Inside Pediatrics Spring 2015

P E D I A T R I C S A Publ ication by Chi ldren’s of Alabama

New aerodigestive team treats medically complex children

Institute for cancer survivorship comes to Alabama

Dr. Randy Cron gives JIA patients hope for TMJ pain relief

Spring/Summer 2015

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Welcome to the premier issue of Inside Pediatrics magazine. Our goal is to share with you the remarkable work that is happening here at Children’s of Alabama, the state’s only freestanding pediatric hospital. We’ve been taking care of kids since 1911. Last year, families from every county in Alabama, 42 other states and 10 foreign countries came through our doors, representing more than 653,000 outpatient visits and nearly 14,000 inpatient admissions. We’ve grown from a modest 11-bed hospital housed in a Birmingham residence to a 332-bed facility that’s the third largest in the United States. But our mission has never wavered: to provide the finest pediatric health services to all children in an environment that fosters excellence in research and medical education, to be an advocate for all children and to work to educate the public about issues affecting children’s health. Within these pages you’ll meet some of the brightest minds and boldest sub-specialists in our field and learn more about the innovative programs they’re bringing to pediatric health care. Physicians like pediatric rheumatologist Randy Cron, M.D., Ph.D, and hematologist-oncologist Smita Bhatia, M.D., M.P.H. Cron’s seven-year-old program is already the largest in the Southeast and, more importantly, is making life-changing progress in treating juvenile idiopathic arthritis and aggressively

tackling TMJ arthritis in those patients. Bhatia is an internationally renowned leader in cancer survivorship research who came to Children’s from City of Hope to establish a comprehensive program for cancer outcomes and survivorship research to complement our existing clinical survivorship program. These doctors and others represent the powerful partnership we enjoy with our colleagues at the University of Alabama at Birmingham. You may already know many of the other physicians we’ll be spotlighting or have heard their names. We hope Inside Pediatrics will serve as a valuable connection to them as we join you in a united effort to improve the health and well-being of children everywhere. Enjoy this first issue and let us know what you think.

Mike Warren CEO and President Children’s of Alabama

Children’s of Alabama is the only freestanding pediatric hospital in the state and home to some of the Southeast’s premier pediatric health care programs. Children’s offers inpatient and outpatient services across its Russell Campus on Birmingham’s historic Southside with additional specialty services provided throughout the metro area and in Huntsville and Montgomery. Primary care is provided at more than a dozen medical offices in communities across central Alabama. Many of the programs and services offered at Children’s are unique in Alabama and include the state’s only pediatric burn center, dedicated pediatric bone marrow transplant facility, ECMO service, pediatric kidney dialysis service and the only pediatric cleft and craniofacial center. And Children’s leadership in child health goes beyond state lines with one of the Southeast’s largest pediatric cardiovascular programs, one of the nation’s largest pediatric rheumatology programs and the only accredited pediatric epilepsy monitoring unit in the United States. It is consistently ranked among the best pediatric medical centers in the nation by U.S. News & World Report . Children’s is a private, not-for-profit hospital that serves as the primary site of the University of Alabama at Birmingham (UAB) pediatric medicine, surgery, psychiatry, research and residency programs. This dynamic relationship ensures world-class care and cutting edge therapies across all sub-specialties.

Children’s of Alabama 1600 7th Ave. S. Birmingham, Alabama 35233 (205) 638-9100 www.childrensal.org For questions, more information or to share your feedback, please email us at insidepediatrics@childrensal.org . An online version of the magazine is available at www.childrensal.org/insidepediatrics . Inside Pediatrics President and CEO...................Mike Warren Chief Communications Officer............................... Garland Stansell Editor..................................... Kathy Bowers Design.....................................Trent Graves Photography...........................Denise McGill Digital Content........................... Amy Dabbs Contributors............................. Andre Green Adam Kelley John Tracy Tina Wilson Physician Marketing........ Tiffany Kaczorowski facebook.com/childrenshospitalofalabama linkedin.com/company/children’s-of-alabama twitter.com/ChildrensAL Instagram.com/childrensofal

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Save the Date The 6th Annual Advancements in the Care of Pediatric Cancer and Blood Disorders Symposium will focus on “Transforming Care.” Invited speakers include Laurence Cooper, M.D., Ph.D., from M.D. Anderson, Houston; Andrew Gilman, M.D., from Carolinas Healthcare Group in Charlotte; Ellen Olson, P.N.P., from Children’s Healthcare of Atlanta; and Avi Maden-Swain, Ph.D., Alyssa Reddy, M.D., Hilary Haines, M.D., Wendy Landier, Ph.D., and Smita Bhatia, M.D., all of Children’s of Alabama. Frederick Goldman, MD, director of the Children’s of Alabama Pediatric Blood and Marrow Transplant program, is organizing the conference. October 23, 2015

