Greenville Health System Pediatric Focus fall 2015 fnl by Prisma Health

An Epic EMR Transition Inaugural Pediatric Education Symposium CME: Evaluating and Preventing Child Abuse Safe Kidsâ&#x201E;˘ Upstate Celebrates 20 Years

Vol. 27.3 Fall 2015

on Pediatrics

Acclaimed Autism Researcher Joins Childrenâ&#x20AC;&#x2122;s Hospital

Focus on Pediatrics is published quarterly by Children’s Hospital of Greenville Health System. Medical Editor Joseph L. Maurer, MD Managing Editor Lark Reynolds

FROM THE MEDICAL DIRECTOR

GHS Photographer AV Services Art Director GHS Creative Services Editorial Board Linda Baumbach, CAP Nichole Bryant, MD Sally Cade Kristi Coker, MSN, MHA, RN Jeanine Halva-Neubauer Jennifer Hudson, MD Emily Hughes Eric Nash Terri Negron, MN, RN Janine Sally, MS, CCC-SLP Robert Saul, MD Kerry Sease, MD, MPH If you would like your name added to or removed from our mailing list or have any comments, questions or suggestions, please send the appropriate information to: Marketing Services Greenville Health System 300 E. McBee Ave. Suite 200 Greenville, SC 29601 (864) 797-7544 The information contained in the Focus is for educational purposes only—it should not take the place of medical advice or diagnoses made by healthcare professionals. All facilities and grounds of Greenville Health System are tobacco free. “Greenville Health System” and GHS symbol design are trademarks of Greenville Health System.

Another First for Children’s Hospital As noted in this issue’s lead article, the autism program at Children’s Hospital of Greenville Health System took a giant leap forward this summer with the addition of Manuel Casanova, MD, and his team of renowned researchers. Dr. Casanova is one of the world’s foremost leaders in autism research. He joins us as a SmartState™ Endowed Chair in Pediatric Neurotherapeutics through collaboration with the University of South Carolina (USC) and the Medical University of South Carolina (MUSC). The SmartState Program was created by the South Carolina General Assembly in 2002 and is funded through the South Carolina Education Lottery. Children’s Hospital, along with our two research university collaborators, competed successfully for an award that supports three endowed chairs in childhood neurotherapeutics, with one endowed chair at each of our institutions. At MUSC, the focus will be on basic autism research. At USC, the emphasis will be on autism research using animal models. Dr. Casanova’s research team will center on translational autism research, taking what has been learned in the lab and with animal studies directly to clinical trials involving patients with autism. Dr. Casanova comes to us from the University of Louisville where he held the Gottfried and Gisela Kolb Endowed Chair in Psychiatry and

served as Vice Chair for Research. Trained as a neuropathologist at the Johns Hopkins Hospital, he has devoted his career to studying brain function in children. His most recent research has focused on vertical units of brain cells called minicolumns that appear to be altered in individuals with autism. Dr. Casanova is a proliﬁc researcher, speaker and writer. His clinical investigations have been well supported by national funding organizations. He sits on the boards of multiple prominent national and international groups whose missions are to cure autism. Additionally, he has published over 100 scientiﬁc articles on autism and is an invited speaker around the globe. In October 2015, his work was highlighted in Newsweek. We welcome Dr. Casanova and his team to Children’s Hospital. His expertise will surely augment the excellent autism diagnosis and treatment program pioneered here by Drs. Desmond Kelly and Anne Kinsman.

William F. Schmidt III, MD, PhD

CONTENTS

New Endowed Chair a Boost to Autism Research 2 Manuel Casanova, MD, hopes to bring Greenville to the forefront of the autism world with a groundbreaking clinical trial.

GHS Transitions to Epic 5 Single systemwide electronic medical record improves information sharing and patient engagement.

CME: Preventing Child Abuse

Pediatricians have a critical role to play in identifying risk factors for abuse as well as early detection of abuse.

Special Program 24 Pediatric Nurse Telephone Triage program provides after-hours guidance

Departments What’s New 7 Birthing Center, Pediatric Infusion Center Open

Medical Staff Spotlight 8 Meet Our New Physicians

Academic News 9 Inaugural Pediatric Education Symposium

Quality Counts 15 Maintenance of Certiﬁcation and QI

Celebrations 16 Safe Kids turns 20; Other Philanthropic News

Clinical Research Update 21 Current Diabetes Research

Case Study 22 Systemic Juvenile Idiopathic Arthritis

Ask the Faculty 26 Cardiac Considerations When Evaluating Student Athletes

24 On the cover: Manuel Casanova, MD, has been appointed to the SmartState™ Endowed Chair in Childhood Neurotherapeutics, and brings his groundbreaking autism research to Children’s Hospital and the upstate community. Cover photography by Greg Beckner (gregbeckner@hotmail.com)

To access this publication online, go to www.ghs.org/publications.

LEAD STORY Children’s Hospital of Greenville Health System (GHS) welcomes Manuel Casanova, MD, as the Endowed Chair in Childhood Neurotherapeutics.

Poised for a Breakthrough Arrival of World-renowned Autism Researcher a Boost for Children’s Hospital

Manuel Casanova, MD, a founding member of numerous international autism organizations, has performed extensive research on the brains of individuals with autism. He is the SmartState Endowed Chair in Childhood Neurotherapeutics at GHS and USC School of Medicine Greenville.

A new endowed faculty chair through the South Carolina SmartState™ Chairs program has brought a world-renowned autism researcher to GHS Children’s Hospital. Manuel Casanova, MD, was appointed to the SmartState Endowed Chair in Childhood Neurotherapeutics in June. He is a University of South Carolina (USC) research professor, with appointments in the Department of Biomedical Sciences at USC School of Medicine Greenville and in Children’s Hospital’s Department of Pediatrics, where he will spend the majority of his time. In that role, he will carry out research on autism and related neurodevelopmental disorders and serve as director 2

of research for the DeLoache Fellowship in DevelopmentalBehavioral Pediatrics. The SmartState Program seeks to advance South Carolina’s knowledge economy through sponsored research at the state’s research universities. The program comprises six industryfocused Smart Clusters and about 50 Centers for Economic Excellence, within which the supported research takes place. Dr. Casanova’s presence serves as a boost to existing autism services at Children’s Hospital. The multidisciplinary Autism Wonders program, established in 2008, provides families of

children with autism spectrum disorder with a coordinated evaluation and care program. Autism Wonders focuses on early diagnosis, treatment, whole-family support, research and community outreach. This program, a collaboration between the divisions of Developmental-Behavioral Pediatrics and Pediatric Psychology, performs about 600 autism evaluations a year, a ﬁgure that Dr. Casanova says is noteworthy. “That’s huge!” he exclaimed. “That’s bigger than what I’ve seen at some of the major autism clinics, not only around the country but also around the world. Children’s Hospital has one of the better resources for autism-related efforts in the whole nation— it’s just not known.” That’s saying something, considering Dr. Casanova has traveled to nearly every continent and maintains a worldwide network of connections. He also was a founding member of the National Alliance for Autism Research, along with numerous other autism organizations and brain banks. Dr. Casanova’s extensive body of research focuses on an experimental therapy called transcranial magnetic stimulation (TMS), in which rapidly reversing magnetic ﬁelds create electric currents that, depending on parameters, either stimulate or depress nerve cells in the brain. The precursor to his research in this area was a realization that he had been focusing on the wrong paradigm in seeking answers for the pathology of autism. While most of neuropathology focuses on individual cells, Dr. Casanova broadened his vision to look at the groupings of cells and the circuitry in the brain. “Instead of looking at single cells, we started studying circuits within the cerebral cortex called minicolumns, and we found major abnormalities there in patients with autism,” Dr. Casanova explained. “These minicolumns have an excitatory core and a periphery of inhibitory cells surrounding that core. In autism, it’s that periphery—that insulation, if you will—that appears to be defective.”

