CHOC Helps Parents with Prenatal Surgery Planning

CHOC surgical servicesSome babies are born with complex conditions requiring surgery during the first few hours following birth. From the moment prenatal testing reveals an abnormality, CHOC Children’s is ready to help with the prenatal care and birth planning necessary to ensure the best-possible outcome.

CHOC has a trained and experienced team that includes perinatologists, neonatologists, pediatric surgeons and NICU nurses to guide families through the months before delivery. And families are essential to the planning process.

“The well-being of the child is surprisingly dependent on the well-being of the family, both psychologically and emotionally,” said Dr. David Gibbs, division chief, pediatric surgery, CHOC Children’s Specialists. “Preparation helps the family cope better, and the family that is coping better is able to provide better care for their child.”

According to Dr. Gibbs, recent advances in the care and outlook for babies born with abnormalities have come from closer prenatal coordination with perinatologists and families, combined with highly specialized neonatal intensive care. The CHOC NICU is rated by the American Academy of Pediatrics as a Level 4 NICU, the highest designation available and given only to facilities that also provide onsite surgical repair of serious congenital or acquired malformations.

That immediate access to the full NICU medical team, resources and support is critical for babies born with gastroschisis, a condition that requires surgery within the first hour following birth, and omphalocele, which must be corrected within the first few days. For the smallest and sickest, CHOC’s Small Baby Unit offers additional support to help babies grow and recover more quickly with fewer infections and setbacks.

For babies born with congenital diaphragmatic hernia, the CHOC Surgical NICU provides the optimal environment in which to stabilize and gain strength before surgery. One room inside the CHOC NICU converts into a state-of-the-art operating room, allowing pediatric surgeons to perform delicate procedures within the unit.

And babies born with congenital cystic adenomatoid malformation (CCAM) may actually get to go home for continued evaluation months before surgery.

Dr. Gibbs added that an important element of prenatal planning is deciding in advance where your baby will be born. Moms who know their baby will need surgery may choose to deliver at a hospital that is near a pediatric facility like CHOC. When the baby is born, the CHOC Transport Team is ready 24 hours a day to transport the baby to CHOC from hospitals throughout the region. Specially trained and equipped, this team uses ground and air transportation to travel to and from hospitals throughout Orange, Los Angeles, Riverside, San Bernardino and San Diego counties — and even beyond.

“We expect most children will do well and have normal lives,” Dr. Gibbs said. “But the first step is meeting with the perinatologist, pediatric surgeon and NICU team. Starting that relationship as soon as possible will make the process of coping with what may seem to be an overwhelming process a lot easier.”

CHOC’s surgeons provide cardiothoracic surgery, gastrointestinal (GI) surgery, general surgery, neurosurgery, urological surgery, otolaryngological (ENT) surgery, plastic surgery, ophthalmologic surgery and orthopaedic surgery.

Learn more about surgical services at CHOC.

In the Spotlight: Neal Nakra, M.D.

Dr. Neal NakraAs medical director of the CHOC Children’s pediatric sleep program, Dr. Neal Nakra is examining sleep study data to further analyze the relationships between sleep and obesity, metabolic syndrome and other pediatric conditions.

Dr. Nakra’s initial interests in sleep medicine deepened during his pulmonary medicine fellowship at Yale-New Haven Hospital, in Connecticut. Already well aware of the respiratory issues associated with obesity, his research found that the presence of obstructive sleep apnea was associated with obesity and markers for metabolic syndrome.

He focused his interests in obesity, sleep apnea and metabolic syndrome, and became board certified in pulmonology, pediatrics and sleep medicine. A few years later, Dr. Nakra was co-director of the Cystic Fibrosis Center and associate director of the pediatric residency program at St. Joseph Children’s Hospital in New Jersey, when he heard about an opportunity at CHOC.

The CHOC Sleep Center had recently doubled in size, becoming one of the largest programs in the state. Dr. Nakra was drawn by the opportunity to grow the program further and to work with CHOC pediatric subspecialties.

“Sleep inherently deserves multidisciplinary treatment with other pediatric subspecialties,” said Dr. Nakra, who is working with CHOC otolaryngologists, plastic surgeons and endocrinologists. “One of the joys of practicing sleep medicine at CHOC is the ability to collaborate on a multidisciplinary platform, pick the brains of the best and brightest in the fields, and work together to help the kids of Orange County.”