News Children’s of Alabama has earned accreditation as a Pediatric Heart Failure Institute by The Healthcare Colloquium, a national group of hospitals dedicated to improving patient outcomes through expert-to-expert collaboration. The accreditation is the highest level available and makes Children’s the first pediatric facility in Alabama, and one of only nine in the nation, to be awarded this distinction. To broaden Children’s existing child abuse treatment and prevention program and elevate it to the Children’s Hospital Association’s Advance Tier level, a new division of child abuse pediatrics has been established. Michael Taylor, M.D. , will serve as division director. The new division expands Children’s commitment to child abuse treatment and prevention through the Children’s Hospital Intervention and Prevention Services (CHIPS) Center. Taylor will work with Melissa Peters, M.D. , David Bernard, M.D., and the CHIPS staff which is comprised of specially trained and licensed professional counselors, doctors, social workers and sexual assault nurse examiners. Honors & Awards

A c c r e d i t e d P e d i a t r i c H e a r t F a i l u r e I n s t i t u t e S M T h e H e a l t h c a r e C o l l o q u i u m , A B a t t e l l e C o m p a n y

• Traci Jester, M.D. , pediatric gastroenterology, has been selected to join the Crohn’s and Colitis Foundation of America’s Pediatric Affairs Committee. • David Smith, M.D. , pediatric emergency medicine, received the 2015 Society for Pediatric Research Clinical Fellows Research Award. • Michele Kong, M.D. , pediatric critical care, presented “Protease Dysregulation in RSV Disease” at the 2015 Pediatric Acute Lung Injury and Sepsis Investigators meeting at Salt Lake City earlier this year. • Prem Fort, M.D. , neonatology, received the 2015 Fellows’ Section Clinical Research Award from the Society for Pediatric Research as well as the Southern Society of Pediatric Research Clinical Science Young Investigator Award. • Namasivayam Ambalavanan, M.D. , neonatology, has been selected as the Southern Society of Pediatric Research 2015 Founders’ Award recipient. • David Kimberlin, M.D. , will present the Philip Porter Lecture at Grand Rounds MassGeneral Hospital for Children on Sept. 29. • Mike K. Chen, M.D. , pediatric surgery, has received the 2015 American College of Surgeons/American Pediatric Surgical Association Executive Leadership in Health Policy and Management Scholarship. • The American Society of Clinical Oncology Post recently highlighted Smita Bhatia, M.D. , and her team’s findings in an article, “Less Than 95% Adherence to Mercaptopurine Maintenance Associated with Nearly Threefold Increased Risk of Relapse in Pediatric ALL.” The research is a Children’s Oncology Group study reported in JAMA Oncology . • Suresh Boppana, M.D. , received the inaugural Congenital CMV Award at the 5th annual International Congenital CMV Conference in Brisbane, Australia in April.

• T. Prescott Atkinson, M.D. Ph.D , pediatric allergy, asthma and immunology, has been appointed vice chair of the American Board of Allergy and Immunology. • Tim Beukelman, M.D., MSCE , pediatric rheumatology, was selected as a visiting professor to the Florida Hospital Medical Center in Orlando as part of the American College of Rheumatology’s Rheumatology Research Foundation Pediatric Visiting Professor program. • The Society for Pediatric Research has named Waldemar Carlo, M.D. , neonatology, the 2015 recipient of the Douglas K. Richardson Award in Perinatal and Pediatric Healthcare Research. • Randy Cron, M.D., Ph.D , pediatric rheumatology, has been selected to serve on the editorial board for Arthritis Care & Research. • Sergio Stagno, M.D. , former physician-in-chief at Children’s of Alabama, has been appointed Chair Emeritus in the University of Alabama School of Medicine. • Tina Simpson, M.D. , Krista Casazza, M.D. , and Jasmine Pagan, M.D. , general pediatrics and adolescent medicine, received The 2015 Association of Teachers of Maternal and Child Health Innovative Teaching Award. • Gregory Friedman, M.D. , pediatric hematology/ oncology, participated in an NIH-sponsored advanced training course, “Frontiers in Stem Cells in Cancer,” in Ponce, Puerto Rico. He spoke on “Pediatric Cancer Stem Cells: Biologic Strategies with Oncolytic Virotherapy” and taught a lab, “Pediatric Cancer Stem Cells: Intracranial Injections and Immunofluorescent Staining.” • Drew Davis, M.D. , pediatric rehabilitation medicine, will serve a three-year term as vice chair of education for the Pediatric Rehabilitation/Developmental Disabilities Council of the American Academy of Physical Medicine and Rehabilitation. • Kathy Monroe, M.D. , pediatric emergency medicine, has been elected to serve as a member on the AAP’s Executive Committee of the Council on Injury, Violence and Poison Prevention.

