to pain at the left temporomandibular joint. Her lungs are clear bilaterally and heart sounds are regular with no You see the patient and obtain the following information: This murmurs, rubs, or gallops. Her abdomen is soft, non-tender, young lady’s symptoms began approximately one year earlier non-distended without hepatosplenomegaly. Her extremities are when she developed pain in both her feet which progressed to warm with good perfusion and her nails and nailbeds are nor- involve her hips, shoulders, wrists, thumbs, and jaw. The pain is mal. She has sharply demarcated and fairly symmetric hypopig- described as aching, 6/10 in severity, and lasting five to seven mented skin lesions on the dorsal surfaces of her fingers, hands, days then improving and moving to other joints. The pain is usu- and feet. Joint examination is notable for decreased range of ally present simultaneously in a few joints and does not com- motion of her left shoulder with limited extension, abduction, pletely resolve before developing in another location. The pa- and external rotation due to pain. She also has limited internal tient reports some intermittent swelling noted at her thumbs and rotation of her hips. Her knees are noted to have small effusions the tops of her feet but denies any redness. The pain is worse in with mild limitation on full extension but no increased warmt h the mornings and is associated with some stiffness and restric- or erythema. She has no significant lymphadenopathy. Her cra - tion in range of motion due to pain. The pain awakens her two to nial nerves are intact, and her strength, reflexes, and sensation three times per night and improves somewhat with ibuprofen. are normal. Cerebellar function is intact and her gait is normal. Most recently, the patient has significant pain in her left jaw, left shoulder, and right foot. She denies any history of trauma. She Initial laboratory analysis reveals normal electrolytes, BUN, also reports intermittent fevers in the range of 101-102°F for the creatinine, hepatic enzymes, PT, PTT, CK, LDH, and uric acid. past six months, but occurring almost daily for the past two Albumin is slightly low at 2.6 g/dl. CBC shows pancytopenia weeks. She has generalized fatigue with weakness and has had with wbc 4300/mm3 (41% segs, 29% bands, 7% monos, 23% difficulty climbing stairs and walking long distances. She has lymphs), hemoglobin 10.8 g/dL with an MCV of 79 fL (low had a decreased appetite and a forty-pound weight loss over the normal) and a reticulocyte count of 0.8%, and platelets 117,000/ past four months. On review of systems, she denies headache, mm3 . CRP is 0.7 mg/dl and ESR is 36 mm/hr. Urinalysis dip- seizures, chest pain, cough, abdominal pain, vomiting, diarrhea, stick is negative except for 1+ protein and the microscopy shows constipation, dysuria, numbness, and mouth ulcers. She has oc- 8 red blood cells/hpf. Plain films of the feet are normal. casional nosebleeds but denies further bleeding. She reports dark urine with no visible blood. She has noted diffuse hair loss over At your institution subspecialty consultants are not available to the past year with hair falling out in the shower and on her pil- see the patient, so you carefully consider which of the following low in the mornings. She also has had intermittent eye redness would be the best approach to recommend: and irritation for a year, but denies eye pain or visual distur- bance. She reports a pink rash described as “flushing” that has a. Order ANA, complement levels, and “lupus panel” for sus- appeared on her face for days at a time during fever episodes. pected SLE. b. Contact the pediatric hematology service at the nearby The patient was born in the United States via full-term c-section children’s hospital to discuss transfer of the patient for delivery with no pre- or post-natal complications. Her past medi- bone marrow biopsy for suspected malignancy. cal history is significant for hip dysplasia treated with a Pavlik c. Order an upper GI series and contact the pediatric gastro- harness as an infant and vitiligo since infancy with recent areas enterology service at the nearby children’s hospital to dis- of hypopigmentation developing on her feet and hands. She cuss transfer of the patient for endoscopy for suspected takes no medications, has no drug allergies, and is up to date on inflammatory bowel disease. her immunizations. Family history is only significant for a ma - d. Order an HIV test, PPD, and titers for CMV, EBV, and ternal aunt with arthritis diagnosed in her thirties. The patient brucella and discuss the case with the infectious diseases lives with her mother and brother in an apartment. She was pre- service for evaluation of fever of unknown origin. viously a B to C student but since the onset of her symptoms is e. Arrange transfer to the nearby children’s hospital so that now failing most of her fifth grade classes. She denies recent all the consultative services (rheumatology, hematology, travel, exposure to incarcerated persons or persons with tubercu- gastroenterology, and infectious diseases) can be directly losis, sexual activity, drug use, exposure to animal products, and involved in the work-up. ingestion of unpasteurized milk. Continued on p. 7
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 7 7 Page Issue No. No. 1 2007 Issue 1 2007 found in 50% of patients at initial presentation, most commonly, You Are the Consultant Continued from p. 6 diffuse proliferative glomerulonephritis. Pulmonary features may include pleuritis and effusions, and cardiac disease may Discussion: involve any layer of the heart, most often the pericardium. Cen- Answer: a tral nervous system features may include both psychiatric symp- toms or neurologic symptoms such as seizures or headache.1,2 Based on the constellation of signs, symptoms, and laboratory abnormalities, you strongly suspect SLE to be the most likely Your patient met 3 criteria for SLE based on the history and diagnosis for your patient. The diagnosis of SLE is confirmed physical exam findings (malar rash, migratory polyarthritis, oral with the laboratory results: the ANA serology was positive with ulcer) with evidence of 2 more criteria on initial laboratory stud- titers 1:1280 and C3 and C4 levels were both low at 34 mg/dl ies (proteinuria with microscopic hematuria, pancytopenia). and 2 mg/dL, respectively. In addition, the patient had elevated Many of her other findings, although non-specific and not SLE- titers of anti-double-stranded DNA, anti-Smith antigen, anti- defining criteria, are consistent with SLE: fever, fatigue, weight SSA Ro, and anti-cardiolipin antibodies on the “lupus panel.” loss, hair loss, episcleritis, and deterioration of school perform- ance. By seeking further laboratory evidence of SLE with serol- SLE is a multi-system autoimmune disease diagnosed clinically ogy for ANA and other characteristic auto-antibodies, the diag- by the presence of > 4 of 11 criteria established by the American nosis was confirmed. Involvement of rheumatology would be College of Rheumatology in 1982, revised in 1997. See Table 1. appropriate at any point along the process when the diagnosis of SLE is being strongly considered, and is necessary when the di- Table 1: American College of Rheumatology criteria to agnosis is confirmed. diagnose SLE (must meet > 4 of 11 criteria). In the case of this patient, after the results of the laboratory stud- 1. Malar rash 8. Neurologic disorder ies confirmed the diagnosis of SLE, the pediatric rheumatologist 2. Discoid rash 9. Hematologic disorder was contacted and the patient was transferred to the nearby chil- 3. Photosensitivity 10.ANA dren’s hospital to his service. There the patient was treated with 4. Oral lesion 11.Immunologic disorder oral bolus steroid therapy for three days, plaquenil, and napro- 5. Arthritis (e.g., anti-DNA, anti-Sm, syn twice daily for anti-inflammatory effects with excellent 6. Serositis antiphospholipid symptomatic relief. A chest xray was obtained which was nega- 7. Renal disorder antibodies) tive for pleural effusions. A 24-hour urine collection was per- formed to evaluate renal function and quantify the degree of pro- Approximately 15% of all patients who have SLE are diagnosed teinuria. Her creatinine clearance was low normal range (83 in childhood, most often during adolescence with a female pre- ml/minute) and her urine protein was 527 mg/day which is con- dominance.1,2 SLE is more common among individuals of sistent with low-grade proteinuria (150- 1,000 mg/day). The pa- Asian, Hispanic, or African descent compared to Caucasians. tient was discharged to home with rheumatology follow-up as The most common initial manifestations of childhood SLE are well as renal follow-up for renal biopsy for SLE staging. musculoskeletal and mucocutaneous with associated constitu- tional symptoms. Musculoskeletal complaints include arthritis, Malignancy should always be high on the differential when arthralgias, weakness, and myalgias. The arthritis in SLE is typi- evaluating a patient with unexplained fevers, weight loss, ar- cally polyarticular and symmetrical, involving both the large and thralgias or bone pain, and pancytopenia. Bone pain is a pre- small joints. It is often migratory and commonly painful out of senting symptom in 30% of acute leukemia and may be con- proportion to clinical findings. Mucocutaneous involvement fused with rheumatologic bone pain