воскресенье, 30 сентября 2012 г.

Emerging Role of the Pediatric Nurse Practitioner in Acute Care. - Pediatric Nursing

The pediatric nurse practitioner role in the tertiary setting is one of several emerging roles gaining recognition in the various groups of advanced practice nursing programs today. The advanced practice nurse (APN) who is a pediatric nurse practitioner (PNP) in an acute care setting helps to provide cost-effective, quality patient care for critically and chronically ill children who are in these settings. The foundation of advanced practice nursing in this role incorporates the general role expectations of advanced nursing preparation, including case management, clinical pathway development, consultation and education, research, and collaboration, with the specific knowledge and skills of the pediatric nurse practitioner to function effectively with sick children in the acute care areas.

The acute care nurse practitioner (ACNP) specializing in pediatrics is one of several new and emerging advanced clinicians being developed in nursing

education for employment in the complex acute care health settings around the country. By combining the expertise of the pediatric nurse practitioner (PNP), the preparation to function in the tertiary pediatric intensive care units of some hospitals, and the role expectations of the nurse in advanced practice, the ACNP can provide a range of benefits to the health system and the children they serve. This specialty practitioner is one of several advanced practice nursing (APN) career choices in nursing programs today. Based on the roles of clinical nurse specialists (CNSs) and primary care nurse practitioners (NPs), two of several APNs, the ACNP can have a wide range of nursing experiences that offers effective solutions to manage complex and uncertain situations (Parr, 1996).

Foundations of Advance Practice Nursing -- Specialists and Practitioners

APNs include the various specialized advanced nursing professionals who may be NPs, CNSs, certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs). Their roles have been repeatedly demonstrated through research to be associated with high quality care, cost effectiveness, and patient satisfaction (Ingersoll, 1995).

The roles of the CNS and the NP were developed for two reasons primarily related to economic conditions: (a) to improve nursing practice and (b) to improve patient care. The role of the CNS was developed by nurse educators in the post World War II era in an effort to improve the quality of nursing care in a period of massive knowledge and technical growth (Hamric, Spross, & Hanson, 1996). CNSs are educated and trained as consultants and professional experts. They act as case managers, educators, and directors of patient care, although typically not as direct caregivers. They are unique in their ability to provide holistic care without direct patient involvement. The role of NP was developed in the 1960s in response to a physician shortage in primary care. In 1964 the first pediatric NP program was started at the University of Colorado, soon followed by Massachusetts General Hospital, and by 1980 there were nearly 300 NP programs (Millonig, 1994). NPs are trained in direct patient care and are able to perform assessment, diagnosis, and management of conditions, including prescribing treatments.

Just as the NP role was created in the primary care setting in response to economic conditions, a new role is emerging for the advanced practice nurse in acute care. As health consumers demand safe, quality, and cost-effective health care in today's tertiary care settings, nursing has responded (Keanne, Richmond, & Kaiser, 1994). By blending some of the similar characteristics of CNS and NP roles in graduate preparation, nursing education has developed an advanced practice clinician role, producing a nurse who may be able to take on a variety of responsibilities. APNs as practitioners are not only seen in the primary care setting, but are also emerging as practitioners in the acute care setting. Because of decreasing department budgets as well as decreasing numbers of residents in hospitals, the ACNP has emerged to assist with managing patients who are acutely ill or who have exacerbations of chronic health problems. This new type of APN combines the direct care provision of the NP with the traditional CNS care services in acute care to produce the advanced practice clinical role (Dracup et al., 1994).

The new ACNP offers many unique contributions to the tertiary care setting. The ACNP role differs from the CNS role. While the CNS works with staff nurses giving direction and education, they traditionally do not do direct patient care. The ACNP brings medical and nursing paradigms to the acute care setting (Keanne et al., 1994). The ACNP is responsible for direct patient management through admission, performing histories and physicals, evaluating clinical data, prescribing treatments, performing invasive procedures, educating and supporting the families, and facilitating patient discharges. The ACNP collaborates with other members of the health care system, writes orders, and has prescription privileges (although these privileges vary from state to state). This acute care advanced nurse can be found in specialty areas such as pediatric and neonatal intensive care units, oncology, cardiology, gastrointestinal, and pulmonary acute care settings.

Advanced Practice Roles

According to the American Nurses Association (ANA), advanced practice nurses perform comprehensive health assessments and demonstrate skilled autonomy in the diagnosis and treatment of individuals, families, and communities to manage acute and chronic illness and promote wellness. The ANA states that nurses from all the various areas of advanced clinical nursing practice must be masters prepared. The ACNP receives advanced training focusing on the assessment and pharmacological management of patients in acute care settings. Nurses in advanced practice bring cohesiveness between nurses, physicians, and other members of the health care team (Berger et al., 1996). The general areas of advanced roles in this specialty practice can include: case management, clinical pathway development, educator/consultant, research, and collaboration.

Case management. Case management assists providers and consumers in the pediatric tertiary setting in order to ensure continuity of care, cost containment, and quality outcomes. National standards of practice that have been established by the Case Management Society of America (CMSA) guide care management responsibilities. CMSA specifies standards of practice that include assessment, case identification and selection, problem identification, planning, monitoring, and evaluating outcomes (CMSA, 1995). Case management models are designed to provide high quality care in a cost-effective manner. Two nursing case management models were developed in the mid 1980s after the introduction of Diagnostic-Related Grouping (DRG) reimbursement system.

The New England Medical Center (NEMC) model focuses on the control of resources used during the patient's hospitalization. Through the use of protocols, decreased cost, decreased length of hospitalization, and decreased variability of patient care have all been achieved. The NEMC model enhances quality of care, increases provider and patient satisfaction, and reduces the cost of care delivery (Cook, 1998).

The Professional Nursing Care Management (PNCM) model integrates nursing services across the care continuum. Developed at St. Mary's Hospital in Tucson, Arizona, the PNCM model focuses on the supportive environment, both in the institution and in the community. The goals of the PNCM model are 'high satisfaction and quality, lowered costs, and reduced length of stay' (Cook, 1998, p. 38).

The pediatric ACNP can be in a unique position to fill the case manager role. Although CNSs and professional nurses are capable of performing these functions, facilitation of planning, communication, and coordination of care can be provided by the ACNP in a leadership role (Sohl-Kreiger, Lagaard, & Scherrer, 1996). ACNPs who are PNPs can apply critical thinking and advanced knowledge to promote holistic care in managing clinical situations (Berger et al., 1996). These case managers would be uniquely qualified to facilitate uniform, consistent care for children in a tertiary setting.

Clinical pathway development. Clinical pathways are multidisciplinary plans used to follow events for patients with the same diagnosis. A natural extension in the role of the advanced nurse as case manager is a role in development of clinical pathways. While traditionally a CNS function, the ACNP can add clinical management knowledge to the interdisciplinary task. Pathways were first developed and brought into the health care system in 1980 in response to health care employers and consumers demanding efficiency and cost effectiveness. Tertiary care is often complex and expensive. Pathways promote positive patient outcomes and satisfaction as well as decrease cost and utilization of health care resources (Capuano, 1995). Pathways are used to create effective and efficient organization of care (Uzark et al., 1998) in the tertiary setting.

In hospital settings, continued utilization of pathways occurs following review of the benefits of pathways. Some physicians are resistant to the use of pathways, feeling that they infringe on clinical judgment and individual decision making. The ACNP can present positive outcomes of the use of pathways to the medical team and can help ensure the success of pathways. Key responsibilities for the advanced nurse in development and review of clinical pathways include: (a) developing pathways in areas of expertise, (b) reviewing pathways with families, (c) following pathways to ensure their use, (d) reviewing outcome analysis, (e) developing a plan for resolution of problems involved with patient care, (f) acting as a resource for the health care team, (g) acting as communication liaison between members of the health care team, (h) attending clinical pathway meetings, and (i) revising pathways as indicated (Capuano, 1995).

Education/consultation. The advanced nursing roles of educator and consultant, while not unique to the tertiary setting, have a beneficial influence on patients, families, and multidisciplinary team members. The education/consultant role of the APN in the acute care setting has grown dramatically because of the increase in chronically ill children requiring complex management.

The ACNP performs in the role of educator in relationships with patients and families as well as in daily interactions with staff. The ACNP in the role of patient or family educator brings relevant information while integrating theories as a means to influence patient outcomes (Parrinello, 1995). Relevant nursing theories provide a strong foundation for the ACNP to educate patients regarding their plan of care, self-care, prevention issues, discharge planning, and follow-up. The ACNP, who is more often a direct hands-on provider of care, may also work with the CNS in the role of staff educator, coordinating educational nursing in-services and teaching didactic content, skills, and competencies in critical care orientation (Parr, 1996). Over time, the ACNP and the nursing staff may form a collaborative relationship in which the staff seek clinical consultation from the ACNP's expert knowledge.

The ACNP may also participate in schools of nursing activities as a nursing educator, as well as serve as a clinical preceptor for students, staff, and others (Parrinello, 1995). Through classroom activities and in practice, ACNPs can act as role models for new ACNPs, offering an exemplary foundation on which to base their practice.

The ACNP consultant role aims at improving patient care and nursing practice based on expertise in various areas of specialization (Parrinello, 1995). The ACNP is able to analyze clinical data and discuss outcome benefits for the patient and family. ACPN's clinical expertise allows them to act as consultants when planning critical pathways for specific populations. The consultant role places the ACNP in the position to develop patient and family teaching materials that will enhance overall patient outcomes.

Research. Research is essential for the expansion and enhancement of all the APN roles (Porter- O'Grady, 1996). Current trends in health care delivery have dramatically affected both the mode of APN's practice and the demands placed upon them. As a result, nurses can no longer rely solely on experience in making policy and patient care decisions, but must provide evidence that their delivery of health care will positively affect patient outcomes while containing cost (McGuire & Harwood, 1996). Nursing research provides that evidence by validating and quantifying the outcomes of advanced nursing practice as unique, cost-effective, and efficient. Additionally; research provides a scientific basis for advanced nursing practice and provides evidence of accountability (Talbot, 1995). Research also provides an avenue to introduce innovations that can change and improve practice. According to Hawkins and Thibodeau (1996), research is essential to define, implement, validate, and evaluate advanced nursing practice.