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Inside the Red Line

Parents face a world of practical challenges in obtaining care for children with medical complexities. Multiple appointments with different specialists, therapy teams, labs and procedures require time off from work and finding child care for siblings. Many travel hundreds of miles to the hospital, adding the extra burden of costs for fuel, meals and sometimes overnight lodging. Add the difficulty of transporting a child who is tethered to medical equipment and a logistical — and exhausting — nightmare for Mom and Dad becomes an all-too- familiar scenario. At Children’s of Alabama, a program introduced in 2012 is alleviating much of that stress by streamlining the entire process. The aerodigestive program is a collaboration of the pulmonary, gastroenterology and otolaryngology divisions headed by pulmonologist Tom Harris, M.D., who serves as co-medical director with ENT Brian Wiatrak, M.D., FACS, FAAP, and gastroenterologist Reed Dimmitt, M.D., MSPH. “The goal is to comprehensively and efficiently evaluate and manage the medical needs of children with complex airway and nutritional problems by coordinating care,” Harris said. Streamlining the evaluation process The process begins in the aerodigestive conference, held twice monthly, where the team reviews the medical history and records of new patients and determines if further assessment via triple endoscopy, including direct laryngoscopy, flexible bronchoscopy and esophagogastroduedenoscopy (EGD), is needed. “We do a complete assessment of the upper aerodigestive tract,” Wiatrak Opposite page: Drs. Tom Harris (left) , pulmonary, and Reed Dimmitt (right) , gastroenterology, hepatology and nutrition, are slated to join Dr. Brian Wiatrak in presenting to the Alabama Chapter of the American Academy of Pediatrics this fall.

Dr. Brian Wiatrak, ENT, said Children’s aerodigestive program is the result of a nationwide movement over the past two decades toward a multi-disciplinary approach to caring for complex kids.

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Medically Complex Children

said. “All the participating doctors meet with the parents at one time to review all the results.” Following the assessment, the patient is seen in clinic where doctors from all three disciplines evaluate options for medical treatment or other interventions, if needed. Clinic coordinator Ashley Chapman, RN, BSN, attends those visits to coordinate follow-up care. “Sometimes surgery is required. Sometimes a patient needs medical management. Sometimes it’s rehabilitation. And other times, the child may just need to outgrow the condition. This coordinated care helps take away the uncertainty and allows us to confidently care for the child,” Harris said. Program includes new intensive feeding therapy Often the patient is referred to Children’s sleep center for studies or to the new intensive feeding program, one associated with an aerodigestive program. “The intensive feeding program was developed and is directed by clinical psychologist Michelle Mastin, Ph.D. Her comprehensive team includes speech and language pathology, occupational therapy, clinical nutrition, social work, psychology and medicine,” Harris said. “These experts work on changing the learned barriers children sometime face with feeding. For example, even after the anatomical reasons for swallow dysfunction have corrected, comprehensive trans-disciplinary behavior modification may be necessary to overcome aversions and relearn how to eat.” More than 200 patients are currently receiving care through the aerodigestive program. Some are referred by their primary care physicians, some are self- referred and others are referred internally by other sub-specialists at Children’s. “Patients come in from the different disciplines with different symptoms and The collaborative spirit of the program is the backbone of its success. “It’s the quintessential way of breaking down silos to talk about patient care,” Dimmitt said. “We learn from one another. It’s generated a new trust and appreciation for what the other person does. There’s more familiarity with our colleagues in other divisions that’s fostered better communication.” different issues,” Dimmitt said. Collaboration is key of the few in the U.S. and the only one that is directly

Academically, the aerodigestive program provides a wealth of data. “There’s a lot to be learned from these complex patients,” Wiatrak said. “We’ve already enrolled 300, and we’ve started to capture information in an aerodigestive database. Then we can conduct studies and research projects in all three disciplines.” The improvement in patient care has inspired Dimmitt to adapt the structure of the aerodigestive program to four other multidisciplinary programs within the GI division: eosinophilic esophagitis, which is a collaboration of GI and allergy; intestinal rehab/short bowel, which combines GI and surgery; colorectal, another collaboration between GI and surgery; and the hepatobiliary program, where GI, pediatric surgery and transplant surgery collaborate. And it’s not just a local program. Patient referrals have already come from become the destination program not only in the state but regionally, nationally and internationally,” Dimmitt said. More information is available at www.childrensal.org/ aerodigestive . neighboring states. “Our hope is to

“The goal is to comprehensively and efficiently evaluate and manage the medical needs of children with complex airway and nutritional problems by coordinating care.” — Tom Harris, M.D.

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Inside Good Health Regional Poison Control Center Reduces Emergency Room Visits, Saves Lives

A single telephone and a passionate young doctor became the first pipeline of information that has saved untold lives and curtailed unnecessary, expensive emergency room visits. The Regional Poison Control Center (RPCC) at Children’s of Alabama had its beginnings 60 years ago when pediatricians from around the state began regularly calling the hospital seeking help for patients who were presenting with symptoms of toxic ingestions from medications and household products. At a time before product labeling and child-resistant packaging were mandated, doctors were limited in the knowledge that was available to help them identify and treat suspected poisonings. “Manufacturers collectively felt little responsibility for adequately warning of poison hazards,” said Don Palmer, M.D., a pediatrics resident at the time. “Contact information for the manufacturer was more often than not missing on the label, and warnings the calling — and soon became the “go-to guy” for providing diagnostic and treatment guidance. By 1958, he had founded the Regional Poison Control Center at Children’s, one of the first 14 established in the United States. Eight years later, Paul Palmisano, M.D., became the center’s first medical director, installing a “poison phone” in the pharmacy so that it could be answered around-the-clock. The program rapidly expanded during his tenure. In its first year, the new poison center fielded about 100 calls. “During those early years, staff members would use an old index card system to help guide them through the triage and treatment recommendations,” Children’s Child Safety Institute divisional director Bill King, Dr.PH, R.Ph, said. By 1979, the cards had been replaced by microfiche and the first toll-free hotline in Alabama for poison information established. At the same time, the center began tracking the calls received, noting were woefully inadequate or wrong.” Palmer answered the calls   and