Dr. Casanova’s preliminary research into the effectiveness of TMS found that many maladaptive behaviors of children with autism improve after the child undergoes the therapy. “Behaviors such as irritability, restlessness, tantrums, inability to stand still, sit or listen to a teacher—they all improve,” Dr. Casanova reported. “There are marked changes in terms of the behaviors of the patients, in a positive way.”

Augusta Womack undergoes a session of TMS in one of Dr. Casanova’s clinical trials. Evidence from his studies to date supports TMS as a possible treatment to improve some maladaptive behaviors in children with autism.

He said teachers usually are the ﬁrst to notice these changes. While parents may not notice incremental changes from day to day, when the child returns to school at the end of therapy, the difference often is remarkable. And while outcome measures in autism treatments tend to be subjective, Dr. Casanova can claim some objective results, too. “We had signiﬁcant results in error negativity, which is the ability of the patient to self-monitor for mistakes,” he pointed out. “It’s a higher cognitive function, called an executive function.” At GHS, Dr. Casanova plans to perform a large-scale Phase III trial for TMS in autism, which he says would vault Greenville to the center of the autism world. “This would be the major center for the treatment of those with autisim, if not in the whole world, at least in the US,” he emphasized. “It’s in part because of the novel approach, in part because of the number of patients that a Phase III trial would need. We will be treating hundreds of children.” As far as Greenville being a major player in the autism world, that has long been a goal for Desmond Kelly, MD, who was medical director of the Division of Developmental-Behavioral Pediatrics before assuming the role of Vice Chair for Academic Affairs in the Department of Pediatrics. Dr. Kelly is providing direction for Dr. Casanova’s work. “We’re building on previous very generous philanthropic support that we received to establish our Autism Wonders program and are in the process of establishing a collaboration with the Division of Developmental Pediatrics at the School of Medicine in Columbia and Palmetto Health Children’s Hospital,” Dr. Kelly said. “A big component is going to be research and workforce development.” 3

The addition of Dr. Casanova to the team at Children’s Hospital will certainly give the program a boost, he added. “I think it’s very exciting to have a researcher of his caliber join us,” noted Dr. Kelly. “It enables us to develop our research programs to a much more sophisticated level, with the potential for groundbreaking diagnostic and treatment approaches for children with autism spectrum disorder and related neurodevelopmental disorders.”

Autism Wonders Autism Wonders is a multidisciplinary program providing diagnostic and follow-up treatment services to families of children with autism spectrum disorder. Lisa Castellani, MD, a former upstate pediatrician, and her family helped establish the program with a $2 million gift in 2008. Dr. Castellani and her spouse were forced to navigate their way through autism services when their son was diagnosed with autism nearly a decade ago. “As a pediatrician, you think you know the system and what to do,” Dr. Castellani recalled. “But getting services was incredibly difficult because the system ﬂowed everyone to developmental-behavioral pediatricians. They were very backed up, so you had to wait almost a year just to see them. So in the middle of your frustration, your grief, you want answers, but you’re having a hard time getting any.” After their experience, it became the couple’s mission to create a model that would get important information to families quickly. With Autism Wonders, a clinical service coordinator meets with the family within three weeks of initial referral. The coordinator provides the family with material and an introduction to the program, and gathers information about major concerns, medical history and treatment history. Patients then are scheduled for either a full evaluation or a focused developmental assessment, based on data collected at the initial screening. “Our goal was to feed kids into the system appropriately and efficiently and to get rid of that bottleneck for all children with neurodevelopmental disorders, particularly those with autism,” Dr. Castellani emphasized. “It’s so important with autism that children get diagnosed and start getting services as soon as possible.”

Lisa Castellani, MD, a pediatrician whose family worked closely with the Department of Developmental-Behavioral Pediatrics to develop Autism Wonders, said she is excited about Dr. Casanova’s arrival on multiple levels. Nearly a decade ago, Dr. Castellani and her husband, Robert, adopted a 16-month-old who has since been diagnosed with autism. “I think of it as a physician and I’m incredibly excited about the prospect of using our community and our children with autism to create studies, but I also think about it as a mom, and I wonder if my son would potentially be a candidate, and could he beneﬁt,” Dr. Castellani stated. Her son has tried a number of therapies and drugs, Dr. Castellani said, but “wouldn’t it be fantastic if there were a nonpharmacologic way of helping him to improve his concentration, his focus, his attention span and decrease those OCD loops in his mind?” Currently, Dr. Casanova is raising awareness in the Upstate about his research and goals for autism services in South Carolina. He also is continuing to seek funding for the next phase of his TMS research. All the while, he hosts autism experts from around the globe right here in Greenville.

“We’re attracting other researchers from around the world who are coming to visit us and collaborate and learn from Dr. Casanova,” Dr. Kelly stated. As for Dr. Casanova, he is excited to join the team at Children’s Hospital, especially Dr. Kelly and William Schmidt III, MD, PhD, medical director of Children’s Hospital. “One of the things that drew me here was the opportunity to enjoy collaboration with an established infrastructure,” Dr. Casanova remarked. “Dr. Kelly is very well-known within the ﬁeld, and he’s very easy to get along with. And Dr. Schmidt is very proactive. They will make dreams happen.”

FEATURE STORY

Epic News at Children’s Hospital

On June 1, Greenville Health System (GHS) took the first step in instituting a comprehensive electronic medical record (EMR) system called Epic that encompasses both inpatient and ambulatory care. On this date, two pediatric pilot sites went live using Epic. Following this initial brief testing, ambulatory practices across the system began using the software July 16. Epic is the pre-eminent EMR now used in the US. KLAS has ranked it No. 1 for the last five years, particularly for large academic healthcare systems like GHS. Epic integrates inpatient, ambulatory and ancillary patient care services on a single platform, reducing redundancy and improving continuity of care. We have had a successful Ambulatory go-live, but the full benefits of this software will be

reached after February 2016, once all aspects of patient care have transitioned to using it. The goal of any EMR is to improve patient care while concurrently increasing patient engagement. Epic successfully combines both of these principles by improving access to patient information through a single database. A single database increases the amount of material available not only within GHS, but also—using other Epic-speciﬁc utilities such as CareEverywhere—with other health systems. In June alone, 15.3 million patient records were shared among Epic’s 355 hospital systems in the nation via CareEverywhere. In our region, providers are noting the beneﬁts of communicating

Epic integrates inpatient, ambulatory and ancillary patient care services on a single platform, reducing redundancy and improving continuity of care. 5

As part of Epic, patients also have increased access to their medical record through MyChart, the software’s award-winning patient portal.

more openly with Bon Secours St. Francis Health System and Medical University of South Carolina. Further improvements in patient care likely will occur as additional systems—including Spartanburg Regional Healthcare System and Self Regional Healthcare—soon transition to Epic. As part of Epic, patients also have increased access to their medical record through MyChart, the software’s awardwinning patient portal. GHS has developed and built workflows to increase patient engagement through the patient portal while continuing to offer ways to protect patient privacy, particularly for adolescent patients. Providing the ability to control access to the MyChart application with simple changes in patient and proxy status (full, limited, blocked) has worked so well in the version GHS built that Epic has elected to include it in the company’s future versions. The patient portal also improves communication between provider and patient. In the outpatient setting in particular, the portal can decrease work and improve efficiencies of staff by simplifying communications such as appointment reminders, return phone calls and medication refills. Providers and staff have done an incredible job transitioning to Epic. Some practices have gone directly from paper, but the majority transitioned from eCW. Epic requires some changes in workflow to improve overall efficiencies and optimize use. One of the biggest changes has been increased in-room computing and placement of computers in the majority of exam rooms. Staff members have moved from laptops to more stable and secure desktops in many settings. Docking stations with increased monitor sizes have made laptops more efficient as well.