Changes in today's health care system challenge all APNs to develop a research-based practice that ensures personal and professional competence (Talbot, 1995). Research questions evolve from problems noted in clinical practice, education, political or ethical issues, and from needs identified in specific patient populations and/or communities. Specialists and practitioners commonly explore research findings from the analyses of existing research and databases. Issues surrounding role definition and credibility must be explored to expand the role of the ACNP. Answers to these questions provide a scientific basis for nursing practice (Hawkins & Thibodeau, 1996). ACNPs must use the research utilization process to interpret and integrate research findings into practice, to evaluate studies to examine nursing practice, and to gather material that will generate knowledge and define optimal nursing interventions and outcomes.

Collaboration. Collaboration implies that all members of the health team agree to work cohesively to strive for a common goal. Effective collaboration requires the understanding and acceptance of each other's practice, roles, and responsibilities. Cooperation and effective communication can only be achieved through mutual trust and respect between health care professionals. The nurse with advanced education brings to the table a unique set of skills in health promotion, prevention, adaptation, education, counseling, and access to community resources. Understanding each provider's scope of practice and responsibilities enhances the advanced practice clinician's role as a team member.

The ACNP, in addition, must demonstrate clinical competence and credibility in order to collaborate effectively with the medical team. Credibility can be achieved through education and experience, as well as commitment to direct patient care. APNs can promote collaboration by establishing productive, respectful, and contributory relationships with the medical team as well as with their patients and families.

Strategies to Enhance the ACNP Role

In the changing health care world ACNPs must establish strategies to increase their credibility and success in the acute care setting. Acute care training programs for practitioners at the graduate level is vital to ensure the ACNP credibility. Training should include management of acute illnesses and chronic conditions in children. In addition to graduate education, certification by a professional nursing organization and licensure by the state in an advanced practice category are credentials needed to legitimize the practice of the ACNP.

Practitioners must market themselves by advertising their important contributions in the acute care setting. APNs in acute care must be assertive in controlling their practice and defining what constitutes advanced practice. Practitioners must emphasize that they are not replacing medical residents. ACNP skills go beyond history taking and physicals; they do more than provide direct patient care. The ACNP's unique approach to health care results in a high level of patient care and satisfaction.

PNPs who can function in advanced roles in acute care bring his or her background in pediatric nursing to the tertiary care setting that provides a base of expertise and allows them to understand and communicate with other pediatric nurses. PNPs also have the advanced degree that gives them a strong medical understanding thereby facilitating communication with the physicians. Therefore, care provided by a PNP to an acutely ill pediatric patient can have several advantages over care provided by a physician, CNS, or professional baccalaureate prepared nurse in certain situations.

ACNPs can solidify their role through active collaboration with physicians, problem solving with nurses, conducting and facilitating research, and continuing role development and protocols for the profession (Hravnak, Rosenweig, & Baldisseri, 1996). The lack of a clear definition of the advanced practice role in education, title, and credentialing has contributed to confusion within the nursing profession and within members of the health care system. Future advanced roles will need to have delineated requirements for advanced practice skills. Practitioners in advanced practice roles must be accountable to all patients and families under their care.

Evaluating Outcomes for the ACNP

ACNPs must demonstrate the value of their role through evaluation of outcomes. Evaluation can be done via structure factors, process evaluations, outcome measurements, and through evidence of cost effectiveness. Evaluation will allow the ACNP to explore practice-setting characteristics, examine direct patient care, and follow-up for short or long-term outcomes of patients seen by the APN (Ingersoll, 1997). Other types of evaluations that can be useful include performance evaluations and ratings from nursing colleges. Performance evaluations must include: clinical practice, education, consultation, research, and professional development. Activity logs are important to ACNPs since they can be used as evidence of the impact of care provided by practitioners over time. According to Ingersoll (1997), items to include in activity logs are listings of consumers, peers, medical records, consultation notes, process logs, quarterly reports, letters, meetings, hospital quality improvements, publications, presentations, and grant proposals.

There is mounting evidence that the advanced practice role in acute care is cost effective and credible extrapolated from research on other advanced roles. Unfortunately, barriers to, advanced practice still exist. Through marketing strategies, evaluation outcomes, continued education, and dedication to direct patient care, APNs as acute care practitioners can overcome existing barriers. The role of the ACNP should be defined to allow accountability for practice to be shared between nursing and medicine where indicated. Shared accountability will benefit children and their families.

References

Berger, A.M., Eilers, J.G., Pattrin, L., Rolf-Fixley, M., Pfiefer, B.A., Rogge, J.A., Wheeler, L.M., Bergstrom, M.I., & Heck, C.S. (1996). Advanced practice roles for nurses in tomorrow's healthcare systems. Clinical Nurse Specialist, 10(5), 250-255.

Capuano, T. (1995). Clinical pathways: practical approaches, positive outcomes. Nursing Management, 26, 34-36.

Case Management Society of America (CMSA). (January, 1995). Standards of practice for case management. Little Rock, AR: Author.

Cook, T.H. (1998). The effectiveness of inpatient case management: Fact or fiction? JONA, 28(4), 36-46.

Dracup, K., DeBush, R.F., Demots, H., Gaile, E.H., Norton, J.B., & Rudy, E.B. (1994). Task force three - Partnerships in delivery of care. Journal of Critical Care, 24, 296-303.

Hamric, A.B., Spross, J.A., & Hanson, C.M. (1996). Advanced nursing practice: An integrative approach. Philadelphia: W.B. Saunders Company.

Hawkins, J.W., & Thibodeau, J.A. (1996). The advanced practice nurse. New York: Tiresias Press, Inc.

Hravnak, M., Rosenweig, M.Q., & Baldisseri, M. (1996). Credentialing and privileging: insight into the process for acute care nurse practitioners. AACN Clinical Issues, 8(1), 108-115.

Ingersoll, G. (1997). Evaluation of the advanced practice nurse role in acute and specialty care. Critical Care Nursing Clinics of North America, 7(1), 25-33.

Keanne, A., Richmond, T., & Kaiser, L. (1994). Critical care nurse practitioners: Evolution of the advanced practice nursing role. American Journal of Critical Care, 3(3), 232-237.

McGuire, D., & Harwood, K. (1996). Research interpretation, utilization, and conduct in advanced nursing practice, an integrative approach. Philadelphia: W.B. Saunders Co.

Millonig, V.L. (Ed.). (1994). Pediatric nurse practitioner certification review guide (2nd ed.). Potomac, MD: Health Leadership Associates, Inc.

Parr, M.B. (1996). The changing role of advanced practice nursing in a managed care environment. AACN Clinical Issues, 7(2), 300-308.

Parrinello, K.M. (1995). Advanced practice nursing: an administrative perspective. Critical Care Nursing Clinics of North America, 7(1), 9-16.

Porter-O' Grady, T. (1996). Research and value. Advanced Practice Nursing Quarterly, 2(3), 72-73.

Sohl-Kreiger, R., Lagaard, M.W., & Scherrer, J. (1996). Nursing case management: Relationships as a strategy to improve care. Clinical Nurse Specialist, 10(2), 107-113.

Talbot, L. (Ed.). (1995). Principles and practice of nursing research. St. Louis: Mosby-YearBook, Inc.

Uzark, K., Frederick, C., Lamberti, J., Worther, H., Ogino, M., Mainwarning, R., & Moore, J. (1998). Changing practice patterns for children with heart disease: A clinical pathway approach. American Journal of Critical Care, 7(2), 101-105.

Stacey Teicher, MS, RN-CS, CNS, CPNP, is a pediatric oncology nurse, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, CA.

Karl Crawford, MS, RN-CS, CNS, CPNP, is a pediatric CT surgery/Cardiology nurse, Brenner Children's Hospital, Winston-Salem, NC.

Barbara Williams, MS, RN-CS,CNS, CPNP, is a pediatric CT surgery nurse, Alfred I. duPont Hospital for Children, Wilmington, DE.

Brandy Nelson, MS, RN-CS,CNS, CPNP, is a pediatric CT surgery/Cardiology nurse, National Children's Medical Center, Washington, DC.

суббота, 29 сентября 2012 г.

Manual of Pediatric and Postpartum Home Care Procedures: A Valuable Reference for Nurses.(Review) - Pediatric Nursing

Manual of Pediatric and Postpartum Home Care By Robyn Rice First Edition: 1999 Mosby Year-Book St. Louis, MO

The recent publication of Robyn Rice's Manual of Pediatric and Postpartum Home Care Procedures (St. Louis: Mosby, 1999) adds a significant contribution to the literature on pediatric home care. The book will be extremely useful to home care agencies providing pediatric services as well as to nursing educators training nurses in home care procedures, individual nurses in home care, and any nurses discharging infants and children to care in the home.

The author of Manual of Pediatric and Postpartum Home Care Procedures, Robyn Rice, is an experienced home care nurse, having worked in home care for over 10 years. She has authored several other books and numerous articles related to home care. While the 13 contributors and 13 consultants involved in this book lend additional substance to the project, most of the contributors and consultants are from only two geographic areas, a potential weakness since home care practices do vary from one region to another across the country.

The Manual of Pediatric and Postpartum Home Care Procedures is divided into five broad sections. Part One is a comprehensive section on infection control in the home. Topics range from cleaning baby bottles and other equipment, to handwashing, maintaining supplies and equipment in the car, collection and transport of a wide variety of specimens, and managing a variety of infectious conditions in the home.

Part Two addresses medical-surgical procedures in the home setting. The five chapters in this section include: Assessment Procedures; Intravenous Therapy: Principles of Catheter Management and IV Therapy; IV Therapy: Infusions; Medications (including instructions for a variety of administration routes); and Therapeutic and Technical Care, which addresses a wide variety of topics including burn and cast care, dressing changes, specialized feeding techniques, and respiratory procedures. Where appropriate, separate guidelines are offered by age group (for example -- IV injections).

Part Three, called Postpartum Procedures, includes both the care of maternal conditions and care of a range of infant conditions from cradle cap and diaper dermatitis to more technological concerns such as apnea monitoring and home phototherapy.

Part Four of the book focuses on emergency care and special concerns and addresses medical emergencies, such as airway obstruction and poisoning, and social concerns including child abuse and neglect, domestic violence, and safety in the community. The inclusion of these social concerns is a strength of this book that could easily have been overlooked in the development of a procedure manual. The inclusion of adolescent depression in this chapter is another strength.

Part Five focuses on pediatric hospice care. Organized differently than the rest of the book, this section offers an overview of the topic and an in-depth discussion of specific issues including symptom management, pain management, psychosocial issues, spiritual care, and bereavement concerns. While hospice care is worthy of an entire book itself, its inclusion in this manual will be helpful to the nurse.