particularly if joints are in- takes the form of a malar rash with nasolabial sparing in 85% of volved. In a study comparing onset of disease in patients with patients.3 Other common mucocutaneous findings include ul- JRA and leukemia, nocturnal pain and non-articular bone pain ceration, vasculopathy, photosensitivity, discoid lesions, and were more commonly seen in patients with leukemia.4 Physical alopecia. Mucous membrane lesions on the hard palate are asso- exam may reveal point tenderness over diaphyses of long bones, ciated with active disease and are usually painless and therefore lymphadenopathy, hepatosplenomegaly, or signs of bruising and may not be noticed by the patient. Ocular mucosa may be in - bleeding.5 Pancytopenia, is a red flag for possible malignancy, volved in the form of episcleritis, seen in 9% of patients in one and may indicate infiltration of the bone marrow with malignant study.3 Though episcleritis may be an isolated, idiopathic condi- cells. Underlying malignancy was considered in the differential tion, patients with episcleritis caused by systemic inflammation for your patient due to her unexplained fevers, significant weight typically have episodic flares with bilateral involvement. Pa - loss, joint pains awakening her at night, and pancytopenia, how- tients complain of redness, irritation, and watering but have no ever, the chronicity of her symptoms, localization of pain to the eye pain or visual disturbance. Alopecia generally begins in the joints, as well as the additional physical exam findings of a ma- frontal areas and is diffuse. Constitutional symptoms such as lar rash, palatal erythema, and episcleritis pointed away from fever, weight loss, and malaise are common in SLE. Approx i- this diagnosis. Though your patient had pancytopenia, she did mately 70% of patients with SLE initially present with one or not have blasts on the smear and LDH and uric acid levels were more blood cell lineages depleted. More than half have a nor- normal, making the diagnosis of malignancy less likely. mocytic normochromic anemia associated with chronic infla m- Another consideration in the differential for your patient was mation. Autoimmune thrombocytopenia may occur due to anti- inflammatory bowel disease (IBD) such as Crohn’s disease. platelet antibodies. Leukopenia (WBC <4500/mm3 ) with ly m- Though most patients with inflammatory phopenia (<1500/mm3 ) may also occur. Renal involvement is Continued on p. 18
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 8 Issue No. 1 2007 Practice Profile Interview with Jeremy Friedman, MBChB, FRCPC, FAAP, Head, Division of Pediatric Medicine and Associate Professor, Depart- ment of Pediatrics, University of Toronto; conducted by Susan Wu, MD, Assistant Professor of Clinical Pediatrics, Division of Gen- eral Pediatrics, Children’s Hospital Los Angeles and University of Southern California. SuWu@chla.usc.edu Program Name Hospital for Sick Children lower length of stay for patients on the staff-only team, even Location Toronto, Canada controlling for age, gender, and co-morbidities. Academic Affiliation University of Toronto Areas Covered Ward, Image Guided Therapy service, Consul- All calls regarding general pediatric admissions are handled by tation Service the physician carrying the “bed manager” pager. This includes FTEs 7.0 hospitalists, with 11 FTE other faculty ICU transfers, outside hospital transfers, and emergency depart- Unique Aspects Resident teams as well as staff-only teams; ment admissions. When the physician holding the bed manager subspecialty fellows providing night and weekend coverage; pager gets called, he/she calls the referring physician directly and Coverage of Image Guided Therapy Service determines whether it is an appropriate transfer for the general pediatrics service. If so, the physician assists the referring center Program History and Overview with interim management, then calls the nursing leadership to The general pediatric hospitalist program at the Hospital for Sick assess bed availability and details of transfer. Then the patient is Children (HSC) in Toronto, Canada was created in 1995 in part assigned to either the CTU or CPU at the discretion of the physi- as a response to decreased resident staffing and restrictions on cian holding the pager. There are no private practice physicians resident duty hours. Since then, it has grown into a highly suc- who admit to HSC, except for those who participate as CTU at- cessful academic pro- tendings for at least 2 gram, which incorpo- Table 1. Hospital for Sick Children Patient Care Teams months/year. During rates direct patient Clinical Teaching Unit Clinical Practice Unit the daytime, one of the care, teaching, re - (CTU) (CPU) hospitalists carries the search, and quality im- bed manager pager. At provement. Initially Attending Staff 1 3-4 night, the senior resi- the group started with Fellows None 1 dent on the CTU car- 2 FTE’s, and has now ries the pager. The expanded to 7 FTE’s. Resident staff 2-3 PGY-1, 1 PGY-3 Elective only hospitalist staff at- The Hospital for Sick tempt to direct more Medical students 1-2 Elective only Children is a tertiary admissions onto the care pediatric aca- Other staff None CNS-NP, sometimes chief CPU during the day so demic health science resident the residents can pri- center in Toronto with oritize teaching; dur- 320 beds and 50,000 Night coverage (after 5) Housestaff (attending Subspecialty fellow ing the nighttime, ED visits per year. The available from home) (attendings available from more admission are general pediatrics hos- home) directed to the CTU’s. pitalist service man- Weekend coverage Housestaff (attendings Subspecialty fellow Although there are no ages close to 3,000 round from 9-3, then are (attendings available from formal guidelines for admissions per year. available from home) home) distributing patients to either team, many of Ward Coverage Census Capped at 15 35-45 (no cap) the complex patients There are 3 general Patient type Fewer special needs More special needs patients with frequent hospital pediatric inpatient admissions who are ward teams - 2 Clinical Teaching Units (CTU) and 1 Clinical well known to the faculty will be admitted to the CPU for better Practice Unit (CPU). Table 1 outlines these teams. The CTU’s continuity of care. Over time, the group has found that an in- each consist of 1 attending physician, 2-3 PGY-1 residents, 1 creasing proportion of the complex care patients are being placed PGY-3 resident, and1-2 medical students. The CPU is a staff- on the CPU team. only team, and consists of 3-4 hospitalists, 1 CNS-NP, 1 pediat- ric fellow, and sometimes, additional trainees (chief resident, Staffing residents or medical students on electives). The CTU’s are Within the Division of Pediatric Medicine, there are 7 FTE of capped at 15 patients per team; the CPU has no cap, however the general pediatric hospitalists, as well as 11 FTE of other faculty. total census between the 3 teams is usually between 50 and 60. The hospitalists generally spend > 7 months of the year on inpa- The CNS-NP cares for a subset of patients with special needs tient care, whereas the other faculty spend 2-3 months on the who are frequently admitted; this person also follows these pa- teaching service. The hospitalists spend 1-2 months on the CTU tients in the outpatient clinic. The hospitalist group published a with the rest of their inpatient service on the CPU. They are re - study comparing outcomes between the CTU and CPU sponsible for inpatient care from 8 am to 5 pm on weekdays, and (Pediatrics 2004:114(6);1545-1549). They found that the two round on the weekends from 9 am to 3 pm. At nighttime, resi- groups had comparable mortality, readmission rates, or fre - dents staff the CTU’s, and pediatric subspecialty fellows cover quency of consultation. There was, however, a significantly the CPU. These fellows are mostly foreign Continued on p. 9
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 9 Issue No. 1 2007 residents, and fellows. Faculty also lead small groups for medi- Practice Profile Continued from p. 8 cal students on the art and science of clinical medicine, and prob- lem-based learning. They conduct bedside rounds with residents pediatricians doing subspecialty fellowships who are required to as well as give lectures on general pediatric clinical topics, medi- provide night and weekend coverage for the CPU as part of their cal education, quality, safety, and clinical research. In addition to contract. ward attending duties, many of the hospitalists are involved in quality improvement, patient safety, drug utilization, research Other Services ethics board, morbidity/mortality review, and many other com- The HSC hospitalist service also provides coverage Monday mittees. Several of the hospitalists also have prominent positions through Friday 8 am to 5 pm for patients on the Image Guided in hospital management and administration; for example, the di- Therapy (IGT) service. These are patients receiving radiology vision chief is a hospitalist, as is the chief of undergraduate procedures, such as feeding tube placement, PICC lines, stents, medical education. Research within the group includes a wide biopsies and drainages. The physician on the IGT service is re- range of activities, from medical education to case reports to sponsible for pre-operative evaluation and post-operative follow- clinical trials. These