Tools within Epic such as SmartPhrases and SmartText help providers do their jobs more effectively and efficiently. In addition, GHS’ IT department has made a commitment to a full roll-out of DragonSpeak, a voice recognition software that can be used in conjunction with Epic in both the ambulatory and inpatient settings. Currently, 73 percent of encounters are being closed on the same day and 93 percent within five days. Learning any new system is a process. It will be important to continue to optimize workflows, integrate technology and create further scripting for Dragon and SmartPhrases to address ongoing bottlenecks in the care process and provider documentation. Attending ongoing optimization courses such as the Thrive sessions, hosted by Epic and the IT department, will provide additional training in the successful use of all available tools within Epic. However, perhaps the best way to improve efficiencies within the new EMR is to continue to learn from and share successes with colleagues, keeping an open mind on how to adjust workflows as familiarity with Epic grows.

Article author Dominic Gault, MD, is one of two physician Epic champions for Children’s Hospital. He also is a physician at GHS Children’s Hospital’s Center for Pediatric Sleep Disorders and was recently named Pediatrician of the Year by that hospital.

WHAT’S NEW? Greenville Health System debuts a new birthing center and announces a pediatric infusion center.

Birth Center Expands Delivery Options

Greenville Midwifery Care, part of Greenville Health System (GHS), has opened a birth center in the same building as its office, 35 Medical Ridge Drive. The center features three birth suites, each with a queen-sized bed, Jacuzzi-style tub and full bathroom with shower. An outdoor serenity garden adds to the spa-like atmosphere. The center’s location across from Greenville Memorial Hospital ensures that any woman who decides she wants an epidural or needs medical care can be quickly transported to the hospital.

The center’s new name is Greenville Midwifery Care & Birth Center. The phone number is (864) 797-7350.

GHS Adopts New Referral Algorithm for Obesity New Impact: A Healthy Lifestyles Program is the weight management partner of the Division of Pediatric Endocrinology. These two entities work closely to optimally manage patients who are overweight and their co-morbidities. Most referrals for overweight/obesity should go directly to New Impact. Concerns about the program’s cost have been addressed in recent years so that families will be better able to afford these services. For more information and to view the algorithm, visit ghschildrens.org/obesity.

Enlarged Outpatient Infusion Center Opens In November, GHS Children’s Hospital opened an expanded pediatric outpatient infusion center. The center provides a wide range of infusions along with support services such as Port-A-Cath ﬂushing, central line malfunction assessment and treatment, accessing of AV ﬁstulas, and administration of IV and IM medications. The center operates weekdays and can hold eight patients. Outpatient infusion services previously have been provided by Children’s Hospital at the divisions of Pediatric Gastroenterology and Pediatric Hematology/Oncology. However, with the growth of the upstate community, the volume and scope of services had exceeded the capacity of the existing infusion sites. Pediatric Hematology/Oncology will continue to provide infusions for patients receiving blood-related products and chemotherapy. Other pediatric infusions will be administered at the new center, located at 57 Cross Park Court in Greenville. The phone number will be (864) 220-7270.

MEDICAL STAFF SPOTLIGHT Children’s Hospital of Greenville Health System (GHS) welcomes ﬁve new physicians.

Meet Our New Physicians Developmental-Behavioral Pediatrics

Pediatric Rheumatology

Tara A. Cancellaro, MD, earned her medical degree from East Tennessee State University’s Quillen College of Medicine in Johnson City, Tennessee. She completed her pediatric residency at the Medical University of South Carolina in Charleston, and a fellowship in developmental-behavioral pediatrics at GHS. Dr. Cancellaro can be reached at (864) 454-5115.

Lara M. Huber, MD, MSCR, graduated from Marshall University School of Medicine in Huntington, W.Va. She completed a residency in internal medicine and pediatrics and a fellowship in internal medicine and pediatrics rheumatology at the Medical University of South Carolina in Charleston. Dr. Huber also holds a Master of Science in Clinical Research degree. She can be reached at (864) 454-5004.

General Pediatrics Pediatric Surgery Sara E. Ryder, MD, earned her medical degree from Pennsylvania State University College of Medicine in Hershey. She completed her residency training in pediatrics at Carolinas Medical Center in Charlotte, where she served as chief resident in 2014-15. Dr. Ryder is working at the Center for Pediatric Medicine. She can be reached at (864) 220-7270.

Keith M. Webb, MD, attended medical school at the University of Oklahoma College of Medicine in Oklahoma City. Dr. Webb completed a general surgery residency at GHS. He then completed fellowships in pediatric colorectal surgery, pediatric surgical critical care and pediatric surgery. Dr. Webb can be reached at (864) 797-7400.

Pediatric Critical Care Christina M. Goben, MD, a University of South Carolina (USC) graduate, earned her medical degree at the USC School of Medicine in Columbia. Dr. Goben completed her pediatric residency at GHS and a fellowship in pediatric critical care at Vanderbilt Children’s Hospital in Nashville, Tennessee. Dr. Goben is working in the Pediatric Intensive Care Unit at Children’s Hospital. She can be reached at (864) 455-7146.

Dr. Millon Retires Angela D. Millon, MD, retired in July after 18 years of service with Children’s Hospital’s Center for Pediatric Medicine. Dr. Millon began working at the center when she ﬁrst moved to Greenville in 1997. We thank Dr. Millon for her many years of service to upstate children!

Children’s Hospital Physicians Elected to SCAAP Executive Committee Kerry Sease, MD, MPH, was elected secretary-treasurer of the South Carolina chapter of the American Academy of Pediatrics at the organization’s annual meeting in July. Robert Saul, MD, was elected as an at-large member of the executive committee.

ACADEMIC NEWS Children’s Hospital of Greenville Health System (GHS) has expanded the annual DeLoache Seminar in both scope and duration.

A Reason to Celebrate The late William R. DeLoache, MD, was a champion of pediatric education. His legacy lives on in the DeLoache fellowship program in Children’s Hospital’s Division of DevelopmentalBehavioral Pediatrics and in our annual DeLoache lecture. This year, GHS Children’s Hospital expanded that lecture into a twoday symposium that highlights the accomplishments of our Pediatric faculty, residents and fellows and brings together the alumni of the Pediatric Residency Program. Dr. DeLoache was born in South Carolina on March 27, 1920. He completed his undergraduate studies at Furman University in Greenville and graduated from Vanderbilt University School of Medicine in Nashville, Tennessee, in 1943. He and his family moved to Greenville in the early 1950s, where he helped establish Christie Pediatric Group, Greenville’s oldest pediatric practice, and what is now the Bryan Neonatal Intensive Care Unit at GHS—the Upstate’s ﬁrst NICU. Dr. DeLoache made caring for children his life’s mission and was not afraid to take unusual steps to make sure those children received the care they needed. He even used his own station wagon as one of the ﬁrst neonatal transport vehicles! Even in retirement, Dr. DeLoache spent years raising support for and launching Greenville’s Center for Developmental Services—a multidisciplinary facility serving the needs of children with developmental differences. He also lobbied extensively for legislation requiring car seats for children.

Symposium Highlights This year’s DeLoache Symposium, a two-day event, both celebrated and educated current and alumni residents on what is and has been happening in the Pediatric Residency Program at GHS. The William R. DeLoache Pediatric Education Symposium kicked off with a lecture by the keynote speaker Thursday evening. Upstate pediatricians, Pediatric Residency Program alumni and advanced practitioners attended the lecture and the announcement of Children’s Hospital’s Pediatrician of the Year (see page 10). Posters from residents’ quality improvement projects also were displayed. Friday featured a joint Grand Rounds with Internal Medicine featuring the visiting speaker, followed by a brief research symposium with platform presentations highlighting research projects of GHS Children’s Hospital faculty members. That evening, participants attended a gala in Greenville’s West End.