Most chapters of the book, with the exception of some of those in the hospice section, are arranged using the following standard format:

1. Purpose (of the procedure);

2. Related procedures (e.g., the chapter titled 'Gastrostomy Tube Replacement' lists enteral/gavage feedings and gastrostomy care/general guidelines as related procedures addressed in the book);

3. General information about the topic;

4. Equipment (a list);

5. Procedure (a detailed, step-by-step outline);

6. Nursing considerations (including suggestions for teaching, assessment, and referral); and

7. Documentation guidelines.

This standard format is easy to follow and the amount of detail provided is appropriate for nurses with a range of levels of experience. The occasional use of diagrams and photographs enhances the text.

Relatively few books focus on the topic of pediatric home care. Robyn Rice's Manual of Pediatric and Postpartum Home Care Procedures is an important contribution. Its clear and comprehensive focus on pediatric procedures will benefit nurses caring for children in the home setting and the children and families they care for.

Editors' Choice is a bimonthly 'biased' book review on a hot new book for pediatric nurses! Each issue, a member of the Pediatric Nursing editorial board picks a recent favorite publication and offers readers a brief description of why they would recommend it for their personal or library collections.

пятница, 28 сентября 2012 г.

Data on pediatric surgery in children discussed by researchers at Keio University, Department of Pediatric Surgery.(Report) - Health & Medicine Week

Fresh data on pediatric surgery are presented in the report 'Transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation in children.' According to a study from Tokyo, Japan, 'Portal venous stenosis is relatively a rare complication after liver transplantation in children and it sometimes leads to life threatening event due to gastrointestinal bleeding or graft failure (see also Pediatric Surgery). Recently, balloon dilatation has been widely accepted as a treatment of choice for the management of portal venous stenosis.'

'The purpose of this study was to evaluate the feasibility of transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation (LDLT) in children. The records of 57 pediatric liver transplants were retrospectively reviewed. Nine patients (15.8%) with portal venous stenosis were identified. Seven symptomatic children with portal venous stenosis underwent balloon dilatation. Two approaches were employed for balloon dilatation; the transileocolic venous approach and the percutaneous transhepatic approach. In patients with recurrent stenosis, careful follow-up was carried out while they were asymptomatic. Twelve balloon dilatations were performed in seven children with primary or recurrent portal venous stenoses. The initial technical success rate was 91.7% (11/12), while 6 out of 12 (50.0%) procedures resulted in recurrent stenosis. Five out of six recurrent stenoses required repeated balloon dilatation. The clinical success rate of balloon dilatation in our study was 85.7% (6/7). Other than recurrent stenosis, two procedure-related complications occurred,' wrote R. Hotta and colleagues, Keio University, Department of Pediatric Surgery.

The researchers concluded: 'Transileocolic venous balloon dilatation was a safe and effective procedure for portal venous stenosis after LDLT in children.'

Hotta and colleagues published the results of their research in Pediatric Surgery International (Transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation in children. Pediatric Surgery International, 2007;23(10):939-45).

For additional information, contact R. Hotta, Keio University School of Medicine, Dept. of Pediatric Surgery, 35, Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

The publisher of the journal Pediatric Surgery International can be contacted at: Springer, 233 Spring Street, New York, NY 10013, USA.

Keywords: Japan, Tokyo, Angiology, Bioengineering, Biomedical Engineering, Biomedicine, Gastroenterology, Gastrointestinal Bleeding, Liver Transplant, Living Donors, Organ Transplant, Pediatric Surgery, Stenosis, Therapy, Transplantation, Treatment.

четверг, 27 сентября 2012 г.

Pediatric vaccine stockpile policies need to be revisited, researcher says. - Biotech Week

CHAMPAIGN, Ill. - Vaccine manufacturers and public health decision-makers need to collaborate in a more efficient and effective manner not only to reduce the likelihood of supply shortages for pediatric vaccines but also to maximize community immunity by using vaccine doses to increase coverage, according to research published by a University of Illinois researcher who specializes in statistics and data analysis (see also Whooping Cough).

Sheldon H. Jacobson, a professor of computer science and the director of the simulation and optimization laboratory at Illinois, says that the Pediatric Vaccine Stockpile Program administered by the Centers for Disease Control and Prevention should not simply be seen as a repository of vaccines, but rather as a 'repository of opportunities' for enhancing the collective immunity of children.

'We hear a lot about bioterrorism and pandemics, but the fact of the matter is, the threat to routine immunization is one of the greatest threats we face,' Jacobson said. 'If we had problems with our vaccine supply chain, it would have the potential to cause more deaths than any of those other issues.'

With an average of 11,000 children in need of immunization on any given day, Jacobson says that managing pediatric vaccine stockpiles shouldn't simply be limited to increasing the levels of the stockpile itself.

'Just like perishable goods, vaccines have a shelf life,' Jacobson said. 'They're not like canned goods that you can simply stockpile and forget about for an extended period of time.

'When you have finite economic resources, you have to make choices. But we also want to create a buffer that will create the widest possible public health safety net.'

The CDC's current policy of maintaining a six-month rotating vaccine stockpile isn't the most optimal solution for achieving 'herd immunity,' which Jacobson defines as 'the smallest percentage of a population that must be immunized against a disease so that unvaccinated individuals are also protected.'

Jacobson, who published his research in the Journal of Industrial and Management Optimization, considered the relative mortality and morbidity of diseases to determine what levels stockpiles should be set at to minimize the risk of shortage and maximize coverage opportunities while minimizing costs.

'We took all of these factors into account and created a multi-attribute model using utility theory to solve for appropriate levels.'

Jacobson said that when actual vaccine shortages have occurred over the last 10 years, the duration of the shortages were between 16 and 18 months.

'Even though we're preparing for six months out, we never see six months,' he said. 'The shortest time period in the last 10 years has been a 7-month period. That's a byproduct of one-size-fits-all policy for stockpiles. Although it's easy and simple to do, it's not the most efficient policy. We need to re-engineer the objectives of our pediatric vaccine stockpiles and establish more flexible policies for maximizing their utility.'

Jacobson's research proposes a stochastic model to determine the stockpile levels that minimize the risk of a vaccine shortage during a supply interruption while also maintaining a given coverage rate.

'For some vaccines, you need very little stockpiles; for others, you need much larger ones,' he said.

Pertussis, or whooping cough, as it's more commonly known, can be a 'very deadly, virulent disease if it spreads, while mumps, on the other hand, rarely causes death,' Jacobson said.

'When we're talking about vaccines, equal is not effective. The recent pertussis outbreaks in California and Ohio highlight the needs for differentiated stockpile levels, meaning we have to look at the characteristics of the diseases in terms of achieving herd immunity as well as how deadly the disease is.'

Jacobson, who also is a professor of pediatrics at the College of Medicine on the Urbana campus, said that although routine immunization is the most effective public health strategy to prevent the occurrence and spread of infectious diseases, there's always going to be a certain small percentage of the population who will not be immunized, because of religious beliefs or allergies to the vaccine.

'The CDC's goal for immunization is 95 percent compliance,' he said. 'They don't expect 100 percent. But if you get to 95 percent, you're typically going to have a herd immunity.'

Ultimately, vaccination is a critical public health issue that can't be run by the vagaries of emotion.

'If we allow our emotions to guide our policies, we'll pay the price somewhere down the line. The public health system saves rather than costs our nation money. And any way that we can reduce mortality and morbidity through immunization would be beneficial to the health-care system both in cost and value and to the nation as a whole.'

Keywords: Biological Products, Communicable Disease Control, Environment and Public Health, Immunization, Pediatrics, Public Health Practice, University of Illinois at Urbana-Champaign, Vaccines, Whooping Cough.

среда, 26 сентября 2012 г.

pediatric group's study touts benefits of circumcision.(Front) - The Virginian-Pilot (Norfolk, VA)

By Elizabeth Simpson

The Virginian-Pilot

The nation's largest pediatric organization released an updated policy today, saying the benefits of circumcision for newborn males clearly outweigh the risks, and, for the first time, recommending that insurance pay for the procedure.

The American Academy of Pediatrics stopped short of advising it for all newborn boys, saying the decision needs to be left to parents within the context of their religious, cultural and personal preferences.

Since the policy was last updated in 1999, a growing body of studies has shown circumcision lowers the risk of getting HIV, genital herpes, human papillomavirus and syphilis. Removing the foreskin of the penis also lowers the risk of penile cancer over a lifetime and urinary tract infections in the first year of life. Males who have been circumcised also are less likely to transmit sexual diseases.

Dr. Wally Carlo, who served on the American Academy of Pediatrics task force that reviewed the policy, said the scientific evidence is included in the updated policy, which doctors should review with parents.

The review was prompted by studies and statistics that show a decline in circumcision rates.

'The rates of circumcision have gone down in the last 20 years, and it's not clear why,' Carlo said. 'In a number of states, Medicaid has stopped paying for circumcision.'

In 2010, 55 percent of newborn boys had the procedure, a drop from 58 percent in 2001, according to statistics from the federal Centers for Disease Control and Prevention. That compares to 68 percent in 1995.

In Virginia, circumcision is covered by Medicaid, the joint federal-state health insurance for low-income families. Recent surveys by the media and various health organizations have shown circumcision is not covered by Medicaid in 18 states, and that some states have dropped the coverage within the past few years.

Some health experts have questioned whether that has led some parents to forgo the procedure.

In other cases, parents decide against it because they believe it causes unnecessary pain and is more of a cosmetic consideration than a medical one.

An organization called Intact America opposes circumcision and 'other forms of medically unnecessary genital alteration, whether carried out for cultural conformity or profit, in medical or non-medical settings.'

A statement from executive director Georganne Chapin took issue with the academy's updated policy, saying Intact America 'deplores the focus on selective evidence supporting medical benefits of removing normal foreskins from baby boys.'

The statement said the task force failed to consider 'the large body of evidence from the developed world that shows no medical benefits for the practice, and has given short shrift, if not dismissed out of hand, the serious ethical problems inherent in doctors removing healthy body parts from children who cannot consent.'

The procedure is typically performed by a pediatrician or obstetrician before a baby goes home from the hospital. Circumcisions done for religious reasons are usually performed by people trained in the procedure.

Dr. Jyoti Upadhyay, a pediatric urologist with Children's Hospital of The King's Daughters, said that if the procedure is done when babies are older, the cases are referred to pediatric urologists. The cost is greater at that point, and insurance is likely to decline to cover the procedure unless there's a medical reason.

But she said she has noticed an increase in parents being referred to urologists with older babies because it wasn't done before discharge, in some cases because of insurance issues.

She said she agrees with the updated American Academy of Pediatrics policy and hopes it will lead to more insurance coverage.

