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M E D I C A L U P D A T E F O R referrin g pro v ider s Summer 2010
Physical Therapy Aids Young Athletes
Connecticut Children’s Physical
Therapy Department has a
long-standing reputation for
excellence in treating children with
chronic disorders and disabilities. That
same commitment to excellence also
extends to the PT team’s services for
children with sports-related injuries.
“In our rapidly expanding department,
we currently have four therapists who
specialize in sports medicine and who
are an integral part of Connecticut
Children’s Elite Sports Medicine
Program,” says Scott Van Epps, PT,
MS, PCS, ATP, the Medical Center’s
manager of physical therapy. “We
have expertise in working with young
athletes, whether they’ve had bruises,
bumps and strains or serious injuries
requiring orthopaedic surgery. We help
all of them get back on the field as
soon as possible.”
The therapists who
focus on sports
medicine are all
certified strength
and conditioning
specialists uniquely
qualified in upperand lower-extremity
injuries. In addition to
providing rehabilitative
therapies, they provide
patients with exercise
programs to help
prevent future
injuries and are
skilled in testing
to make sure the
athlete is ready to
get back into play.
Connecticut Children’s Physical Therapy Department has expertise in working with
young athletes.
Services are provided both in Farmington,
where the department is co-located with
Elite Sports Medicine, and at Connecticut
Shunt Implant Infection Rate
Approaches Rock Bottom
In just a little over three years, a
concerted effort by Connecticut
Children’s neurosurgeons and
operating room staff has driven
the rate of infection from shunt
implants down to a remarkable 0.8
percent — one-tenth the national
average. The rate is based on
procedures performed by the Medical
Center’s two pediatric neurosurgeons,
Drs. Paul Kanev and Jonathan Martin,
over 38 months. The two insert
approximately 125 shunts or
shunt revisions annually.
Shunt insertion/revision typically makes
up 25 to 40 percent of the procedures
performed by a pediatric neurosurgery
practice. While the surgery itself is
straightforward, it is associated with the
highest infection and complication rate
in neurosurgery. Preventing infection
after shunt implantation is critical for
many reasons, explains Dr. Kanev.
“If infection develops, a child will have
to be hospitalized for at least a week
and will need two additional surgeries:
one to remove the infected shunt and
one to implant a new one,” Dr. Kanev
says. “Once infection occurs, the risk
Continued on page 3
Children’s Specialty Care Center
in Glastonbury.
To refer a patient, call 860.284.0246 or
fax prescriptions to 860.284.0341.
Now Online Directory
Of
Programs And Services
In the interest of ensuring up-to-date
information — and being kind to the
environment — we’re now publishing
our Directory of Programs and Services
exclusively online. You’ll find the
2010-2011 edition by clicking on the
link on our homepage,
www.connecticutchildrens.org.
CASE REVIEW
Going Weak In The Knee
Kristin Welch, MD, Pediatric Emergency Medicine attending, prepared this issue’s case, which was referred by
Lisa Smith, MD, of St. Francis Pediatric Clinic in Hartford.
Presentation
A previously healthy 7-year-old
boy was referred to the Emergency
Department by his pediatrician for
evaluation of left-sided weakness.
His mother reported that she had
first noticed a slight limp about two
weeks prior. He did not appear to be
in pain, and his activities were not
limited. After several days, the limp
did not improve, and he was seen
in his pediatrician’s office. He was
thought to most likely have a mild
muscle strain, and was instructed to
follow up if the limp didn’t improve.
Over the next week, the limp
worsened, and the patient started
falling down frequently. In addition,
he started having decreased use of
his left arm. He was seen again in the
pediatrician’s office, where he was
found to have weakness of the left
arm and leg, prompting the referral
to the Emergency Department. He
had not had any headaches, nausea,
vomiting, speech changes or obvious
vision changes. He did not have
any fevers.
Diagnosis and Management
In the Emergency Department, the
patient was alert and comfortable,
with no fever and normal vital signs.
On examination, his pupils were
equal and reactive, fundoscopic
exam was normal and he had no
facial asymmetry. His heart, lung
and abdominal exams were normal.