a more comprehensive picture of the increasingly important and complex role of poison control centers. Today, technology permits instantaneous posting and analysis of data derived from received calls. That data is surveilled by the Centers for Disease Control and Prevention to recognize and evaluate emerging trends and public health risks. The data is also used to kick-start prevention efforts and even spark legislative efforts. In Alabama, for example, spikes in the number of calls related to synthetic cathinone derivatives, or “bath salts,” led to new legislation that reclassified the substance as a Schedule 1 controlled substance and banned its possession, manufacture and distribution. Similarly, a sharp rise in the number of carbon monoxide exposures following Hurricane Katrina being improperly used across Alabama by families who were without electricity for days after the storm. Such close monitoring of data is useful for a wide array of public health hazards and would be crucial in the occurrence of a bioterrorism event. Community outreach Beyond telephone triage and data reporting, the RPCC at Children’s provides a statewide educational program to heighten public and professional awareness of the center, to inform parents and caregivers of the best preventive actions, and to provide continuing education for health care professionals on the assessment, triage and management of poisoned patients. Advanced Hazmat Life Support courses help train first responders in the event alerted public health officials to the number of home generators

details that would eventually be used to monitor trends and enhance the triage process. Since 1999, the RPCC has used electronic medical records, which allow data to be uploaded to the National Poison Data System in real time. Training and certification In 2014, the RPCC fielded 50,941 calls related to poison information and toxic ingestions in children, adults and animals. About 53 percent were pediatric cases. Each is answered by one of 22 staffers, all specially trained registered nurses and pharmacists. To become a certified poison center specialist, each licensed health care professional must complete six to 12 weeks of intense training in toxicology, log 2,000 hours of work in the poison center and answer 2,000 calls before sitting for the national certification exam. Certification must be renewed every seven years. “At least 50 percent of a poison center’s staff must be certified in order for the center to gain accreditation. We have 90 percent,” explained managing director Ann Slattery, Dr.PH, RN, R.Ph, CSPI, DABAT. In addition to King and Slattery, board- certified emergency medicine pediatrician Michele Nichols, M.D., and Erica Liebelt, M.D., who is also board-certified in pediatric emergency medicine and medical toxicology, serve as co-medical directors. Advanced level consultation beyond the initial contact with center staff is available around-the-clock from this team. Funding is provided primarily by Children’s along with limited state and federal dollars, and a significant annual contribution from Blue Cross Blue Shield of Alabama through The Caring Foundation. Impact on public health The numbers help tell the story of the growth of the RPCC, but the far-reaching impact of those calls and the center’s commitment to educational outreach gives

The RPCC is the only poison control center in Alabama and was one of the first 14 established in the U.S.

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of industrial chemical exposures, spills and toxic terrorism. The RPCC team also presents grand rounds on topics in clinical toxicology and offers medical toxicology consultations and other educational and clinical services. Special emphasis is placed on providing such education and service to rural, traditionally underserved areas through a partnership with the Alabama Department of Public Health program. The collaboration has resulted in significant increases in the awareness of poison risks among those communities. In 2013, the RPCC launched the state’s first mobile application designed to identify toxic plants, venomous and poisonous snakes and insects, and dangerous common household products. The “PoisonPerils” iPhone app boasts more than 2,900 downloads to date and an Android version is in the center’s plans. Then and now Changes in American society over the past 50 years are reflected in many ways through the number and types of calls the RPCC receives. Laundry detergent pods and nicotine refills for e-cigarettes number among the most common ingestions these days, along with designer drugs such as “spice,” cleansers and medication that resembles candy. Last year, Children’s RPCC became the state’s only poison center following the somewhat sudden closing of a similar program in Tuscaloosa. The transition has increased the RPCC’s call volume by 60 percent and necessitated the immediate hiring of an additional six full- time employees. “Our phone never stops ringing,” Slattery said. More information is available at www.childrensal.org/rpcc .

Managing Director Ann Slattery (top) leads the RPCC staff comprised of specially trained registered nurses and pharmacists in answering more than 50,000 calls each year and compiling data that helps formulate public health policy.

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Cron Leads Worldwide TMJ Arthritis

Inside the Medicine

The jaw opens and closes about 2,000 times a day. The motion is spontaneous and automatic, easy and fluid, both deliberate and involuntary. It’s also painless, or it should be. For children suffering from temporomandibular joint (TMJ) arthritis as a complication of juvenile idiopathic arthritis (JIA), though, the jaw can be a source of pain, and sometimes disfigurement, that most physicians struggle to treat. But pediatric rheumatologist Randy Cron, M.D., Ph.D, at Children’s of Alabama, is seeing some success in a uniquely aggressive approach to screening for and managing TMJ arthritis in his JIA patients. TMJ arthritis in children with chronic arthritis is difficult to diagnose. Too often, the first indication of disease is when evidence of deterioration and inflammation is clear. “We screen every child with JIA at the time of diagnosis by MRI with contrast because they’re asymptomatic until the damage is done,” Cron said. “The longer you wait, the harder it is to treat.” Those MRIs are performed in the Children’s imaging department, headed by Radiologist-in-Chief Yoginder Vaid, M.D. “Up to 80 percent of JIA patients have disease in the jaw at diagnosis,” Vaid said, “but it is clinically silent. We try to diagnose it early with MRI. It has become the gold standard.”

