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Hospitalists

p. 4

piCU

p. 8

pediatriC sUrgery

p. 12

pain Control

p. 14

a joUrnal for pHysiCians

norwood

p. 16

proudly serving children since 1948, Children’s Hospital is the only full-service, pediatric health care center in nebraska. located in omaha, it provides expertise in more than 30 pediatric specialty services to children and families across a five-state region and beyond. the 142-bed, non-profit hospital houses the only dedicated pediatric emergency department in the region and offers 24-hour, in-house services by pediatric critical care specialists. Children’s Hospital has achieved the Magnet designation for nursing excellence and is an infoworld 100 award winner for innovation in information technology. a pediatric affiliation established between Children’s Hospital and the University of nebraska Medical Center College of Medicine supports enhancements in pediatric education, research and clinical care. Children’s is also the primary teaching site for the family practice and joint pediatric residency programs at Creighton University and UnMC. for more information on Children’s Hospital go to Childrensomaha.org.

Hospitalists

p. 4

doctors from around the region can refer patients to Children’s with confidence, knowing that in one call to Children’s Hospitalist service they can pass along all the patient’s pertinent information.

piCU

p. 8

the piCU at Children’s handles a challenging mix of critical-care cases. working with a team of dedicated staff and using innovative technology, Children’s pediatric intensivists have helped place Children’s piCU success rate among the top such units in the nation.

pediatriC sUrgery

p. 12

Minimally invasive techniques are now used on even the smallest patients and simplify many common procedures formerly requiring more invasive surgery.

pain Control

p. 14

pediatric anesthesiologists provide one-on-one care and pre-anesthesia testing to better ensure patient safety and reduce recovery time.

norwood

p. 16

Cardiothoracic surgeons see success rates increase using first-stage norwood procedure and a team dedicated to pediatric cardiac care.

Contents

speCialty pediatriC Center

p. 7

UnMC affiliation

p. 19

neonatal transport

p. 20

gastroenterology groUp expands

p. 22

qUiCk referenCe direCtory

p. 23

also:

When Harlan, Iowa, pediatrician Sarah Devine, MD, has a sick child requiring surgery or examination by perhaps several sub-specialists, she makes one phone call to the Hospitalist Service at Children’s in Omaha.

In that single call, Dr. Devine passes along all pertinent information and arranges for her patient’s admission and any procedures or examinations the child may need.

“I like that with the Children’s program there is always someone available, either there at the hospital or on-call,” she says. “I know the providers and I trust them.”

The Hospitalist Service at Children’s is available 24/7. Any physician may refer a patient, and referrals come from throughout the region.

The hospitalists provide attending level inpatient care, pediatric consultation and subspecialty coordination for the referring physician’s hospitalized patient.

The hospitalists strive to provide frequent communication with the referring physicians and provide written discharge information

Dr. Devine, who practices at Myrtue Medical Center in Harlan, has been referring patients an average of one every three months to the Hospitalist Service since its inception in 2001. Her familiarity with many of the staff hospitalists helps put her patients and their parents at ease.

“For me, the best aspects of the Hospitalist Service are its availability, the way that they keep me informed during my patient’s hospitalization and after discharge, and the fact that it’s Children’s,” says Dr. Devine. “Parents trust a program that’s dedicated to pediatrics. It gives them, and me, peace of mind.”

Jay Snow, MD, is the medical director of the Hospitalist Service. He was a senior resident when the program began and became chief resident five months later. He’s been a

full-time member of the Hospitalist Service since June 2002.

“The service provides consistency of care committed to evidence-based medicine, using studies that support what we’re doing,” Dr. Snow says. “Our goal is a seamless route of care, where a referring physician can make one call to our service that will take care of everything from the admission to the discharge summary.”

Referring physicians may access the Hospitalist Service by calling the Physicians’ Priority Line at 1-888-592-7955. The service is staffed with at least one hospitalist at Children’s from 7 a.m. to 10 p.m. on weekdays and from 7 a.m. to 5 p.m. on weekends. A hospitalist is on-call overnight.

Although it has only been around about 10 years, the hospitalist specialty is a field that has seen rapid growth. The Society for Hospital Medicine reports a total of 15,000

one Call links region’s pHysiCians to CHildren’s

Hospitalist serviCe

Hospitalist serviCe

p. 4

hospitalists practicing in 2005. According to the society, that number is projected to reach 30,000 in 2010.

Today, the Hospitalist Service consists of five full-time equivalent positions divided between six physicians. For five of the physicians, the hospitalist duty accounts for a majority of their clinical practice, Dr. Snow says.

In addition to Dr. Snow, the pediatric hospitalists at Children’s are listed at right.

Gary Lerner, MD, is a graduate of the University of Missouri school of Medicine who completed his pediatric residency at Children’s Mercy Hospital, kansas City, Mo. dr. lerner joined the staff at Children’s in 1979. for 15 years, he has served as medical director of the Children’s developmental Clinic at the hospital. the clinic offers evaluation and ongoing consultation for a variety of developmental disabilities. dr. lerner has served as medical staff president and as a member of numerous hospital committees, including the hospital’s ethics committee, where he is the chairman. He is a board member at the omaha down syndrome parents network.

SheiLah SnyDer, MD, is a graduate of the University of nebraska Medical Center (UnMC) who completed her pediatric residency at the Creighton-nebraska Universities Health foundation. she is a faculty member at UnMC.

Sharon StooLMan, MD, is a graduate of UnMC who also performed her pediatric residency at the medical center. dr. stoolman also serves as director of Undergraduate Medical education at UnMC.

Stephen DoLter, MD, is a graduate of the University of iowa College of Medicine who served his pediatric residency at Creighton-nebraska Universities Health foundation.

naDia abrahaM, MD, is a graduate of the University of Missouri-kansas City school of Medicine who served her pediatric residency at UnMC and the Medical College of ohio. she came to Children’s Hospital after nearly two years with the pediatric Center in toledo, ohio.

“oUr goal is a

seaMless roUte

of Care, wHere a

referring pHysiCian Can Make one Call

to oUr serviCe tHat will take Care of

everytHing froM tHe adMission to tHe

disCHarge sUMMary.”

Jay SnoW, MD, MediCal direCtor, Hospitalist serviCe at CHildren’s, is a graduate of Creighton University school of Medicine in omaha, neb., who completed his pediatric residency with the Creighton-nebraska Universities Health foundation.