She said it helps pediatricians to consider what's best for a child during his entire lifetime rather than just his first 18 years.

A study by Johns Hopkins University researchers released this month found that if circumcision rates remain in the 50 percent range instead of the higher rates of years past, the lifetime health-care costs for all of the babies born in one year would rise by about $211 million.

That study, published in the Archives of Pediatric and Adolescent Medicine, found that nearly 80 percent of the additional projected costs would be linked to HIV infection.

The pediatrics academy said the procedure is safest and offers the most benefits if performed during the newborn period, and it should be performed by trained and competent providers, using sterile techniques and effective pain management.

Health providers should inform parents-to-be before or early in pregnancy to give them time to consider the information.

'The health benefits outweigh the risks, but parents still should be given a choice,' Carlo said. 'That's what this is about, giving parents a choice.'

вторник, 25 сентября 2012 г.

Pediatric Unit a Hallmark of CHS - Mercer Business

Capital Health System (CHS) has had an outstanding year, filled with many accomplishments. Their centers of excellence in oncology, dialysis, trauma services, maternal child health, mental health, orthopaedics and infectious disease continue to thrive and expand.

Despite the continuing struggles faced by the healthcare industry, CHS continues to move forward in their mission to provide comprehensive, quality healthcare services that honor the dignity of every person.

The process of blending clinical services at Capital Health System has begun, and through consolidation, they are creating programs that are unsurpassed for their quality and efficiency. A major milestone was recently marked with the integration of the Pediatric Unit to the Mercer Campus. Pediatric patients and their families are already benefiting from this enhancement of services, and the unit is just one reason why CHS is the unparalleled regional leader in maternal child health services.

The expanded Pediatric Unit on the Mercer Campus has 36 beds. It offers the outstanding nursing care that is a hallmark of CHS, retaining excellent nurses with roots at both campuses. CHS has the only inpatient pediatric unit in the county, as well as a Level III Neonatal Intensive Care Unit.

With recent approval from the State of New Jersey, Capital Health System has consolidated in-patient maternity services to a new, expanded unit on the Mercer Campus. This new Maternity Unit is now home to all special deliveries. They are the only healthcare provider in the region to have 24-hour, in-house coverage of obstetricians, midwives, neonatologists and anesthesiologists seven days a week. Families have their choice of birth settings, and we offer individualized nursing care and a full range of education and support programs for the entire family.

Nineteen ninety-nine was quite a year for emergency services at CHS. In the prehospital care arena, the 911 Communications Center for Mercer County received 48,000 calls for help. Their critical care transport service assisted 540 critically injured or ill patients. Mobile intensive care providers for Mercer County were dispatched to over 20,000 calls and treated 7,200 patients.

As for hospital emergency care, the Fuld and Mercer Campuses treated over 60,000 patients in our Emergency Departments in 1999. And more than 1,000 trauma victims were treated at the Level II Trauma Center at the Fuld Campus.

Experienced trauma surgeon Dominick J. Eboli, MD recently joined Capital Surgical Associates (CHS' trauma team). Dr. Eboli received both his undergraduate and post-graduate training at UMDNJ - Robert Wood Johnson Medical School. With the addition of Dr. Eboli, the current focus on the Fuld Campus Trauma Center will expand to reflect full clinical capabilities including general surgery, minimally invasive surgery, trauma surgery and surgical critical care.

Earlier this year, CHS added patient transport to its extensive array of emergency services. The patient transport vehicle will be staffed by two emergency medical technicians who provide basic life support and transportation services for Capital Health System patients. It will be used to transfer over 3,000 patients annually between the Fuld and Mercer Campuses. In addition, CHS will use the vehicle to transport patients to nursing homes, and for those who can't walk, home from CHS.

Renal dialysis services at Capital Health System remains a leader in supporting the healthcare needs of the community. Since 1970, patients with end stage renal disease from Mercer, Bucks, Burlington, Hunterdon and Warren counties have been served by this program. It is the only hospital-based program in the area and offers comprehensive dialysis services that include hemodialysis home hemodialysis and home peritoneal dialysis (CAPD and CCPD).

A highly trained professional team works with the patient to help maintain maximum health. Patient care is directed by outstanding nephrologists and supported by a professional staff of registered and licensed practical nurses, dietitians and social workers. Care is given using state-of-the-art equipment in a friendly, spacious environment, which recently expanded and received over a $500,000 in renovations.

Additionally, Capital Health System has renovated and expanded its Adult Clinic area on the Fuld Campus, and added a state-of-the-art computed tomography (CT) system from Siemens Medical Systems, Inc. to its Radiology Department. The new CT system allows CHS to expand diagnostic services to substantially more patients in the region. CHS is the only hospital in Mercer County with this high level of CT capability.

Partnerships with other outstanding organizations lift up CHS' clinical quality and reputation for excellence. Through these organizations, CHS is participating in national studies that will greatly impact the future of the medical profession.

As a member of the Penn Cancer Network, CHS is. participating in the STAR trial, Study of Tamoxifen and Raloxifen. One of the largest breast cancer prevention studies, STAR is being conducted by the National Surgical Adjuvant Breast and Bowel Project, a network of research professionals, and is supported by the National Cancer Institute.

The trial includes 22,000 post-menopausal women with an increased risk of breast cancer. It aims to determine whether the osteoporosis prevention drug raloxifen (Evista) is as effective in reducing the chance of developing breast cancer as tamoxifen (Nolvadex) has proven to be.

CHS is also taking part in a first trimester Down syndrome screening being conducted by researchers at Thomas Jefferson University Hospital. This screening method gives expectant parents important information about the health of their unborn child and the possibility of birth defects.

The CHS Maternal Fetal Medicine Department has been providing the new screening since the beginning of August. The department has been seeing an average of four to five patients a week. There is no charge for the screening test and referrals from insurance companies are not necessary.

понедельник, 24 сентября 2012 г.

Research findings from University of California update understanding of pediatric nursing. - Pediatrics Week

Data detailed in 'Socioeconomic predictors of health and development in middle childhood: variations by socioeconomic status measure and race' have been presented. 'Socioeconomically disadvantaged children have poorer physical and mental health and lower social and school/academic functioning compared to children with higher socioeconomic status (SES). These associations are not static but may vary by choice of SES indicator and child race/ethnicity,' researchers in the United States report.

'However, little is known about these associations in middle-childhood, a distinct and critical developmental period. We explore these associations in a small exploratory study designed to examine associations between SES and child developmental outcomes in middle childhood. We recruited 60 families with a child between 8-12 years of age from the San Francisco Bay area September 2005-June 2006. The MacArthur Health and Behavior Questionnaire was used to assess health and adaptive functioning across four developmental domains: physical health, mental health, social functioning, and school/academic functioning. We examined a range of SES measures including continuous and categorical assessments of poverty, income, wealth, maternal and overall family educational attainment, subjective social status, and cumulative social risk. A series of multivariate ordinary least squares regressions was performed on the total sample and within race-specific groups. Although the long-recognized, graded relations among SES and outcomes were present, associations employing categorical representations of SES were far more pervasive; and stronger in magnitude. Wealth and highest degree earned in the family showed the strongest associations across virtually all health/functioning domains. Health and functioning was more strongly associated with educational attainment among Whites and financial resources among Blacks. Among Whites more wealth was associated with worse outcomes. Further research is needed to confirm the study findings. However, this study raises important questions about the measurement of SES for studying disparities in child health and developmental outcomes,' wrote A.M. Nuru-Jeter and colleagues, University of California.

The researchers concluded: 'This initial research suggests that improvements in health and functioning in middle childhood may require more significant status transitions; more targeted social interventions to address racial/ethnic disparities in child health and developmental outcomes; and a need to intervene on adversities facing affluent youth, a potentially hidden yet vulnerable group in middle childhood.'

Nuru-Jeter and colleagues published their study in Issues In Comprehensive Pediatric Nursing (Socioeconomic predictors of health and development in middle childhood: variations by socioeconomic status measure and race. Issues In Comprehensive Pediatric Nursing, 2010;33(2):59-81).

For additional information, contact A.M. Nuru-Jeter, University of California, Berkeley, California USA.

Publisher contact information for the journal Issues In Comprehensive Pediatric Nursing is: Taylor & Francis Group Ltd, 2 Park Square, Milton Park, Abingdon, Oxford OX14 4RN United Kingdom.

Keywords: City:Berkeley, State:California, Country:United States, Child Health, Mental Health, Pediatric Nursing, Pediatrics.

Complex pediatric feeding disorders: using teleconferencing technology to improve access to a treatment program.(Report) - Pediatric Nursing

Although the territory of high-tech and high-cost communication devices were previously more difficult to attain, videoconferencing is now readily available in more and more community settings. Today, most health care professionals have dedicated phone line access (ISDN) in their offices, which is the technology required, along with a video camera and viewing station, that to enable the provision of videoconferences with remote specialty care providers.

The medical home model has crystallized health care's commitment to providing comprehensive care to children and their families. As health care providers strive to provide quality care in the child's home community whenever possible, telemedicine appears to be a critical part of that comprehensive care, increasing access to pediatric specialists and services (Marcin et al., 2004; Spooner & Gotlieb, 2004). On average, about one-quarter of the young children followed by health care providers experience feeding difficulties (Mays & Volkmar, 1993). Most of these children will respond well to suggestions offered to parents on feeding methods, food choices, approach, and behavioral recommendations.

However, when children need more specialty care than health care providers can offer, it is unlikely that the necessary care will be available in the community. The numbers of complex feeding disorders in any given community is too small to necessitate a comprehensive feeding program in each community. The answer is an ISDN phone connection away.

Numerous models effectively bring specialty care closer to patients' homes through the use of telemedicine. For example, in Boston beginning in 1996, Beth Israel Deaconess Hospital's Baby CareLink was one of the first applications of teleconferencing to reduce family burden and improve understanding of a child's follow-up care (Halamka, 2001). In Georgia, California, and Texas (among others), telemedicine has made care and consultation for children with special needs accessible to rural communities (Karp et al., 2000; Marcin et al., 2004; Robinson, Seale, Tiernan, & Berg, 2003). There are also models of teleconferencing being used to facilitate training, communication, and follow-up. These pilot projects have demonstrated the value of telemedicine in providing pediatric specialty care and have paved the way for applications to lower the incidence of developmental disorders in pediatric populations.

In the case of specialty programs found in only a few centers across the United States, the mandate to make the program accessible to families is very clear. These programs are designed to treat low frequency, high complexity pediatric disorders that cannot be effectively treated in each geographic community. Enhancing the availability of these programs to distant communities serves to improve health care outcomes while at the same time limiting its costs.