Dr. Nakra has quickly become an integral part of that team. At a recent CHOC Grand Rounds presentation, he discussed screening guidelines for obesity, metabolic syndrome and obstructive sleep apnea. The American Academy of Pediatrics recommends during routine office visits for pediatricians to ask families about how the patient sleeps at night and for the presence of multiple nighttime awakenings, difficulty breathing, loud snoring and pauses in breathing. This is especially true for overweight and obese children.

“We’re trying to break the cycle of obstructive sleep apnea and obesity,” he said. “Often, the families do not volunteer this information, but when asked, will confirm symptoms of obstructive sleep apnea. In this case, further evaluation by a sleep physician or referral for an overnight sleep study would be warranted.”

Dr. Nakra advises physicians to ask about sleeping when evaluating other symptoms, such as hyperactivity and behavioral disorders in elementary or middle school-age kids. For teens, improved sleep has been shown to improve academic performance and reduce motor vehicle crashes.

When to Refer

An overnight sleep study is recommended for patients with concerns for:

  • Nighttime snoring
  • Persistent mouth breathing
  • Witnessed pauses in breathing while sleeping at night
  • Frequent nighttime awakenings

Further evaluation in the pediatric sleep clinic is warranted based on the results of the sleep study or prior to the study based on pediatrician or parental concerns.

Dr. Nakra sees patients at CHOC Children’s Hospital; CHOC Children’s Health Center, Mission Viejo; and CHOC Children’s Health Center, Huntington Beach. For more information or to schedule a consultation, call 714-509-8622.

CHOC’s Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants

CHOC Children’s clinicians have determined that a dedicated Small Baby Unit (SBU) improves quality and outcomes in extremely low birth weight (ELBW) infants (babies born at 28 weeks gestation or less and weighing less than 1,000 grams), according to results of an article they published in Pediatrics[i].

“In recent years, the survival rates for ELBW infants have improved with the latest advances in neonatal intensive care, but many are still released from the hospital with significant challenges, including neurodevelopmental delays and/or chronic medical problems,” said Mindy Morris, DNP, the SBU program coordinator and co-author. “Our goal was to improve these outcomes by utilizing a dedicated team with expertise in the care of this population.”

The objective of the CHOC neonatology team was to cohort ELBW infants in a single location physically separated from the main Neonatal Intensive Care Unit (NICU), and to recognize that progressive changes in culture were essential for successfully shifting the practice model. This space became the 12-bed SBU, which consisted of four individual patient rooms, two of which are surgical suites, and three four-bed pods. Different from a traditional NICU, this smaller unit allows for a darker, quieter environment that encourages developmentally supportive care. The goal is to create an environment that respects and supports the physiologic needs of the baby to grow and develop after being born so prematurely. Grouping this population also provides parents an opportunity to form strong bonds with other families sharing similar experiences.

Outcomes from the two years before and four years after opening the SBU in March 2010:

  • Reduction in chronic lung disease from 47.5% to 35.4%.
  • Rate of hospital-acquired infection decreased from 39.3% to 19.4%.
  • Infants being discharged with growth restriction (combined weight and head circumference, < 10th percentile) decreased from 62.3% to 37.3%.
  • Reduced resource utilization was demonstrated as the mean number per patient of laboratory tests decreased from 224 to 82 and radiographs decreased from 45 to 22.

The research found that improved outcomes in ELBW infants can be achieved by changing the culture of the practice. The successful outcomes likely reflect the benefits of consistency in practice by a dedicated team that gained expertise in the care of this population in a separate developmentally appropriate location. Additionally, there was a reduction in illness and complications among infants after leaving the SBU. Engaging the team on an ongoing basis can sustain improved outcomes.