In A ReCenT SuRvey OF ReFeRRIng PHySICIAnS,

87% OF ReSPOnDenTS RATeD CHILDRen’S HOSPITALIST SeRvICe exCeLLenT OR gOOD.

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pHysiCian’s priority Hotline 1.888.592.7955

“We have youth and we have extensive experience,” Dr. Snow says. “We have university experience and extensive private practice. Most of all, we have a highly-qualified and dedicated group of people trained to respond to a wide array of complex pediatric issues.”

At Children’s, the Hospitalist Service is a source of pediatric instruction for medical residents from the university of nebraska Medical Center and Creighton university Medical Center.

“It’s a primary teaching component of the pediatric residency program for both medical centers,” Dr. Snow says. “The program allows us to enhance the educational opportunities for the medical students. I believe the good foundation we provide them here enhances the care they will give their pediatric patients.”

Leon gebhardt, MD, a pediatrician with Heartland Pediatrics, PC, in norfolk, neb., says he has utilized the Hospitalist Service since its inception. “I’ve referred a large variety of patients, from injuries to infections,” Dr. gebhardt says. “It’s been a little bit of everything.”

He says the service is “extremely convenient for the referring physician. The ability to call just one doctor when you have a complex patient and have them arrange all the specialists and sub-specialists without having to make calls to each of the areas is extremely helpful. I feel very comfortable talking to any of the hospitalists.”

As a pediatrician, most of his practice focuses on young families with very small children. “I’m not sure they really understand how the program works when I explain it to them, but after they’ve been to Children’s and experienced it, they’ve all had really positive comments about the care and how they’ve been treated.”

Dr. Snow says the hospitalists function as a team. “The physician who takes the admission may not be the one who follows the child. That’s why communication is key to the success of the service.”

That communication extends to the referring physician.

“It’s our goal to provide a copy of the written discharge summary to the referring physician within seven days. When we have a complex patient, we make every attempt to place a call either upon discharge or within a day of their discharge. We are committed to do all we can to strengthen and improve our lines of communication.”

At Children’s, the hospitalists manage 22 to 30 inpatients per day. They see the patients, arrange for examinations by sub-specialists, make rounds with residents and medical students.

Dr. Snow says it takes a committed physician to serve as a hospitalist.

“The hours we work, the total number and when, are clearly different than for a general practice physician,” he says. “The intensity of care, the complexity of the patient’s needs and the severity of illness can be stressful.

“Hospitalists see only an intense slice of a child’s care. There’s not that continuity of care which allows you to enjoy any well-checks at the clinic or the office. you only see kids when they’re sick.

“Then you add in that element of teaching and all the joys and frustrations teaching involves. It requires dedication and commitment.”

And an innate flexibility.

“you have to possess an ability to change thought processes very quickly as you move from one complex problem to the other,” Dr. Snow says. “I just saw seven kids, for example, and not one had a similar problem.”

Dr. Devine says she considers the Hospitalist Service at Children’s to be “the best option” when she can’t provide the necessary care herself. “Being at a distance, with one call I can arrange specialty services and get that feedback that is so essential.”

Dr. Snow says the service is valuable to outlying physicians.

“For a physician taking care of a medically complex case, we not only arrange for specialized care, but also act as a filter when they’re unsure which sub-specialist may be needed,” he says. “We can coordinate and satisfy those multiple needs.”

And it all begins with just one phone call.

We HAve A HIgHLy-quALIFIeD AnD DeDICATeD gROuP OF PeOPLe TRAIneD TO ReSPOnD TO A WIDe ARRAy OF COMPLex PeDIATRIC ISSueS.

tHe Hospitalist serviCe at CHildren’s Hospital is available 24/7 for inpatient Care. any pHysiCian May refer a patient to tHis serviCe. pHysiCians sHoUld Call tHe pHysiCians’ priority line at 1-888-592-7955.

p. 6

When it opens to patients in January 2010, the new Specialty Pediatric Center will help Children’s Hospital “expand its already well-recognized programs and push others to new heights,” says vanessa Walls, vice president for ambulatory services at Children’s.

“We want Children’s Hospital to be the destination for pediatric care for our region and beyond,” Walls says. “The new Specialty Pediatric Center is the next step in bringing the Children’s campus up to our state-of-the-art standard.”

Pediatric services are currently compartmentalized in the Scott Pavilion. The new center, to be built on land the hospital has acquired at 84th Street and West Dodge Road, will be “more modern in design and much more flexible for our needs,” Walls says. “We’ll have a lot of multi-use space that we can utilize for growth.”

The new pediatric center will enable the

specialty clinics and sub-specialty health care services to grow to meet increasing demand. visits to the clinics have gone up an average of nine percent during each of the past six years.

“We expect to record 29,000 visits this year,” Walls says. “By the end of 2010, we expect more than 50,000 visits.”

The new five-story, 135,000-square-foot building will connect to Children’s Hospital

and the Scott Pavilion. The cost is estimated at $55 million, with funds from operational reserves, philanthropic gifts and proceeds from a recent bond issue.

“The new building will allow us to concentrate all our pediatric services in one place, it will improve access for our families and our patients, and it will allow for future growth,” Walls says. “It also will provide the space we need to strengthen our affiliations with the university of nebraska Medical Center and Creighton university Medical Center, and broaden our joint medical, research and educational opportunities.”

The building will include 364 parking stalls on three lower levels and along West Dodge Road. Construction begins in early 2008.

new speCialty pediatriC Center will address growing deMand

“tHe new bUilding will allow Us to ConCentrate all oUr pediatriC serviCes in one plaCe, it will iMprove aCCess for oUr faMilies and oUr patients, and it will allow for fUtUre growtH.”

vanessa wallsviCe president for aMbUlatory serviCes, CHildren’s Hospital

speCialty pediatriC Center

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intensivists, new teCHnologies distingUisH CHildren’s piCU

piCU

p. 8

“we started partiCipating in janUary 1997. every year sinCe, we’ve

ranked aMong tHe top tHree Units in tHe prisM database. we

Consistently oUtperforM CoMparable Units in tHe CoUntry.”

george reynolds, Md, MMM.MediCal direCtor, pediatriC intensive Care Unit, CHildren’s Hospital

The presence of highly-trained intensivists – coupled with state-of-the-art technology and medical equipment – have firmly established the Pediatric Intensive Care unit (PICu) at Children’s Hospital among the top such units in the nation.

