The (R)evolution of Children’s Hospital Care

From facilities to care delivery, pediatric hospitals have taken a great leap forward

By: Linda Harder
Photography by: Tracey Brown

To learn how inpatient pediatric care is evolving, Maryland Physician spoke with the heads of pediatrics at Johns Hopkins, University of Maryland (UMCH), Sinai and Children’s National.

Giant yellow puffer fish suspended from a soaring ceiling. Abstract rhino sculptures in the courtyard. Marine motifs and live broadcasts from the National Aquarium. Pediatric ICUs where both parents can stay overnight. Many of today’s spacious pediatric facilities only vaguely resemble hospitals of the past, with family-friendly, private rooms that are stuffed with electronic amenities like video games and flat screen TVs.

Why are pediatric facilities enhancing services when vaccines and treatment advances result in fewer and shorter hospitalizations? In part, the ability to treat formerly life-threatening conditions, such as congenital heart disease and fetal neurology deficits, has increased the need for intensive pediatric care.

“Across the country, community hospitals are questioning whether they should partner with a tertiary hospital or get out of the pediatric business,” says David L. Wessel, M.D., senior VP, The Center for Hospital-based Specialties, Children’s National Medical Center. “There’s a focus on inpatient service being tertiary and quaternary.”

Flexible, Innovative Facilities
With the help of private donations, all four of Maryland’s local children’s hospitals are investing multiple millions in their facilities, staff and technology to dramatically alter care delivery. Sinai Hospital opened its new 23,000 sq. ft. Herman & Walter Samuelson Children’s Hospital in mid March, Hopkins opened the new 205-bed, 560,000 sq. ft. Charlotte R. Bloomberg Children’s Center on May 1st, and UMCH and Children’s National have added new facilities and completed major overhauls of existing ones.

Todays’ rooms are large, private and replete with high tech features. One or both parents can sleep overnight with their child, even in the ICU. Teens enjoy high-tech options in separate lounges so they don’t have to mix with younger children.

Flexibility is key. Medical/surgical rooms can be converted to ICUs simply by increasing the nurse staffing ratios. Joseph M. Wiley, M.D., FAAP, chief, Department of Pediatrics, the Herman and Walter Samuelson Children’s Hospital at Sinai, says, “In our new children’s hospital, we designed the flex unit to have three pods, each with two rooms; the rooms can be used as an ICU so we don’t have to move sicker patients.”

“The strength of our new facilities is that we can adapt to change quickly so that we can still take care of patients in 20 years,” notes George J. Dover, M.D., director, Johns Hopkins Children’s Center. “We’ve also designed the new hospital so that new technology can be available to both children and adults. Further, we’ve grouped related pediatric services on the same floor. For example, we’ve grouped our new NICU, delivery suites, ORs devoted to C-sections, and a nursery on the same floor. On another floor, we have a large PICU adjacent to a suite of pediatric ORs that can handle both same-day and complex procedures, a huge recovery area and pediatric radiology.”

Sinai’s solution to the confining isolation rooms of the past is to create a wing where four isolation rooms have glass on three sides and anterooms. The entire facility is also HEPA-filtered to reduce infectious transmission. “We now have a physical facility that matches the way we want to practice medicine,” remarks Dr. Wiley.

“Our approach is to invest our dollars to get the maximum return,” says Steven J. Czinn, M.D., professor and chairman, Department of Pediatrics, University of Maryland Medical Center. “We’ve built a new pediatric hybrid cardiac catheterization lab and are finalizing plans for a new state-of-the-art NICU. We have often retooled existing space to use the dollars efficiently. For example, we converted existing space to mostly private rooms and separate teen, toddler and family lounges.”

Growth in Pediatric Subspecialized Care
Hospital pediatrics has become highly intensive and subspecialized, encompassing more than 20 subspecialties, including pediatric emergency physicians, pediatric gastroenterologists, neurosurgeons, oncologists, cardiologists and anesthesiologists.

“One of the biggest transformations is in pediatric ICU care,” Dr. Wessel observes. “In the near future, nearly 50% of our beds will be ICU beds. In addition to a 54-bed NICU and 39-bed PICU, we opened a new cardiac ICU with 26 beds in early 2012. Even though we built the unit for growth, we already are nearly full.”

Children’s National has had success with a hypothermia program to cool newborn body temperatures to 32 to 34 degrees Celsius following cardiac arrest. They also are expanding fetal and transitional medicine, with specialized services in utero that extend to advanced post-delivery care. In the brain, doctors can now determine brain development by measuring brain folding and metabolism. “It’s a very exciting area and we rebuilt a whole suite for fetal medicine,” enthuses Dr. Wessel.

“We have the only pediatric hybrid cardiac catheterization lab in the state, or perhaps the region,” says Dr. Czinn. “We spent $3 million to provide both cardiothoracic and interventional cardiology services in the same lab.” Another area of strength at UMCH is its pediatric GI program that includes pediatric anesthesia, a GI infusion center, and wireless capsule endoscopy to evaluate the small bowel.

Dr. Wessel notes, “Our whole east tower inpatient unit is only two years old. We have the only dedicated cardiac PICU in the area. We can open an aortic valve in a preemie weighing less than two pounds in that ICU, a procedure that would have been impossible eight to 10 years ago.”

