CHOC Named One of the Safest Hospitals in the Nation

CHOC Children’s Hospital has once again been named a “Top Hospital” by The Leapfrog Group for providing the safest and highest quality health care services to patients.  CHOC is one of only nine children’s hospitals in the nation—and the only one on the West Coast— to earn the prestigious distinction.

“CHOC is committed to becoming the world’s safest children’s hospital. While this is a never-ending journey, being named as a Top Children’s Hospital for the eighth time by the Leapfrog Group suggests we are on the right track. Leapfrog has always emphasized patient safety as the top priority, one with which our patients, families and partners would no doubt agree. It’s a humbling honor, and serves as both encouragement and motivation to continue our efforts to provide the safest, highest quality care possible,” said Dr. James Cappon, chief quality officer, CHOC.

The selection of Top Hospitals is based on the results of the 2016 Leapfrog Hospital Survey. Performance across many areas of hospital care is considered in establishing the qualifications for the award, including infection rates and a hospital’s ability to prevent medication errors. The rigorous standards are defined in each year’s Top Hospital Methodology.

“Being acknowledged as a Top Hospital is an incredible feat achieved by less than three percent of hospitals nationwide,” said Leah Binder, president and CEO of The Leapfrog Group. “With this honor, CHOC has established its commitment to safer and higher quality care. Providing this level of care to patients requires motivation and drive from every team member. I congratulate CHOC’s board, staff and clinicians, whose efforts made this honor possible.”

 

Infantile Spasms: What Pediatricians Should Know

Though seizures in children are always worrisome, pediatricians should be especially watchful for infantile spasms, a type of epilepsy that occurs in young infants typically between ages 3 and 8 months, a CHOC Children’s neurologist says.

These seizures should be considered a medical emergency due to the potentially devastating consequences on the developing brain, Dr. Mary Zupanc says. Many children with infantile spasms go on to develop other forms of epilepsy because a developing brain undergoing an epileptic storm essentially becomes programmed for ongoing seizures and cognitive/motor delays.

To that end, here’s what pediatricians should look for:

  • Infantile spasms often occur in clusters, with each spasm occurring every five to 10 seconds over a period of minutes ranging from three to 10 minutes or longer.
  • Though there is almost always a cluster of spasms in the morning when the child awakens from sleep, infantile spasms can occur at any time during the day or night.

Infantile spasms can be easily missed because they can mimic common symptoms and conditions such as sleep disturbances, gastroesophageal reflux, startle and shuddering attacks.

Diagnosis, treatment

If infantile spasms are suspected, a pediatrician should quickly refer the child to a pediatric neurologist. CHOC neurologists admit these children urgently for long-term video electroencephalogram (EEG) monitoring to confirm the diagnosis.

Infantile spasms are diagnosed on the basis of clinical spasms, in association with a markedly abnormal EEG showing a hypsarrhythmia pattern. A hypsarrhythmia pattern is characterized by very high amplitude electrical activity and multifocal areas of the brain demonstrating epileptic discharges.

High-dose adrenocorticotropic hormone, or ACTH, is CHOC neurologists’ first line of treatment for infantile spasms, per the American Academy of Neurology’s 2004 practice parameter. Vigabatrin (Sabril), the parameter states, is probably effective in the treatment of infantile spasms, especially in children with tuberous sclerosis and infantile spasms.

If started within four to six weeks of seizure onset therapy has better success at stopping spasms, eliminating the hypsarrhythmia pattern and improving developmental outcomes regardless of etiology.

The course of treatment is approximately six weeks. During this time, and for two to three months after the ACTH course, immunizations should not be administered. The effectiveness of ACTH may be as high as 85 percent, though a recent published study placed the efficacy at a slightly lower percentage, regardless of etiology.

Side effects, causes

Side effects of ACTH, a steroid, include high blood pressure, increased appetite and weight gain, increased sugar in the blood, temporary suppression of the immune system, and sometimes gastritis. All side effects are monitored during the time of the ACTH, and they disappear after the course of treatment.