DeLoache Symposium Keynote Speaker: Colleen Kraft, MD Colleen Kraft, MD, medical director for the Health Network by Cincinnati Children’s (HNCC), was the keynote speaker at the inaugural William R. DeLoache Pediatric Education Symposium. A graduate of Virginia Tech (undergraduate) and Virginia Commonwealth University (medical school), Dr. Kraft is an expert in the development and implementation of community-based networks of pediatric providers whose mission is to improve the system of health care for children. In particular, HNCC is responsible for two of the ﬁve managed-care organizations in Ohio that provide pediatric care for the Medicaid population. Dr. Kraft has been active in private practice, managed care administration and pediatric residency program development. She is an author of pediatric care manuals, a content expert for numerous endeavors and is actively engaged in numerous projects for the American Academy of Pediatrics.

In 2006, the DeLoache family offered a $1 million challenge grant, which was matched by community partners, to fund an endowment for a fellowship program in developmentalbehavioral pediatrics.

The DeLoache Fellowship ensures that at any given time, three fellows can be in training at Children’s Hospital. With up to 15 percent of children in the nation experiencing developmental or behavioral problems, an ever-increasing need exists for well-trained developmental-behavioral pediatricians. This spirit of providing the best available educational opportunities to our pediatric residents continues today. Thirty-one Children’s Hospital physicians and 25 pediatricians in GHS practices around the region are products of our Pediatric Residency Program, ﬁrst started in 1972.

Pediatrician of the Year Congratulations to Dominic Gault, MD, medical director of GHS Children’s Hospital’s Center for Pediatric Sleep Disorders, who received the 2015 Pediatrician of the Year award. Dr. Gault was recognized by his colleagues for his dedication to his patients’ needs, his willingness to collaborate with other specialties and his tireless efforts to shepherd colleagues through the transition to Epic. Regarding the transition to Epic (see page 5 for an overview), one peer noted, “Dr. Gault has remained available for assistance with all matters, big and small, and is always willing to lend a hand in trying to solve any issue.” Dr. Gault commented, “This is a tremendous honor. The implementation of Epic has given me the opportunity to work with colleagues from other departments within the hospital, which has been a great experience.”

QI Projects Win Awards Two posters by GHS residents won awards at the SC American Academy of Pediatrics meeting in July. Meagan Aiken, MD, and S. Chad Hayes, Dr. Hayes Dr. Aiken MD, earned ﬁrst place for “Get LARC’d: Improving Utilization of Postpartum Birth Control.” Their project assessed the need for improved use of long-acting reversible contraceptives (LARCs) in mothers with young children. Medicine-Pediatrics residents Andrew Burgess, MD, and Teresa Williams, MD, earned second place with “For the QIDS: A QI Initiative to Dr. Burgess Dr. Williams Decrease Smoking in Parents of Pediatric Patients.” The project aimed to improve smoking cessation counseling for parents, along with caregiver access to cessation resources, thus improving pediatric health outcomes by reducing exposure to second-hand smoke.

Dr. Grisham Named Director Matthew Grisham, MD, was named director of Children’s Hospital’s Pediatric Residency Program in October. Dr. Grisham graduated from the program himself in 2010. He served as co-chief pediatric resident the following year, and for the last four years has spent time as a pediatric hospitalist at Children’s Hospital and a pediatrician at Christie Pediatric Group.

GOOD NIG HT GRE ENV

RADLE Y

MAURE R/B

Penned by GHS’ Joseph Maurer, MD, this popular hardback promotes reading and features familiar sights of Greenville. Best of all, proceeds beneﬁt Child Life Services at Children’s Hospital! The book is available online and at select stores—learn more at goodnightgreenville.com.

ILLE

Give the Gift of Goodnight Greenville

Written Illustrat by Joe Maure r ed by Jose ph Bra dley

CONTINUING MEDICAL EDUCATION

Preventing Child Abuse More than 3.5 million referrals were made to Child Protective Service agencies in the United Stated in 2013, an 11.6% increase over the number of referrals in 2009. Of those referrals, 2.1 million cases were screened in (accepted for investigation), with the largest percentage of children being less than 1 year of age. More than 1,500 children died from abuse and neglect in 2013, with the largest number of children again being less than 1 year old. Figure 1 (next page) shows the breakdown of child maltreatment cases from 2013 into the categories of neglect, medical neglect, and physical, psychological and sexual abuse in the US. Physical abuse rates in South Carolina were twice the national average (see Figure 2, next page). According to Kids Count data from the state Department of Social Services (DSS), Greenville County had the highest number of cases for investigation of child abuse and neglect in 2013 despite having the second highest mean family income.1 Adverse Childhood Experience (ACE) studies have shown that maltreatment as a child has a profound impact on adult health, both physically and mentally. A higher number of adverse experiences during childhood—including physical abuse, sexual abuse, exposure to domestic violence, physical neglect, and exposure to drug and alcohol abuse—impacts morbidity and mortality throughout adulthood.2 The amount of toxic stress on an individual has inﬂuence beyond the patient, affecting his or her family and even generations to follow. The lifetime cost for each surviving victim of child maltreatment is estimated to be $210,012. In comparison, a stroke has an estimated lifetime cost per person of $159,846, while type 2 diabetes is estimated to cost between $181,000 and $253,000.3 Unlike these conditions, child abuse is 100% preventable, and every case of abuse we as pediatricians can prevent represents a positive impact, both ﬁnancially and socially, on our health as a nation. The Division of Child Abuse and Neglect/Forensic Pediatrics at Children’s Hospital of Greenville Health System (GHS) actively participates in a statewide network, the SC Children’s Advocacy Medical Response System (SCCAMRS). This network consists

of physicians and nurse practitioners trained to evaluate children who may be at risk for abuse and neglect. The network not only provides data collection on the children evaluated across the state, but also peer reviews and an active presence in Columbia to encourage legislation against child maltreatment. Across the state, the majority of referrals to SCCAMRS relate to sexual abuse (51.2%), with physical abuse second (23.8%). The largest percentage of referrals comes from DSS (41.1%), followed by law enforcement (33.8%) and medical providers (12.5%). In the Upstate in 2014, 5,051 children were in need of medical evaluations as part of the initiation of an investigation for abuse, neglect or threat of harm. This number was 500 more than the number of children in the Midlands and almost twice as high as the number in the Lowcountry.

Figure 1 About 500 of those upstate children were evaluated within Child Abuse and Neglect/Forensic Pediatrics. Of those, 64.5% of the cases were attributed to abuse. In 24.9% of cases, the cause was undetermined; in 7.4% abuse was not indicated.

Intervention Efforts Thorough evaluations are extremely important, not only to identify children who have been abused, but also to identify the existence of risk factors within a family that could potentially lead to abuse or neglect. It is equally as important to identify children who are not victims of abuse despite an injury or scenario creating suspicion.

Figure 2

Pediatricians have a unique opportunity to reduce the toxic stress on children through anticipatory guidance/prevention efforts, early identiﬁcation and intervention for children being abused or at heightened risk for abuse, and supporting families when intervention is needed. Risk factors outlined in the American Academy of Pediatrics’ “Clinical Report—The Pediatrician’s Role in Child Maltreatment Prevention”4 serve as a guide for physicians in evaluating situations that may create higher risk environments for children and their families (see Table 1). It is important for physicians to become comfortable in asking some of these difficult and often complex questions.