projects have resulted in multiple publica- up. They do not, however, provide sedation services. In addition, tions in peer-reviewed journals, presentations at international one hospitalist is assigned to the Inpatient Consultation service meetings, and substantial intramural as well as extramural grant on a monthly rotation. This is usually staffed by an associate funding. chief resident. Most of the consultations are provided to the sur- gical services. One of the hospitalists who has done a fellowship Fellowship Program in Child Abuse, provides 50% of her time on the Suspected Due to the success of the hospitalist program, a large number of Child Abuse and Neglect (SCAN) team. pediatric trainees have become interested in hospitalist careers upon graduation. Recently, a pediatric hospitalist fellowship pro- Academic Activities gram was started. This program is highly individualized, and al- As the hospitalist program developed, it evolved from a program lows fellows to develop a curriculum which meets their career prima rily designed to meet staffing and throughput needs, to one objectives. The fellowship program includes direct patient care that is broad and diverse. Each member of the hospitalist team on the services described above, broad elective opportunities, has created their own unique job profile. As ward attendings, the night call, research, teaching, and the option of a masters level hospitalist group is very involved in both bedside and didactic degree. Currently, one of the fellows is a former chief resident teaching of medical students, residents, fellows, and nurse practi- working on a masters in bioethics, and the other is an experi- tioners. The hospitalist staff has won numerous teaching and de- enced hospitalist from the US completing a 2 year program fo- partmental awards. They are involved in didactic as well as bed- cusing on teaching and clinical care. side teaching and supervision for CNS-NP’s, medical students, New Directions As the program grows, it is taking on many new projects to im- prove the care of children. In the near future, the group plans to establish a comprehensive complex care program for patients with special health care needs, who need coordination of both inpatient and outpatient services. They hope to examine the suc- cess of different models of care for this population. Another pri- ority area is inpatient safety and quality assurance. One of the hospitalist members is undertaking a project on medication rec- onciliation. Medical education is another priority; in the upcom- ing years the division plans to strengthen its resident elective and hospitalist fellowship programs. Samir Shah For more information, contact Dr. Jeremy Friedman, Head of the This text combines the advice of over 100 pediatricians and Division of Pediatric Medicine, or Dr. Michael Weinstein, Direc - specialists to bring you the latest tor of Inpatient Services at mweinstein@sickkids.ca, or (426) guidelines, procedures, and 813-5281. treatment and management strategies for inpatient pediatric care. Highly accessible and easy to use on the wards, this book is arranged alphabetically by clinical area, and organized in a consistent format with uniform headings throughout —perfect for whenever you need information fast. 978-4051-0428-9 · $39.95 Wolters Kluwer Lippincott Health Williams & Wilkins
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 10 Issue No. 1 2007 Pediatric Critical Care & Sedation Arming Pediatric Hospitalists for Critical Care from 1969 through 2003 identified key features contributing to Responsibilities the effectiveness of simulation based education. These features include provision of specific and immediate feedback, repetitive Stephanie N. Sudikoff, MD practice, a broad range of task difficulty, clinical variation, a Assistant Professor of Pediatrics controlled environment, individualized learning, and defined Medial Director, Pediatric Transport Services educational outcomes(4). Because the simulations are com- Director, Pediatric Simulation Education pletely staged, participants perform critical interventions, wit- Co-Director, Pediatric Simulation ness their outcomes and learn from the experience without any risk to patients. Linda K. Snelling, MD, FCCM, FAAP Associate Professor of Pediatrics and Surgery (Clinical) Simulation training is effective; when paramedic students were Chief, Pediatric Critical Care Medicine taught endotracheal intubation in a simulation center, their sub- Medial Director, Pediatric Inpatient Medicine sequent success with live patients was as good as students Medical Director, Pediatric Sedation Service trained in an operating room(5). Internal medicine residents taught ACLS via medical simulation performed better than those Pediatric Hospitalists are working in the Pediatric Intensive Care who did not receive simulation based teaching(6). Second year Unit (PICU) with increasing frequency. As opposed to the rap- pediatric residents at our institution participate in an 8 hour idly increasing number of pediatric hospitalists entering the field simu lation based “airway day” at the Rhode Island Hospital each year, the influx of pediatric intensivists is flat and contin- Medical Simulation Center, based on our own data showing im- ues to fall short of demand. Approximately 40% of pediatric provement in their performance after participating in this educa- hospitalists now work in intensive care units(1). The benefits of tional intervention. this development surpass the obvious advantage of increased The skill sets required for effective stabilization of a critically ill numbers of providers; Tenner et al demonstrated that a PICU child are often organized or prioritized with the rubric “ABC”. staffed with in-house Pediatric Hospitalists, with immediate Essential airway (“A”) skills include proficient bag-valve-mask phone availability of an intensivist, had a better survival rate and ventilation, appropriate use of nasopharyngeal and oral airways, shorter length of stay than a PICU staffed with in-house res i- endotracheal intubation, and insertion of a laryngeal mask air- dents with similar intensivist availability(2). way as an emergency airway rescue device. Critical “B” skills Preparing hospitalist physicians to care for critically ill children include needle decompression of a tension pneumothorax and poses significant challenges. In a recent survey, 92% of pediat- performance of tube thoracostomy, either by the open or the ric hospitalists indicated greater skill levels in performing crit i- Seldinger (“guide-wire”) technique. Both infant and school-age cal care procedures as the area most in need of attention(3). In sized mannequins allow for placement of these devices. addition to appropriate back-up from an intensivist, critical care Adequate “C” skills require complete mastery of several options requires the hospitalist to have appropriate cognitive expertise to access the circulation, as well as use of cardiac electrical ther- and procedural skills. Cognitive expertise improves with time, apy devices. In an emergent situation, peripheral intravenous on the job experience, and appropriate teaching from and in- (IV) or intraosseous (IO) access may be more expedient than volvement with pediatric intensivists. Telephone consultation is obtaining central venous access (or a CVL for central venous often sufficient back-up for developing cognitive skills, and line). If urgent venous access is obtained via the IV or IO route, complex advice and plans can be made with consultation from resuscitation can begin and a CVL can be deferred until the pa- remote locations. tient is more stable or a pediatric intensivist arrives. All sizes Procedural skills are a more urgent matter. Acute clinical situa- and models of pediatric simulators support placement of IV and tions requiring critical care procedural interventions are often IO infusion devices. In some critically ill patients, an urgent high stakes, low volume events, and may not easily allow for CVL will be necessary. Currently, no pediatric mannequins al- sufficient or appropriate on the job “practice” before proficiency low insertion of a CVL, but separate “task trainers” support in- is required. Telephone consultation is not a substitute for ex- ternal jugular, subclavian and femoral vein cannulation. With perience when a procedure or emergency intervention is re- proper staging of the environment, and “draping” of the task quired, and some interventions cannot wait for the arrival of an trainer, a realistic experience can be created for CVL insertion. out-of-hospital intensivist. Because the femoral vein is a relatively straightforward vein to cannulate, most pediatric hospitalists can learn femoral vein can- Medical simulation centers offers realistic clinical settings for nulation readily with a few supervised real-life experiences. introduction and enhancement of both cognitive and procedural skills. Medical simulation uses life-sized, high-fidelity comput- In addition to procedural and cognitive skills, orchestrating a erized patient mannequins that respond in real-time to clinical successful emergency intervention or resuscitation requires ef- interventions and medications. This allows trainees to learn and fective team management and leadership. Emergency situations practice life -saving procedural, decision-making, and team man- are, by definition, crises. With specific teamwork training, a agement skills in an intense and life -like environment, before pediatric hospitalist is more likely to transform a loosely organ- these skills are required in a real patient situation. A best evi- ized working group into a superior performing team. Medical dence systematic review of the medical simulation literature simulation is an excellent means of teaching Continued on p. 11