Successful therapy is marked by two achievements: the cessation of the infantile spasms and the elimination of the hypsarrhythmia pattern. But because clinical spasms can be very subtle and the hypsarrhythmia pattern may sometimes only be seen during deep sleep, therapy’s success can only be confirmed through objective long-term video EEG monitoring.

The etiologies for infantile spasms can include:  tuberous sclerosis; cortical dysplasias; stroke; infection including meningitis and encephalitis; hypoxic-ischemic injury; trauma; or genetic conditions such as Down syndrome and metabolic disorders.

 

CHOC Children’s Clinicians Ensure Happy Holidays for Families

The commitment and dedication of CHOC Children’s clinicians will ensure happy holidays for many families – including the McLeods.

This will be the first holiday season for the new family of four, only recently reunited at home following son Ryan’s 17-week stay in CHOC Children’s Small Baby Unit (SBU).

Ryan was born this past winter at just 27 weeks gestation and weighing only 2 pounds and 1 ounce.

The care for babies of his size and age is the very specialty of the SBU. A portion of CHOC’s neonatal intensive care unit (NICU), the unit is dedicated to the care of babies born with extremely low birth weights – those born at less than 28 weeks gestation or weighing less than 1,000 grams, or about 2 pounds and 3 ounces.

There, “micro-preemies” like Ryan receive coordinated care in a developmentally appropriate environment. A trailblazer in neonatal care nationwide, the unit is saving babies who just decades ago wouldn’t have likely survived.

“With its coordinated care in an environmentally appropriate location, the Small Baby Unit is designed to care specifically for babies like Ryan,” says Dr. Kushal Bhakta, Ryan’s neonatologist and medical director of the SBU. “When he came to the unit, he required significant ventilator support due to an ongoing infection, and he had a long road ahead of him.”

Danielle’s breezy pregnancy took a sudden turn early in her second trimester when her doctor found in her womb a subchronic hematoma, an indicator that she might deliver her baby early.

Danielle was put on bed rest, but a few weeks later, bleeding and signs of labor showed. At the hospital, doctors were able to stop the labor and admitted Danielle to keep it from beginning again too early. But about six weeks later, Danielle’s water broke and she underwent an emergency cesarean section.

On Valentine’s Day, after two weeks of ups and downs, Ryan was transferred to the SBU at CHOC and the McLeod family began their four-month journey.

“I don’t think people understand the pain that comes with having a child and not being able to hold him immediately or not being able to take him home shortly after delivery and share him with the world,” Danielle says.

“It was difficult knowing that there were many obstacles for Ryan to overcome before he could even think about coming home,” she says. “Simple things like eating by mouth, a task that should come naturally, are challenging for babies born premature.”

During that time, while also focusing on growing, Ryan also battled chronic lung disease and a brain bleed, and learned to eat and breathe on his own. Meanwhile, Danielle and husband, Jared, learned how to care for a baby born more than three months early.

“I’ll never forget our first day at CHOC,” she says. “I was so overwhelmed, scared, and nervous. Once Ryan was settled in the SBU, his nurse came in to do his very first set of cares. I sat and watched, afraid to touch him. He was so fragile. His nurse said, ‘Get in there, mama. You can do it.’ She had me put my hand on him, my hand covering his whole little torso. She talked me though what to do when caring for an extra small baby. From then on, I felt confident to be close to my little fighter.”

After 17 weeks in the SBU, Ryan finally went home to join his parents and brother. He still receives oxygen treatment and undergoes physical therapy twice a week, but is doing well.

“During his stay in the unit, Ryan overcame great obstacles, thanks to the partnership between his care team and his parents,” Dr. Bhakta says. “Our goal in the unit is to get our patients home with the best possible outcomes. Today, Ryan is doing well and has a bright future ahead.”

Overall, Ryan is doing well. Small but mighty, he is doing great at rolling over and pushing himself up, and is working toward sitting up by himself.

“He also loves smiling and laughing, especially at his big brother,” Danielle says.

“We’re moving in the right direction,” she says. “We are so grateful to all the wonderful nurses and doctors who cared for Ryan. I know he is doing so well because of the amazing care he received while in the SBU. We love our little fighter. He’s such a good baby. He is truly a miracle and we are blessed to be able to witness this little guy’s journey.”