Since its inception in 1995, the Feeding Disorders Program at Children's Hospital, Richmond, VA has served children and families from distant geographic areas. These children are in some cases dependent on feeding tubes for nutrition, and in other cases, unable to eat age-appropriate food textures; or not growing well, or demonstrating behaviors, making it impossible for their families to feed them adequately. In addition to their feeding difficulties, most of the children have other chronic medical conditions (such as cerebral palsy, short gut syndrome) that complicate their care. Their families have exhausted resources in their home communities. Their community health care providers seek effective consultation and treatment options that will allow these children to eat effectively, thereby enhancing their health, independence, and psychosocial functioning.

Despite the obvious need, traveling hundreds or thousands of miles for an intensive treatment program several times per week is costly, and does not ensure that children will be able to maintain gains once they return home. To address these issues, it was determined that a pilot application of teleconferencing would be carried out to assess its value in extending program access to diverse communities. Goals of this pilot program are listed in Table 1. The goals are family-centered, with a focus on providing needed services in a convenient, low cost, and effective manner.

Pilot Project Method

Planning began in 2001 to evaluate the feasibility of adding a teleconferencing option at Children's Hospital that would enable health care providers and families to have remote access to the specialty team of the Pediatric Feeding Disorders Program. The planning group included representatives from information technology, psychology, case management, and program manager to identify the needs and goals of the teleconference.

Preliminary planning for implementing the program was extensive. The planning group:

* Conducted a site visit to the University of Virginia Medical Center's Telemedicine program. This consisted of observing telemedicine conferences in progress as well as gathering information about equipment needs.

* Developed informed consent to make sure family members understood that the teleconference was observed by multiple team members and to assure that information was kept confidential. This document was modified from the informed consent that family members typically sign when they are treated in the medical facility.

* Clarified legal and medical record issues. This involved consultations with the hospital's legal representative to discuss any potential concerns. The director of the medical records department was also consulted to determine how the teleconference would be documented and how this would become part of their medical record at the hospital.

* Pilot-tested equipment at the local facility. A local site with the necessary equipment was identified, and a pilot clinic was set up. The nurse practitioner, psychologist, and dietitian conducted the clinical interview and observed the child feeding. The network administrator and case manager were also present. The families that participated provided feedback, which supported further work on the project.

* Secured grant support was necessary to purchase the equipment and fund the clinicians' and case manager's time when participating in the teleconferences.

* Purchased and tested equipment to make sure it was compatible with the authors' network system and to assure disconnection would not occur in the middle of the appointment.

* Developed evaluation forms for families and feeding team members to complete after each teleconference. This was important for assessing the positive and negative feedback used to improve the process.

* Developed information packets to determine appropriate candidates. This was developed by the case manager and the psychologist.

* Completed room preparation for optimal viewing on the receiving end. Lighting and background wall color were adjusted for best contrast. This involved consulting with the head of the hospital facilities department for recommendations of paint color and installation of adjustable lighting.

Each teleconferencing visit during this pilot study required careful planning. Numerous details had to be thoroughly addressed to ensure a smooth process. Details included having adequate clinical information, identifying a remote site convenient to parents, testing the connection prior to the scheduled appointment, arranging schedules to enable health care providers to accompany families to the teleconferencing visit, and planning for needed materials, including food and utensils, adequate seating (for example, high chair, booster seat), and quiet toys available for the child during the session.

Results

From September 2002 to October 2004, the teleconferencing pilot project served 15 children with complex feeding disorders referred from locations from 300 to 3,500 miles away. Twelve children were seen for initial evaluation, and three children for follow up. The six girls and nine boys ranged in age from 8 months to 10 years old; 80% of the children were younger than 5 years old.

Children, families, and health care professionals participated in teleconferences from a site close to their homes with the remote team at Children's Hospital. Remote sites varied from pediatric clinics to universities. As Table 2 indicates, the children seen resided in 11 states and one foreign country. Typical participants at the remote sites included the child patient, two parents/ family members, and the child's health care provider(s). In several cases, a speech therapist attended the session as well as the treating physician.

Follow up to the sessions was accomplished by phone and with a detailed letter to the child's treating health care provider documenting findings and recommendations. In 50% of the initial screenings, additional recommendations were made for improving treatment in the child's home community. In the other 50%, admission to the comprehensive day treatment program at Children's Hospital was required to accomplish treatment goals.

Additional follow up with the families participating in the teleconferencing was accomplished through administration of a questionnaire by phone or fax (according to family preference) during the several days following the teleconference. This questionnaire included queries about the family's comfort with the teleconference, ways in which it had an impact on their child's care, level of satisfaction, and whether they would choose teleconferencing again. For the first four patients participating, similar questionnaires were completed by remote health care providers and by the Children's Hospital team to provide input into ways to improve the process for the remainder of the pilot project.

Participants, both families and health care providers, reported a high level of satisfaction with the teleconferencing option for care. Costs were reduced dramatically for families due to minimizing travel. Clinical outcomes demonstrated decreased reliance on feeding tubes for nutrition and improved skills and confidence for community-based providers in supplying ongoing care.

Reduced burden to families. The costs of care are a significant barrier to families when their children require specialty care from distant locations. Costs savings in this project were captured by using an online travel search engine (Travelocity.com) to identify the cost of preplanned coach air travel for the child and one family member from the airport closest to the family to the Richmond, VA, airport. Added to this cost were local per diems of $74 for one night overnight lodging and $64.50 per day (full rate for parent, 50% of standard for child) for meals for 2 days (Virginia Commonwealth University, 2006). This was compared to local travel costs of 30 miles round trip car travel at 0.365/mile. Due to the variability in salaries and work schedules, missed work time was not included in the calculations, though typically, one-half day was missed for the telemedicine consultations as compared to 2 full days for children who must travel to the Children's Hospital Feeding Clinic. For participants within the United States, costs of travel to the program for transportation, food, and lodging alone averaged $917, as compared to less than $20 for a locally based teleconferencing session. For many, if not most, of the families, this cost differential made the difference between access and no access.

Family satisfaction. Satisfaction with the care provided by the teleconferencing consultations included ratings on a 1 (very dissatisfied) to 5 (very satisfied) Likert-type scale assessing three components:

1. How satisfied were participants with teleconferencing?

2. How comfortable did they feel using this modality?

3. How effective was the communication between their home community health care provider and remote medical team? Participants were also asked how likely they would be to use teleconferencing in the future for their children. As Table 3 indicates, families were very satisfied with this consultation modality. All 15 families stated that they would use teleconferencing again, with many adding comments such as 'Of course,' and 'Saved time and money.'

Families made additional comments about the reduced burden of care. Some of these comments suggested an increase in satisfaction of care due to the reduction of stress often accompanied with long-distance travel. 'It was easier to stay in town than having to pack up everything and come out.' Families also recognized teleconferencing could help them avoid the high level of physical demands that long-distance travel can produce, especially for children with complex medical needs. 'He would have been real tired if he had to travel out there.' Other comments suggested satisfaction with the ease in which families were able to access the health care providers not typically offered in their communities. 'It was easier to gain access to [specialty] physician.'

Team members and community care providers were pleased with the modality as well. Many commented on how much easier teleconferencing was than phone consultation due to the face to face communication and ability to ensure that both local and remote provider were observing the same feeding behavior. Community care providers noted the value of having a convenient method of consulting specialty care providers. Children's Hospital Feeding Team members appreciated the teleconferencing option as a method for getting information, believing that they were able to get a more comprehensive picture of the child from this modality than via written records or phone calls.

Clinical outcomes. As mentioned previously, half of the initial consultations resulted in recommendations that enabled the child to be treated effectively in their home community. These included recommendations for additional tests (such as gastrointestinal studies, swallow studies), a specific therapeutic approach (such as Beckman oral motor exercises), behavioral interventions or medication.

Six children were recommended to travel to the intensive day program at Children's Hospital for an approximate 6-week stay. These children had treatment goals that included discontinuing their tube feeding, expanding their range of accepted foods, and transitioning from supplemental formulas to a regular diet. A typical patient among them was a 3-year-old girl who on baseline was taking in an average of 338 calories per treatment day by mouth, of an overall daily caloric requirement of 1,326 calories. Behavioral observations showed that this child accepted 56% of bites offered to her at a meal, and swallowed her food only 44% of the time. Thirty-five percent of the time she made negative vocalizations during a bite. These behaviors made mealtime a stressful and negative experience for all family members. By discharge, this child was eating an average of 1042 calories per treatment day, accepting 91% of bites offered, and swallowing food effectively 99% of the time. Her negative vocalizations had decreased from 35% to 2%, greatly improving her and her family's enjoyment of mealtime.

Other children demonstrated similar successes, with improvement in the age appropriateness of their eating behavior and the range of foods accepted, increased jaw strength and swallowing ability, decreased in supplemental and/or tube feeding, and decreased family burden as feeding behaviors and success improved.

Problems. Although all participants viewed the teleconferencing positively, some problems did occur. Scheduling was an issue for remote site health care providers, as they often had to travel to a location separate from their primary office. Technical difficulties with the teleconference connection were experienced in several instances, resulting in at least brief interruptions in the flow of the conference as the two sites had to be reconnected.

Discussion

The Agency for Health care Quality and Research (AHQR) and the American Academy of Pediatrics (AAP) Center for Child Health Research sponsored a meeting in September 2000 and concluded that pediatric research using information technology needs to address certain topics. Among the issues discussed, AHQR placed emphasis on using telemedicine to increase the availability of pediatric health care and improve the medical assessment of children, while taking into consideration the children's needs. Shiffman, Spooner, Kwiatkowski, and Brennan (2001) emphasize that the research also should give attention to the expense and effectiveness of the technology used. The current project addresses just these issues, demonstrating that for the low incidence population of children with severe feeding disorders, teleconferencing can improve access to specialty services and improve the clinical outcomes of these children.

What's next for teleconferencing for children with complex feeding disorders? In all likelihood, the next leaps to be expected include expanding teleconferencing into more health care providers' offices, rural communities, and schools (Whitten, Cook, Shaw, Ermer, & Goodwin, 1998), enhancing the use of teleconferencing to train professionals at a distance, and improving the reimbursement picture for teleconferencing when it occurs across state lines (Lobe, 2004). For specialty programs, such as the treatment of complex feeding disorders, it is a disservice to develop a high-intensity, low-volume program for every metropolitan community. A better use of health care resources is to share the knowledge via the rapidly expanding technology options available today.