The scans are performed on an outpatient basis, although they may require anesthesia or IV sedation to keep the children, especially the youngest patients, still enough to get clear images. Some patients are scanned at Children’s main campus in downtown Birmingham, where the imaging department is equipped with both a 1.5 and a 3.0 TESLA MRI machine. Others are seen at the Children’s South outpatient center, about 20 miles away, where a 1.5 TESLA machine is in operation. Scans are repeated in children with JIA at least every six months if disease is present, Vaid said. “I think I can comfortably say our radiologists have read more TMJ MRIs since 2008 than anyone else on the planet,” Cron said. When signs of changes in the jaw are present on the images, Cron and his team have found that early and aggressive use of systemically administered arthritis medicines, such as tumor necrosis factor inhibitors, seem to partially help prevent such abnormal bone development as micrognathia (or small jaw), but are not completely effective in treating TMJ arthritis. “While almost all other arthritic joints in children with JIA respond very well to early and aggressive systemic therapy with tumor necrosis factor inhibitors like etanercept [Enbrel],

Dr. Randy Cron, rheumatology, said one in 1,000 children in the U.S. will develop chronic arthritis.

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Efforts to Unlock the Puzzle of

“We’ve probably pushed forward the screening and treatment of TMJ arthritis in children with JIA as much as anyone I know.” — Randy Cron, M.D.

infliximab [Remicade] and adalimumab [Humira], the TMJ is largely resistant,” he said. In addition to the aggressive systemic therapy, Cron and his team partner with their colleague, Peter Waite, MPH, DDS, M.D. who is chief of oral and maxillofacial surgery at the University of Alabama at Birmingham (UAB.) With the patient under anesthesia, Waite administers intra-articular long-acting corticosteroid injections, much like rheumatologists would do for other treatment refractory joints. The treatment, Cron said, is effective in only about half the cases. For those patients who do not realize significant improvement from the steroids, Waite will subsequently inject the TMJs directly with infliximab, a TNF inhibitor. These intra-articular infliximab injections appear to benefit another 25 percent of patients with refractory TMJ arthritis, but Cron said there is still room for improvement.

Efforts continue in researching effective treatments and improving diagnosis. Vaid and his team have already established international uniform protocols for performing the TMJ MRI scans. He and Saurabh Guleria, M.D., have also developed and published a scoring scheme to provide a grading system for evaluating the extent of both active and chronic TMJ arthritis. “We’ve probably pushed forward the screening and treatment of TMJ arthritis in children with JIA as much as anyone I know,” Cron said. “It’s not a home run, but we’re doing the best we can.” More information is available at www.childrensal.org/ rheumatology .

Dr. Cron and Dr. Yoginder Vaid (below) , radiology, were both invited speakers to the American College of Rheumatology National Scientific Meeting in Boston last year. Cron presented “Development of TMJ Arthritis Clinical Trials” and Vaid presented “A Scoring System for Evaluation of TMJ Arthritis in Children with JIA.”

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Inside the Mind

Expands Psychiatric

When an Alabama family needs help for a child with mental illness, they don’t have a lot of options. Resources are limited, and demand for services, far exceeds the number of pediatric psychiatrists, psychologists, psychiatric nurses and therapists available to care for these children. Lack of insurance coverage for vital non-traditional services such as family therapy and intensive outpatient group therapy sessions, further complicates the situation. In June, 2014, Children’s of Alabama took a major step toward improving pediatric mental health services with the completion of The Ireland Center. Its namesake, the late Birmingham businessman Glenn Ireland, was a longtime advocate for mental health, and The Ireland Center represents an expansion of the family’s commitment to providing much-needed psychiatric care for those with mental illness. Located on an extensively remodeled floor of the hospital, The Ireland Center consolidates inpatient and most outpatient services in a safe, secure, updated setting. The attractive décor features a soothing oceanside theme. All patient rooms are private, hallways are wide, and dayrooms are brightly lighted and comfortably furnished. Most importantly, construction of The Ireland Center enabled Children’s to expand its inpatient psychiatric child- adolescent department to 34 beds. The changes to the unit go far beyond merely cosmetic. “We are working to change the culture of the unit,” said Beverly Brown, BSN, RN, who serves as department director for inpatient psychiatry. “Our goal is a more therapeutic experience for our patients. Most of our patients have experienced some sort of trauma in their lives. They are in crisis, and they desperately need a welcoming environment that provides some immediate comfort.”

10 A bright décor provides a soothing environment for the inpatient care provided by a team of psychiatrists, clinical psychologists, primary therapists, nurses and occupational therapists.

