Clearing pediatric patients for sports after COVID-19: Tips for pediatricians

While there is less data about pediatric patients, emerging evidence shows that people infected with COVID-19 are at increased risk for myocarditis. Because of this, it is important that pediatricians appropriately evaluate patients before they are cleared to return to play as sports resume after a prolonged COVID-prompted off season.

Here, Dr. Matthew Kornswiet, a sports pediatrician in the CHOC Primary Care Network, and Dr. Chris Koutures, a CHOC pediatrician and sports medicine specialist, share what providers ought to know when clearing young athletes or students for a return to sports following a COVID-19 infection.

Patients should be seen in the provider’s office for an in-person, formal evaluation and physical exam to determine clearance, recommend Drs. Kornswiet and Koutures. The following decision tree can aid in triaging patients, as well as providing consistent patient care. This decision tree is applicable to middle and high school athletes, as well as to those who compete in high-exertion activities and to other patients on an individual basis.

The California Interscholastic Federation recommends that if a patient’s infection was over three months ago, they had an asymptomatic, mild or moderate illness, and the patient has regained fitness or is back to full activity without symptoms, then they can return to sports as long as they have an active/recent preparticipation physical exam.

Once an athlete is cleared for a return to sports, Drs. Kornswiet and Koutures recommended that they go through a gradual and step-wise return to play. This is similar to the return-to-play protocol for concussions, and should be performed under the supervision of a physician and athletic trainer, if possible.

Each phase should last at least 24 to 48 hours and should not cause return of symptoms. If the athlete/student experiences a return of symptoms or develops unexpected fatigue, dizziness, difficulty breathing, chest pain/pressure, decreased exercise tolerance, or fainting, then they should stop their return progression and return to their physician for further evaluation.

These protocols are not substitutes for medical judgment, and additional queries should be directed to pediatric cardiologists or sports medicine specialists.

Following are more general return-to-sports guidance for parents and coaches:

Refer a patient to CHOC Cardiology

How CHOC pediatricians helped raise immunization rates in Orange, Los Angeles counties

Further championing the importance of vaccines in protecting children’s health and well-being, a quality improvement project recently completed by CHOC pediatricians successfully increased childhood immunization rates in Orange and Los Angeles counties. The project produced a number of QI strategies that could be replicated by pediatric providers across the country who are likewise seeking to improve immunization rates among their patients.

The project, funded by an American Academy of Pediatrics grant, focused on children ages 19 months to 35 months and their adherence to the Combo-10 portion of the AAP immunization schedule. The immunization panel known as Combo-10 includes DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV and Influenza vaccinations. The AAP’s immunization schedules outlines recommended ages for routine immunization administration.

Nationwide, the compliance rate for Combo-10 is between 40-50%. This means as many as half of U.S. children are not considered up to date on vaccinations, leaving them vulnerable to contracting these 10 illnesses the Combo-10 panel protects against.

“We sought to make sure that children ages 19-35 months were up-to-date with all immunizations they should have received by their age,” says Dr. Dan Kowabunpat, a CHOC pediatrician and project co-leader.

Dr. Dan Kowabunpat, a CHOC pediatrician and project co-leader.

Participating in the project were 15 practices across CHOC’s Primary Care Network including 87 providers who collectively care for approximately 60,000 patients. Each practice sought to raise immunization rates 5% over baseline figures – a goal they would not only meet but succeed, with immunization rates raising 5.8% overall.

Also participating in the project were UCLA, Vanderbilt Children’s Hospital, Penn State Children’s Hospital, the Children’s Hospital at Oklahoma University Medical Center and Gundersen Health System.

Although a recent California law eliminating the possibility of a personal belief exemption for immunizations raised kindergarten vaccination rates, rates for younger children had remained low.

“Southern California’s vaccination rates skew low. CHOC’s Primary Care Network tends to have higher than average vaccination rates for our area with between 60% and 70% of our children fully immunized, but we recognized there was still work to be done to protect children,” says Dr. Eric Ball, a CHOC pediatrician and study co-leader.

The reason behind lower-than-desired immunization rates, per Dr. Ball, is not necessarily because parents don’t want to immunize.

“The fault lies with missed opportunity,” Dr. Ball says. “If a patient is sick during a visit, or if their well check was scheduled before they’re due for a vaccine, over time these missed opportunities build up and then we have kids who are not fully immunized.”

The quality improvement project, completed earlier this year, included both clinical education for staff, as well as strategies that could be replicated and implemented by other practices with similar goals.

Dr. Eric Ball, a CHOC pediatrician and study co-leader.