Although this pilot project demonstrates that teleconferencing can be used effectively to improve medical care and reduce family burden, the issues of funding telemedicine have yet to be adequately addressed (Farmer & Muhlenbruck, 2001). This barrier remains. The current pilot project, like other inter-state telemedicine applications to date, was externally funded. Federal guidelines for payment across state lines are needed to facilitate the availability of this modality in the future as it becomes more commonplace and funding sources become less available.

Conclusions

In conclusion, relatively few children in any one health care provider's office or community will require specialty care for complex feeding disorders. Those who need specialty care that is unavailable in their community often continue for long periods on tube feedings. More intensive specialized intervention can enable these children to progress in their feeding capabilities. The availability of a teleconferencing option for screening and follow-up care enables community-based pediatricians to provide comprehensive care, and to maintain excellent communication and follow up when treatment at a distant specialty program is required.

Acknowledgment. The support of Nordstrom in funding equipment purchase and clinician time during this project is gratefully acknowledged.

References

Farmer, J.E., & Muhlenbruck, L. (2001). Telehealth for children with special health care needs: Promoting comprehensive systems of care. Clinical Pediatrics, 40, 93-98.

Halamka, J. (2001). Inside a virtual nursery. Health Management Technology, 22, 37-38.

Karp, W.B., Grigsby, R.K., McSwiggan-Hardin, M., Pursley-Crotteau, S., Adams, L.N., Bell, W., et al. (2000). Use of telemedicine for children with special health care needs. Pediatrics, 105, 843-847.

Lobe, T.E. (2004). Telemedicine and the future of health care for our children. Pediatics, 113, 130.

Marcin, J.P., Ellis, J., Mawis, R., Nagrampa, E., Nesbitt, T.S., & Dimand, R.J. (2004). Using telemedicine to provide pediatric subspecialty care in children with special health care needs in an underserved rural community. Pediatrics, 113, 1-6.

Mays, L.C., & Volkmar, F.R. (1993). Nosology of eating and growth disorders in early childhood. Child and Adolescent Psychiatry Clinics of North America, 2, 15-35.

Robinson, S.S., Seale, D.E., Tiernan, K.M., & Berg, B. (2003). Use of telemedicine for children with special health care needs. Telemedicine Journal and e-Health, 9, 57-61.

Shiffman, R.N., Spooner, S.A., Kwiatkowski, K., & Brennan, P.F. (2001). Information technology for children's health and health care: Report on the information technology in children's health care expert meeting, September 21-22, 2000. Journal of the American Medical Informatics Association, 8, 546-551.

Spooner, S.A., & Gotlieb, E.M. (2004). Committee on clinical information technology; committee on medical liability. Telemedicine: Pediatric applications. Pediatics, 113, e639-e643.

Virginia Commonwealth University. (2006). Virginia Commonwealth University travel reimbursement guidelines. Retrieved May 31, 2006, from http://www.vcu.edu/ procurement/travel.htm

Whitten, P., Cook, D.J., Shaw, P., Ermer, D., & Goodwin, J. (1998). Telekid care: Bringing health care into schools. Telemedicine Journal and e-Health, 4, 335-343.

Betsy Clawson, MS, PhD, LCP, is a Behavioral Coordinator, the Children's Hospital, Richmond, VA.

Martha Selden, PT, is Program Manager, the Children's Hospital, Richmond, VA.

Mandy Lacks. is a Feeding Technician, the Children's Hospital, Richmond, VA.

Ann V. Deaton, PhD, is a Faculty Member, the Children's Hospital, Richmond, VA.

Brian Hall, MCP, is a Network Administrator at Children's Hospital, the Children's Hospital, Richmond, VA.

воскресенье, 23 сентября 2012 г.

Renal transplantation feasible in pediatric BMT recipients. - Health & Medicine Week

2004 NOV 8 - (NewsRx.com & NewsRx.net) -- Kidney transplantation is feasible in pediatric bone marrow transplant recipients.

'Improving survival rates following pediatric bone marrow transplantation (BMT) will likely result in greater numbers of children progressing to end-stage renal disease (ESRD) because of prior chemotherapy, irradiation, sepsis, and exposure to nephrotoxic agents,' scientists in the United States explained. 'Renal transplantation remains the treatment of choice for ESRD; however, the safety of renal transplantation in this unique population is not well established.'

S.E. Thomas and coauthors at the University of Michigan described their 'experience with living related renal transplantation in three pediatric patients with ESRD following prior BMT' - '[t]wo patients with neuroblastoma and ESRD because of BMT nephropathy, and one patient with Schimke immuno-osseous dysplasia and ESRD because of immune complex mediated glomerulonephritis and nephrotic syndrome.'

'Age at time of BMT ranged from 2 to 7 yr. All patients had stable bone marrow function prior to renal transplantation,' the investigators noted. 'Age at renal transplant ranged from 8 to 14 yr.'

'All three patients have been managed with conventional immunosuppression, as no patient received a kidney and BMT from the same donor source,' according to the report. 'These patients are currently 7 months to 6 yr status post-living related transplant,' and all have 'functioning bone marrow and kidney transplants, with serum creatinine levels ranging 0.6-1.2 mg/dL.'

'There have been no episodes of rejection,' published results indicated. 'One patient with a history of grade III skin and grade IV gastrointestinal graft-vs.-host disease (GI-GVHD) prior to transplantation, had a mild flare of GI-GVHD (grade I) post-renal transplant and is currently asymptomatic.'

'The incidence of opportunistic infection has been comparable with our pediatric renal transplant population without prior BMT,' study data showed. 'One patient was treated for basal cell carcinoma via wide local excision.'

'Renal transplantation is an excellent option for the treatment of pediatric patients with ESRD following BMT. Short-term results in this small population show promising patient and graft survival, however long-term follow-up is needed,' the researchers concluded. 'Patients who have undergone renal transplantation following BMT are at high risk for opportunistic infections and malignancy, and need life-long medical surveillance.'

Thomas and colleagues published the results of their study in Pediatric Transplantation (Successful renal transplantation following prior bone marrow transplantation in pediatric patients. Pediatr Transplant, 2004;8(5):507-512).

For additional information, contact S.E. Thomas, University of Michigan, C.S. Mott Children's Hospital, Pediatric Nephrology Section, Pediatric Kidney Transplantation Program, Division of Pediatric Nephrology, F6865-Box 0297, Ann Arbor, MI 48109, USA.

The publisher of the journal Pediatric Transplantation can be contacted at: Blackwell Munksgaard, 35 Norre Sogade, P.O. Box 2148, DK-1016 Copenhagen, Denmark.

The information in this article comes under the major subject areas of Hematology, Immunology, Pediatric, Renal, Stem-Cell Transplantation and Surgical Technology.

суббота, 22 сентября 2012 г.

Pediatric-Surgery Clinic Is Proposed for Hurst, Texas, Hospital. - Knight Ridder/Tribune Business News

Knight Ridder/Tribune Business News

Oct. 21 -- HURST, Texas -- Cook Children's Medical Center plans a $6 million outpatient pediatric surgery center on its Hurst campus, officials say.

That means the state's only two facilities of that kind will be within six miles of each other in Northeast Tarrant County.

Texas Pediatric Surgery Center, a similar clinic in North Richland Hills, performed its first procedure -- inserting tubes in a baby girl's ears -- four months ago.

'We just think there's adequate population growth and need for services out there,' Cook Children's spokeswoman Carolyn Bobo said. 'Most of the research in health care shows that when these can be established in neighborhoods closer to home, people like the convenience.'

The proposed day-surgery center would offer outpatient services such as ear tubes and tonsillectomies. The urgent-care portion of the 30,000-square-foot building would be for treating minor emergencies, such as influenza and sprained ankles.

The proposed center would be at Cook Children's campus at Precinct Line Road and Mid-Cities Boulevard.

Texas Pediatric Surgery Center was called the first of its kind when it opened as an extension of the 38-year-old North Hills Hospital, the oldest hospital in Northeast Tarrant County.

Randy Moresi, administrator at North Hills, said that before and during construction on the $2.7 million center he tried to work out a partnership with Cook Children's.

'Everybody knows that there are very scarce resources in health care right now, and there are way more needs than there are resources, and so we thought, `Let's be a trendsetter,'' Moresi said. '`Let's do what everybody seems to be asking, whether it's the physicians or patients or the public, and show that we can work together.' Unfortunately, for whatever reason, they elected not to do that.'

About one-third of Northeast Tarrant County residents travel to downtown Dallas for their pediatric health care, Moresi said. The hope was to bring some of the health-care money back to Tarrant County.

Bobo said that Cook Children's has not done partnerships in the past and that the hospital, which opened in 1918, has a reputation that stands on its own.

'We expect everybody to have choices and convenience, and good quality all the way around, from different providers,' she said.

Bobo declined to say how many children would be anticipated to use the center, which officials say would take a year to 18 months to complete.

Texas Pediatric expects to serve about 1,800 children in its first year, officials have said.

Northeast Tarrant County apparently is not the main target of Cook Children's expansion plans.

Cook Children's also is negotiating to buy a prime Interstate 20 site for a pediatric outpatient clinic in south Arlington, according to people familiar with the deal. The hospital is in the due-diligence stage of acquiring 4 acres at I-20 and Matlock Road, the sources said.

Bobo said the hospital could not confirm the Arlington location or divulge specific plans. But, she said, the hospital soon may make an announcement about a south Arlington pediatric medical facility.

This year, Cook Children's conducted focus groups to gauge Tarrant County usage trends at its area operations and to determine what is needed.

Because metropolitan Tarrant County is a high-growth area, 'it sounds like it is the right thing for [Cook Children's] to be exploring,' said Bryan Sperry, president of the Children's Hospital Association.

пятница, 21 сентября 2012 г.