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 11 Issue No. 1 2007 Spotlight on Research MORE Evidence Based Medicine for Pediatric The rating system supports an Internet-based alerting system Hospitalists (excerpted with permission from the MORE website) and “best evidence” database of links to original articles and systematic reviews to help doctors keep up to date with the Pediatric Hospitalists have an opportunity to contribute to the medical literature. MORE then uses the ratings to help select development of Evidence Based Medicine within Pediatric articles that are most interesting to raters and readers. Hospital Medicine by participating in the McMaster Online Rating of Evidence (MORE) project. It’s a fun, quick, stimu- The rating system has several “perks” for raters: lating way of keeping up with the literature, honing your ana- 1. MORE sends only articles that have passed defined criteria lytic skills, and contributing to our discipline while collecting for scientific merit CME at the same time. 2. MORE provides raters with scores from other raters for the same articles The Health Information Research Unit at McMaster University 3. MORE grants CME credits has developed the McMaster Online Rating of Evidence 4. MORE provides the highest rated articles to all raters in a (MORE) system to help define the best research to support evi- given discipline dence-based clinical practice, tailored to the individual interests of clinicians. This past summer, MORE added Pediatric Hos- Ratings are used to prepare evidence-based journals and texts, pital Medicine to the list of disciplines in which articles are re- including: viewed. • Evidence-Based Medicine and bmjupdates+ for the BMJ Publishing Group MORE uses set methodological criteria to identify studies • Medscape Best Evidence Alerts for WebMD. whose design warrants review. To these criteria, MORE adds ratings by clinicians (Sentinel Readers) to determine relevance To become a contributor to MORE, send an e-mail expressing to clinical practice and newsworthiness. Ratings are then com- your interest to MORE@mcmaster.ca or check out their web- bined to identify the highest rated articles in a given discipline. site http://hiru.mcmaster.ca/more/ Pediatric Hospital Medicine articles reviewed by MORE recently and identified as stellar include the following: o Probiotics for pediatric antibiotic -associated diarrhea: a meta-analysis of randomized placebo-controlled trials. Johnston, B et al. CMAJ. August 15, 2006; 175 (4). o EMLA and amethocaine for reduction of children’s pain associated with needle insertion Lander JA et al. The Cochrane Data- base of Systematic Reviews 2006, Issue 3. o Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Sonnappa, S et al. American Journal of Respiratory and Critical Care Medicine, Jul 15, 2006. o Surfactant therapy for bronchiolitis in critically ill infants. Ventre K et al. The Cochrane Database of Systematic Reviews 2006, Issue 3. likely to be encountered by a pediatric hospitalist in a PICU – Pediatric Critical Care and Sedation or elsewhere. Continued from p. 10 References “crisis resource management” and effective leadership to pediat- 1. Ottolini MC, Pollack MM. Pediatric Hospitalists Improve ric hospitalists responsible for resuscitation and resource mobili- Critical Care Outcomes. Crit Care Med. 2003 Mar;31 zation for critically ill patients. Finally, an often overlooked but (1):986-7. essential component of effective emergency intervention is fa- 2. Tenner PA et al. Improved Survival with Hospitalists in an miliarity with the assembly and function of emergency equip- Pediatric Intensive Care Unit. Crit Care Med. 2003 Mar;31 ment and supplies. Facility with equipment is critical for profi- (1):847-52. ciency in critical care procedures, and is achieved only with 3. Lye PS et al. Pediatric hospitalists: report of a leadership hands on practice. conference. Pediatrics. 2006 Apr;117(2):1122-30. 4. Issenberg BS, et al. Features and Uses in High-Fidelity Expanding Pediatric Hospitalists’ procedural, leadership, and Medical Simulations that Lead to Effective Learning: a communication skills will optimize their ability to lead a mu l- BEME Systematic Review. Medical Teacher, Vol. 27, No. tidisciplinary team effectively through a critical event. The use- 1, 2005, pp.10-28. fulness of these critical care skills extends beyond the PICU. 5. Hall RE et al. Human Patient Simulation is Effective for Acute decompensation can occur anywhere, and hospitalists Teaching Paramedic Students - Endotracheal Intubation. may be the first (and most locally definitive) responders to Academic Emergency Medicine 2005;12:850-855. many locations outside of a PICU, including a general care 6. Wayne DB, Butter J, et al. Simulation-Based Training of unit, emergency department or procedural sedation site. Medi- Internal Medicine Residents in Advanced Cardiac Life Sup- cal simulation offers an efficient means of providing the neces- port Protocols: A Randomized Trial. Teaching and Learning sary training for low frequency, high stakes events that are in Medicine, 17(1), 210-216.
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 12 Issue No. 1 2007 Neonatal Medicine Update Selective Serotonin Reuptake Inhibitors syndromes are well-defined in adults. Multiple reports of babies Effects in Pregnancy, Lactation and the Neonate with high Neonatal Abstinence Score scoring and low or unde- tectable serum levels of medication have lead many to classify Ursula S. Kneissl MD (Ukneissl@crhc.org) this as withdrawal(5,6). However, particularly in drugs with long Angela Yerdon McLeod DO (Ayerdon@chrc.org) half-lives, toxicity is also likely. Laine et al. demonstrated clear Assistant Professors of Community and Family Medicine, evidence of toxicity in a group of newborns exposed to fluoxe t- Dartmouth School of Medicine ine(7). In a prospective controlled follow-up study, they measured New Hampshire/Dartmouth Family Practice Residency, drug levels, an indirect marker of CNS serotonin activity and Concord NH. scored serotonergic symptoms and demonstrated that the symp- toms correlated with low drug levels and high CNS serotonin Selective serotonin reuptake inhibitors (SSRIs) are commonly activity. It seems most likely that both exist – some babies ex- used to treat depression in pregnancy. There have been numer- perience toxicity, some withdrawal and some may experience ous reports of infants exposed to SSRIs in utero with adverse both. effects, prompting a Health Canada warning in August 2004 and an FDA warning in December of 2005. In our institution we Table 1. (Briggs GG, Freeman RK and Yaffe SJ. Drugs in Preg- have seen a number of SSRI-exposed infants develop symptoms nancy and Lactation. In 7th ed. Philadelphia, PA: Lippincott Wil- after birth. In this article we examine the available evidence re - liams & Wilkins; 2005.) garding the use of SSRIs in pregnant and lactating women and the effects on their offspring. Category A: Controlled studies in women fail to demonstrate a risk to the fetus in thefirst trimester (and there is no ev i- Mothers, Depression and Pregnancy dence of a risk in later trimesters), and the possibility of fetal harm appears remote. The overall prevalence of depression is 14-23% in women before Category B: Either animal-reproduction studies have not demo n- pregnancy and 11-32% postpartum1 . Studies have shown that strated a fetal risk but there are no controlled studies in most women being treated for depression are on SSRI medica - pregnant women or animal-reproduc-tion studies have tions2 . Discontinuing medication during pregnancy increases the shown an adverse effect (other than a decrease in fer- risk of depression relapse from 23% (in treated patients) to 43% tility) that was not confirmed in controlled studies in (in women who had discontinued their medications)3. Untreated women in the first trimester (and there is no evidence depression in and of itself poses risks for both the mother and the of a risk in later trimesters). Category C: Either studies in animals have revealed adverse effects neonate, resulting in increased risk of low birth weight, preterm on the fetus (teratogenic or embryocidal or other) and birth, maternal suicide, infanticide, and a range of psychosocial there are no controlled studies in women or studies in consequences including loss of supports, increased drug and al- women and animals are not available. Drugs should be cohol use, and lack of prenatal care. given only if the potential benefit justifies the potential risk to the fetus. The SSRIs have a mild side-effect profile. All are hepatically Category D: There is positive evidence of human fetal risk, but the metabolized, lipid soluble, cross the placenta and are excreted benefits from use in pregnant women may be accept- into breastmilk. Table 1 lists how drugs are categorized during able despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for pregnancy. Fluoxetine and sertraline are pregnancy category B, which safer drugs cannot be used or are