His extremities had no deformity
or swelling, but he did have several
bruises on his left arm and leg,
consistent with frequent falls to the
left as described by his mother. His
muscles had normal bulk, with no
tenderness to palpation. He had
decreased strength on the left, 4/5
of both upper and lower extremity,
and increased biceps, patellar, and
Achilles deep tendon reflexes of the
left compared to the right, but no
2
Babinski reflex. When ambulating,
he had no ataxia, but did have
mild left foot drop. The findings of
unilateral upper- and lower-extremity
weakness with increased reflexes
were suggestive of a lesion of the
upper motor neuron. We arranged
for an MRI of the brain and spinal
cord. After the MRI, for which he
received mild sedation, the patient
was noted to have a slight left facial
droop, suggestive of intracranial,
rather than spinal cord, pathology.
MRI revealed a well-demarcated
lesion in the right internal capsule,
which enhanced mildly with contrast.
Neurosurgery was consulted, and
the patient was admitted to the
hospital. Treatment with intravenous
dexamethasone was initiated, and
the following day the patient had
significant improvement in his
left-sided weakness. Biopsy of the
lesion was done and final pathology
was consistent with a thalamic
germinoma. He was discharged
home in good condition with plans
to follow up with Oncology for
outpatient chemotherapy.
Discussion
The evaluation of weakness depends
on the timing of onset, location,
and associated symptoms and
physical exam findings. Weakness
may arise from any portion of the
motor unit, including the upper
motor neuron, lower motor neuron,
peripheral nerve, neuromuscular
junction or the muscles themselves.
Upper motor neuron weakness
arises from lesions in the cerebral
cortex and corticospinal tracts.
Acutely, patients may present
with weakness and hypotonia, but
ultimately they develop spasticity
and hyperreflexia. Lesions in the
cerebral cortex include hemorrhage
(traumatic or due to congenital
malformation/aneurysm), infection
(abscess), stroke (a rare cause in
children, but may be associated with
thrombosis in hypercoagulable states
such as factor V Leiden, protein
C or S deficiency, and sickle cell
disease; embolism in children with
congenital or acquired heart disease;
vasculitis or vasculopathy), seizure
(Todd’s Paralysis), and brain tumor
(malignant or benign). Lesions in
the spinal cord include those due
to trauma (including spinal cord
concussion and epidural hematoma),
paraspinal infection (epidural abscess,
discitis) and transverse myelitis.
History and physical exam can
usually suggest the location of the
lesion. In this case, asymmetric
or unilateral weakness was most
suggestive of intracranial tumor,
hemorrhage, stroke and spinal cord
lesions. The subacute presentation;
absence of any medical history such
as sickle cell disease; and lack of
symptoms such as fever, headache,
nausea/vomiting, or altered mental
status made a tumor the most likely
diagnosis. Because the patient was
stable, we were able to wait for
an opening in MRI, as this is the
best imaging modality. However,
if the patient were having rapidly
progressive symptoms, or if MRI
was not available, cranial CT would
be indicated, with follow-up MRI
scheduled if needed.
MRI and biopsy confirmed the
presence of a malignant brain tumor,
in this case a germinoma. This is a
fairly rare cause of brain tumors in
children, accounting for only 3 percent
of all pediatric brain tumors in the
United States. Intracranial germinomas
are highly sensitive to radiation and
chemotherapy, and generally have
good prognosis, with overall survival
exceeding 90 percent.
Shunt Implant Infection Rate Approaches Rock Bottom, continued from page 1
increases that future shunts will
become infected or malfunction.
Depending on the child’s condition,
shunt infection can increase risk of
seizures and compromise learning and
intellectual function. Plus, nationally,
each infection adds a cost of $60,000.”
A Team Effort
Disciplined use of best-practice
procedures has been the main factor
in reducing infections, according to
Dr. Kanev. In addition to using
antibiotic-impregnated catheters,
the surgeons, OR nurses and
technicians have all embraced very
uniform procedures. They administer
intravenous antibiotics perioperatively
and for 24 hours postoperatively. They
touch the shunt only with special,
rubber-tipped instruments—never with
their hands. Prepping of the skin is
meticulous, with the final Betadine
Solution allowed to dry completely
before the procedure. Physicians and
staff double-glove, and every effort is
made to minimize traffic through the
operating room.
“The more disciplined the adoption of
each procedure, the better the infection
rate,” says Dr. Kanev. “Although good
luck helps, too.”
A First In Pediatric Cardiac MRI
Late last year,
Connecticut Children’s
pediatric cardiologist
Olga Toro-Salazar,
MD, performed the
region’s first cardiac
MRI on a newborn.
Dr. Toro-Salazar and
a team comprising professionals from
both Connecticut Children’s and Hartford
Hospital performed the test on a baby
who was only 2 days old.