[i] Morris M., et al., Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants, Pediatrics (2015), http://pediatrics.aappublications.org/content/early/2015/09/01/peds.2014-3918

Peds2040 Challenges How People Think About the Future of Pediatric Medicine

What do you envision the field of pediatric medicine will look like in 2040? How about the next year? Innovation and intelligence leaders from across the globe will come together for an exciting four-day conference focused on game-changing and emerging technologies shaping the future of pediatrics — and how parents, clinicians, and health care leaders can best be positioned for the next era of medicine.Peds-2040-Logo-Vector

Presented by CHOC Children’s, Peds2040, taking place on Jan. 6-9, 2016 in Dana Point, Calif., features an impressive line-up of speakers highlighting the latest trends in genomic and precision medicine; regenerative medicine and 3D printing; pediatric nanomedicine; medical devices and connected health; robotics and robotic surgery; artificial intelligence and big data; and innovations in health care delivery.

“Peds2040 is a unique opportunity to witness the future of pediatrics as it unfolds. Anyone interested in understanding new and emerging technology and networking with the brightest minds in pediatric medicine and in innovation should attend. The event will redefine how attendees think about medicine and its impact on children and families for generations to come,” says Dr. Anthony Chang, chief intelligence and innovation officer at CHOC and Peds2040 program chair.

Call for Abstracts – Deadline is Nov. 15

Individuals are encouraged to make critical contributions to the learning experience by submitting abstracts. A variety of submissions, including completed works, works-in-progre
ss and project ideas, will be considered if they are relevant to the conference themes: genomic and precision medicine; regenerative medicine and 3D printing; pediatric nanomedicine; medical devices and connected health; robotics and robotic surgery; artificial intelligence and big data; and innovations in health care delivery. One winner will be selected for each of the seven themes and awarded: round-trip economy class airfare to attend Peds2040; complimentary three-night accommodations at The Ritz-Carlton, Laguna Niguel; and the opportunity to present the abstract at the conference.

Submit abstracts at online no later than Nov. 15, 2015.

IT Update from the Chief Medical Information Officer: Dr. Bill Feaster

What’s New With IT These Days?

There are several IT projects underway, with perhaps the most anticipated one being the switch from Groupwise to Outlook for emails, calendaring and other functions. We are currently implementing Microsoft Office 365, the web-based version of Office, and we should have everyone converted over to Outlook by the end of January 2016.

Bill Feaster, MD, MBA, CHOC Children's Chief Medical Information Officer
Bill Feaster, MD, MBA, CHOC Children’s Chief Medical Information Officer

We’re also putting a mobile device tool in place to allow people to access the enterprise network on their phones and tablets. That needs to be completed before we roll out, beginning in spring 2016, the iPad version of Powerchart called Powerchart Touch. The combination of network access and email accounts on Outlook should dramatically improve provider access to and use of our choc.org email accounts.

The promised move to badge authentication into Cerner is also starting soon, but had to wait until we got rid of Groupwise (network incompatibilities). This is another one of those nasty interdependencies, but this project will get underway in the spring and carry over into the next fiscal year.

Is anything happening with CUBS?

The last major specialty to move to electronic documentation and applications is oncology. Work to implement Cerner’s oncology product will begin in May, but take at least a year to complete. Most of our development work outside of oncology will be focused on increasing the usability of CUBS, with the goal of improving provider education on using the system, reducing the number of clicks to do things, and creating specialty-specific views, when available, to better present needed information to the provider.

ICD-10 seemed to go better than anticipated. The world didn’t end after all! It was a very smooth transition to the new coding system. But that took over three years of hard work to complete, several millions of dollars, some very skilled people on the project, and some very savvy providers and coders using the system. Early information is that the bills not only went out on time, but are actually getting paid! We’re still having a few issues with Diagnosis Assistant and a bit of confusion over diagnoses that can’t be fully specified, but fixes and education are in progress.

I’ve heard a lot about population health and the pediatric system of care. How is that going?

We’ve implemented a new Cerner solution called the Healthe Intent platform. It’s a “big data” system that takes in data from multiple sources, including CUBS, and programs running on that data implement evidence-based disease registries for chronic diseases, report on compliance with the measures in those registries, and support our care managers helping patients and parents to navigate the healthcare system. We are piloting the registries in our Garden Grove clinic beginning Nov. 2, and will be rolling the registries out to the rest of the organization soon. We are helping Cerner develop the care management piece of the platform, and it should be ready in the second quarter of 2016.