“We are the only pediatric intensive care unit in the region with 24/7, in-house, board-certified intensivists,” says george Reynolds, MD, MMM., medical director of Children’s PICu. “That really makes us unique. It means that 365 days a year, if you come to Children’s, you get that kind of high quality care.

“It’s what the patients need,” he says, “and it’s the right thing to do.”

In addition, the 17-bed unit at Children’s is staffed round-the-clock by nurses and respiratory therapists trained in the care of critically ill and injured children.

The PICu at Children’s handles a challenging mix of critical-care cases. Dr. Reynolds estimates that at any given time, the patients in the unit are divided almost evenly between surgery cases and medical cases.

Because of the variety and complexity of cases, there is a full range of pediatric medical and surgical sub-specialists available at all times, as well as advanced technologies that include extracorporeal membrane oxygenation (eCMO), high frequency oscillatory ventilation, inhaled nitric oxide and heliox therapies.

eCMO is the use of an artificial lung to put oxygen into the blood and send the blood to the body tissues. The PICu at Children’s is the only unit in the region that provides eCMO service for both cardiac surgery patients and pediatric shock and respiratory failure patients.

When Dr. Reynolds joined the PICu at Children’s in 1996, he was nebraska’s first full-time pediatric intensivist, a fellowship-trained physician who specializes in the care of critically-ill children and whose practice is devoted to patients in the PICu.

“We hired our tenth intensivist here in September,” Dr. Reynolds says.

Intensivists work with the nurses, respiratory therapists and others in the PICu, and with other physicians such as primary care doctors, surgeons and subspecialists.

The combination of dedicated staff and innovative technology has yielded a success rate that has again placed the Children’s PICu among the top such units in the nation, according to the latest Pediatric Risk of Mortality (PRISM) scores.

“Of all of the factors that can be measured concerning a patient, the PRISM scores gauge the things that are most important in predicting mortality,” Dr. Reynolds says. “PRISM scores are validated across 30,000 patients and against three dozen other hospitals.

“We started participating in January 1997. every year since, we’ve ranked among the top three units in the PRISM database. We consistently outperform comparable units in the country.”

ContinUeD

Dr. Reynolds also serves as chief of the Division of Pediatric Critical Care Medicine and Medical Director of the PICu at the university of nebraska Medical Center (unMC), which is housed at The nebraska Medical Center, the primary teaching hospital for unMC. Approximately 95 percent of the patients at the medical center PICu are surgical cases.

Since July 2005, the doctors from Children’s have staffed both PICus. Children’s PICu is a primary pediatric teaching site for unMC and Creighton university Medical Center.

“This is further evidence of our commitment to work together, through care and education, for the children,” Dr. Reynolds says.

He says maintaining quality of care becomes a greater challenge as the volume at both PICus increases each year. “There are times when both facilities are full. That never used to be the case.”

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In addition to his PICu duties, Dr. Reynolds is Chief Medical Informatics Officer at Children’s. He has worked to shepherd many technological advancements that are changing methods throughout the hospital.

The latest is a tablet PC device called the “Motion C5” which Motion Computing has specifically designed for the health care market. The lightweight, hand-held mobile clinical assistant (MCA) is designed to bring accurate data management directly to the point-of-care for hospital pharmacists.

A 10-inch LCD screen and attached pen and stylus allow the user to input clinical documentation as well as administer medication and take digital photographs via a single, portable device that incorporates integrated high-speed wireless connectivity. It has handwriting recognition and can be used with a docking station to provide full desktop functionality.

“We are one of the first hospitals to use it and are partnering with the manufacturer to demonstrate the utility of the device,” Dr. Reynolds says. “We will be implementing it throughout the hospital over the next few months.”

Children’s collaborated with Motion Computing in an effort to reduce the impediments to the pharmacists’ workflow caused by desktop PCs and

other stationary electronic devices in the PICu.

“Our plan is to use it as our primary way to enter and retrieve routine data such as vital signs, intake and output, as well as identify patients and connect them with the correct medications, known as the five rights of medication administration – right patient, right med, right time, right dose, right route – using the built-in barcode and radio frequency identification (RFID) reader.”

Children’s piloted the use of the Motion C5 with eclipsys Sunrise Medication Manager software in a study conducted in the PICu. Dr. Reynolds says preliminary results indicate an increase of 15 percent productivity and efficiency within the pharmacy rounding workflow.

“Mobile point-of-care solutions are important tools to help hospitals improve the return on their investments in digital health technologies and use these technologies to improve health care delivery and clinician satisfaction,” he says.

Last fall, Children’s implemented eclipsys Sunrise Pharmacy software to help ensure the safety of its medication management processes. Sunrise Pharmacy provides advanced clinical decision support capabilities to ensure the safe ordering and administration of medications.

“This is especially critical in pediatric medicine where ordering and dosing are more complex,” he says.

Another such advancement is Computerized Provider Order entry (CPOe). In the PICu, intensivists, surgeons, residents, nurse practitioners and physician’s assistants enter orders directly into Sunrise Clinical Manager. This enables the provider to select the correct medication dose, choose appropriate lab tests and select the right concentrations and additives to intravenous fluids, continuous medication drips and total parenteral nutrition.

“virtually all of the orders in the PICu are written on the computer,” he says. “We plan to move the entire hospital to CPOe over the next several months.”

Dr. Reynolds says he is proud of the care that is received in the PICu at Children’s.

“We have a state-of-the-art facility that operates in state-of-the-art fashion,” he says, “and we have the results to prove it.”

vIRTuALLy ALL OF THe ORDeRS In THe PICu ARe WRITTen On THe COMPuTeR. GeorGe reynoLDS, MD

Motion C5 tabLet

GeorGe reynoLDS, MD, MMM

Motion C5 tablet piloted at CHildren’s

p. 10

SUSan e. Day, MD, a graduate of vanderbilt University, completed her residency at the University of alabama at birmingham and her fellowship at University of pittsburgh school of Medicine. dr. day is adjunct assistant professor of pediatrics at the University of nebraska Medical Center (UnMC) and medical director of the Children’s transport program.