The survival of infants and children with serious conditions has led to the need for new services to treat them as they grow up. UMCH offers a Pediatric Oncology Survivorship Program to examine and monitor the most common side effects that develop in children who have undergone radiation and chemotherapy treatments. Dr. Czinn comments, “If we see them at regular intervals, we can prevent problems.”

Dr. Dover says, “Hopkins has the largest cystic fibrosis program in the region. Those children have now grown up and we’ve had to train internal medicine providers to deliver cardiac, pulmonary and other care to them as they’ve become adults.”

Pioneering and Rapid Adoption of Advances
Whether pioneering new technology in infants, or more quickly adopting adult advances to children’s care, these facilities drive change. Dr. Dover comments, “At Hopkins, we don’t wait for things to be developed in adults first. From the operation to repair the congenital heart condition, Tetralogy of Fallot, in 1944 to today, advances often start in pediatrics.”

Dr. Wessel notes that the first reported use of Viagra was treating pulmonary hypertension in a 6-week old girl in the late 90s. He also cites the heart/lung machine as an example of technology that was adopted for use in adults only after it was developed for children.

Adds Dr. Czinn, “Because there is a larger market for adult advances, technological advances tend to occur first in the adult world and trickle down to children. We’re committed to speeding the adoption of those advances to pediatric care.”

Community Hospitals Adapt
Dr. Dover says, “There’s a new model of community pediatric hospitals that was started at Howard County General, is now at GBMC and Franklin Square, and is spreading to Upper Chesapeake and Bayview. In this model, pediatric ER, observation and inpatient services are all staffed by a shared set of pediatric nurses and hospitalists. We’ve developed protocols that guide when to transfer children needing more specialized care to us, to keep as many patients at the community hospitals as we can.”

IT Transforms Care Delivery
Telemedicine is facilitating the communication between community hospital pediatric staff and tertiary centers. Children’s National has developed telemedicine technology to network area community hospitals with its emergency and inpatient specialists, Hopkins is launching telemedicine in its new hospital, and UMCH has telemedicine pilots underway.

Dr. Wessel says, “We have media rooms that connect to other centers across the country. A community hospital can do a cardiac ultrasound and feed it to us. We can make the diagnosis and transport the child when necessary. We transport more than 6500 patients a year.”

“With telemedicine,” Dr. Czinn remarks, “we can speak to the referring physicians, look at the child’s lab and imaging results in real time and make a decision to transfer them here or treat them there. It will dramatically influence the value of the healthcare dollar.”

Both Hopkins and Sinai have advanced electronic medication ordering systems in which medications are delivered directly to a locked cabinet in each patient’s room. Dr. Wiley notes, “Nurses no longer have to retrieve medications from a med room, where they risk being interrupted. They can check the dose and scan the bar codes to match the medication to the child.” Dr. Dover adds, “Hopkins will soon assign a pharmacist to each floor to work with the providers there as a team.”

Family Centered Care
Making pediatric care more family-centered is not just a nice touch, it’s good medicine. In most facilities, both parents can be accommodated for overnight stays, and bathrooms are designed with adult needs in mind, as well as the child’s.

At Children’s National and Sinai, their family-centered rounds intimately involve the family. “Research has demonstrated that this approach increases information accuracy, reconciles medication dosing with the child’s condition and lets the family know what diagnoses we’re considering so there are no surprises,” Dr. Wiley states.

Adds Dr. Wessel, “We invite parents to join us every morning, even in the ICU.” Parents are even allowed to stay during cardiac resuscitation of their children if they wish, and under certain conditions.

Child Life specialists add a critical dimension of care. According to Dr. Dover, Hopkins has one of country’s oldest child life programs. These specialists have a strong background in child development and family systems so they can provide emotional support to the entire family as well as the hospitalized child’s development. “Normal play can be the best therapy,” observes Dr. Wiley.

Easy Single-Point Access
Tertiary hospitals used to be infamous for their lack of access. While they have worked on improving access for years, these hospitals are striving to make additional enhancements. Sinai has Pediatric One Call and has developed a reputation for being well connected to its referral base. Dr. Wiley claims, “As long as a bed is available, we can get the patient in. The ED can be bypassed as appropriate.”

At Children’s National, Kurt Newman, M.D., the new president and CEO, has set ambitious goals to have a single person and number to call for each service. “His single greatest focus is to increase access,” says Dr. Wessel. In addition to UMCH’s One Call system, Dr. Czinn says, “Pediatricians can keep one phone number on speed dial – mine. My commitment is that doctors can call me directly at 410-328-6777.”

Dr. Dover concludes by commenting, “Pediatrics is the jewel in the crown for Hopkins.” With new facilities and care paradigms, it’s clear that pediatric care is a shining jewel for all four of these specialty hospitals.

Joseph M. Wiley, M.D., FAAP, chief, Department of Pediatrics, the Herman and Walter Samuelson Children’s Hospital at Sinai.
George J. Dover, M.D., director, Johns Hopkins Children’s Center, professor of Pediatrics, professor of Oncology, Given Professor and director, Department of Pediatrics
David L. Wessel, M.D., senior VP, The Center for Hospital-based Specialties and division chief, Critical Care Medicine, Children’s National Medical Center
Steven J. Czinn, M.D., professor and chairman, Department of Pediatrics, University of Maryland School of Medicine, and Physician-in-Chief, University of Maryland Children’s Hospital

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