Use of nurse practitioners in pediatric kidney transplant: a model for providing comprehensive care to children and families - Progress in Transplantation

It is well documented that kidney transplantation is the treatment of choice for children with end-stage renal disease. Pediatric kidney transplant patients are a complex population because of their need for lifelong immunosuppression, potential for delayed growth and development, and increased risk of heart disease and cancer. Although many large pediatric kidney transplant programs use nurse practitioners, the role of the nurse practitioner is still emerging in relation to the transplant coordinator role. This article describes the practice of pediatric nurse practitioners caring for children who require a kidney transplant and why nurse practitioners are ideal for providing comprehensive care to this population. Transplant programs are regulated by the United Network for Organ Sharing and the Centers for Medicare and Medicaid Services. Both organizations require transplant programs to designate a transplant coordinator with the primary responsibility of coordinating clinical aspects of transplant care. Incorporating transplant coordinator activities into the role of the pediatric nurse practitioner is discussed as a model for providing care throughout the process of kidney transplantation. Transplant pediatric nurse practitioners are in a unique position to expand the care for pediatric kidney transplant patients by assuming the role of clinician, educator, administrator, and coordinator. (Progress in Transplantation. 2011;21:306-311)

The first pediatric kidney transplant was performed in 1959. Kidney transplantation is well established as the treatment of choice for children with end-stage renal disease (ESRD) because it allows improved growth and development and avoids the potential complications of dialysis and azotemia. Today, patients' survival rates 1 and 5 years after pediatric kidney transplant are 98% and 93%, respectively, and 5-year graft survival rates are between 77% and 85%, depending on whether the transplanted organ is from a deceased or a living donor.1 Complexities of pediatric transplant patients include the burden of lifelong immunosuppression, the risk of delayed growth and development, and the management of long-term medications. These unique patients demand a multidisciplinary approach to care. The ever-evolving field of transplant medicine provides a unique opportunity for pediatric nurse practitioners (PNPs) to provide continuity of care before and after transplantation.

A review of pediatric kidney transplant programs reveals that larger programs tend to have dedicated transplant nursing staff, most often serving as a transplant coordinator. Although at least 15 pediatric kidney transplant centers use nurse practitioners, it is still a unique and emerging position in relation to the transplant coordinator role.2 In this article, we discuss the practice of the PNP caring for children requiring kidney transplant and why PNPs are well suited to provide comprehensive care. Specifically, incorporating transplant coordinator activities into the role of the PNP is discussed as a model for providing care throughout the process of kidney transplantation. Unique health care considerations for this population are also addressed.

Children With ESRD and Kidney Transplant

ESRD is still rare in children. Between 800 and 900 kidney transplants occur annually in children in the United States.2 Unlike adults, who are most likely to have their disease progress to ESRD from diabetes, the 4 most common causes of ESRD in children are obstructive uropathy, reflux nephropathy, renal dysplasia, and focal segmental glomerular sclerosis.1 Children with chronic kidney disease and renal failure are prone to specific medical conditions and complications, including metabolic abnormalities, bone disease, anemia, and hypertension. Furthermore, these young children often experience growth failure exacerbated by strict limitations on diet and fluid intake. Growth hormone therapy may be indicated to achieve adequate linear height and weight for transplantation. Placement of a gastrostomy tube is often essential before transplant for administration of fluids, enteral feedings, and medications. Central catheters are also a necessity for young transplant patients, and the PNP can oversee selection of the appropriate catheter type and management of the device. All young people with ESRD are prone to infections such as pneumonia and urinary tract infection.3 Because many pediatric pretransplant patients have urological causes of ESRD, close intervention and follow-up are essential.

It is well known that patients who have had ESRD, including children and adolescents, have increased cardiovascular morbidity and mortality from uremic vasculopathy and cardiomyopathy.4 In reality, young adults with kidney failure have cardiovascular-related mortality rates higher than those in elderly persons, which leads to a reduction in life expectancy. Even after transplantation, the risk for adverse cardiovascular events is higher than the risk in the general population, and PNPs can play a role in helping modify their patients risk through close monitoring of patients' blood pressure, cholesterol level, and weight. Transplant recipients are at greater risk for infections and getting certain types of cancers in adulthood and thus require close surveillance. Transplant PNPs are in a unique position to expand the care for these patients by assuming the role of clinician, educator, administrator, and coordinator.

In the United States, 10762 kidney transplants have been performed on children, as documented by the North American Pediatric Renal Transplant Cooperative Society.5 Children younger than 18 years of age make up approximately 3% of the patients actively waiting for deceased donor kidney transplants. In 2005, the United Network for Organ Sharing (UNOS) revised its guidelines for organ allocation with respect to pediatric priority. This decision was made in response to several factors: children on dialysis for a prolonged period have worse outcomes than adults have, are unable to attend school or participate in activities, and have more technical problems with dialysis catheters.6 Pediatric patients are given priority for deceased donors under the age of 35. These changes in the rules have decreased the wait times for children. Since this change was implemented, more children have received kidney transplants from deceased donors. Concerns have surfaced because pediatric patients are receiving less well-matched kidneys and in turn are having higher rates of rejection and thus higher rates of allograft failure. Further research on this topic is necessary to answer these questions.

Pediatric Kidney Transplant Centers in the United States

According to data from the Scientific Registry of Transplant Recipients, a total of 1 14 programs in the United States have performed kidney transplant for patients less than 18 years of age. Most programs are relatively small- 54% of these programs performed fewer than 5 pediatric kidney transplants annually. The 15 largest programs in the United States performed kidney transplants for at least 16 children per year.2 Children with ESRD require high-level medical care at tertiary centers. Large medical centers are often at universities with teaching hospitals, and much of the care at transplant centers involves clinicians in training. Certainly, advantages exist in centers with this model. One negative aspect can be that patients are often seeing and being cared for by different providers. Gallagher and Kane7 discussed the advantage of using nurse practitioners to provide care for transplant patients, because nurse practitioners are not only able to provide expertise and knowledge to resident physicians but can serve as the constant in an ever-changing academic medical center.

Roles and Regulations

Medical centers performing transplants are required to adhere to the bylaws of UNOS (Table 1) and the Centers for Medicare and Medicaid Services (CMS, 2007 Conditions of Participation: Requirements for Transplant Centers8). CMS requirements state that the daily multidisciplinary team rounds be composed of individuals from medicine, nursing, nutrition, social service, transplant coordination, and pharmacology. CMS mandates nursing participation in multidisciplinary planning and the designation of a clinical transplant coordinator with primary responsibility for coordinating clinical aspects of transplant care, including continuity of care for patients and living donors throughout transplantation and donation.9 Both CMS and UNOS state that the transplant coordinator should be a registered nurse or licensed clinician. Hospitals performing kidney transplants are required to show evidence of nurses' involvement throughout the transplant process when representatives from CMS and UNOS visit.

The role of nurses in transplant medicine is well established in the literature. McNatt10 published a review of the wide variation in the roles and duties of transplant coordinators, who may or may not be advanced practice nurses. She found a lack of clear guidelines about educational preparedness and licensure, with little consistency among these roles, and she reported that boundaries between transplant coordinators and advanced practice nurses are often blurred in the field of kidney transplantation. She noted that the practice of the transplant coordinator is autonomous, and she questioned whether transplant coordinators are sometimes functioning beyond their legal scope of practice. Gallagher and Kane7 recently described the role of a nurse practitioner for inpatients undergoing solid organ transplant. Their article elucidated a positive and effective model for the medical management of kidney and liver donors and recipients.

Although various staffing models are used, in a traditional model, a registered nurse functions as a transplant coordinator performing the duties listed in Table 1 . The traditional role of a PNP includes diagnosing medical conditions, prescribing medications, educating patients, ordering tests, and monitoring therapies. However, the PNP role is often and appropriately expanded to that of researcher, liaison among specialists, and consultant.3 Morse' illustrated the value of having the advanced practice nurse provide care throughout the process of heart transplantation. She described the ideal educational background for a transplant advanced practice nurse as similar to those of a clinical nurse specialist and a nurse practitioner while also serving as a public educator, supervisor, consultant, and researcher.'

Pediatric Kidney Transplant Program at the University of California, San Francisco

The pediatric kidney transplant program at the University of California, San Francisco, averages approximately 26 transplants per year, making it one of the largest programs in the United States. The medical team on the pediatric nephrology service is made up of pediatric nephrologists and nephrology fellows. Two PNPs work 4 days per week. The team is rounded out by a designated clinical social worker and a registered dietitian. The surgical team consists of transplant surgeons who perform kidney, liver, small bowel, and pancreas transplants in children and adults. Financial counselors provide counseling to patients' families before and after transplant.

A dedicated living donor team of transplant nephrologists and coordinators and a living donor social worker evaluate the adult living donor candidates for pediatric recipients. Having a separate team ensures the long-term health and best interests are considered separately from the child or adolescent who is in need of a transplant. Adult transplant coordinators provide transplant procurement call for both pediatric and adult patients. The referral base is a large geographic area in Northern California. The Bay Area has approximately 7 million people. Although most patients receive their general nephrology care at the University of California, San Francisco, before transplant, approximately 45% of pediatric patients are referred from other centers that do not perform pediatric kidney transplants. Out-of-state and international referrals are done on a case-by-case basis.

Before Transplant

The pretransplant evaluation is comparable for adults and children. The nurse may assume the role of a clinical transplant coordinator, PNP, or clinical nurse specialist. Our model is unique in that we are involved in the care of pediatric kidney transplant patients from the time of referral until their care is transferred to the adult nephrologists. The PNP and the rest of the pediatric kidney transplant team evaluate the patient. This process includes managing their pretransplant workup, listing, and referring potential donor candidates for evaluation. As opposed to a model that would separate nursing roles before and after transplantation, in this model, the PNP can evaluate patients, fulfill listing and regulatory duties, follow up patients through the waiting period and intraoperatively, facilitate discharge, coordinate care, and manage patients after hospitalization.

Although the attending nephrologist and surgeon have the ultimate responsibility for major treatment decisions after transplant, they rely heavily on the input and expertise from the team, and central to this is the PNP. The relationship between the nephrologist and the PNP is that of professional colleague and allows for notable independence in practice.12 It has long been recognized that a multidisciplinary team approach involving the surgeon, transplant nephrologist, advanced practice nurse, social worker, dietitian, and financial counselor provides the best care for this diverse and complex population of patients. This team model enables the child and his or her family to benefit from shared expertise.

Evaluations are completed by all providers, nurses, social workers, nutrition specialists, and members of the medical and surgical teams. The PNP provides education on listing and UNOS status, types and indications for transplant, preoperative and postoperative routine, and outpatient care. Each member highlights his or her area of expertise in addition to discussing the additional value of living donor transplantation and the necessity of compliance with clinic, followup, dietary guidelines and most importantly, the ability to take medications. The team strives to present a cohesive and holistic approach while providing familycentered care. The PNP adds a synoptic view of the transplant experience from the time the patient is admitted to the hospital until their family life begins to normalize several months later. It is vital to assess the patient's readiness for transplant, not only medically but also psychologically, continually. The PNP is available to assist in the medical management of the child awaiting transplant, including formulating modified immunization schedules, starting growth hormone therapy, and placing gastrostomy tubes to promote weight gain. All referrals are prescreened by the PNP to ensure that patients whose disease is rapidly progressing toward dialysis are given high priority and inappropriate referrals are deferred.