“The baby had a suspected congenital
anomaly of the aortic arch, which also
involved the thoracic aorta,” says
Dr. Toro-Salazar. “The prenatal people
weren’t sure what it was. We used MRI to
better define the anatomy of the patient’s
aorta. We found there was an aneurysm
of the PDA. It was changing quickly and
getting smaller – a very lucky finding.”
MRI has several advantages over
echocardiogram in cases such as this,
according to Dr. Toro-Salazar, including the
fact that it provides a three-dimensional
view of the entire arch at once, to help
clinicians better assess the condition.
An added advantage is the lack of
radiation exposure.
“Cardiac MRI is an imaging modality being
used more frequently in the evaluation
of patients with congenital and acquired
heart disease,” Dr. Toro-Salazar notes.
Connecticut Children’s pediatric cardiac
MRI program, which began in 2005,
has benefited children and families by
eliminating the need for them to travel
out of state.
Family-Centered Care
Families Take Part In Patient Rounding
Connecticut Children’s is committed to
ensuring the best possible experience
for patients and families. To do this, the
hospital has adopted an approach that
puts families at the center of care. One
of the ways this family-centered model is
manifested is in family-centered patient
rounds, which have been instituted on
several units, including med/surg, NICU,
PICU and Connecticut Children’s pediatric
unit at Saint Mary’s Hospital in Waterbury.
The American Academy of Pediatrics
issued a policy statement in 2003
advocating family-centered care. Since
that time, research has shown that parents
much prefer to be at their child’s bedside
during rounding and that bedside rounding
is a good teaching tool for residents.
A Structured Approach
The Medical Center has a structured
approach to family-centered rounds. When
a child is admitted, a nurse explains to the
family that they can choose to participate
in rounds. The family can choose which
family members can be present, indicate
whether the child should be involved and
list any topics they do not wish to have
discussed in front of their child. Families
Continued on page 5
When to Refer
Shoulder Pain
Carl Nissen, MD, director of
Connecticut Children’s Elite Sports
Medicine program, provided the
information for this issue’s column.
Shoulder pain in adolescents and young
adults usually results from instability
or overuse. Patients may have shoulder
pain they can’t quite localize or pain
after activities. These symptoms indicate
inflammation, and the first step in
treating pain of this kind is rest. If the
patient rests the shoulder, but the pain
persists, the PCP should refer the patient.
If a patient complains of sharp pain
while doing activities, this usually
indicates a mechanical problem in
the shoulder. In 72 percent of cases,
a dislocated shoulder results in a
torn labrum, which can be the cause
of mechanical problems following
a dislocation. Research shows that
arthroscopic surgical repair of the tear
performed within three to four weeks
of the injury yields better long-term
outcomes. These patients should be
referred for further evaluation and
treatment discussion.
Pain during activity and a sense of
something “shifting” during exam also
indicate a mechanical problem in the
shoulder and these symptoms warrant
referral.
Shoulder pain may also result from
proximal humeral epiphysiolysis, a
widening of the growth plate sometimes
called “Little Leaguer’s shoulder.” This
condition is not easily diagnosed, and
the patient should be referred.
Patients with acromioclavicular
separations that are painful, causing
significantly decreased range of motion
or that are discolored immediately
following the injury should be referred,
as these symptoms may indicate serious
injury to the ligaments or fracture.
A subset of patients with clavicle
fractures do better over the long term
if the fracture is repaired. If a patient
has pain out through the shoulder or
in toward the middle of the body, he
or she should be referred.
3
Sedation Service On Call
It was just three years ago that
David Marcello, MD, proposed
that Connecticut Children’s create a
formal sedation service. Today, the
service is not only a reality, but is
growing, and it stands ready to step
in whenever needed. Sedation can be
an important option when children
are facing a test or procedure that is
uncomfortable or anxiety-provoking
or that requires they remain as
motionless as possible.
Thanks to the Medical Center’s
commitment to the sedation service,
sedation is now Dr. Marcello’s
full-time role, and he is joined by
Christine Cosenza, PA-C, who
provides minimal and moderate
sedation coverage in Radiology five
days a week.
“Before Christine was hired, I spent
the majority of my time in Radiology,
as it was and remains the busiest part
of the service,” says Dr. Marcello.
“Christine’s constant presence has
freed me to expand the sedation
service beyond Radiology.”