Care for Children in Alabama

Inpatient care The unit is under the direction of

Outpatient care Children’s Behavioral Health (CBH), the outpatient component of The Ireland Center, sees patients at The Ireland Center and also in offices in Homewood, a suburb of Birmingham. “We know the likelihood of recidivism after inpatient treatment increases when children and their families do not receive the follow- up therapy they need in an outpatient setting,” said Stacy White, MBA, MSHA, program administrator for outpatient and psychiatry physician services. “We want to reach children and families to arm them with the coping skills they need to succeed. We’re striving to be a center of excellence so our patients benefit from the continuum of care, from hospitalization to outpatient treatment to advocacy and education in their homes, schools and communities.” Like the inpatient service, CBH employs a multidisciplinary team approach in caring for children and adolescents with psychiatric and behavioral health problems. Diagnoses include ADD, ADHD, anxiety, mood disorder, depressive disorder, bipolar disorder, conduct disorder, schizophrenia, Asperger’s syndrome, autism and others described in the Diagnostic and Statistical Manual of Mental Disorders. Services provided include individual therapy, medication management, support groups and behavioral therapy. CBH also provides recommendations to schools, communicating with educators to advocate on behalf of the patient. “We are here to offer hope and partnership to parents so our patients can grow to become happy, healthy and confident individuals,” said Laura Barefield, M.D., who serves as medical director for outpatient services. “Each child and family has treatment needs that must be tailored to him or her. We value innovative approaches to treatment, but understand that there are no shortcuts to

a good assessment and individualized treatment plans. Evidence shows that treatment combining therapy and medication administration is superior to medication alone. We focus on providing our patients and families with tools to navigate life’s storms and to maximize their opportunities for success.” Unfortunately, the demand for outpatient services also exceeds supply. “Our outpatient wait time for a new appointment can be anywhere from four to six months,” White said. To fill the void, The Ireland Center offers a new evidence-based program called Parent- Child Interaction Therapy. “It’s a 20-week program through which parents are coached in appropriate parenting skills and behaviors management,” White explained. “The parent interacts with the child while a psychologist behind an observation window transmits suggestions for behavior management through an earpiece.” According to White, very few of the patients seen under the umbrella of The Ireland Center have true psychiatric diagnoses. For most, the problems are behavioral in nature. “To make an impact, we must provide services that support the entire family. Our goals are pretty straightforward,” she said. “We will continue to recruit psychiatrists and psychologists, and to work for grant funding to provide mental health services. Our goal is to decrease recidivism by working to help not just our patients — but our families.” More information is available at www.childrensal.org/the-ireland-center- inpatient-and-outpatient-psychotherapy .

attending psychiatrists who are also the leaders of a multidisciplinary team that includes primary therapists, licensed clinical social workers, registered nurses, behavioral interventionists, psychiatric clinical assistants and occupational therapists. Clinical psychologists are available for consultation and testing. Each child has an individualized plan of care that, according to Brown, guides her staff each day. Census on the inpatient psychiatric unit stays at about 97 to 99 percent, and most of the patients are covered by Medicaid. The average length of stay is 10.8 days, but Brown said they have had patients who needed their care for as long as 18 months. A variety of support services supplements the treatment provided within The Ireland Center. The hospital’s Sunshine School, which employs certified teachers, offers educational support and assistance with school assignments. The child life team provides age-appropriate group and individual programs and activities. Occupational therapists teach life skills and provide learning through play, while pastoral care lends spiritual support as needed. To ease the transition from inpatient to outpatient status, the inpatient staff has created the Family Education Empowerment Team, or FEET. “This group is open to parents and guardians to help prepare for their child’s return home after hospitalization,” Brown said. “They meet weekly to share issues and to hear about the techniques our experts use to help children maintain control and manage their behaviors in a positive way. We tell them, ‘This is the group you and your family need to assist in keeping your child out of the hospital and to keep you in control.’”

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On Service Heads New Institute for Cance

Dr. Smita Bhatia brings her knowledge and expertise to Children’s to provide increased and ongoing attention to the medical and social needs of pediatric cancer survivors.

When Mitchell Cohen, M.D., began his tenure as chair of the University of Alabama at Birmingham Department of Pediatrics and physician-in-chief at Children’s of Alabama last September, both institutions were expecting great things of him with regard to recruiting, expanding the department’s academic mission and supporting the development of new research and service programs. He did not disappoint. Before the month was out came word of a recruitment coup: distinguished pediatric oncologist Smita Bhatia, M.D., MPH, announced that she would be leaving City of Hope in Duarte, California, to lead a new Institute for Cancer Outcomes and Survivorship at UAB and Children’s, beginning in January of 2015. pediatrics, vice chair for outcomes in the department of pediatrics and associate director for cancer outcomes research at the UAB Comprehensive Cancer Center. She would be a member of the Children’s medical staff and would co-direct the Center for Outcomes and Effectiveness Research and Education. “Both my husband [Ravi Bhatia, M.D., also a cancer researcher of international renown] and I were offered incredible opportunities to lead programs at UAB, and I was given an exciting opportunity to set up a new institute,” she said. “We found the leadership here to be dynamic, intellectually stimulating and nurturing of individuals who want to invest in an academic career. The idea of growing In addition, she would serve as a professor in the UAB department of and developing strong academic programs is energizing to us.” Bhatia’s research focuses on understanding the burden of illnesses faced by cancer survivors of all ages, from neonatal to geriatric, identifying cancer survivors at the highest risk of treatment-related complications