Figure 3

One initiative that focuses on this challenge is the SEEK program (Safe Environment for Every Kid)5 being used at the University of Maryland. Through this program, pediatricians are provided with training in handling sensitive family issues, and parents are given a simple questionnaire at their child’s well visits that screens for targeted risk factors in the home environment, such as maternal depression, alcohol and substance abuse, intimate partner/domestic violence, parental stress/difficulty coping, and food insecurity. The program also includes collaboration with a social worker to help with referrals to community resources, and parent handouts to bolster advice given in the office. We hope to pilot this same program at GHS Children’s Hospital’s Center for Pediatric Medicine this fall.

The Period of Purple Crying P – Peaks in the ﬁrst 2-4 months of life U – Comes on unexpectedly R – Resistant to soothing P – Infant looks like he or she is in pain L – Long lasting E – Happens in the evening Source: purplecrying.info

Infant crying often is one of the earliest struggles facing new parents. Crying has historically been one of the most common triggers for abusive head trauma.6 The Period of Purple Crying (Figure 3) is an educational program at GHS to help new parents understand the normal aspect of crying, how to deal with it appropriately and the risk as it relates to abusive head trauma. Education begins during the prenatal period, and it continues at the baby’s birth and during the early well-child checks.

Table 1

Factors and Characteristics Placing a Child at Risk for Maltreatment Child: • Demanding infant • Special healthcare needs • Physical, developmental or emotional/behavioral disability • Premature birth • Unplanned/unwanted pregnancy

Safe Sleep A major risk factor for infants that often goes unnoticed is unsafe sleep practices. Despite most families having appropriate places for their newborns to sleep, some still choose cosleeping. Convenience for breastfeeding, bonding and, ironically, safety, often are given as reasons for this choice despite the clear recommendations for safe sleep by the AAP.7 During well-child checks throughout the first year, pediatricians should consider asking if parents ever sleep with the baby. A discussion may ensue that could be the most valuable anticipatory guidance they receive. Cribs for Kids is a resource that can help families with limited financial means ensure a safe sleep environment (portable crib) for children under 6 months old. In addition to identifying risk factors for child abuse or neglect, pediatricians also must have knowledge about where to refer families for services once concerns are identified. The United Way 211 program can be an excellent source of information for community resources.

Parent: • Low self-esteem • Poor impulse control • Substance use • Alcohol abuse • Young parental age • History of abuse as children • Depression/mental illness • Tendency to devalue children/self • Lack of knowledge about child-rearing • Punitive child-rearing style

Environment: • Parental isolation/low social support • Poverty • Unemployment

TEN 4 When concerns arise that a child may be experiencing physical abuse, pediatricians sometimes face uncertainty with how to proceed. The recent clinical report “The Evaluation of Suspected Child Physical Abuse” by Cindy Christian, MD, outlines a thorough overview of current approaches. Two key concerns when evaluating a young child are ﬁndings of bruises and/or fractures. The mnemonic “TEN 4” can help identify bruises that are a concern for abuse: T—Torso E—Ear N—Neck 4—In children less than 4 years of age and ANY bruise in an infant less than 4 months8

• Food or employment insecurity • Low maternal education • Single-parent family • Single female living with non-biologically related male • Adult intimate partner abuse • Poor access to community services

Source: AAP Committee on Child Abuse and Neglect

Child abuse prevention and treatment is the responsibility of the entire community. Education of risk factors needs to be offered frequently. The earlier article “Bruises in infants and toddlers; those who don’t cruise rarely bruise”9 also studied bruise patterns in children and found that bruises are rare in infants and precruisers. Skeletal injury is common in the general pediatric population, but fractures in the youngest of children, especially those who are not mobile, are of concern. A fracture can be caused either by abuse or an accident. The history, quickness to care, witnesses and developmental level of the child can be an aid to determining whether an injury was accidental or intentional. Long bone fractures are of increased concern for intentional injury, especially in children less than 1 year old. Skeletal surveys are indicated in all children less than age 2 with obvious abusive or suspicious injuries.10

References 1.

KIDS COUNT South Carolina. Children’s Trust of South Carolina http://www.scchildren.org/advocacy_and_media/kids_count_south_ carolina/. Accessed 10/7/2015, 2015. 2. Adverse childhood experiences (ACE) study. Child Maltreatment Violence Prevention Injury Center CDC http://www.cdc.gov/ violenceprevention/acestudy/. Accessed 10/7/2015, 2015. 3. Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl. 2012;36(2):156-165. 4. Flaherty EG, Stirling J,Jr. Clinical report—the pediatrician’s role in child maltreatment prevention. Pediatrics. 2010;126(4):833-841. 5. The institute for innovation & implementation http://theinstitute. umaryland.edu/seek/. Accessed 10/7/2015, 2015. 6. Flaherty EG. Analysis of caretaker histories in abuse: Comparing initial histories with subsequent confessions. Child Abuse Negl. 2006;30(7):789-798. 7. Laughlin J, Luerssen TG, Dias MS. Prevention and management of positional skull deformities in infants. Pediatrics. 2011;128(6):1236-1241. 8. Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125(1):67-74. 9. Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med. 1999;153(4):399-403. 10. Christian CW. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337-e1354.

CME Credit Information

Conclusion Child abuse prevention and treatment is the responsibility of the entire community. Physicians are mandated to report to DSS/ Law Enforcement if they believe a child has been abused or neglected, but even before that point, they have an opportunity to make an impactful difference in the life of a child and family. Education of risk factors needs to be offered frequently, addressing and referring families to the appropriate resources in the community. Ongoing discussion of newborn crying and normal childhood development can help reinforce expectations for families. Pediatricians also can help families understand normal sexual behavior and how best to approach conﬂict. Our patients, too, would greatly beneﬁt to learn skills to handle peer pressure, bullying, Internet safety and dating violence. Building resiliency in your patients and advocating for them can promote lifelong health.

To receive possible continuing medical education (CME) credit for this article, please complete the online Q&A that can be accessed below. Both physicians and nurses are eligible to test for the credit. It is the policy of the GHS Continuing Medical Education Committee to ensure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored education activities. Article author Nancy Henderson, MD, has disclosed that she has no significant financial interest or relationship with any company that may be considered an actual or potential conflict of interest with this educational activity.

CME Questions Available Online As a convenience for our audience and to conserve resources, Focus on Pediatrics has transitioned to an online format for the Q&A portion of CME articles. Here is a link and a QR code you can use to access the CME questions online. http://www.ghs.org/PediatricsElectronic

Article author Nancy Henderson, MD, is a physician in GHS Children’s Hospital’s Division of Child Abuse and Neglect/ Forensic Pediatrics.

The Greenville Health System (GHS) designates this enduring activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Greenville Health System is accredited by the South Carolina Medical Association to provide continuing medical education for physicians.