Four nurses were selected as a core
group to become more specialized
in sedation care, and they have
been great assets to the Radiology
Department, according to
Dr. Marcello. He adds that
Connecticut Children’s has been
very supportive of that model.
“In my opinion, the patient care is
safer and more efficient when the
staff do this day in and day out,”
says Dr. Marcello. “Practice definitely
makes perfect, and patients and
families benefit from staff confidence
and comfort. It is almost contagious.”
Child Life specialists are an
integral factor in patient cooperation.
Dr. Marcello says it is amazing how
distractions such as music, blowing
bubbles and playing electronic games
can get the patient to cooperate and
possibly even enjoy the experience.
Child Life staff, collaborating with
the sedation team, can decrease
the need for sedative/analgesic
medications.
4
Connecticut Children’s Radiology sedation team includes (l-r) Maribel Martinez, RN; Lisa Lane, RN; Kristi
Lovelace, RN, BSN (lead nurse); David Marcello MD; Darlene Burgwardt, RN; and Christine Cosenza PA-C.
Demand for sedation is growing.
The service did more than 700
cases in 2009, compared with only
300 in 2006. To make it easier for
people within the hospital to request
and schedule a sedation consult,
Connecticut Children’s has established
a special sedation e-mail account
([email protected])
that is monitored constantly.
Branching out
With Radiology largely covered by
Ms. Cosenza, Dr. Marcello is now
doing more sedation procedures in
other areas. Pediatric providers can
consult him if they have a patient
who previously failed to be sedated
with typical agents. In that case, deep
sedation may be the answer.
insertion or central line placement
with the newly established bedside
PICC service.
Looking Toward the Future
Dr. Marcello hopes to expand the
service to Hartford Hospital, with
members of Connecticut Children’s
team providing sedation during a
child’s Interventional Radiology or
Nuclear Medicine procedures. He
would like to work with Connecticut
Children’s pediatric unit at Saint
Mary’s Hospital to establish a
sedation service there. He is also
exploring the idea of creating a course
for nurses who want to be certified in
sedation.
The Urology Department has called
on him for help with outpatient
urodynamic testing, and consultation
with the sedation service is available
to other outpatient centers.
“I don’t think there is a readily
available, nursing-associationcredentialed sedation course available
in the United States,” Dr. Marcello
says. “We want to be a reliable source
of sedation education for nurses
here at Connecticut Children’s and
elsewhere. We also would like to
be seen as an educational
resource for the Connecticut
Children’s community.”
The sedation service has expanded its
inpatient coverage, providing sedation
for children who must undergo
painful wound care, chest tube
For more information about the
sedation service, contact
Dr. Marcello at 860.545.8584 or
[email protected].
“A dozen or so cancer patients get my
services on a regular basis,” he says.
“They may need a spinal tap or bone
marrow aspirate.”
Families Take Part In Patient Rounding, continued from page 3
can change their preferences at any time.
Family-centered rounds began to be
introduced at Connecticut Children’s in
May 2008. To date, roughly 90 percent of
families have chosen to participate.
Christine Skurkis, MD, of the Inpatient
Management Team was one of the
people at Connecticut Children’s who
was instrumental in implementing
family-centered rounds.
“When we started this in 2008, we were
at the beginning of a major movement,”
Dr. Skurkis says. “At the time, only a
handful of institutions were doing it. Now
there are a lot more, but not too many
do it in as structured a way as we do.
They often do bedside rounds, but not
family-centered rounds.”
The distinction is an important one. Just
having family present is not sufficient;
the health care team must be sure to
engage the family members by asking for
their comments and inviting them to ask
questions. Connecticut Children’s also
focuses on educating all involved about
the process. It is thoroughly explained
to parents beforehand, and all members
of the health care team are required
to participate in education about
family-centered rounds.
Positive Response
Dr. Skurkis expects to do more formal
studies of how all involved respond to
family-centered patient rounds, but she
says the anecdotal evidence, reported
largely by the nursing staff, is promising.
“The reaction from patients and families
has been very positive,” she says. “Just
letting them know it’s their right to
participate has improved their
satisfaction with the hospital.”
Residents and supervising physicians
were a little wary at first, but Dr. Skurkis
says that follow-up surveys have
revealed “a move to people feeling
more comfortable.”
Fellowship Programs Flourishing
An increasing number of the
pediatric subspecialists of tomorrow
are obtaining their education and
experience at Connecticut Children’s,
thanks to the Medical Center’s growing
fellowship programs.