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r Outcomes and Survivorship

and developing behavioral and pharmacological interventions to reduce the burden of morbidity. The expertise she brings to The Alabama Center for Childhood Cancer and Blood Disorders at Children’s, already a nationally renowned center of excellence, is a source of pride for Cohen and also for Raymond G. Watts, M.D., director of the division of pediatric hematology-oncology. “Our goal is to cure all childhood cancer and to have our cured patients lead a normal life,” Watts said. “The Institute for Cancer Outcomes and Survivorship is poised to help us do just that — and to will be among the first to benefit from the new multidisciplinary institute. “We will be seeing patients here in clinic in Birmingham, so this is where it has to begin — with Birmingham first and the state of Alabama,” Bhatia said. “Our goal is a state-of-the-art survivorship program to ensure our children are not suffering as a consequence of the treatment they receive for cancer.” She said the mission of the institute is two- fold. “First, it is our responsibility to reduce the burden of morbidity associated with cancer across all cancer diagnoses and all ages,” she said. Also of concern to Bhatia is the disparity in outcomes for the Hispanic and African American populations. “No matter how far we have progressed in our fight against cancer, there are vulnerable populations that continue to need special attention,” she explained. “We have found that adherence to oral chemotherapy plays a critical role also increase the impact of our work both locally and nationally.” Children’s cancer survivors

in preventing relapse in children with acute lymphoblastic leukemia. We also found that certain populations were less adherent than others, and this could account for the observed differences in survival. We are now conducting a national trial to enhance treatment adherence by sending parents and the child a text message each night to remind them to take the oral chemotherapy. If this strategy is successful, we hope to include it as a standard of care for all children with leukemia,” Bhatia said. Bhatia serves as associate chair for the Children’s Oncology Group,

of Hodgkin’s lymphoma. This finding resulted in a reduction in radiation doses used for managing Hodgkin’s lymphoma in girls during their teenage years and trials to develop risk-reduction strategies for girls treated with chest radiation. Also during her tenure there, Bhatia made significant scientific contributions toward identifying chronic health issues among cancer survivors, including patients undergoing hematopoietic cell transplantation. And - she established multidisciplinary survivorship clinics, providing cancer survivors with state-of-the- art comprehensive follow-up care.

“I told a colleague recently that I am so delighted with our decision to move

“Our goal is a state-of-the-art survivorship program to ensure our children are not suffering as a consequence of the treatment they receive for cancer.” — Smita Bhatia, M.D.

here,” she said. “Being a part of UAB and Children’s of Alabama is such a beautiful opportunity to bring what I have learned and then have it multiply exponentially because of all the collaboration and support we have been offered here.”

coordinating survivorship research across 200 pediatric oncology institutions. In 2006, she was elected to membership in the American Society for Clinical Investigation in recognition of meritorious and outstanding contribution as a physician. She is a recipient of the Frank H. Oski Lectureship Award from the American Society of Pediatric Hematology-Oncology,

More information is available at www.childrensal.org/cancer .

Department chair and Physician-in-Chief Dr. Mitch Cohen, (left), recruited Bhatia to work closely with Dr. Raymond G. Watts, director of The Alabama Center for Childhood Cancer and Blood Disorders at Children’s (center) .

which honors outstanding investigation in pediatric hematology-oncology. In 2012, she was also elected to the board of directors of the American Society of Clinical Oncology. While at the University of Minnesota, she discovered an increased risk of radiation-related breast cancer among adolescent girls exposed to chest radiation for the treatment

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Inside the Technology

Practice Makes Perfect

mimic symptoms of illness or injury, such as rapid heart rate or shallow breathing. From her keyboard, Tofil can distend the high-tech mannequin’s stomach or make its mouth turn blue from lack of oxygen. She can also dictate the patient’s response to treatment, which often includes “real” injections, IV fluids, intubation and electric defibrillation. “Scenarios can be designed to train learners on a wide variety of illnesses and injuries,” director of education and research Dawn Taylor Peterson, Ph.D, explained. “The simulation experience gives them the opportunity to practice clinical and teamwork skills in a realistic setting without putting a patient at risk.” Mock codes provide real-time clinical experience Once a month, Marjorie Lee White, M.D., director of the UAB Office of Interprofessional Simulation and Education who also serves as adjunct faculty in the PSC, activates a mock trauma code to provide real-time clinical experience in emergency situations. Participants, who often don’t know that the trauma is a simulation until they arrive on the scene, are encouraged to immerse themselves in the scenario, performing all procedures and maneuvers as if the mannequin were a living patient. Tofil also runs a weekly mock code just for residents on service in the pediatric intensive care unit. Those simulations are more in-depth, last longer and include a briefing after the event that allows participants to discuss what they learned and hear feedback from Tofil. “We’re not trying to re-create curriculum,” she said. “But we are trying to bring the curriculum to life.” A key part of simulation training is the presence of “family” members. They allow participants to practice interacting with distraught parents during a high- stress situation as well as how best to approach death and dying discussions. The curriculum As the center begins its seventh year, Tofil and her colleagues have expanded the educational offerings to provide