GHS Children’s Hospital Physician Directory For admission to Children’s Hospital: (864) 455-0000 Phone Fax William F. Schmidt III, MD, PhD 455-8401 455-3884 Medical Director; Chairman, Department of Pediatrics Adolescent Bariatric Surgery Eric S. Bour, MD 676-1072 676-0729 Adolescent Medicine Michael F. Guyton Jr., MD 220-7270 241-9211 Allergy, Immunology and Asthma Charles W. Greene Jr., MD 675-5000 675-5005 James L. Kuhlen Jr., MD 675-5000 675-5005 John M. Pulcini, MD 675-5000 675-5005 Ambulatory Pediatrics/Center for Pediatric Medicine (Medicaid) J. Blakely Amati, MD 220-7270 241-9211 Jessica P. Boyd, MD 220-7270 241-9211 Britni M. Bradshaw, MD 455-9261 455-9264 Elizabeth W. Burton, MD 220-7270 241-9211 Rachael D. Davis, MD 220-7270 241-9211 Janelle E. Godlewski, MD 220-7270 241-9211 Jill D. Golden, MD 220-7270 241-9211 Lochrane Grant, MD 220-7270 241-9211 Matthew P. Grisham, MD 220-7270 241-9211 Michael F. Guyton Jr, MD 220-7270 241-9211 Sara E. Ryder, MD 220-7270 241-9211 Robert A. Saul, MD 220-7270 241-9211 Kerry K. Sease, MD, MPH 220-7270 241-9211 Cady F. Williams, MD 220-7270 241-9211 Center for Complex Health Conditions W. Kent Jones, MD 220-7270 241-9211 Pediatric Rapid Access (Medicaid) Angela M. Young, MD 220-7270 241-9211 Anesthesiology Carlos L. Bracale, MD 242-4602 242-0129 Michael G. Danekas, MD 242-4602 242-0129 Lauren H. Doar, MD 242-4602 242-0129 John P. Kim, MD 242-4602 242-0129 Richard F. Knox, MD 242-4602 242-0129 Laura H. Leduc, MD 242-4602 242-0129 Steven W. Samoya, MD 242-4602 242-0129 Matthew R. Vana, MD 242-4602 242-0129 Randall D. Wilhoit III, MD 242-4602 242-0129 Cardiology Benjamin S. Horne III, MD 454-5120 241-9202 Jon F. Lucas, MD 454-5120 241-9202 David G. Malpass, MD 454-5120 241-9202 Manisha S. Patel, MD 454-5120 241-9202 R. Austin Raunikar, MD 454-5120 241-9202 Child Abuse/Neglect / Forensic Pediatrics Mary-Fran R. Crosswell, MD 335-5288 331-0565 Nancy A. Henderson, MD 335-5288 331-0565 Critical Care Michael G. Avant, MD 455-7146 455-5380 Eric L. Berning, MD 455-7146 455-5380 Christina M. Goben, MD 455-7146 455-5380 Darryl R. Gwyn, MD 455-7146 455-5380 Robert S. Seigler, MD 455-7146 455-5380

Phone Fax Developmental-Behavioral Peds/Gardner Center for Developing Minds James H. Beard Jr., MD 454-5115 241-9205 Tara A. Cancellara, MD 454-5115 241-9205 Gerald J. Ferlauto, MD 454-5115 241-9205 R. Lynne Hornsby, MD 454-5115 241-9205 Desmond P. Kelly, MD 454-5115 241-9205 Nancy R. Powers, MD 454-5115 241-9205 Victoria L. Sheppard-LaBrecque, MD 454-5115 241-9205 John E. Williams, MD 454-5115 241-9205 Emergency Medicine Elizabeth L. Foxworth, MD 455-6016 455-6199 Jacqueline J. Granger, MD 455-6016 455-6199 Alison M. Jones, MD 455-6016 455-6199 Patrick J. Maloney, MD 455-6016 455-6199 Matthew B. Neal, MD 455-6016 455-6199 Kevin A. Polley, MD 455-6016 455-6199 John D. Wilson Jr., MD 455-6016 455-6199 Endocrinology James A. Amrhein, MD 454-5100 241-9238 Elaine A. Apperson, MD 454-5100 241-9238 Bryce A. Nelson, MD, PhD 454-5100 241-9238 Gastroenterology Liz D. Dancel, MD 454-5125 241-9201 Michael J. Dougherty, DO 454-5125 241-9201 Emily N. Kevan, MD 454-5125 241-9201 Jonathan E. Markowitz, MD, MSCE 454-5125 241-9201 Colston F. McEvoy, MD 454-5125 241-9201 Genetics David B. Everman, MD 250-7944 250-9582 R. Curtis Rogers, MD 250-7944 250-9582 Gynecology Melisa M. Holmes, MD 455-1600 455-2805 Benjie B. Mills, MD 455-1600 455-2805 Hematology/Oncology / BI-LO Charities Children’s Cancer Center Nichole L. Bryant, MD 455-8898 241-9237 Rebecca P. Cook, MD 455-8898 241-9237 Cristina E. Fernandes, MD 455-8898 241-9237 Leslie E. Gilbert, MD, MSCI 455-8898 241-9237 Aniket Saha, MD, MSCI, MS 455-8898 241-9237 William F. Schmidt III, MD, PhD 455-8898 241-9237 Infectious Disease Joshua W. Brownlee, MD 454-5130 241-9202 Sue J. Jue, MD 454-5130 241-9202 Robin N. LaCroix, MD 454-5130 241-9202 Inpatient Pediatrics Greenville April O. Buchanan, MD 455-8401 455-3884 Karen Eastburn, DO, MS 455-8401 455-3884 Jeffrey A. Gerac, MD 455-4411 455-4480 Matthew P. Grisham, MD 455-8401 455-3884 Amanda G. Hartke, MD, PhD 455-8401 455-3884 Russ C. Kolarik, MD 455-7844 455-3884 Elizabeth S. Tyson, MD 455-8401 455-3884 Greer Matthew N. Hindman, MD 455-4411 455-4480 Continued on back

Phone Anderson Callie C. Barnwell, MD 454-5612 Sara M. Clark, MD 454-5612 Carley M. Howard, MD 454-5612 Ann Marie Patterson, MD 454-5612 Allison B. Ranck, MD 454-5612 Senthuran Ravindran, MD 454-5612 Silvia Y. Rho, MD 454-5612 Elizabeth A. Shirley, MD 454-5612 Miranda L. Worster, MD 454-5612 Minor Care Children’s Hospital After-hours Care (Greenville) Staffed by current GHS pediatricians 271-3681 Children’s Hospital Spartanburg Night Clinic George C. Haddad Jr., MD 804-6998 Neonatology/Bryan Neonatal Intensive Care Unit India C. Chandler, MD 455-7939 Benton E. Cofer, MD 455-7939 Nicole A. Cothran, MD 455-7939 J. Thomas Cox, MD 455-7939 R. Catrinel Marinescu, MD 455-7939 Bryan L. Ohning, MD, PhD 455-7939 Jeffrey M. Ruggieri, MD 455-7939 Michael S. Stewart, MD 455-7939 M. Whitson Walker, MD, MS 455-7939 Nephrology & Hypertension Franklin G. Boineau, MD 454-5105 T. Matthew Eison, MD 454-5105 Scott W. Walters, MD 454-5105 Neurology Emily T. Foster, MD 454-5110 Addie S. Hunnicutt, MD 454-5110 Augusto Morales, MD 454-5110 William C. Taft, MD, PhD 454-5110 Neurosurgery E. Christopher Troup, MD 797-7440 Newborn Services Jennifer A. Hudson, MD 455-3512 Rebecca P. Wright, MD 455-3512 Ophthalmology Alison S. Smith, MD 454-5540 Janette E. White, MD 454-5540 Orthopaedic Oncology Scott E. Porter, MD, MBA 797-7060 Orthopaedic Surgery Michael L. Beckish, MD 797-7060 Christopher C. Bray, MD 797-7060 Edward W. Bray III, MD 797-7060

Fax 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121 454-5121

271-3914 596-5164 455-3685 455-3685 455-3685 455-3685 455-3685 455-3685 455-3685 455-3685 455-3685 241-9200 241-9200 241-9200 241-9206 241-9206 241-9206 241-9206 797-7469 455-3884 455-3884 241-9276 241-9276 797-7065 797-7065 797-7065 797-7065