“Fellowships play a vital role in a
medical institution,” says Paul Dworkin,
MD, physician-in-chief of Connecticut
Children’s. “They strengthen academic
status, increase research activities and
productivity and enrich the educational
experience of students, residents and
other trainees.”
“In addition to expanding the staff in
the pediatric subspecialty areas and
improving the efficiency of services,
strong fellowship programs give the
hospital an advantage when it comes
to recruiting faculty,” says Surgeon-inChief Fernando Ferrer, MD.
Connecticut Children’s already has
several ACGME-approved fellowship
programs, and additional ones are now
going through the approval process.
Existing approved fellowships and their
Continuing Medical
Education Programs
Connecticut Children’s now offers
programs in several communities:
Norwich............. Exact location to be
announced
Shelton............... Connecticut Children’s
Specialty Care Center
4 Corporate Dr.
West Hartford.... The Pond House Café
1555 Asylum Ave.
Waterbury...........Saint Mary’s Hospital
56 Franklin St.
Pediatric Evening Lecture Series
Sept. 28, 2010 – West Hartford
Dermatology Update – Speaker: James Dinulos, MD,
section chief, Dermatology (Interim) and program director,
Pediatric Dermatology, Dartmouth-Hitchcock Medical Center
Oct. 21, 2010 – Norwich
ENT Topic TBA – Speaker: Scott Schoem, MD, director,
Division of Otolaryngology, Connecticut Children’s Medical
Center; professor of otolaryngology, University of Connecticut
School of Medicine
April 6, 2011 – Shelton
Cardiology Topic TBA – Speaker: Harris Leopold, MD,
director, Division of Cardiology, Connecticut Children’s Medical
Center; associate clinical professor of pediatrics, University of
Connecticut School of Medicine
April 7, 2011 – West Hartford
Pain Management Topic TBA – Speaker: Neil
Schechter, MD, director, Division of Pain Medicine, Connecticut
Children’s Medical Center; professor of pediatrics, University of
Connecticut School of Medicine
program directors are: Medical Genetics
(Robert Greenstein, MD, and Robin
Schwartz, MS), Pediatric Emergency
Medicine (John Brancato, MD), Pediatric
Endocrinology (Elizabeth Estrada, MD),
Pediatric Pulmonary Medicine (Anita
Bhandari, MD), Neonatal-Perinatal
Medicine (Aniruddha Vidwans, MD) and
Pediatric Gastroenterology (Francisco
Sylvester, MD).
May 4, 2011 – Waterbury
Rheumatology: When to Refer – Speaker: Lawrence
Proposed fellowship programs currently
under review by ACGME are: Pediatric
Surgery (Christine Finck, MD) and
Pediatric Urology (Christina Kim, MD).
education and training, New York University Child Study Center;
director of Undergraduate Studies, Child and Adolescent Mental
Health Studies, New York University College of Arts and Science
Connecticut Children’s robust and
growing fellowship programs are
supported by Fellowship Coordinators
Veronica Tomlinson, Carol Roy and, at
the University of Connecticut Health
Center, Jacki Charrette.
For more information about
fellowships, contact Connecticut
Children’s Director of Academic Affairs
Susan Duckworth at 860.610.4263 or
[email protected].
Zemel, MD, director, Division of Rheumatology, Connecticut
Children’s Medical Center; professor of pediatrics, University of
Connecticut School of Medicine
Andrulonis Child Mental
Health Evening Lecture Series
Oct. 5, 2010 – West Hartford
“To Sleep, Perchance to Dream”: The Diagnosis
and Treatment of Children and Adolescents with
Sleep Disorders – Speaker: Jess Shatkin, MD, director of
Nov. 17, 2010 – Waterbury
Psychopharmacology Update – Speakers: Lisa
Namerow, MD, Division of Psychiatry, Connecticut Children’s
Medical Center; attending physician, Child and Adolescent
Psychiatry, Institute of Living/Hartford Hospital; assistant professor
of psychiatry, University of Connecticut School of Medicine
Jan. 25, 2011 – West Hartford
Bereavement – Speaker: Priscilla Pandozzi-Valentin, LCSW,
social worker, Division of Family Support, Connecticut Children’s
Medical Center, Department of Family Support staff
March 15, 2011 – West Hartford
Behavioral Management of Oppositional/Defiant
Children and Adolescents – Speakers: Alan Kazden,
PhD, director of Parenting & Child Study Center, Yale University;
John M. Musser professor of psychology, Yale University
For additional information, contact
Diane Mouradjian (860.610.4264 or
[email protected])
or Deirdre Palmer (860.610.4281 or
[email protected]).