Clinician education

  • Physician learning sessions — Led by pediatric infectious disease experts from CHOC, these sessions provided vital education on both quality improvement efforts, as well as strategies for discussing the importance of vaccines with parents.
  • Front-office staff learning sessions — While essential to practice operations, many of these clerical team members do not have formal medical training. As the first faces patients and parents see before their doctor, these staff members would routinely fields questions such as, “Am I getting shots today? Do I need this vaccine? What does this vaccine do?” With more comprehensive training, staff members were better able to speak to these topics, and curious patients and parents were more informed.

Monthly strategies

For the first three months of the project, participating practices implemented strategies aimed at boosting immunization rates outlined by project leaders. For subsequent months, each practice identified strategies based on their specific patient population and office dynamics. Proven strategies include:

  • Checking eligibility at all visits — Providers began checking immunization eligibility at every non-sick visit, rather than just well-checks. For instance, if a patient visits their pediatrician for a sports physical, their doctor checks for vaccine eligibility and administers any necessary vaccines. Before this project, checking vaccine eligibility was only done at well checks, but 75% of appointments are not checkups.
  • Implementing a recall system In collaboration with CHOC’s information services department, each practice developed a recall program to identify patients who were not up to date on vaccinations. The practice would then send calls/texts/postcards to remind patients to come in for immunizations.
  • Promoting staff vaccinations Practices took this project as an opportunity to provide education that staff were receiving vaccinations, too. For example, each CHOC staff member’s employee badge features a color-coded sticker updated annually indicating they receive an influenza vaccine that year. New signs in some offices read, “If you see this sticker on my badge, it means I got my flu shot, just like you.”
  • Waiting room activities One practice created a flu quiz for patients to complete in the waiting room, as a way to start a conversation with kids about vaccines.
  • Nurse appointments Walk-in flu shot offerings were implemented with nurses. Historically, patients had to make an appointment with their pediatrician.
  • One-on-one QI sessions Quality improvement advisers from CHOC’s population health team held on-on-one sessions with providers to pour over their practice’s immunization rates and how it compared to other practices and discuss strategies for boosting immunization rates.
  • Comfort measures — Comfort measures for immunization delivery, including distraction devices, sucrose solution for babies and mindfulness techniques for older children.
  • Collaboration CHOC physicians leaders collaborated with colleagues at participating sites around the country to share findings and best practices.

Meet Dr. Charles Golden

CHOC wants community providers to get to know its physicians. Today, meet Dr. Charles Golden, a board-certified pediatrician and executive medical director, Primary Care Network, CHOC.

Q: What is your education and training?

A: I earned a Bachelor of Science in Biology at University of California, Riverside. After completing my undergraduate studies, I attended Western University of Health Sciences College of Allied Health and earned a certificate as a physician assistant. I worked at Southern Orange County Pediatric Associates (SOCPA) as a physician assistant until I started medical school at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, in Pomona. I completed my internship and residency, including a year as chief resident, at Children’s Hospital Los Angeles.

Q: How long have you been at CHOC?

A: Just over a year.

Q: What are your special clinical interests?

A: I love all aspects of clinical medicine, but get energized when I have the opportunity to teach. I believe that every encounter with a patient is an opportunity to teach them something about the body and explain why we make the decisions that we do in medicine. I’m also passionate about teaching medical students and residents, as they continually challenge me to stay up to date with new research. I love the feeling I get from contributing to the development of their careers as physicians.

Q: Are there any new programs or developments within CHOC’s Primary Care Network?

A: In the near future, we plan to open an after-hours clinic for the entire community. By the end of summer, we’re planning on implementing a single electronic health record (EHR) through Cerner for all our primary care offices so that all of our providers chart on patients in the same record, and a patient’s medical information can securely be available to whoever they see in our group. This will continue to improve communications within the practices.

We’re also growing our comprehensive adolescent medicine services. We will be hiring another adolescent medicine specialist to address this unique, complex patient population. Additionally, we’re working on the use of digital vision screening devices to look for problems with vision in children younger than 4 years old, who are often too young to read a visual acuity chart.

In addition, we’re working closely with CHOC’s chief psychologist, Dr. Heather Huszti and her team to provide a mental health professional in each of our primary care offices to help the medical team screen for and address mental health issues. This is a component of CHOC’s mental health initiative, including the mental health inpatient center opening this spring.

Q: What would you like specialists to know about primary care at CHOC?

A: I would want the specialists to know about the high-quality care that our physicians provide on a daily basis, as well as the breadth of our network – from central and north Orange County to the most southern part of the county in San Clemente – and the broad diversity of the patients that we care for.

I’d also like them to know that they can feel comfortable collaborating with our pediatricians, and that they can count on us to provide evidence based care to our patients, consistent with what we know their divisions to do. Lastly, I’d want them to see CHOC primary care as a trusted partner in our health system, where we are keeping children healthy through regular examinations, screening, education and integration, and strive to treat our patients and their families holistically rather than simply by disease process.