ineffective). citalopram, escitalopram and venlafaxine (SNRI) are category C, Category X: Studies in animals or human beings have demon- and paroxetine has a category D status for increased risk of con- strated fetal abnormalities or there is evidence of fetal genital anomalies. Table 2 lists common SSRIs, their pregnancy risk based on human experience or both, and the risk category, percentage of dose transmitted to the fetus in breast- of the use of the drug in pregnant women clearly out- milk and half-life. weighs any possible benefit. The drug is contraind i- cated in women who are or may become pregnant. Newborns The effects of SSRIs in the newborn are related to its actions in There are multiple studies that have demonstrated an increased utero. Serotonin regulates cardiovascular and respiratory func- risk of respiratory distress in SSRI-exposed newborns (8,9) . The tion, circadian rhythms, is a trophic signal for CNS development, most troubling study demonstrates an increased risk of persistent plays a direct role in pulmonary artery smooth muscle develop- pulmonary hypertension in SSRI-exposed neonates. Chambers ment, modulates nocioception and assists in platelet aggregation. et al. demonstrated an odds ratio of 6.1 of developing PPHN for SSRI-exposed infants over unexposed infants 10 . This would Infants exposed to SSRIs exhibit both unusual symptoms and in- translate to an absolute risk of 6-12 per 1,000 live births. SSRI creased incidence of some usual complications. Symptoms in- exposure before 20 weeks gestation or other antidepressant exp o- clude irritability, restlessness, tremor, hypotonia, respiratory dis- sure did not increase the risk of PPHN. In studies that have ex- tress, feeding problems. Other, less common symptoms include amined the timing of exposure, none have demonstrated signifi- hyper-reflexia and myoclonus, continuous crying, sleeping prob- cant effects in babies exposed before the third trimester. lems 4 . This has been termed the “neonatal behavioral sydrome”. There are excellent studies showing attenuated pain response in One critical question is whether infants with in utero SSRI exp o- SSRI-exposed infants11,12 . However, the long-term implications sure are experiencing withdrawal or serotonin toxicity. Both of this are unclear. There are case reports of Continued on p. 13
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 13 Issue No. 1 2007 home. Symptomatic infants should be treated with supportive Neonatal Medicine Update Continued from p. 12 care: low noise, low lights, swaddling and kangaroo care as much as possible. Infants with severe symptoms may need phar- intracranial hemo rrhage in term SSRI-exposed infants with no macotherapy. There is no clear protocol, but SSRIs should not other risk factors for bleeding, but no higher-level evidence cur- be given to the baby due to the possibility of toxicity. rently exists4 . Finally, it is critical that pediatricians continue to assess women The biggest question for pregnant women is that of long-term for depressive symptoms during routine well child care as un- effects. There have been 13 studies of long-term effects on neu- treated maternal depression may have harmful consequences on rocognitive development. 11 have found no long-term effects, 2 a developing child. demonstrated mild motor delay 13 . To date, no study has shown any long lasting effects on cognitive, emotional or behavioral References development. 1. Gaynes, BN, Gavin, N, Meltzer-Brody, S, et al. Perinatal de - pression: prevalence, screening accuracy, and screening out- comes. Evid Rep Technol Assess (Summ) 2005; 1. Table 2. (Data taken from Hale TW. Medications and Mother’s 2. Reefhuis et al. Selective serotonin-reuptake inhibitors and Milk . In 12th edition. Amarillo, Texas: Hale Publishing; 2006.) persistent pulmonary hypertension of the newborn. N Engl J Infant dose Med. 2006; 354(20):2188-90; author reply 2188-90. Pregnancy (relative % in 3. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major Drug Name Category Breastmilk) Half Life (hrs) depression during pregnancy in women who maintain or dis- Fluoxetine B 6.8 1 to 3 days continue antidepressant treatment. JAMA 2006; 295:499-07. 4. Nordeng H and Spigset O. Treatment with Selective Seroton- Norfluoxetine 7 to 15 days in Reuptake Inhibitors in the Third Trimester of Pregnancy: (active metabolite) Effects on the Infant. Drug Safety 2005; 28(7):565-581. Sertraline B 2.2 26-65 5. Nordeng et al. Neonatal Withdrawal Sydrome After In Utero exposure to Selective Serotonin Reuptake Inhibitors. Acta Paroxetine D 2.1 21-26 Peadiatr 2001; 90:288-291. Citalopram C 3.6 36 6. Levinson-Castiel et al. Neonatal Abstinence Syndrome After In Utero Exposure to Selective Serotonin Reuptake Inhibitors Escitalopram C 27-32 in Term Infants. Ach Pediatr Adolesc Med 2006; 160:173- Venlafaxine C 6.4 5-11 176. 7. Laine et al. Effects of Exposure to Selective Serotonin Reup- take Inhibitors During Pregnancy on Sertonergic Symptoms Lactation in Newborns and Cord Blood Monoamine and Prolactin Con- All SSRIs are transmitted via breastmilk to the infant, however centrations. Ach Gen Psychiatry 2003; 90:720-726. the relative infant dose varies (Table 2). It is clear that many in- 8. Oberlander et al. Neonatal Outcomes After Prenatal Exposure fants can be exclusively breastfed and demonstrate no adverse to Selective Serotonin Reuptake Inhibitor Antidepressants effects even in the face of high infant serum drug levels. There and Maternal Depression Using Population-Based Linked have been case reports of infants with worsening symptoms and Health Data. Arch Gen Psychiatry 2006; 63(8):898-906 high levels who may have been poor metabolizers. Reviewing 9. Costei et al. Perinatal Outcome Following Third Trimester the current literature, it seems that breastfeeding is safe, and Exposure to Paroxetine. Arch Pediatr Adolesc Med 2002; there is no reason to check levels unless the infant is symptomat- 156:1129-1132 ic. If infants become symptomatic, checking levels and consider- 10.Chambers et al. Selective Serotonin Reuptake Inhibitors and ing discontinuing nursing or switching the mother to a medica- Risk of Persistent Pulmonary Hypertension of the Newborn. tion with a shorter half-life or lower infant dose could be consid- NEJM 2006; 354(6): 579-587. ered. 11.Oberlander TF et al. Pain Reactivity in 2-Month-Old Infants After Prenatal and Postnatal Selective Serotonin Reuptake Recommendations Inhibitor Medication Exposure. Pediatrics 2005; 115(2):411- Our recommendations given the current literature for pregnant 425. women include: screen for depression and try adjunctive thera- 12.Morag I et al. Paroxetine Use Throughout Pregnancy: Does It pies (cognitive-behavioral therapy, psychotherapy). If medical Pose Any Risk to the Neonate? J of Toxicology – Clinical therapy is needed, paroxetine should be avoided due to its cate- Toxicology 2004; 42(1):97-100. gory D status. Other SSRIs may be used after a discussion with 13.Gentile, S. SSRIs in Pregnancy and Lactation: Emphasis on the patient regarding the risks and benefits of therapy, both for Neurodevelopmental Outcome. CNS Drugs 2005; 19(7):623- herself and for her infant. The minimum effective dose should be 633. used, and polypharmacotherapy should be avoided if possible. Newborns born to mothers on SSRIs in the third trimester are clearly at risk of complications. They should be monitored closely, likely for 48 hours. Close follow-up should be assured, given the risk that symptoms may develop after discharge to
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 14 Issue No. 1 2007 Hospitalists On-Line Non-Compete and Restrictive Covenant Clauses: Pro and Con The issue of non-compete or restrictive covenant clauses in employment contracts for hospitalists is a hotly debated topic. The fol- lowing two authors have bravely decided to offer their opinions on both sides of the discussion. Pro: Con: Non-Compete Clauses in Physician Contracts – Restrictive Covenants: Appropriate for Small Why They Are Good For Hospitals Business But Not for Hospitals Phil Kibort, MD, MBA Richard Rohr, MD, MMM Vice President Medical Affairs and Chief Medical Officer Director, Hospitalist Service, Milford Hospital Children’s Hospitals and Clinics of MN Chair, Medical Procedures Subcommittee, SHM Phil.kibort@childrensmn.org Richard.rohr@milfordhospital.org I will start by stating that I am writing this piece from the view- Restrictive covenants were originally created to protect small point of the hospital, which has its own unique set of fiduciary business owners. For example, when selling a small business in responsibilities. If I were a physician who was still in practice or which the owner deals directly with customers (as in a medical who had recently applied for a job, I would not automatically practice), the purchaser often pays a premium over the asset feel comfortable signing a contract with a non-compete clause, value of the business with the expectation that the established as many others have stated. Nevertheless, although the state of customers will continue to patronize the business. This premium employment determines the degree to which they are enforce- is called the goodwill value. If the former owner then sets up a able, non-compete clauses are a reality that many physicians new business in the same general area as the original business, must face. the customers may go to the new location. The