5
Physician Motivated To Prevent Injuries
As an emergency medicine specialist
at Connecticut Children’s, Steven
Rogers, MD, sees injured children and
teens nearly every day. That’s why
he’s also working with Connecticut
Children’s Injury Prevention Center
on several research projects aimed at
preventing injuries in the first place.
“It’s great to treat injuries after they
occur, but if you can prevent them
from happening, that’s even better,”
Dr. Rogers says. “My goal is to put
myself out of business as far as the
injury side of emergency medicine is
concerned.”
Car Seat Safety for Newborns
One of the research studies Dr. Rogers
is involved in focuses on the very
first car ride newborn infants take.
Although the American Academy of
Pediatrics has long recommended
that all newborns go home from the
hospital in car safety seats, there is
nothing in place to educate parents
on proper use of the seats. Dr. Rogers
and his colleagues conducted a
study of 101 mother/newborn dyads
discharged from Hartford Hospital.
A Milestone
Procedure
Connecticut
Children’s pediatric
surgeon Donald
Hight, MD, recently
performed the
hospital’s 200th
minimally invasive
procedure to correct
pectus excavatum. Dr. Hight began using
the minimally invasive Nuss technique
in 1998, shortly after it was introduced.
The procedure involves implanting a
stainless steel bar in the chest to elevate
the sternum. The bar is left in place
for approximately three years, during
which time the bone grows into a new
position. Connecticut Children’s is the
only hospital in Connecticut that offers
the Nuss procedure.
6
They found that about 50 percent of
newborns were not properly secured
and that in roughly 30 percent of
cases parents did not even attach the
car seat to the vehicle. The pilot study
was terminated early out of concern
for infants’ safety, and the team is
now exploring better ways to educate
parents in the use of safety seats.
Reducing Suicide Risk
Dr. Rogers is the principal
investigator of a study aimed at
preventing adolescent suicide through
“means restriction.” In this pilot
study, parents of children brought to
Connecticut Children’s Emergency
Department following a suicide
attempt will be counseled about how
to restrict the means of suicide in the
home by locking up potentially lethal
medications, firearms and alcohol. Dr.
Rogers is also developing a related
study to improve compliance with
the follow-up care of these high-risk
suicidal patients.
“We want to see if we can improve
our ability to counsel families on the
concept of means restriction, decrease
return visits to the ED for suicidal
behaviors and, overall, decrease one
of the highest causes of adolescent
mortality,” says Dr. Rogers.
Safer Teen Drivers
A third study, funded by the
National Highway Traffic Safety
Administration, will explore whether
participating in a computer-based
driving simulator program will reduce
motor vehicle violations and car
accidents among novice teen drivers.
The randomized clinical trial will
involve approximately 3,600 16- and
17-year-old drivers over two years.
Director of Pediatric Trauma Brendan
Campbell, MD, MPH, a longtime
advocate of measures to increase
teen driving safety, is the principal
investigator. Dr. Rogers and Injury
Prevention Center Senior Program
Manager Kevin Borrup, JD, MPA, are
co-principal investigators.
For information about how
to get involved in the Injury
Prevention Center’s efforts, contact
Garry Lapidus at glapidu@
connecticutchildrens.org.
Orthopaedics Expands In Shelton
Jeffrey Thomson, MD
Mark Lee, MD
Two additional pediatric orthopaedic
surgeons, Drs. Jeffrey Thomson and Mark
Lee, have joined Dr. Elizabeth Weber in
Connecticut Children’s Shelton office. Dr.
Thomson will be in the Shelton office the
third Wednesday of every month, and Dr.
Lee will be there on the first Wednesday
of each month. They will see patients
with fractures, scoliosis, clubfoot and
other pediatric orthopaedic problems.
Dr. Thomson has special expertise in
using the VEPTR device to treat infantile
scoliosis. The Shelton office is located at
4 Corporate Drive, Shelton, Conn. To refer
your patients to Drs. Lee, Thomson or
Weber, please call 860.545.9100 to make
an appointment.