Phone

Fax

Otolaryngology Nathan S. Alexander, MD 454-4368 454-4348 Robert O. Brown III, MD 455-5300 455-5353 Michael S. Cooter, MD 454-4368 454-4348 Paul L. Davis III, MD 455-5300 455-5353 William D. Frazier, MD 454-4368 454-4348 John T. McElveen Jr., MD 919-876-4327 919-876-6800 Patrick W. McLear, MD 454-4368 454-4348 John G. Phillips, MD 454-4368 454-4348 Andrew M. Rampey, MD 454-4368 454-4348 Charles E. Smith, MD, DMD 454-4368 454-4348 Plastic Surgery and Aesthetics J. Cart de Brux Jr., MD 454-4570 454-4575 Pulmonology Michael J. Fields, MD, PhD 454-5530 241-9246 Sterling W. Simpson, MD 454-5530 241-9246 Steven M. Snodgrass, MD 454-5530 241-9246 Radiology Michael B. Evert, MD 455-7107 455-6614 Michael A. Thomason, MD 455-7107 455-6614 Rheumatology Lara M. Huber, MD, MSCR 454-5004 241-9202 Sarah B. Payne-Poff, MD 454-5004 241-9202 Sleep Medicine/Center for Pediatric Sleep Disorders Dominic B. Gault, MD 454-5660 241-9233 K. Ford Shippey III, MD, MS 454-5660 241-9233 Supportive Care Team S. Brooke Johnston, MD 455-5129 455-5075 Cary E. Stroud, MD 455-5129 455-5075 Surgery Randel S. Abrams, MD 797-7400 797-7405 John C. Chandler, MD 797-7400 797-7405 Robert L. Gates, MD 797-7400 797-7405 James F. Green Jr., MD 797-7400 797-7405 Keith M. Webb, MD 797-7400 797-7405 Urgent Care (Anderson) Artur A. Charowski, MD 512-6544 512-6995 Jennifer B. Harling, MD 512-6544 512-6995 Anna C. Neal, MD 512-6544 512-6995 Jonelle M Oronzio, MD 512-6544 512-6995 Janice L. Rea, MD 512-6544 512-6995 Patrice T. Richardson, MD 512-6544 512-6995 Urology Regina D. Monroe, MD 454-5135 241-9200 J. Lynn Teague, MD, MHA 454-5135 241-9200 Weight Management Program (New Impact) Erin L. Brackbill, MD 675-FITT 627-9131 Laure A. Utecht, MD 675-FITT 627-9131

ghschildrens.org 15-21506727 Revised 10/15

QUALITY COUNTS

Maintenance of Certification and QI in Practice dimensions of quality care: safety, effectiveness, timeliness, equity, efficiency and patient centeredness. The project must contain an aim statement for improvement that includes the target population and a timeframe. Standard QI measures should be used, such as data collection over time, comparison of performance to a recognized benchmark and systematic sampling for data collection upon availability. A specific change with implementation must be defined, and a report should be generated on the performance of the process. These projects need to be relevant and have meaningful outcomes that improve patient care. The physician must be active in all parts of the project.

The American Board of Pediatrics has adopted a Maintenance of Certiﬁcation (MOC) process that involves completing numerous activities. One—improvement in practice— lets physicians apply Institute of Medicine (IOM) quality measures and dimensions to real-life practice. The American Board of Pediatrics now allows for completion of MOC Part 4 in several ways. Nineteen activities can be found on the organization’s website; 42 additional options are sponsored by the American Board of Pediatrics as well as other educational institutions and professional societies. These activities provide a range of opportunities to meet the needs of both subspecialist and general pediatricians. If a physician’s practice recently earned Patient-Centered Medical Home (PCMH) status, all of the necessary process-improvement activities may already be satisﬁed. Physicians who wish to obtain Part 4 MOC by designing their own QI project may submit an application to the American Board of Pediatrics. Individual physicians or groups of up to nine may apply to earn 25 of the 40 necessary points. Doing so requires a $75 fee and takes 12 weeks to receive approval. QI projects must address one or more of the IOM’s six

Other opportunities to satisfy MOC requirements include offerings from the American Academy of Pediatrics. Many Education in Quality Improvement for Pediatric Practice (EQIPP) modules now are included in academy membership. The SC Department of Health and Human Services also offers opportunities to participate in quality improvement; contact Lynne Martin at (803) 898-0093 or martinly@scdhhs.gov.

Dedication to ongoing quality improvement now is integrated into regulatory and practice requirements. Resources continue to become available to assist physicians in this important activity. GHS Children’s Hospital has ongoing projects through its residency program and standing multidisciplinary committees. Pediatricians interested in becoming a part of these activities should contact Dr. LaCroix at (864) 455-3512 or rlacroix@ghs.org.

Article author Robin LaCroix, MD, is vice chair of Medical Staff Affairs for Children’s Hospital at Greenville Health System (GHS) and a Pediatric Infectious Disease physician at GHS.

CELEBRATIONS

Children’s Hospital of Greenville Health System (GHS) has many reasons to celebrate! Development Council Awards At its annual celebration in September, GHS’ Children’s Hospital Development Council honored several employees, community volunteers and supporters of Children’s Hospital. Seven Caregivers of the Year were selected for their special caring for children and their families: • Carol Whitten: Bryan NICU • Gabriela Carvalhal: Inpatient, PICU and Hematology/ Oncology Nursing • Krista Meeks: Outpatient Services • Allison Gilbert: Physician Practices and Specialty Care • Ayesha Ahmad: Inpatient and Outpatient Non-nursing • Brittany Wimphrie: Outpatient Primary Care • Dianne Dillon: Non-clinical Professional

Above: Lesley Griffith holds the Buddy’s Spirit award, ﬂanked by Ryan Rosenfeld and Linda Brees. Right: Linda Brees presents the GHS Legislative Advocacy award to Joe Waters of the Institute for Child Success.

The GHS Legislative Advocacy award went to the Institute for Child Success for the rigorous lobbying efforts of its leaders on issues that relate to successful education of all South Carolina children. Lesley Griffith won the Buddy’s Spirit award for embodying the spirit of giving back to Children’s Hospital through time, talent and treasure. This honor is given to a council member.

(l-r) Caregivers of the Year: Dianne Dillon, Ayesha Ahmad, Allison Gilbert, Brittany Wimphrie, Krista Meeks, Gabriela Carvalhal, Carol Whitten.

In addition, outgoing members of the Children’s Hospital Development Council were recognized. The council primarily consists of community champions for children, with special emphasis on reducing unintentional injury, improving health care, and providing education and advocacy efforts for the betterment of upstate children.

CELEBRATIONS

Dr. Lookadoo Earns Recognition The Children’s Hospital Family Advisory Council presented Stephen Lookadoo, MD, with its ﬁrst Family-Centered Care Award in July. The award recognizes Children’s Hospital staff who go above and beyond to provide great care to patients and to partner with the patient’s family to provide that care. Dr. Lookadoo was nominated for the award by the father of a patient seen for a rectal tear. The father said in his nomination form that “Dr. Lookadoo has shown on many occasions that he is an expert and has all the knowledge to help with our three young sons. His ‘bedside’ manner is great!”

Dr. Schmidt works on his dish, black bean pudding with whipped cream and berries, with teammate Donna Johnston (far left) while joking with Tammie Francis of sponsor Francis Produce, at the CHOP! Cancer event. (Photo by Jason Ayers Photography and Video)

Dr. Schmidt Cooks for Cancer William F. Schmidt III, MD, PhD, medical director of Children’s Hospital, was one of 18 local celebrities to participate in the ﬁrst-ever CHOP! Cancer event, which raised money for a Cancer Survivors Park in Greenville.

Dr. Lookadoo receives the Family-Centered Care Award from Emily Durham (left), Child Life Supervisor and staff facilitator of the Children’s Hospital Family Advisory Council, and council member Susan Budd.