more in-depth experiences and to address more complex scenarios that extend beyond the specific clinical skills employed at the bedside. One of the new courses addresses communication between nurses and physicians, and the mental pitfalls that often exist that can hamper patient care. The three-part course includes a computer-based training module that includes real-life stories, a simulation in the PSC and finally, a “worst case scenario” simulation on the patient unit. This is Children’s first course required for every nurse in the organization that utilizes the PSC. “Because everyone is doing it, it will affect the culture,” Tofil said. “It has the reach to affect the whole institution.” Another method used in the PSC teaches participants to use a very specific set of

Practice makes perfect in any setting, but in the hospital setting, it can also mean the difference between life and death. At Children’s of Alabama, that valuable practice is provided by the Pediatric Simulation Center (PSC), where students, residents and staff members from a wide variety of disciplines learn how to care for critically ill youngsters via high-tech equipment and simulated scenarios. Children’s PSC is the only pediatric simulation center in the state of Alabama. It was established in 2007 to provide physicians, nurses, respiratory therapists, pharmacists, students and other health care professionals with opportunities to perform common medical procedures and respond to rare, complex conditions and life-threatening emergencies in a safe, realistic environment. Critical care intensivist Nancy M. Tofil, M.D., M.Ed, serves as medical director. Staff includes physicians, nurses, educators and 20 to 30 adjunct faculty. Last year, more than 7,000 learners received training through the PSC during 690 sessions and 1,045 hours of simulation. More than half were licensed and credentialed staff, including physicians, nurses, respiratory therapists, pharmacists, radiology technicians and even chaplains. More than 40,000 learners have received training since an identity and a medical history, and can talk and breathe. Each has a pulse and a variety of anatomical features that allows learners to practice venous access, CPR, airway management, intravenous drug delivery, defibrillation, cardioversion and external pacing. The simulators have realistic heart, lung and bowel sounds and can provide ECG, arterial, invasive and noninvasive blood pressure, intracranial, central venous pressure and oximetry. Each mannequin is directly connected — four of them wirelessly — to a laptop computer where Tofil and other educators can digitally manipulate many of its bodily functions to the PSC opened. The patients Ten high-fidelity simulators comprise the patient population of Children’s PSC. Each represents a child of a different age, from premature infant to teenager. Each has

PSC medical director Dr. Nancy Tofil and a staff of full-time certified educators and adjunct faculty provide hands-on training to 7,000-plus learners every year.

14

in the World of Simulation

Simulation/Learning Resource Centers Conference in Orlando. Thirteen of the team’s poster submissions were accepted at conferences that included the 14th Annual Meeting on Simulation in Healthcare in San Francisco and the Association of Pediatric Program Directors 2014 Annual Spring Meeting in Chicago. Three members of the PSC team were on an abstract presented at the International Meeting on Simulation in Healthcare in New Orleans that was chosen “Best Research Abstract” from nearly 200 entries. More information is available at www. childrensal.org/pediatricsimulationcenter .

protocols for managing the critical patient and encourages them to work through the steps automatically rather than considering each next step of care. “It reinforces the idea that when there’s one way to do it, such as neonatal resuscitation, and we know the best way, we need to almost automate the decisions and thought processes, and not think about it,” Tofil said. A newly designed course for physical therapists and occupational therapists helps ease the discomfort those professionals may feel when working with certain patients. “The PT/OT course allows staff to learn how to work with medically complex patients who may have an abundance of tubes, lines and other

equipment. It’s an effective and safe way for them to practice before going into a

critical situation,” Peterson said. International influence

The innovation and thoroughness of the training provided in Children’s PSC has gained widespread attention both at home and abroad. In 2014 alone, six articles submitted by members of the PSC team were published in the Journal of Graduate Medical Education, Journal of Hospital Medicine, Pediatric Anesthesia and Prehospital Emergency Care. They also presented at the 6th International Pediatric Simulation Symposia and Workshops in Vienna and the 2014 International Nursing

15

1600 7th Avenue South Birmingham, Alabama 35233

48th Annual Southeast Pediatric Cardiology Society Conference

PEDIATRIC CARDIOVASCULAR SERVICES

The famed Robert Trent Jones Golf Course at the Renaissance Ross Bridge is one of the longest courses in the world.

September 25-26, 2015

Renaissance Ross Bridge Golf Resort & Spa n

Birmingham, Alabama

TOPICS

n Quality Improvement and Improved Outcomes n Update on Genetics of Arrhythmias ---Practical Considerations n Treatment of Congestive Heart Failure, VADS and Heart Transplant Patients n Update on Aortopathies and Interventional Catheterization

Register TODAY at www.ChildrensAL.org/SPCS2015

Questions? Call Conference Organizers at 205.934.3460

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Yung R. Lau, MD n

F. Bennett Pearce, MD n

Paula Midyette, RN, CCNS n

Ashley Moellinger, RN, CRNP