Q: What would you like patients and families to know about your division at CHOC?

A: For many people, bringing your child to seek medical care can be a stressful event. There are many sources of information out there regarding children’s health, and in some cases those sources may contribute to more confusion and anxiety. I would like patients and families to know that when they choose a CHOC pediatric provider, they can trust that the care being delivered is state of the art, up to date and based on clinical and scientific evidence, combined with years of expertise. They will be greeted by empathic staff who are skilled in making children feel comfortable, and providers who are not only skilled at diagnostics, but bring a warm and compassionate touch to the visit.

Further, our pediatricians are partners with our specialists, and through this partnership they share knowledge, collaborate in patient care, and help to create a sense of calm for patients and their families.

Q: What inspires you about the care being delivered at CHOC?

A: Every day pediatricians, pediatric specialists, nursing staff, technicians and so many other professionals come to CHOC to make a difference in the lives of children in need. It’s a calling, and they’re passionate about it. You can feel it when you walk through the door, whether it’s from the smiles and greetings from the folks at the information desk, or when you see a security guard assist a family. Perhaps it’s when you see an associate go out of their way to offer hospitality to a random person in an elevator, or the cutting edge surgical and medical treatments that are happening every day. To try to answer what inspires me most about the care being delivered by CHOC would do a disservice to every little thing that occurs on our campus that makes CHOC a special place. I’m incredibly proud to be a part of it!

Q: Why did you decide to become a doctor?

A: I fell in love with science as a teenager. Around the same time, my father had a heart attack. I remember going to the hospital and learning about his heart and how the medicine was working to provide care for him. I was fascinated by it all and never looked back.

Q: If you weren’t a physician, what would you be and why?

A: I would probably be a general contractor. I’ve always enjoyed working with my hands.

Q: What do you like to do in your spare time?

A: I love spending time with my wife and children. I also enjoy cycling and mountain biking, and being involved in my kids’ sports.

To refer a patient, please call 1-855-212-6740.

Learn more about CHOC Primary Care Network.


iRounding For Real-Time Results

CHOC is the nation’s first pediatric hospital to implement iRounding, a digital survey tool on an iPad that allows staff to identify and respond to CHOC families’ needs in real time. CHOC received the 2014 Ventana Research Award for its pioneering use of this technology.

For years, hospitals have relied on paper surveys mailed home after a visit to assess patient satisfaction. While very important, this survey method also has limits. Paper surveys can only ask questions. But at CHOC, iRounding has started very important conversations.

“We want to know what is important to our patients and families, and iRounding is about so much more than checking boxes,” said Carmen Namenek, manager of CHOC Primary Care Clinic Operations and Community Education. “This portable, HIPAA-compliant tool allows our staff to engage with patients and families, and gather more robust data than we can with traditional survey methods. We may now also get information from populations previously not surveyed, such as adolescents.”

She said families’ top concerns are not always what the staff thinks they are. At one CHOC outpatient clinic, the staff thought waiting time was most important. But iRounding revealed that families would rather wait a little longer in order to see the same provider at each visit.

Automatic, real-time iRounding reports allow CHOC staff to act more quickly to resolve and follow up on opportunities for improvement. Positive comments may also be shared immediately with physicians and staff.

Further, iRounding allows staff to quickly spot trends and modify or add questions if the survey focus changes. And as issues are resolved, spot checks may be conducted with families to make sure the new changes are working. CHOC staff found iRounding an invaluable tool to assess family perceptions during recent changes to hospital parking and laboratory registration procedures.

“Eliminating the costly, time-consuming manual process of collecting data has freed our staff to do more of what they do best,” Namenek said.

Leading the Nation
Implemented in 2013 in part by a grant from Tustin Toyota, iRounding is now taking place at all CHOC locations, including CHOC at Mission Hospital. CHOC has expanded the web-based application to some private practices in the community.

“It’s an opportunity to share best practices with each other,” Namenek said. “We realize families may be seeing community physicians as well as specialists at CHOC, and the experience at all locations is important.”

Dr. Mark Colon, who practices at the CHOC Clinic, Santa Ana, at the Boys & Girls Club, quickly saw the benefits of real-time results.

“The thing I love about iRounding is that I don’t have to wait up to three months for the NRC Picker results,” Dr. Colon said. “If there is a negative comment or issue, my staff and I will see it right away, and address it right then and there. We can clear up any kind of misunderstanding before the family leaves the office.”

CHOC continues to participate with The Advisory Board Company, a national organization dedicated to sharing best practices and further leveraging iRounding technology within the pediatric healthcare setting. While CHOC was the very first pediatric organization to utilize iRounding, several pediatric hospitals have since followed suit.

“For many of them, CHOC was a big influence in the decision to use this product,” Namenek said. “They are looking to us as the leaders.”