GeorGe reynoLDS, MD, MMM., earned his medical degree from Hahnemann University in philadelphia and his master of medical management degree from Carnegie Mellon University in pittsburgh. He completed his general pediatric residency and critical care fellowship at Children’s Hospital of los angeles and is board certified in pediatrics and pediatric critical care.

prior to coming to omaha, dr. reynolds served as medical director of the piCU at valley presbyterian Hospital in van nuys, Calif., and was the staff pediatric intensivist for the cardiothoracic iCU at Children’s Hospital of los angeles.

tHe intensivists of tHe pediatriC intensive Care Unit at CHildren’s Hospital are:

Jeffrey S. DeMare, MD, is a graduate of Creighton University Medical school in omaha. He completed his pediatric residency and critical care fellowship at the University of texas southwestern Medical Center in dallas. dr. deMare is the medical director of the Children’s advocacy team, providing specialized care for abused and neglected children, and is head of the hospital’s eCMo (extracorporeal Membrane oxygenation) program.

KeLLy KaDLeC, MD, received his medical degree from Creighton University school of Medicine in omaha. He completed his post-graduate education in emergency medicine at the University of arkansas for Medical sciences in little rock and in pediatrics at the Children’s Health Center, st. josephs Hospital and Medical Center in phoenix, where he also served as pediatric chief resident. He completed his pediatric critical care fellowship at the University of Minnesota Children’s Hospital in Minneapolis.

anDreW J. MaCfaDyen, MD, graduated from the alabama school of Medicine and completed his pediatric residency at the national naval Medical Center in bethesda, Md. after serving as a general pediatrician in the U.s. navy, he performed his fellowship in pediatric critical care at the Children’s Hospital of alabama. through the palliative Care program, dr. Macfadyen works to identify children and families for whom hospice care would be most appropriate, helping families and physicians deal with difficult medical questions regarding quality of life and aggressiveness of therapy.

LUKe noronha, MD, graduated from and served his residency at kasturba Medical College, louisiana state University. He performed fellowships in pediatric critical care at the University of Minnesota Hospital and Clinic and pediatric pulmonology at st. louis Children’s Hospital in Missouri.

Mohan r. MySore, MD, attended medical school at the armed forces Medical College in pune, india and graduated from poona University. He completed a three-year internship and residency at the University of Minnesota Hospitals and Clinics, and a three-year fellowship at the University of texas southwestern Medical Center in dallas. He serves as chairman of the resident education committee at the society of Critical Care medicine and has helped develop an online curriculum for pediatric critical care.

briDGet norton, MD, completed her residency at Children’s Memorial Hospital in Chicago and her pediatric critical care fellowship at rainbow babies and Children’s Hospital in Cleveland.

JayeSh C. thaKKer, MD, graduated from medical school at bombay University in india and served residencies in pediatrics at king edward Memorial Hospital in bombay and Cook County Hospital in Chicago. during his fellowship in pediatric critical care medicine at Medical College of wisconsin and Children’s Hospital in Milwaukee, dr. thakker earned a master’s degree in physiology.

eDWarD J. trUeMper, MD, is a graduate of the University of Mississippi school of Medicine. He completed his pediatric residency at oklahoma Children’s Hospital and his critical care fellowship at texas Children’s Hospital in Houston. He has published more than 50 book chapters, medical articles and abstracts in medical journals.

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The application for pediatric surgical fellowship certification to establish Children’s Hospital as a fellow training facility will place Children’s among an elite list.

“We know of perhaps 35 such training programs in north America,” says Children’s Pediatric Surgeon Steve Raynor, MD

Dr. Raynor says certification would mean an even higher level of care for Children’s patients and would serve to raise the academic profile of the hospital. Although application is a very competitive process, “we feel confident we have a very strong shot at approval.”

It would also assist the hospital as it works toward designation as a Level 2 Trauma Center.

“With the ICu (intensive care unit) care we provide here, it’s a natural,” Dr. Raynor says. “Children’s has the best resources to deal with this level of injured patients.”

The application for certification follows the addition of Pediatric Surgeon Shahab Abdessalam, MD, who joins Dr. Raynor and Pediatric Surgeon Robert Cusick, MD.

“Dr. Abdessalam brings a rare combination of skills to the team,” Dr. Raynor says. “In addition to his five years of general surgery and two years of pediatric surgery training, he has additional fellowship training in surgical oncology and pediatric critical care.

“There are about five people in the nation trained in pediatric surgery and surgery oncology.”

The two came to know each other when Dr. Abdessalam completed his pediatric surgery rotation with Dr. Raynor and his partners. “He saw coming to Children’s as an opportunity for a busy clinical practice and to build more surgical oncology experience.”

Dr. Abdessalam earned his undergraduate and medical degrees at Ohio State university.

He performed his surgical residency at the university of nebraska Medical Center. After his residency, he completed a surgical oncology fellowship through the Ohio State university Hospitals. He then completed critical care and pediatric surgery fellowships through Columbus Children’s Hospital in Ohio.

In April, Kenneth Azarow, MD, will join the pediatric surgery team after retiring from the u.S. Army.

Dr. Azarow, a colonel in the Army Medical Corps, is professor of surgery at uniformed Services university and Chief of Surgery at Madigan Army Medical Center in Tacoma, Wash.

In addition to new surgical expertise, pediatric surgery continues to provide patients more options for minimally-invasive procedures, including various abdominal operations such as splenectomies, adrenalectomies, repair of pectus excavatum and laparoscopic pull-through procedures for

new teCHniqUes enHanCe pediatriC sUrgiCal options

pediatriC sUrgery

p. 12

Hirschsprung’s Disease, a congenital absence of bowel nerve cells.

“A bowel without nerve cells stays contracted and forms a blockage,” Dr. Raynor explains. “In the procedure, we remove the area without nerve cells and pull the good bowel down to the anus.”

The procedure formerly required two or three stages of operations. “now, with the use of the laparoscope, it’s only one.”

Dr. Cusick says the trend in surgery is for more and more minimally invasive procedures.

“Many common procedures that we formerly conducted in open fashion now we only use laparoscopy,” he says. “All appendectomies, colostomies, gastrostomies, fundoplications, pectus repairs and empyemas are done in minimally invasive (MI) fashion. These are very common procedures that have all transitioned to MI.”

In addition, Dr. Abdessalam has recently performed minimally invasive lung resection and diaphragmatic hernia repair.

“The patient’s small size and the complexity of the issue are no longer limitations for minimally invasive procedures,” Dr. Cusick says.