CHOC Encourages Appropriate Use of Antimicrobial Agents

By: M. Tuan Tran, infectious disease pharmacist at CHOC, and Dr. Negar Ashouri, infectious disease specialist at CHOC

With the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission set to require the adoption of core elements of antimicrobial stewardship in 2017, CHOC Children’s will continue to uphold the appropriate use of antimicrobial agents through its existing antimicrobial stewardship program.

CHOC’s multidisciplinary collaborative’s goals include:

    • Optimizing selection, dosing and duration of therapy
    • Reducing adverse events including secondary infection (e.g. clostridium difficile infection)
    • Improving patient outcomes
    • Slowing the emergence of antimicrobial resistance
    • Preserving supply especially during critical shortages and reduce health care expenditures

The collaborative’s strategies include:

    • Pre-authorization of broad spectrum agents such as meropenem, cefepime, vancomycin, daptomycin and linezolid
    • Daily review (prospective audit with feedback) of antimicrobial orders
    • Development of care guidelines, dosing protocols and order sentences in the electronic health record
    • Dose optimization based on PK/PD principles (e.g. prolonged infusion of beta-lactams)
    • Document indication and duration for all antimicrobial orders
    • Antibiotic time-out at 48-72 hours to: reevaluate need to continue treatment; streamline, de-escalate based upon culture result; convert intravenous to oral route when appropriate; reassess optimal treatment duration
    • Track trends and share antibiotic utilization data as well as resistance trends
    • Provide education for staff, patients and family of optimal antimicrobial therapy use

Changes to clinical practice patterns to promote the appropriate use of antibiotics is a patient safety issue and public health imperative:  Antibiotics are the second most commonly used class of drugs in the United States, and studies indicate that 30 to 50 percent of antibiotics prescribed in hospitals are unnecessary or inappropriate. Further, antibiotic exposure is the single most important risk factor for the development of clostridium difficile infection.


“Through education and teamwork we can reduce the unnecessary use of antibiotics, therefore minimizing the risk of potential side effects to ensure we have effective antibiotics available for the generations to come.”

– Dr. Negar Ashouri, infectious disease specialist at CHOC


The Centers for Disease Control and Prevention (CDC) estimates that 2 million illnesses and 23,000 deaths are caused annually by drug-resistant bacteria in the U.S. alone. Avoidable costs from antibiotic misuse range from $27 billion to $42 billion per year in the U.S. At the same time, the discovery and development of new antibiotics have dropped precipitously from the 1980s onward. All antibiotics approved for use in patients today are derived from a limited number of classes of agents that were discovered by the mid-1980s (see figure 1).

Figure 1.

figure1

Source: A Scientific Roadmap for Antibiotic Discovery. The Pew Charitable Trusts, May 2016.

Here are some common reasons for misuse of antibiotics in health care settings:

  • Use of antibiotics when not needed
  • Continued treatment when no longer necessary
  • Use of broad-spectrum agents when more targeted/narrower options are available
  • Wrong antibiotic given to treat an organism/infection
  • Incorrect dosing and frequency

Antibiotics can also affect beneficial bacteria that are part of our normal flora:

  • An average child receives 10 to 20 courses of antibiotics before age 18
  • Antibiotics affect microbiota flora which may not fully recover after a course of antibiotics
  • Overuse of antibiotics may be contributing to obesity, diabetes, inflammatory bowel disease and asthma

For information about the appropriate use of antibiotics for your patients and families, please visit our CHOC Blog.

CHOC Neonatology by the Numbers

In honor of Prematurity Awareness Month, we share an inside look at our neonatologists and services they provide to care for babies daily in Orange County. CHOC Children’s is proud to have a Neonatal Intensive Care Unit (NICU) rated by the American Academy of Pediatrics as a Level 4 – the highest rating available. Our NICU is also rated among the top 35 NICUs in the nation by U.S. News & World Report. CHOC is proud to be entrusted with giving babies a healthy start.

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