Referring Providers Consulted On IT Plans
Referring providers are among the
stakeholders involved in shaping
Connecticut Children’s five-year strategic
plan for information technology. The
initiative is being spearheaded by Chief
Information Officer Kelly Styles. Practice
Director Deborah Weber, who works closely
with the Referring Provider Advisory Board,
has been talking with RPAB members to
elicit their thoughts on how the Medical
Center’s IT systems can best meet their
needs going forward. The goal is to have a
functionally integrated electronic medical
record that incorporates documentation
across the continuum of care. Mr. Styles
will present recommendations on the plan
to Connecticut Children’s board
this summer.
Referral Guidelines Advancing
Referring Provider Advisory Board identified the initiative
as a top priority for 2010.
Specialists at Connecticut Children’s are
making good progress in developing
referral guidelines for use by referring
providers, according to Connecticut
Children’s pediatric endocrinologist Karen
Rubin, MD, physician champion of the
Referring Provider Relations Program.
The benefits of well-designed referral
guidelines have been well-established, and
sets of referral guidelines are currently
in use at a number of leading children’s
hospitals throughout the country. This year,
community primary care providers who
serve on Connecticut Children’s Referring
Provider Advisory Board (RPAB) identified
the development of comprehensive
referral guidelines as a priority for the year.
“The Referring Provider Advisory Board
prioritizes several new areas to focus on
each year, and we develop a response to
that,” says Dr. Rubin. “This year’s request
was development of at least one referral
guideline for each specialty practice, and
we are on track to meet this target.”
Laura Chandhok, MPH, project manager
for the initiative, says she expects the first
group of referral guidelines to be available
by the end of August and for all of them
to be available by the end of September.
Guidelines will be posted on the Referring
Provider section of the hospital’s Web site
when finalized.
The process for developing referral
guidelines is rigorous. Each guideline
is developed by a designated specialist
utilizing a uniform template to ensure the
inclusion of essential components. Each
specialist reviews the latest literature on
the condition and reaches consensus
on best practices with their specialist
colleagues. This initial draft is then
reviewed by a group of primary care
pediatricians and ultimately approved
by the Connecticut Children’s Specialty
Group Quality Committee.
Components of Referral Guidelines
The overall goal is for each specialty to
develop a series of referral guidelines for
the conditions that are most often referred.
In this first year of the initiative, the team
decided which conditions to start with
based on input from specialists and
RPAB members.
Each referral guideline will include the
following components:
• Typical symptoms of the condition
• Tests (labs, etc.) the primary care
provider should order
• Initial management strategies primary
care providers should use
• Criteria for making an urgent or routine
referral
• What the referring provider needs to
send to the specialist
• What the specialist’s workup is likely to
include
Benefits
In addition to improving access to the
specialist and quality of care, Dr. Rubin
says, the referral guidelines will reduce
unnecessary referrals and, if a child is
referred, make the visit more productive,
because all of the appropriate preparation
for the visit will have occurred.
The referral guidelines project is consistent
with national health care reform and policy
promoting collaborative care between
specialists and primary care providers.
Other projects aimed at promoting
collaborative care at Connecticut
Children’s include the Co-management
Pilot Study.
“This is where health care is headed,”
Dr. Rubin says. “When you work together,
avoid unnecessary care and get good
outcomes at a lower cost, you position
your organization to do well in the future.
It’s not how much care you provide but
the appropriateness and quality of it
that counts.”
Grand Rounds Online
Earn CME credit from your home or office
by accessing selected Grand Rounds
presentations online. Just go to
www.connecticutchildrens.org to register
and obtain a password.
Welcome
Aboard!
A warm welcome to the newest
members of our medical staff.
Melanie Sue Collins, MD
Pulmonary Medicine
• Fellowship in pediatric pulmonary
medicine, Connecticut Children’s
Medical Center
• Residency in pediatrics, Connecticut
Children’s Medical Center
• MD, University of Connecticut School of Medicine
• BS, physiology/neurobiology, and BA, piano,
University of Connecticut
Monila Khullar, MBBS
Pulmonary Medicine
• Fellowship in pediatric pulmonary
medicine, Maria Fareri Children’s
Hospital/Westchester Medical Center
• Residency in pediatrics, Westchester
Medical Center/New York Medical
College
• DNB (Diplomate National Board) and DCH
(Diploma in Child Health), Maulana Azad Medical
College, New Delhi
• MBBS, Lady Hardinge Medical College, New Delhi
Christopher McDermott, MD
Hospital Medicine
• Formerly chairman, Department of
Pediatrics, Day Kimball Hospital
• Fellowship in pediatric cardiology,
Children’s Hospital Medical Center,
Cincinnati
• Internship and residency in pediatrics, Albany
Medical Center Hospital
• MD, Albany Medical College
• Pre-medical, State University of New York at Albany
• BA, government, Hamilton College
Kerry Moss, MD
Hematology/Oncology
• Fellowship in pediatric hematology,
oncology and blood marrow
transplant, University of Colorado/The
Children’s Hospital
• Internship and residency in internal medicine/pediatrics,
Connecticut Children’s Medical Center
• MD, Medical College of Virginia
• BA, psychology, University of Virginia
Amy Carlucci Wu, MD
Cardiology
• Formerly attending physician,
pediatric cardiology, Louisiana State
University Health Sciences Center
• Formerly neonatology hospitalist,
Neonatology Associates, Newark, Del.