He says that when he joined the staff at Children’s six years ago, approximately one-third of the fundoplication (reflux) procedures were done in a minimally invasive fashion. “now, 95 percent are done using a minimally-invasive technique.”

These procedures help speed recovery, he says. “And with scarring, at times it’s so minimal it’s difficult to tell in the future that the patient even had an operation.”

While the surgeons have added to their roster of minimally-invasive procedures, they’ve chosen not to perform some minimally-invasive procedures that nationally have indicated higher rates of complications.

“We don’t plan to adopt every procedure that comes along,” Dr. Cusick says. “Just because it’s new doesn’t mean it’s better. We try to be prudent in the use of new technology, especially if the procedure offers no advantage to the patient.”

He says Dr. Raynor and other pediatric surgeons who preceded him at Children’s “set a very high standard of care. As we add technologies, we have to continue to live up to and exceed that standard.”

Those high standards are something the surgeons are eager to pass along through the establishment of a fellowship training program, Dr. Cusick says.

“The elements for training physicians have always been here,” he says, “but now, with our combination of high patient volume and the educational opportunities we offer, we’ve organized those elements in a fashion that is perfectly suited for the training of a fellow.

“With our high clinical volume, we’re also looking toward clinical research opportunities, and to publish the results of programs already in place and data we’ve gathered through the years.”

All with the intention of making Children’s Hospital the region’s best choice for pediatric surgery.

“tHe patient’s sMall size and tHe CoMplexity

of tHe issUe are no longer liMitations for

MiniMally invasive proCedUres.”

robert CUsiCk, MdpediatriC sUrgeon, CHildren’s Hospital

perforMed as MiniMally invasive proCedUres

Splenectomy

Andrenalectomy

Repair of Pectus Excavatum

Laparoscopic pull-through

Appendectomy

Colostomy

Gastrostomy

Fundoplication

Empyemas

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➜

➜

➜

➜

➜

➜

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➜

pre-op CheSt x-ray ShoWinG inteStine in anterior CheSt

SUtUreS pLaCeD CLoSe to hernia

finaL piCtUre ShoWinG CLoSUre of hernia

a

b

C

a

b

C

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pHysiCian’s priority Hotline 1.888.592.7955

no parent wants to see their child in pain.

Reducing pain before and after surgery is shown to yield shorter stays in the hospital and greater rates of satisfaction among patients and their parents.

Developing a pediatric pain service program at Children’s Hospital is a priority for Kimberly Hissong, MD, who was appointed medical director of anesthesia at Children’s Hospital in February of 2007. She had served as interim director since joining the staff in August 2006.

“nationally, the public’s expectations for the control of pain are increasing,” she says. “That is why at Children’s we are actively recruiting medical specialists with experience in the alleviation of post-operative pain.

“Most surgical procedures cause some degree of pain, and we think children should be freed of that as much as possible.”

The number of anesthesiologists on staff at Children’s has increased significantly within the last year. Dr. Hissong says this was done, in part, to address an increase in the volume of procedures and services required, “and to best meet the higher acuity level of care we now see in our pediatric patient population.”

advanCes in pain Control a priority for anestHesiologists

pain Control

KiM hiSSonG, MD

p. 14

In addition to her duties as medical director, Dr. Hissong serves as one of three cardiac anesthesiologists on staff.

Children’s anesthesiologists routinely provide one-on-one care, says Director of Surgical Services Barb Schwarz, Rn, BS. “Having MD anesthesiologists providing care gives a greater level of comfort, not only for our patients and their families, but also for the physicians and surgeons who rely on them.”

Dr. Hissong stresses that the safety of the pediatric patients is paramount. One way to better ensure their safety is to develop and formalize a pre-anesthesia testing process for the hospital.

“Timing has been a challenge,” Schwarz says. “Our desire is to coordinate the processes so they take place on the day of surgery, rather than having the patients and their families come in twice.”

Dr. Hissong came to Children’s from Primary Children’s Medical Center in Salt Lake City, where she was among a group of 26 anesthesiologists. She received her undergraduate degree from nebraska Wesleyan university, her medical degree from the university of nebraska Medical Center, as well as her internal medicine internship. She attended the university of utah for her anesthesia residency and her pediatric anesthesia fellowship training was at Children’s Hospital in Boston.

Dr. Hissong has successfully recruited additional anesthesiologists to Children’s and assisted in the expansion of the Children’s Ambulatory Recovery express Services (CAReS unit). The CAReS unit is a 33-bed pre-and post-surgical care area where patients and families may remain for most of their surgical experience. This portal also may be

utilized for surgical procedures that require a hospital admission.

Schwarz, who has been at Children’s for 28 years, says the number of surgical cases and the complexity of the cases have changed significantly. “The procedures we do now are nothing like what we did even five years ago. We have higher-risk patients and extremely complicated surgeries. Often, these kids come to us really sick.”

To meet these challenges, Children’s has added more procedure rooms, enhanced the services provided by the anesthesia department to other ancillary units, and worked to build a highly-qualified and extremely competent staff.

“We also are evaluating the need for additional operating room space,” Schwarz says. “As the complexity of our surgical procedures increases, so does the amount of time and space needed to complete them. The

average operating room today is 1-1/2 to two times larger than it was at the beginning of my career, mostly to accommodate the highly sophisticated equipment that is being used.”

The anesthesia department currently provides service to six main ORs, the cardiac catheterization lab and three smaller procedure rooms, as well as the radiology unit. Children’s Hospital accounts for nearly all (99 percent) of the pediatric cardiac surgeries in nebraska.

The hospital’s surgical unit is operating well above its budgeted volume, Schwarz says. “That means we have to work hard and we have to work efficiently. It’s more of a challenge when the cases are complex.”

Schwarz says one of her duties as director of surgical services is to organize the teamwork and communications that are vital for the

anesthesia and surgical staff and the sub-specialists at Children’s.

“especially in surgical services, you can’t walk the road alone,” she says. “In any one case, you might have six to eight people working alongside each other in one room. you’ve got to mesh as a team.”

Having the anesthesiologists on staff at Children’s, she says, “better facilitates the alignment of our common goals.”

Dr. Hissong says she returned to nebraska because she has family here and because of the “tremendous opportunity” she perceives at Children’s.

“I see the possibility of being involved in high quality pediatric patient care in nebraska,” she says. “I was at a point in my career where I had to decide whether what I had done was good enough or if I wanted to take on a bit more.”