The PNP maintains the deceased donor list and activates patients for transplant when patients are both medically and socially ready. This step weighs heavily on the success of the transplant. A goal across the board is to perform transplantation preemptively whenever possible, thus avoiding dialysis and its multitude of complications. Once insurance authorization is obtained, and the patient is activated for transplantation, the PNP provides extensive education or a 'refresher course' to prepare the patient and the patient's family for hospitalization, immunosuppression, length of hospital stay, potential complications, and the proposed outpatient visit schedule. A formal pediatric selection committee approves candidates for wait-listing and transplantation. This multidisciplinary team meeting, chaired by the PNP, allows for input from all members of the pediatric kidney transplant team. The goal is have team consensus regarding a patient and family's readiness for transplant before activation on the deceased donor transplant list or scheduling for a living-related transplant.

Transplant

During hospitalization for the transplant, the child is cared for by a team of pediatric specialists and the kidney transplant surgical team. Daily transplant rounds include an attending pediatric nephrologist, pediatric nephrology fellow, pediatric residents, an inpatient dietician, nephrology social worker, pediatric pharmacists, and a nephrology clinical nurse specialist. Child life specialists provide child-centered education on the surgery, incisions, and pain, and they address concerns or fears the child may have. At the time of transplant, the PNP assembles an immunosuppression regimen and tapering schedule for the pharmacists and medical staff. The immunosuppression plan is developed before the transplant and is based on the results of immunogenetic testing, age of the patient, type of transplant, and history of previous transplants. The PNP develops an individualized outpatient plan that includes outpatient visits for 6 months, the surveillance biopsy schedule, and home care instructions that include specific symptoms and reasons to call the PNP or on-call physician. The PNP is in daily communication with the inpatient team regarding readiness for discharge or posttransplant complications that require intervention. However, at our center, the focus of our PNP practice is the pretransplant workup and the outpatient followup care of pediatric kidney transplant recipients.

After Transplant

As with the pretransplant phase, the pediatric kidney transplant recipient is managed in the ambulatory setting by the multidisciplinary transplant team. Patient care management by the transplant PNP consists of the following broad areas: (1) coordination of care, (2) documentation of history and physical examination, (3) ordering diagnostic tests, and (4) treatment interventions. The PNP performs the initial outpatient visits, making use of the PNP' s expertise in educating patients and coordinating care. Although children and their families receive transplant education during their inpatient hospital stay, the process must continue after discharge. Many aspects of hospitalization interfere with a family's ability to learn and retain pertinent information about transplants. Parents are often sleep deprived; children and teens are affected by pain and the side effects of new medications. During the first clinic visits, the PNP provides an extensive review ofd all the patient's medications, fluid and blood pressure monitoring, and the follow-up schedule.

Coordination of care is particularly important for very young transplant recipients, who often require enteral feedings, central catheter care, and compounded suspension of their immunosuppression medications. Ongoing medical management of pediatric kidney transplant patients is provided by the attending nephrologists, nurse practitioners, and pediatric nephrology fellows. The clinician seeing the patient obtains a focused history and physical examination, reviews medications and diagnostic tests, and formulates a plan of care that is reviewed with the entire transplant team during a postclinic conference. This conference provides the opportunity for the plan of care to be communicated to the team. The patient care discussions allow us to learn from each other's unique roles and expertise- and ultimately result in improved outcomes.

The continuity of care provided by the nurse practitioner is beneficial for the patient's family and for the transplant and referring nephrologists. Unlike children with other chronic conditions, pediatric transplant recipients have frequent outpatient visits. Because of the additional risk associated with performing transplantation on small children, these patients are seen often after transplant. Eventually patients with stable allograft function often have laboratory tests and/or clinic visits every 6 to 8 weeks throughout childhood and the pubertal years. Therefore, these patients require long-term care for many years, through the transition to adulthood. In almost all cases, followup care is performed at the transplant center for the first 3 months after transplantation. Depending on the comfort level of the referring provider and the patient's family, the patient may return to the clinic for alternating visits after 3 to 6 months.

In transplant medicine, nurse practitioners are able to function as independent practitioners and well as collaborators.7 Nurse practitioners can contribute special knowledge to collaborative care. Children with kidney transplants have special health care needs, which must also focus on prevention, maintenance, and restoration. There are definite strengths in the independent functions of nurse practitioners, particularly in regard to enhancing timely delivery of patient care. Prescriptive authority is a key example. Pediatric kidney transplant patients have complex lengthy medication regimens that require frequent dose changes and often prior authorization. Infants and preschoolage patients require many of their medications to be compounded and administered via a gastric feeding tube. In California, a registered nurse is not permitted to refill medications. PNPs prescribe medications, adjust dosages in response to results of diagnostic tests and patients' symptoms, and process refill requests and previous authorization requests. The focus on outpatient care allows PNPs to be available for patients' calls, and requests are handled in a timely manner and not dependent on an attending nephrologist who is covering the inpatient unit or seeing dialysis patients.

A primary responsibility after transplant is monitoring for posttransplant complications and side effects. An example of this is the management of febrile infections of the urinary tract, which occur in 15% to 33% of children after kidney transplant and can lead to scarring and interstitial injury and can diminish long-term graft survival.13 Patients with febrile urinary tract infection are treated aggressively with antibiotics. PNPs monitor initial and follow-up cultures to make sure that the choice of urinary prophylaxis is appropriate and to ensure frequent voiding or urinary catheterization. If the patient has recurrent infections of the urinary tract, PNPs will initiate a referral to a pediatric urologist for further care. Our goal as kidney transplant PNPs is not to have as independent a role as possible but rather to facilitate safe and effective care for these patients.

Communication With Outside Providers

Because of the small numbers of children with ESRD, ample referrals are crucial to maintain a pediatric transplant program. Therefore, it is essential to have frequent and open communication with referring providers. Patients who are not yet ready for transplant are seen annually at the University of California, San Francisco. Those patients living at greater distances are seen at quarterly outreach visits to a referring children's hospital. In terms of the posttransplant care, alternating posttransplant follow-up between referring hospital and transplant center allows patients to be seen locally by their nephrologist and to maintain contact with the transplant center. This model ensures that the patient is monitored by the transplant team and complications are quickly identified and treated.14 In 2003, Adedoyin et al14 suggested that pediatric patients could be safely and effectively managed at their referring center after transplant and that alternating visits creates confusion for their families. In our experience, it is the referring nephrologists' goal to manage their nephrology patients after transplant, with the transplant center available for both ongoing consultation and inpatient care should the patient require therapies not available at the referring hospital. This model of 'shared or cooperative care' between the transplant center and the referring center requires maintaining frequent communication between clinicians caring for these patients.

As nurse practitioners providing ongoing medical management of pediatric transplant patients, we are able to provide consultation with referring providers to establish a plan of care in a timely manner without the need to routinely obtain validation from the attending transplant nephrologist. This arrangement allows patients with stable allografts who live a considerable distance to avoid the final and social burden of frequent visits to our transplant clinic. Table 2 shows the PNP responsibilities for outreach to referring clinics.

Conclusions

Transplant continues to be a highly regulated and scrutinized specialty. PNPs manage the regulatory responsibilities defined by UNOS and CMS while providing a strong clinical presence and partnership with the pediatric nephrologist. Further research is needed to build evidence on the effectiveness of PNPs in the care of pediatric kidney transplant patients and improving patients' outcomes in regional transplant centers. From our experience, we believe that the PNP' s role is that of a partner, complementing the duties of the pediatric nephrologist. We provide comprehensive care, an effective and timely service, to often medically fragile patients.

Financial Disclosures

None reported.

[Reference]

References

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2. Scientific Registry of Transplant Recipients 2009 Annual Report: US Hospitals with Kidney Transplant Centers. http://www.srtr.org/csr/current/Centers/TransplantCenters _New201 106x.aspx?organcode=KI. Accessed July 26, 201 1 .

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4. Filler G. Challenges in pediatric transplantation: the impact of chronic kidney disease and cardiovascular risk factors on long-term outcomes and recommended management strategies. Pediatr Transplant. 2011;15(1):25-31.

5 . North American Pediatric Renal Transplant Cooperative Society . https://web.emmes.com/study/ped. Accessed August 9, 201 1 .

6. Agarwal S, Oak N, Siddique J, Harland RC, Abbo ED. Changes in pediatric renal transplantation after implementation of the revised deceased donor kidney allocation policy. Am J Transplant. 2009;9(5): 1237-1242.

7. Gallagher LM, Kane KD. NPs in transplant medicine. Expert providers, facilitators, and collaborators. Adv Nurse Pract 2010;18(7):25-26,48.

8. Centers for Medicare and Medicaid Services. 42 CFR Parts 405,482, 488, and 498 Medicare Program. Hospital Conditions of Participation: Requirements for Approval and ReApproval of Transplant Centers to Perform Organ Transplants; Final Rule. 2007. http://www.cms.gov /CertificationandComplianc/Downloads/Transplantfinal .pdf. Accessed July 29, 2011.

9. United Network for Organ Sharing. Designated Transplant Program Criteria. 2011. http://www.unos.org/docs/Appendix _B_AttachI_XIII.pdf. Accessed July 16, 2011.

10. McNatt GE. Nursing and transplant coordination: a call for clarity. Prog Transplant. 2008;18(3):208-215.

11. Morse CJ. Advance practice nursing in heart transplantation. Prog Cardiovasc Nurs. 2001;16(l):21-24, 38.

12. Bolton WK. Nephrology nurse practitioners in a collaborative care model. Am J Kidney Dis. 1998;31(5):786-793.

13. Ulrike J, Kemper MJ. Urinary tract infections in children after renal transplantation. Pediatr Nephrol. 2009;24(6): 1 129-1 136.

14. Adedoyin O, Frank R, Vento S, Vergara M, Gauthier B, Trachtman H. Outcomes after renal transplantation in children: results of follow-up by nephrologists in a primary referral center. Pediatr Transplant. 2003;7(6):479-483.

[Author Affiliation]

Jessica Brennen, rn, msn, CNS, CPNP, Marilyn McEnhill, RN, MSN, PNP-BC

University of California, San Francisco

Medical Center

Corresponding author: Jessica Brennan,

rn, msn, CNS, CPNP, University of California,

San Francisco Medical Center,

533 Parnassus Ave, U585,

San Francisco, CA 94143 (e-mail: essica.brennan @ ucsfmedctr.org)

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