new owner of the original business will not receive the goodwill value. Thus, sales The most important reason for hospitals to use non-compete contracts for small businesses typically contain clauses that pre- clauses in contracts with individual physicians and physician vent the seller from opening a similar business within a specified groups is to ensure that the hospital’s interests are protected if radius of the original business for a certain length of time. These and when the physician or group decides to leave. If a physician covenants not to compete, also called restrictive covenants, are or group moves to a competitor’s system, the original hospital or an essential part of commerce. hospital system may suffer politically, economically, and from a market standpoint. Physicians possess several attributes, such as The use of restrictive covenants has been extended to situations knowledge and technical skills, that hospital systems utilize to in which an employee joins an established business, develops be successful. Because hospitals are competing with other local relationships with customers, and then leaves to set up a compet- institutions, it is in their interest not to allow these attributes toing business. The employee is using the goodwill created by the be utilized by their competitors. former employer to establish his or her own business faster than would be the case if he or she had set up shop without joining the Non-compete clauses also allow hospitals to protect prior invest- other business first. While there is a legitimate role for restrictive ments associated with the recruitment and hiring of physicians, covenants in this situation, it must be noted that the employee including travel and moving expenses, office space and equip- starts creating his or her own goodwill from the first day of em- ment, staffing, salary and benefits, as well as the time spent coor- ployment. After a period of time, the goodwill generated by the dinating the process. For most physicians, the monetary invest- employee may equal or surpass the goodwill generated by the ment can range from a quarter to a half a million dollars. If the employer. physician leaves to work for the competitor, the move not only hurts the hospital financially, but it also causes the hospital to go As a result, many lawyers now suggest that employment agree- through the entire recruitment process again. ments contain a liquidated damages provision in place of a re- strictive covenant. Liquidated damages refers to a fixed and Finally, consider the ramifications for the employer if it hires a agreed upon sum of money to be paid in the event of a breach of bright and eager physician who can leave at will. The employer contract. In the aforementioned situation, the goodwill value is provides the employee with unlimited access to referral sources, determined in advance. It should decrease over time, reaching patient lists, business models, and payer contract agreements. If zero within a few years. At any time, the employee can buy out the employee leaves, relocates geographically close to the former of the contract for the specified price with no further restrictions. employer, and then sends a letter to each of the former em- ployer’s patients, it could have a substantial negative impact on Neither restrictive covenants nor liquidated damages provisions the former employer. are appropriate for hospitalists employed directly by a hospital or medical school for several reasons. First, if a physician leaves the Non-compete clauses are the right thing to do with regards to the hospital to establish an independent practice, there is no loss of hospital’s fiduciary role. The hospital has legitimate interests to goodwill. The former employee may refer patients to the hospital protect, and non-compete clauses do not keep physicians from for care, and the hospital can continue to use the same methods applying their skills except in a very as before to encourage other patients to use Continued on p. 15 Continued on p. 15
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 15 Issue No. 1 2007 Billing and Coding Corner questions by accessing http://www.ama -assn.org and either logging in with your AMA ID if you are a member, or cre - ating an account): Same Day Admit/Discharge 2. Services are billed when the physician does the work. They Kathy Lindstrom, RHIT are not based on times other staff did their work, nor are Coding Training Manager they based on times when the patient is physically admitted Children’s Hospitals and Clinics of Minnesota to the hospital. Kathy.Lindstrom@childrenshc.org If the attending did not see the patient until the second day, and Sheldon Berkowitz, MD, FAAP on the second day, performed the work of both the admit and Children’s Hospitals and Clinics of Minnesota the discharge, then it would be appropriate to bill using codes Sheldon.Berkowitz@childrensmn.org 99234-99236 (admit and discharge same day). This past summer, our section’s LISTSERV® had a flurry of From the AMA CPT Information Services: "initial hospital care discussion on the subject of coding for same day admit and dis- is the date the admitting physician had the first hospital inpa- charge. As you can imagine, there was quite a bit of variability tient encounter with the patient…if the physician provided all in how section members interpreted the coding “rules”. As a three of the key components …(history, examination and medi- result, I posed the following question to Kathy Lindstrom, Cod- cal decision making) and discharged the patient on the same ing Training Manager at Children’s Hospital and Clinics of date, then the admitting physician should report the appropriate Minnesota. level observation or inpatient care services… performed for that date of service." (Personal communication between Martha A patient is admitted in the evening and seen by the house staff. Espronceda of the AMA and Kathy Lindstrom of Children’s However, the attending physician does not see the patient until Hospitals and Clinics of MN, July 7, 2005) the next morning, at which time an Admission History and Physical is performed. Either at that time or later the same day, In the scenario presented, codes 99234-6 should be used, a decision is made that the patient can be discharged home depending on the length of time involved and/or complexity. (appropriately documented in the chart). Can the codes for One additional question related to this topic is whether provid- Same Date Admit/Discharge (99234-99236) be used or must ing telephone oversight to the admitting resident the night the a Discharge code (99238-9) be used, since the patient was ad- patient is admitted, even though the attending physician does mitted the previous day? not see the patient until the next morning, affects how you bill. Since the attending physician can only bill for services when the 1. Here is Ms. Lindstrom’s response, including a response patient is physically seen by him/herself, then the first billing from the American Medical Association’s CPT Information would be the day that the attending sees the patient. Services (you can contact the AMA directly with coding Hospitalists On Line a patient has the right to choose his or her own physician, and that this right supersedes the need of the employer to protect Non-Compete and Restrictive Covenant Clauses whatever degree of goodwill exists. Pro: Continued from p. 14 Third, hospitals may argue that it is expensive to recruit employ- confined area, for a short period of time. Non-compete clauses ees, but the correct way to minimize recruitment expenses is to help hospitals protect themselves against the threat of a physi- treat employees well with the intent of maximizing retainment. cian departing with a host of patients that he or she acquired Hospitals may try to recoup moving expenses from employees only through his or her association with the hospital. In place of who leave within a short period of time, but this is a separate non-compete clauses, hospitals can instead require liquidated matter from restrictive covenants. Fourth, when there are mult i- damages. In this case, the physician is required to pay the insti- ple competing hospitals in the same geographic area, one institu- tution if they decide to leave. The payment may reflect their por- tion may utilize restrictive covenants in an attempt to keep em- tion of the overhead for one year or a fraction of their salary. ployees from going to a competitor. However, this incorrectly Con: Continued from p. 14 implies that employees are property of the hospital, and there- its services. Second, the Tennessee Supreme Court has ruled that fore should not be permitted by the courts. Palliative Care Subcommittee Continued from p. 5 Otherwise, I will be meeting with my Pediatrics Department Chair in December to formalize plans for a program in Detroit." Meeting updates: • Annual Assembly of the American Academy of Hospice and Palliative Medicine, February 14-17th in Salt Lake City, UT. Visit http://www.aahpm.org/ for more details. • The Ohio Pediatric Palliative & End-of-Life Care Network (OPPEN) in conjunction with the Michigan Alliance for Pediatric Pal- liative Services (MAPPS) is hosting a pediatric palliative care conference in Akron, OH, on October 4-6, 2007. More info to follow. If you are interested in joining the Palliative Care Subcommittee please contact: Maggie Hood (Maggie.hood@multicare.org).