At Children’s she has found a caring environment filled with quality people who work hard, are proud of what they do and who share a vision for what the hospital can become.

“This hospital is ready to take the next big step and become a really big player,” Dr. Hissong says. “The people, the place and the potential – this opportunity won’t come again in my career.”

Schwarz says Dr. Hissong’s enthusiasm and eagerness to help take Children’s to the next level of care are among her strongest attributes. “She brings with her a huge desire to provide high-quality care that will take us all closer to the realization of that potential.”

In addition to her vision, Dr. Hissong brings a unique perspective to her work.

“I trained in Boston and worked in Salt Lake City with a group of unbelievable practitioners who mentored me and really taught me how to be a doctor. Sometimes you need to bring your questions or concerns to someone with a different perspective. That can be invaluable, and I can bring that here.”

Her goal is to one day make a stay at Children’s Hospital as pain-free as possible for all pediatric patients.

“tHe people, tHe plaCe and tHe potential – tHis opportUnity won’t

CoMe again in My Career.”

kiMberly Hissong, MdMediCal direCtor of anestHesia, CHildren’s Hospital

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pHysiCian’s priority Hotline 1.888.592.7955

A heart defect that as little as 20 years ago offered little chance for survival is being treated with impressive success by the cardiothoracic surgeons at Children’s Hospital.

The defect, called hypoplastic left heart syndrome, is an abnormality where the major portion of the left side of the infant’s heart is either missing or too small to support normal cardiac function.

Through a three-stage series of operations that begins with the norwood procedure, surgeons essentially rebuild the child’s heart to use the single, right ventricle for systemic and pulmonary blood flow.

James M. Hammel, MD, one of two cardiothoracic surgeons on staff at Children’s, says the norwood procedure is being performed at the hospital with success rates that rank among the highest in the nation.

“This is an operation that was conceived 25 years ago, and only 15-20 years ago, the likelihood of survival was very, very low.”

Overall, the rate of pediatric heart surgery risk-adjusted mortality at Children’s is considerably better than the national average.

The survival rate from the norwood procedure is considered by the surgical community to be a good indicator of a facility’s overall pediatric cardiac surgery program. “excellent norwood outcomes are accepted as a hallmark of excellent surgical outcomes generally,” Dr. Hammel says.

According to the Agency for Healthcare Research and quality, the risk-adjusted mortality rate at Children’s is 22.41 per 1,000 cases, compared to a rate of 36.55 per 1,000 cases in an average obtained from 43 other pediatric hospitals. The rates are from 2006 and

are not specific to any one procedure. That year, 209 open-heart operations were performed at Children’s, with nearly 300 total cardiac cases.

“I believe the reason for our success is much more than just the work Dr. Kim Duncan (pediatric cardiothoracic surgeon) and I do in the operating room,” Dr. Hammel says. “It reflects the significant investment Children’s Hospital has made in adding three dedicated pediatric cardiac anesthesiologists; three dedicated pediatric cardiac perfusionists; and around-the-clock pediatric intensive care attendance. And it depends on the very hard work of the cardiac operating room and intensive care unit nurses.

“In addition, Children’s continues to refine the eCMO (extracorporeal Membrane Oxygenation) program and the hybrid surgical/interventional cath lab, as well as to make investments in cardiac imaging with

a seCond CHanCe at lifefirst-stage norwood sUrvival rates at CHildren’s rank aMong nation’s best

norwood

DiaGraM of norWooD proCeDUre2

p. 16

“oUr sUrvival rates and faMiliarity witH

sUrgery for CoMpliCated Heart defeCts Mean

tHere is no reason to send a pediatriC patient

anywHere else in tHe CoUntry for treatMent

of a CardiaC defeCt.”

jaMes HaMMel, MdpediatriC CardiotHoraCiC sUrgeon, CHildren’s Hospital

three-dimensional echo, digital echo and cardiac MRI.

“Here at Children’s, vision, collaboration and innovation have come together to improve outcomes and survival for this benchmark procedure.”

The Cardiothoracic Surgery Department at Children’s includes Drs. Hammel and Duncan, along with physician assistants and advanced practice nurses who specialize in the evaluation and surgical care of children with congenital heart disease, acquired heart disease, chest wall deformities, pulmonary disease and chest masses.

Some of the department’s services include, but are not limited to:

Surgical repair or palliation of patients with congenital heart disease,

Surgical repair of children with acquired heart disease and chest wall deformities/masses,

Consultation on risks and benefits of surgery,

Intensive and critical care,

Transitioning a child with congenital heart disease to a normal lifestyle,

Information on growth and development of a child with heart disease, and

Prenatal consultation for mothers delivering an infant with congenital heart disease.

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ContinUeD

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Dr. Duncan, who serves as the department’s medical director, is a graduate of the university of Alberta Medical School in edmonton. He completed his residency at university of Alberta Hospitals and fellowships at the Hospital for Sick Children in London and the Hospital for Sick Children in Toronto.

In addition to his duties at Children’s, he serves as chief for the Section of Cardiothoracic Surgery at the university of nebraska Medical Center (unMC).

Dr. Hammel is a graduate of the university of Michigan Medical School. He completed his residency at unMC and fellowships at the university of Iowa Hospital and Clinics and the Hospital for Sick Children in Toronto. He is a surgical partner in the heart transplantation program at unMC.

He says hypoplastic left heart syndrome “is a very difficult disease. The right ventricle is not designed to be a systemic ventricle.”

In the three-operation sequence of palliation for the disease, the first-stage norwood procedure is done at birth. The second operation is typically around four to six months of age, and the third at about two to four years of age. All three operations are routinely performed at Children’s.

The procedure requires a surgeon to reconstruct the child’s aorta and pulmonary artery with graft tissue so that the right

ventricle is able to provide blood flow to the body as well as to the lungs. The time between the first stage operation and the second stage is the most vulnerable for norwood patients.

A fetal diagnosis is very helpful in identifying norwood candidates. “An antenatal diagnosis and planning prior to delivery simplifies their care, especially in a place like the Midwest where many of the patients come to us from a great distance.”

Any indication of a cardiac defect existing in the womb is good reason to consult with the cardiac specialists at Children’s in Omaha by calling the Physicians’ Priority Line, 1-888-592-7955.