• Fellowship in pediatric cardiology, Children’s
Memorial Hospital/Northwestern University
• Residency in pediatrics, Thomas Jefferson
University/A.I. DuPont Hospital for Children
• MD, Thomas Jefferson Medical College
• Pre-medical, Bryn Mawr College
• BA, English, Colgate University
7
Medical News
M E D I C A L U P D AT E F O R C O M M U N I T Y P H YS I C I A N S
Medical News is also available online
at www.connecticutchildrens.org
Important Numbers For all admissions: 877.MDADMIT. To contact
a specialty service for your patient, call the physician liaison at: 888.KIDS.778
Inside Glance...
Case Review Going Weak In The Knee............2
Medical Editor
John Brancato, MD
Managing Editor
Dennis Crean, RN
Editorial Board
Christopher Boyle
Brendan Campbell, MD, MPH
When to Refer Shoulder Pain.................................................2
Susan Duckworth
Robert Fraleigh
Donald Hight, MD
Harris Leopold, MD
Anand Sekaran, MD
Elizabeth Weber, MD
Writer
Noreen S. Kirk
Designer
Edmond Jalinskas
Physician Liason
Diann Bailey, RN
A First In Pediatric Cardiac MRI.....................2
Physician Motivated To Prevent Injuries.....6
A Milestone Procedure.......................................................6
Orthopaedics Expands In Shelton......................6
Referring Providers Consulted On
IT Plans...............................................................................6
Family-Centered Care Families
Take Part In Patient Rounding............................2
Referral Guidelines Advancing...............................7
Sedation Service On Call.....................................4
Risk Management Is Grand
Rounds Topic..................................................................7
Fellowship Programs Flourishing...................5
Welcome Aboard!............................................................7
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Connecticut Children’s Medical Center
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Connecticut Children’s Medical Center At Your Service
Connecticut Children’s provides a variety of services at locations statewide and beyond. Here’s a summary:
Avon, 120 Simsbury Road
Audiology • Ear, Nose and Throat • Speech-Language
New London, 365 Montauk Avenue
Rheumatology
Farmington, 399 Farmington Avenue
Center for Motion Analysis • Digestive Diseases • Endocrinology •
Hematology/Oncology • Occupational Therapy • Orthopaedics •
Physical Therapy • Pulmonary Medicine • Radiology •
Speech-Language • Sports Medicine • Surgery • Urology
Norwich, 44 Stott Avenue
Genetics
Glastonbury, 310 Western Boulevard
Audiology • Cardiology • Digestive Diseases • Ear, Nose and Throat •
Endocrinology • Hematology/Oncology • Neurology •
Occupational and Physical Therapy • Orthopaedics •
Pulmonary Medicine • Radiology • Speech-Language
Madison, 1347 Boston Post Road
Cardiology
Manchester, 71 Haynes Street
Cardiology
Middletown, 520 Saybrook Road
Cardiology
New Britain, 100 Grand St.
Cardiology • Pulmonary Medicine
To make an appointment, call the specialty’s main number as
listed in the “Directory of Medical Programs and Services.”
Putnam, 320 Pomfret Street
Cardiology
Shelton, 4 Corporate Drive
Cardiology • Digestive Diseases • Endocrinology • Hematology
Nephrology • Orthopaedics • Pulmonary Medicine • Rheumatology
Surgery • Urology
Southbury, 22 Old Waterbury Road, Suite 201
Cardiology
Stamford, 32 Strawberry Hill Court
Endocrinology • Orthopaedics • Rheumatology
Torrington, 157 Litchfield Street
Cardiology • Endocrinology
Waterbury, 64 Robbins Street
Cardiology
Massachusetts, 516 Carew Street, Springfield
Rheumatology • Neurosurgery