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 16 Issue No. 1 2007 Pediatric Hospital Morbidity & Mortality Spotlight on Root Cause Analysis • A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk Mary Ellen Valletta, MD, JD, FAAP thereof. Serious injury specifically includes loss of limb or Assistant Clinical Professor function. The phrase “or the risk thereof” includes any proc- Pediatric Hospitalist, Inpatient Director ess variation for which a recurrence would carry a signifi- University of Florida College of Medicine cant chance of a serious adverse outcome. valleme@peds.ufl.edu • Such events are called “sentinel” because they signal the Case Presentation need for immediate investigation and response. Patient is a 12 year old male who was admitted through the ED on a Friday for fever and a warm, tender, erythematous area Root Cause Analysis (RCA) around the right ankle. There was a preceding insect bite which • development of an action plan to reduce risk of started as a small pustule but three days later had developed into recurrence a warm, erythematous painful swelling. The resident team in the • implementation of the action plan ER cultured the wound and initiated IV antibiotic therapy with clindamycin for coverage of possible CA-MRSA based on • evaluatio n of the effectiveness of the action plan prevalence in the community. The intake nurse recorded a peni- The terms “sentinel event” and “medical error” are not synony- cillin allergy and noted a history of “respiratory distress and mous; not all sentinel events occur because of an error and not rash” as the reaction. The allergy was recorded in the hospital all errors result in sentinel events. [2] electronic database and reflected in pharmacy records. The pa- tient was admitted to the floor for IV antibiotic therapy with clin - In evaluating our case scenario above, a sentinel event as defined damycin. clearly occurred. Although the event did not cause any serious The weekend team cross-covering the floor patients followed up injury, it certainly could have. This patient could have experi- on the culture which was positive for methicillin sensitive enced anaphylaxis when exposed to the oxacillin. Our case sce- staphylococcal aureus and tailored the antibiotic coverage by nario here, like many, was a “near miss.” Because “near switching to oxacillin. The allergies were not noted on the resi- misses” are neither JCAHO reviewable nor reportable events, the dent check out sheet. The resident writing the order did not con- actual response by the institution remains in the discretion of the firm allergies prior to writing the order. The medication was dis- institution’s leadership. An event might be screened and no de- pensed by pharmacy despite the pharmacy records reflecting the tailed analysis done because the cause was obvious and simply allergy. Nursing dispensed the medication despite the band on averted. However, JCAHO expects an “appropriate response” to the patient’s wrist reflecting the penicillin allergy. The patient the “near miss.” An “appropriate response” as outlined by after having received several doses given by multiple nurses de- JCAHO includes a “Root Cause Analysis” (RCA); development veloped itching and rash and the error was ultimately discovered. of an action plan to reduce risk of recurrence; implementation of Fortunately, the patient never developed any respiratory distress the action plan; and evaluation of the effectiveness of the action or anaphylactic reaction to the oxacillin. plan. [2] The “near miss” here was certainly unique and clearly exposed A sentinel event is an unexpected occurrence involv- deficiencies in the system processes. As a defined sentinel ing death or serious physical or psychological in- event, JCAHO expects that the institution will perform RCA on jury, or the risk thereof. this “near miss.” But how do we uncover the real root cause of a sentinel event? How do we perform RCA? Most hospitals have a multidisciplinary team which performs RCA on a regular basis. Discussion Many practitioners though are unfamiliar with the process. Nu- The Institute of Medicine (IOM) in its 1999 report To Err Is Hu- merous different techniques exist for performance of RCA. man, Building a Safer Health Care System spotlighted the mo r- JCAHO requires certain characteristics for the RCA to be ac- bidity and mortality resulting from medical errors. [1] As one ceptable. There must be participation by the key individuals in- might suspect, medication related errors constituted the majority. volved in the systems and processes under review (i.e., phar- In an attempt to reduce medical errors, the Joint Commission on macy, nursing, etc.) as well as individuals involved in the institu- Accreditation of Healthcare Organizations (JCAHO) responded tion’s leadership. The RCA should focus on systems and proc- by requiring participating hospitals to identify and respond esses, not an individual’s performance. It should start from the “appropriately” to all “sentinel events.” A particularly egregious specifics of the scenario and broaden to the common cause in the subset of sentinel events are reportable to and reviewable by organizational processes. Repetitively asking “Why?” forms the JCAHO, including but not limited to patient death, paralysis, basis of the analysis. What were the human and other factors coma or other major permanent loss of function associated with a most associated with the event? The focus then shifts to “How?” medication error. Fortunately or unfortunately, the “near miss,” How can one redesign or implement new system checks or proc- although requiring an “appropriate response” by the hospital, is esses which would reduce the likelihood of recurrence? not reviewable by JCAHO. [2] In evaluating our case scenario above, our Continued on p. 17
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 17 Issue No. 1 2007 Pediatric Hospital Morbidity & Mortality Continued from p. 16 lergy has to actually be removed by order of the Sample Root Cause Analysis for Adverse Drug Event physician. The goal of the action plan is to What happened? Why did this happen? Risk-Reduction Strategy? eliminate human factors and fallibility by creat- Proximate Cause Contributing Factors Action Plan ing additional safeguards. Obviously, numerous different approaches could be considered before Resident Physician 1. Check out sheet did not • Senior resident reviews deciding upon one. ordered drug to which reflect allergy. adequacy of sign-out sheets. patient was allergic. 2. Resident did not confirm • Address workload of residents Although institutions are encouraged to self re- allergies. 3. Resident distracted and education training. port sentinel events and submit RCAs, they are because of busy • Create new order page which not required to. For those sentinel events re- schedule. reflects allergies with patient ported and/or reviewed, JCAHO may conclude 4. Allergies were not name for each order sheet. that such events have been sufficiently frequent reflected at top of order • Door/bed signage and bright across member hospitals to warrant a “Sentinel page. fluorescent colored wrist band on Event Alert.” A Sentinel Event Alert is in the 5. Resident assumed extremity which IV site is. nature of a collective RCA, sort of “lessons pharmacy would double • Consider institution of check order. learned.” These alerts are published and me m- Electronic Medical Record 6. Patient a minor and not (EMR). ber hospitals are expected to follow the intended familiar with allergies. • Consider use of Computerized action plan reflected in those alerts. [3] An exa m- Physician Order Entry (CPOE). ple is the medication reconciliation form now required upon transfer of patient care from one Pharmacy dispensed 7. Too many alerts such that • Reevaluate pharmacy program; level to another or one practitioner to another. [4] medication to which allergy alert ignored. consider program with patient was allergic. 8. No way for program to prioritized alerts. RCAs are labor intensive and have a significant reflect severity of allergic • If allergy alert, require cost to the institution. Their reliability and con- response. clusions are not subjected to scrutiny or con- pharmacist to call ordering or on 9. Too easy for pharmacist to call physician to confirm order.trolled studies. [5] However, they remain an inte- override alert. No click of the button overrides. gral part of JCAHO’s expectations for accredited • Eliminate ability to overr ide member hospitals. For those pediatric hospital- allergy when history of severe ists who participate in quality improvement in i- allergy. tiatives, implementing or participating in the Multiple nurses 10. Trainee nurses acting • Readdress staffing and workload process of RCA can be very revealing and lead administered drug to without supervision. issues. to implementation of changes that significantly which patient was 11. Arm band and alerts • Evaluate adequacy of supervi- improve pediatric inpatient safety. The next, allergic. ignored, perhaps not more proactive step in pediatric inpatient safety, sion and training of trainee sufficiently obvious as nurses. involves the use of the Failure Mode and Ef fects multiple nurses ignored same. • Readdress manner and display Analysis (FMEA). FMEA is often confused of alerts. with RCA but is clearly a distinct and different entity. FMEA is intended to be proactive (not reactive like a hospital’s RCA requires us first to evaluate the event in detail. RCA). Specific