“A physician anywhere in the region shouldn’t hesitate to send a baby to us, whether the cardiac defect appears to be minor or complex,” Dr. Hammel says. “There’s certainly no question in the case of hypoplastic left ventricle. But our survival rates and familiarity with surgery for complicated heart defects mean there is no reason to send a pediatric patient anywhere else in the country for treatment of a cardiac defect.

“Our results show we rank among the best.”

THe TIMe BeTWeen THe FIRST STAge OPeRATIOn AnD THe SeCOnD STAge IS THe MOST vuLneRABLe FOR nORWOOD PATIenTS.

p. 18

Children’s Hospital’s institutional affiliation agreement with the university of nebraska Medical Center (unMC) will firmly establish the two entities as the region’s premier source for pediatric health care, research and education.

“There is a tremendously exciting synergy that is possible by taking full advantage of the expertise both institutions bring to this relationship,” says gary A. Perkins, president and CeO at Children’s. “This is an unprecedented opportunity to transform pediatric health care in the region.”

The agreement brings together the pediatric specialists and care providers of unMC and Children’s to offer quality, cost-effective health care for children; enrich academic experiences for pediatric residents, medical students and other health professionals; and greatly advance clinical and basic science research opportunities for the prevention and treatment of childhood conditions and diseases.

John gollan, MD, Ph.D., dean of the College of Medicine at unMC, says many of the nation’s most innovative children’s hospitals and academic medical centers are successfully combining forces. “This critical step will place us among an elite group of national children’s hospitals such as Boston Children’s Hospital and Texas Children’s Hospital,” he said.

The affiliation will generate opportunities to conduct research into childhood disorders so children and families in the region will have close, convenient access to the most advanced care available.

The affiliation also strengthens the capability to educate medical students and residents at a facility dedicated to high-caliber pediatric health care services, says unMC Chancellor Harold M. Maurer, MD

“This affiliation infuses research and teaching into the delivery of patient care,” Dr. Maurer says. “As a pediatrician, it’s a dream come true.”

under the agreement, the unMC Department of Pediatrics will be based primarily at Children’s Hospital. Certain specialty pediatric services already in place at The nebraska Medical Center will remain there, such as neonatal intensive care and solid organ and bone marrow transplantation.

“This affiliation will enable the institutions to recruit the nation’s highest caliber pediatric specialists and scientists,” Dr. gollan says, “whose desire is to provide patient care in a children’s hospital setting while also being a catalyst for improving children’s health through teaching and research.”

CHildren’s, UnMC affiliation generates opportUnities for qUality pediatriC Care, teaCHing & researCH

“tHis is an UnpreCedented

opportUnity to transforM

pediatriC HealtH Care in tHe

region.”

gary a. perkinspresident and Ceo, CHildren’s Hospital

UnMC affiliation

DaviD ChriStenSen, MDJohn W. SparKS, MD

as part of the affiliation with the University of nebraska Medical

Center College of Medicine, john w. sparks, Md has been

named chair of the University of nebraska Medical Center’s

department of pediatrics. He will work with david Christensen,

Md, senior vice president for medical affairs and chief medical

officer at Children’s Hospital, to advance clinical and basic

science research opportunities for the prevention and treatment

of childhood conditions and diseases.

dr. sparks received his bachelor’s degree from the Massachusetts

institute of technology and his medical degree from Harvard

Medical school. He completed his internship, residency and

fellowship at the University of Colorado Health sciences Center,

where he continued on as assistant professor and then associate

professor. He was professor and director of the neonatal-perinatal

fellowship at the University of texas Medical school at Houston,

and was appointed Chairperson of the department of pediatrics,

where he has served for the past 10 years.

prior to joining Children’s in 2007, dr. Christensen served as

medical director at Mary bridge Children’s Hospital and

Health Center, MultiCare Health system in tacoma, wash.

dr. Christensen received his undergraduate degree from the

University of California and his medical degree from Creighton

University in 1992. He completed his pediatric internship and

residency at stanford University and received a master’s degree

in health care management from Harvard University in 2005. He

is a member of the american academy of pediatrics and the

american College of physician executives and a fellow of the

american academy of pediatrics.

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It’s difficult for any mother to hand her newborn off to a doctor or a nurse. And it’s difficult for those medical caregivers to pass a sick baby off to others to be taken to a hospital many miles away.

But the neonatal Transport Service at Children’s Hospital has found a way to ease those concerns.

They work as a team.

not just the team that is formed by the neonatal nurse practitioner and intensive care unit nurse from Children’s who board the ambulance to provide care for the infant while en route to the hospital in Omaha.

The Children’s team also bonds with the caregivers at the originating hospital, those who know that sending the infant to Children’s is best for the baby and yet have a reluctance to yield their medical responsibility for so small a patient.

uniting in a relationship of trust and professional respect, the two teams become one group that has the infant’s care at heart.

Children’s requests that those using the transport service complete an evaluation form, says Pam Carlson, vice president of patient services for the hospital.

“The comments indicate how impressed people have been by our team from Children’s, how they’ve shown a genuine willingness to work with the medical team at the facility,” Carlson says. “We all work together as a team, from the moment we arrive to the instant the ambulance doors are swung shut.”

Other respondents compliment team members for their expertise and compassion. “The team is always very professional, very good to the infant, very supportive of the parents and also of the staff caring for the baby. They are always great to work with.”

neonatal transport serviCe CoMpletes bUsy first year

neonatal transport

p. 20

“it’s a valUable CoMbination of MediCal knowledge and

nUrsing tHat expands oUr ability to Handle CoMplex

Cases and Make iMMediate jUdgMents on-site.”

joHn jirka, Mdneonatologist, CHildren’s Hospital

One call to the Children’s Hospital Physicians’ Priority Line gives instant access to the neonatal transport service team. A team member will arrange the most appropriate form of transport, whether by ground or air, based on the patient’s needs. Physicians should call the priority line at 1-888-592-7955.

The Children’s transport service is staffed by 10 intensive care unit nurses with experience

in neonatal and pediatric critical care, and nine neonatal nurse practitioners. One member of each group is present on each transport. The team contacts the physician at the sending hospital and can be in contact with the doctors at Children’s while en route.

Having a neonatal nurse practitioner as a component of the transport team is somewhat unique to Children’s, says John Jirka, MD, a neonatologist on staff in the Children’s neonatal Intensive Care unit (nICu).

“It’s becoming more of a standard around the u.S. but rare in our region,” Dr. Jirka says. “It’s a valuable combination of medical knowledge and nursing that expands our ability to handle complex cases and make immediate judgments on-site.”

The service recently completed a busy first year. The number of transports and the distance traveled indicate the service is proving both its need and its value.

From June 2006 to July 2007, the service logged a total of 72 transports from regional hospitals to Children’s and, in some cases, trips back to the original medical facility. The busiest month was August (2006) with a total of 10 transports.

“We had anticipated making an average of one run per week, so the first year has been a little busier than what we expected,” Carlson says.

The transport team, which is currently a ground-based service only, traveled throughout the Omaha metropolitan area and as far as north Platte and grand Island in nebraska; Shenandoah and Sioux City in Iowa; and Maryville in Missouri.

“Although we primarily serve a 150-mile radius, we have gone beyond that when the situation requires it,” Carlson says.

The need for the service arose from several experiences when transporting an infant to Children’s for urgent care was required but the means was unavailable.

Air service via a helicopter or an airplane is still available to get critically ill infants and children to Omaha. But the ground-based transport service can prove extremely valuable when bad weather prohibits flying.

Peg Peterson, a neonatal nurse practitioner with the transport service, says the team

can have an ambulance at Children’s and be aboard and en route in a matter of 30 minutes or less. “usually we’re on the road within about 20 minutes of the call,” she says.

Currently, the transport service is for neonates and infants up to two months old. Carlson says the hospital hopes to launch a similar service for older pediatric patients some time in late 2008.

“We’ve seen the need,” she says, “now we have to decide how best to respond.”

Most likely, as a team.

one Call to tHe CHildren’s Hospital

pHysiCians’ priority line gives instant

aCCess to tHe neonatal transport

serviCe teaM. a teaM MeMber will

arrange tHe Most appropriate forM

of transport based on tHe patient’s

needs. pHysiCians sHoUld Call tHe

priority line at 1-888-592-7955.

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pHysiCian’s priority Hotline 1.888.592.7955

Leanne vitito, aprn

Dr. CryStaL KniGht

Dr. thoMaS attarD

gastroenterology

The gastroenterology group at Children’s Hospital has recently undergone considerable transformation and growth aimed at maintaining excellence in patient care. Dr. Sharad Kunnath, Dr. Crystal Knight and LeAnne vitito, APRn have joined Dr. Fernando Zapata and Dr. Thomas Attard in Pediatric gastroenterology, Hepatology and nutrition to contribute fresh insight and participate in research benefiting young patients.

Dr. Kunnath graduated from the Joint Creighton-nebraska universities Health Foundation pediatrics residency program. He joins us after completing fellowship training in Pediatric gastroenterology at Brown university in Rhode Island. His primary research interest is in inflammatory bowel disease.

Dr. Knight completed her residency training in pediatrics at Seattle Children’s Hospital. She joins us as a research fellow in Pediatric gastroenterology at the university of nebraska Medical Center.

LeAnne vitito APRn received her MS in nursing at Creighton university. She brings to the section her extensive experience as a nurse practitioner in adult gastroenterology and as a case manager in pediatric gastroenterology.

Along with new faces, the gI group has introduced new cutting-edge diagnostic procedures such as capsule endoscopy and impedance-pH probe testing. Staff are actively conducting and recruiting for research studies including infant formula trials and studies in polyposis syndromes and inflammatory bowel disease (IBD). Children’s Hospital is one of seven organizations in the world and one of only three in the u.S. conducting research in the medical treatment of children with hereditary polyposis syndromes.

For more information, or to request a consultation, please contact the Physician’s Priority Line at 888-592-7955.

gastroenterology groUp expands

Dr. fernanDo zapata

Dr. SharaD KUnnath

p. 22

Physicians’ Priority Line (physician-to-physician consult and referral line) 1-888-592-7955

Transport (Physician’s Priority Line) 1-888-592-7955

Hospitalist 955-5400 or 1-888-592-7955

PICU 402-955-4200

NICU 402-955-6230

Clinic Location Frequency Phone

CardIoLogyCarl Gumbiner, MD Norfolk, Neb. Monthly 955-4350 North Platte, Neb. Quarterly 955-4350 Kearney, Neb. Quarterly 955-4350

David Danford, MD Hastings, Neb. Monthly 955-4350 Grand Island, Neb. Quarterly 955-4350

Scott Fletcher, MD Columbus, Neb. Quarterly 955-4350 Sioux City, Iowa Semi-annually 955-4350 Holdrege, Neb. Semi-annually 955-4350

ENdoCrINoLogy/dIabETEsMonina Cabrera, MD Lincoln, Neb. Semi-monthly 955-3871 Sioux City, Iowa Semi-monthly 955-3871

Kevin Corley, MD Lincoln, Neb. Weekly 955-3871Jean-Claude DesMangles, MD Lincoln, Neb. Semi-monthly 955-3871 Sioux City, Iowa Semi-monthly 955-3871

Clinic Location Frequency Phone

gasTroENTEroLogyThomas Attard, MD Lincoln Semi-monthly 955-5700Fernando Zapata, MD Sioux City, Iowa Monthly 955-5700

HEmaToLogy/oNCoLogyDavid Gnarra, MD Lincoln, Neb. Weekly 955-3950

NEUroLogy Ivan Pavkovic, MD Lincoln, Neb. Semi-monthly 955-5372 Young Oliver, MD Sioux City, Iowa Monthly 955-5372 rEsPIraTory mEdICINEMark Wilson, MD Sioux City, Iowa Monthly 955-5570 Lincoln, Neb. Rotates weekly 955-5570

rHEUmaToLogy Larry Jung, MD Sioux City, Iowa Monthly 955-4070 Lincoln, Neb. Semi-monthly 955-4070

CHildren’s Hospital oUtreaCH CliniCs

tHese speCialties will be added wHen tHe CHildren’s speCialty pediatriC CliniC opens in linColn:

Cardiology

Neurosurgery

Endocrinology

Gastroenterology

Infectious Disease

Surgery

Respiratory

Neurology

Hematology/Oncology

Rheumatology

Orthopedics

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openingmarch 2008

4445 s. 86th st.Lincoln, NE 68526402-486-1500

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ChildrensOmaha.org

1.888.592.7955pHysiCians’ priority line

your 24-hour link to pediatric specialists for physician-to-physician consults, referrals, admissions and neonatal transport service.