high risk processes are targeted for analysis with Consideration should be given to whether it occurred during shift the focus to prevent events from occurring rather than avoiding change, the weekend, by cross-cover teams, etc. The second step recurrences. For a detailed discussion of FMEA and tools acces- is to evaluate the proximate causes of the event. Here, the ad- sible see link below. [6] The pediatric hospitalist, by constant in- verse drug event occurred because of three proximate causes: patient management, is in the unique position of discovering pre- one, the physician wrote an order for an antibiotic to which the ventable errors in the inpatient setting and becoming a true advo- patient was allergic, that two, pharmacy dispensed, and three, the cate for pediatric patient safety. nurse(s) administered. Third, one needs to evaluate the latent errors or contributing factors that led to the proximate causes. RCA tools are accessible at http://www.jointcommission.org/ SentinelEvents/Forms/. The final step is to create an action plan. In the scenario above, numerous changes could be considered which would prevent re- References currence. One, the institution could purchase and implement 1. Kohn L, Corrigan J, Donaldson M (eds). To Err is Human: CPOE, although the same error might have been made by the Building a Safer Health System. Washington DC: National physician if there are too many annoying, insignificant alerts on Academy Press, 2000. the CPOE. Two, the pharmacy program could be altered such 2.Joint Commission on the Accreditation of Healthcare Organi- that the pharmacist can no longer override an allergy alert with- zations. Sentinel event policy and procedures. Available at: out contacting the ordering physician and documenting such con- http://www.jointcommission.org/SentinelEvents/ tact. Three, the pharmacy program could be altered such that PolicyandProcedures/ Accessed Nov 14, 2006. history of a serious allergic response (respiratory distress, 3. Joint Commission on the Accreditation of Healthcare Organi- Stevens-Johnson, etc.) does not permit override at all. The al- References continued on p. 18
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 1818 Page Issue No. 1 2007 8 symptoms of pain and swelling. You Are the Consultant Continued from p. 7 As a pediatric hospitalist, you are often challenged with the task bowel disease present with symptoms of abdominal pain and of figuring out complex patient diagnoses with multi-organ sys- bloody diarrhea, extra -intestinal manifestations occur in 25-35% tem involvement. Early input from multiple subspecialists can of patients.6 Arthritis is one of the more common extra-intestinal be helpful, especially when a differential includes serious and manifestations of IBD and may precede the onset of gastrointes- life-threatening illnesses as in this case or when there is risk for tinal symptoms. Usually the arthritis is episodic, lasting a period rapid clinical deterioration, which seemed unlikely in this pa- of weeks, and is most commonly oligoarticular, involving the tient. Input from multiple subspecialists is also helpful when large joints of the lower extremity. Patients with IBD often have prioritizing diagnostic tests that are invasive, difficult to obtain, weight loss, poor growth, and fatigue. Mucocutaneous findings expensive, or have long delays to getting results. However, a often include erythema nodosum or pyoderma gangrenosum and pediatric hospitalist can often initiate an appropriate work-up in aphthous ulcers are common. Ocular involvement is rare but a stable patient. In some settings, it is a key role of the pediatric may cause uveitis or episcleritis in 2-5% of patients with IBD.7 hospitalist to prioritize tests when multiple consultants are rec- Laboratory abnormalities may include anemia, mildly elevated ommending several studies. A sequential approach, instead of a hepatic enzymes, and hypoalbuminemia. Despite the systemic “shot-gun” approach may help limit expense, inconvenience, (fever, weight loss, fatigue) and extra-intestinal (arthritis, epis- discomfort, and risk but must be balanced against potential de- cleritis) complaints, the chronicity of your patient’s symptoms lays in arriving at a diagnosis. with the absence of gastrointestinal complaints placed this diag- References nosis lower on the differential. Also, your patient had lym- 1. Bader-Meunier, B. Initial presentation of childhood-onset sys- phopenia and thrombocytopenia, which are not typical of IBD. temic lupus erythematosus: a French multicenter study. J Pedi- Various infectious etiologies should be considered in a patient atr 2005; 146(5): 648-53. presenting with prolonged, unexplained fevers, weight loss, ma l- 2. Gottlieb, BS. Systemic Lupus Erythematosus in children and aise, and arthralgias. HIV can certainly cause these symptoms as adolescents. Pediatr Rev 2006; 27 (9):323-30. well as the bone marrow dysfunction leading to pancytopenia. 3. Burge, SM. Mucosal involvement in systemic and chronic Because your patient denied sexual activity or other high-risk cutaneous lupus erythematosus. Brit J Dermatol 1989; 121 behaviors and her history did not seem suspicious for sexual (6):727-41. abuse, you first investigated other etiologies to account for her 4. Ostrov, BE, Goldsmith, DP, Athreya, BH. Differentiation of presentation. Viral infections such as CMV and EBV can cause systemic juvenile rheumatoid arthritis from acute leukemia near these symptoms however the course of illness is typically the onset of disease. J Pediatr 1993; 122:595. shorter and often includes lymphadenopathy, hepa- 5. Jones, OY. A multicenter case-control study on predictive tosplenomegaly, and elevated hepatic enzymes. Brucellosis can factors distinguishing childhood leukemia from juvenile rheu- be an indolent cause of such nonspecific symptoms with pancy- matoid arthritis. Pediatrics 2006; 117(5): e840-4. topenia though your patient denied any exposure to animal prod- 6. Hyams, JS. Inflammatory bowel disease. Pediatr Rev 2005; ucts or ingestion of unpasteurized milk. Tuberculosis is a possi- 26(9):314-20. ble cause of fevers, weight loss, and malaise, but osteoarticular 7. Petrelli, EA, McKinley, M, Troncale, FJ. Ocular manifesta- tuberculosis is rare in immunocompetent patients and typically tions of inflammatory bowel disease. Ann Ophthalmol 1982; involves the spine or weight-bearing joints with more localized 14:356. 8. Gardam, M. Mycobacterial osteomyelitis and arthritis . Infect Dis Clin North Am 2005; 19(4): 819-30. Section on Pediatric Hospital Morbidity & Mortality Hospital References Continued from p. 17 zations. Sentinel Event Alert. Available at: http://www. Medicine jointcommission.org/SentinelEvents/SentinelEventAlert/ Accessed Nov 14, 2006. If you’d like to 4. Joint Commission on the Accreditation of Healthcare Organi- zations. Sentinel Event Alert. Using Medication Reconciliation • receive Professional Opportunities To Prevent Errors. Available at: http://www.jointcommission. listings by email, org/SentinelEvents/SentinelEventAlert/sea_35.htm Accessed • review current pediatric hospitalist Nov 14, 2006. resources, 5. Evidence Report/Technology Assessment Number 43 Making Health Care Safer: A Critical Analysis of Patient Safety Practices or Prepared for: Agency for Healthcare Research and Quality U.S. • find out what other programs are Department. Wald H, Shojania KG, Chapter 5. Root Cause doing, Analysis. http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf visit the SOHM Web site. Accessed Nov 14, 2006. 6. Institute for Healthcare Improvement. http://www.ihi.org/ihi/ www.aaphospmed.org workspace/tools/fmea/ Accessed Nov 14, 2006.
  • THE SECTION ON HOSPITAL MEDICINE NEWS Page 20 Issue No. 1 2007 SOHM Executive Committee Committee on Hospital Care Laura J Mirkinson, MD Erin R Stucky, MD Chairperson Chairperson PH: 301/754-7232 PH: 858/966-5841 EM: mirkil@holycrosshealth.org EM: estucky@chsd.org Jennifer A Daru, MD Jamie Calabrese, MD PH: 773/296-7905 PH: 412/420-2268 EM: jadaru@gmail.com EM: jca@the-institute.org Yong S Han, MD Patricia S Lye, MD PH: 832/824-2289 PH: 414/789-1817 EM: yshan@texaschildrenshospital.org EM: plye@mcw.edu Timothy H Hartzog, MD Sanford M Melzer, MD PH: 843/876-8512 PH: 206/987-2622 EM: tim@hartzoghealth.com EM: sandy.melzer@seattlechildrens.org Daniel A Rauch, MD Anthony L Pearson-Shaver, MD, MHSA PH: 914/493-7235 PH: 706/721-4402 EM: daniel.rauch@med.nyu.edu EM: tpearson@mail.mcg.edu Michael E Ruhlen, MD PH: 419/291-5643 LIAISONS: EM: michael.ruhlen.md@promedica.org Laura J Mirkinson, MD Section on Hospital Medicine Representative Jack M Percelay, MD, MPH Immediate Past Chairperson Brad W Warner, MD PH: 201/670-3603 Section on Surgery Representative EM: jpercelaymd@yahoo.com Chris Brown Julia Aquino, MD Liaison, Child Life Council Section on Residents Representative Susan Dull, RN, MSN, MBA AAP STAFF: Liaison, National Association of Children’s Hospitals and S Niccole Alexander, MPP Related Institutions (NACHRI) Manager Division of Hospital and Surgical Services Barbara DeBenham Meeks, RN, MSN, MBA Department of Community and Specialty Pediatrics Liaison, American Hospital Association (AHA) American Academy of Pediatrics 141 Northwest Point Blvd CONSULTANTS: Elk Grove Village, IL 60007-1098 Timothy E Corden, MD PH: 847/434-4799 JCAHO Hospital Professional and Technical Advisory EM: nalexander@aap.org Committee Representative Copyright © 2007 American Academy of Pediatrics Section on Hospital Medicine