Radiothon Raises $295,552 The latest Children’s Hospital Radiothon raised $295,552, thanks to strong community support and its radio partners. These monies help support various initiatives for patients, from PlayStations and DVD players to diapers and funds for children to attend Camp Courage.

Participants were divided into three teams of chefs, with each chef assigned to prepare an appetizer, main course or dessert. Dr. Schmidt’s team, the Soup-A-Stars, was the top team food winner at the event. The CHOP! Cancer event raised $170,000 for the Cancer Survivors Park Alliance. The park will occupy 6.8 acres along the Reedy River in downtown Greenville. Children’s Hospital has A rendering of the bronze sculpture, titled Fear Not, donated $100,000 that will be the centerpiece of the Children’s Garden at the Cancer Survivors Park. A donation from for a large statue Children’s Hospital paid for the sculpture, which was that will be the created by Greenville artist Charles Pate Jr. central feature in a 15,000-foot Children’s Garden in the park.

CELEBRATIONS

Safe Kids™ Upstate Marks Milestone appropriate to review the accomplishments of this awardwinning coalition. Safe Kids Upstate has long been a champion of safe sleep environments for infants under 1 year old. Through its Upstate Cribs for Kids program, begun in 2008, the organization has provided safe sleep education to thousands of families and distributed more than 2,000 portable cribs. Among families participating in this innovative safe sleep education program, no child has died as a result of unsafe sleep practices. Local public safety personnel and health-related characters at the 2010 celebration of Safe Kids Upstate’s 15th anniversary.

In 1994, when Children’s Hospital of Greenville Health System (GHS) created a coalition to reduce unintentional childhood injuries, it was not uncommon for children to ride bicycles and skateboards without helmets or travel in a vehicle without a car seat. 1995 marked the beginning of what is now Safe Kids Upstate, led by GHS Children’s Hospital. The organization spans three counties and aims to reduce unintentional childhood injury and death. In the two decades since its inception, the Upstate has seen a 43 percent drop in childhood deaths from unintentional injuries and a 22 percent drop in unintentional injuries to children. “The ideal way to treat childhood injuries and fatalities is to prevent them from occurring in the ﬁrst place,” said William Schmidt III, MD, PhD, medical director of Children’s Hospital. “That is exactly what Safe Kids Upstate has done for Greenville, Pickens and Oconee counties, preventing hundreds of visits to our Children’s Emergency Center.” The organization’s focus will become even more important as we move forward into a healthcare environment based on population health and prevention. “As health systems like GHS assume more responsibility for our general population’s health, successful programs like Safe Kids Upstate will play an increasingly important role in keeping our children free from preventable injury,” Dr. Schmidt said. At the junction of this turning point in health care and the 20th anniversary milestone for Safe Kids Upstate, it’s 18

Buddy’s Home Safety House, Safe Kids Upstate’s popular mobile home safety exhibit, delivers education about safety around the house to about 2,000 children and their families each year. Safe Kids Upstate also has fitted and distributed more than 24,500 bike helmets and provided safety information through numerous bike rodeos and presentations. Still, bikerelated injuries send more children between ages 5 and 14 to the emergency room than any other sport-related injury. Nationwide, the annual number of bicycle-related head injuries in children has been increasing and now exceeds 40,000. Another area where Safe Kids has had an impact is water safety. Since 1994, the group has distributed personal flotation devices and recently initiated the Life Jacket Loaner Board program in Oconee County. Established in 2012, this program contains information on how to determine if a life jacket fits properly and provides life jackets that families can use and return. The group’s Safety Patrol program is active in 78 elementary and middle schools in Greenville, Pickens and Oconee counties. Safe Kids Upstate offers training and equipment to help develop safe, efficient carpool lines and instill a culture of safety through its Safe Schools program. One of the coalition’s biggest areas of impact is child passenger safety. Over the last 20 years, the organization has checked more than 15,000 car seats at its eight permanent Child Safety Seat Inspection Stations and provided close to 10,000 replacement car seats to families whose existing seats were expired or who did not own the appropriate seat.

CELEBRATIONS

Children and police officers pose for a photo following a bike rodeo event in Simpsonville in 2004.

In addition, Safe Kids provides car seat assistance and ﬁttings to parents of children with special needs. Safe Kids Upstate also played an important role in advocating for laws requiring booster seats for older children. Through these passenger safety efforts, Safe Kids Upstate has contributed to a 30 percent decline in motor vehicle deaths of children less than 1 year old and a 43 percent drop in motor vehicle deaths of children 4 years of age and under. Linda Brees, MS, director of Children’s Advocacy and former Safe Kids Upstate Coalition leader, said the organization’s success has depended on a number of things: a committed lead organization (GHS Children’s Hospital), a parent organization (Safe Kids Worldwide), community volunteers such as those who serve on the Children’s Hospital Development Council, coalition partners from across the Upstate, great staff and leaders, engaged physician champions and, especially, a dedicated program sponsor in the Bradshaw Automotive Group, which has partnered with and supported Safe Kids Upstate for more than a decade.

Children on the Safety Patrols at local schools walk around Fluor Field before the baseball game at Safe Kids at the Drive.

“The Bradshaw family has made our work possible through their philanthropic gifts,” Brees said. “That allows us to save lives every day.” It has been a busy and productive 20 years for the group, but much work remains when it comes to preventing unintentional childhood injuries and death. Thanks to its nearly 100 coalition partners and sponsors, Safe Kids will continue to reinforce the message of keeping children safe.

Safe Kids Upstate has checked more than 15,000 car seats at its Child Safety Seat Inspection Stations around the Upstate.

CELEBRATIONS

Children’s Hospital Goes to Camp! Two special summer camps offered GHS Children’s Hospital patients the chance to enjoy a week of fun and fellowship with other children who share similar health conditions. At Camp Courage, upstate children and teens with cancer or blood disorders can participate in activities such as swimming, horseback riding and rock climbing. The camp takes place at Pleasant Ridge Camp & Retreat Center near Marietta. Staff members of the hospital’s BI-LO Charities Children’s Cancer Center provide 24-hour medical supervision on-site. Camp Luv-A-Lung is an annual event for rising second through eighth graders with respiratory conditions. This camp also takes place at Pleasant Ridge and includes similar activities to Camp Courage. Counselors are members of the GHS healthcare staff, and nurses are available on-site at all hours.

CLINICAL RESEARCH UPDATE Research studies at Children’s Hospital of Greenville Health System (GHS) are approved by GHS’ Institutional Review Board.

Division of Pediatric Endocrinology Research New Studies

Ongoing Studies

Pediatric Diabetes Consortium: The prevalence of type 2 diabetes (T2D) in adults and children continues to rise. In the US, one in three newly diagnosed cases of diabetes in children younger than 18 is T2D.

T1D Exchange: This registry of 68 centers from across the country lists about 35,000 people with T1D. GHS is the only participating center in South Carolina. This research study helps us better understand T1D and also links the centers to help with collaborative research studies.

Currently, only two of 12 FDA-approved glucose-lowering medications are indicated for the pediatric population: insulin and metformin. Evidence suggests that T2D has serious complications for children as soon as two years after diagnosis. To better characterize the T2D pediatric population and coordinate research efforts, a coalition of eight large pediatric diabetes centers across the US was formed. In 2015, the coalition sought 10 new centers to enroll in the Pediatric Diabetes Consortium. Children’s Hospital’s Division of Pediatric Endocrinology at Greenville Health System (GHS) was one of the 10 sites selected from a highly competitive group. Our role is to enroll additional participants in the registry and take part in innovative T2D clinical trials to assess better treatment possibilities for pediatric patients with T2D. Healthcare use in children with type 1 diabetes (T1D) on SC Medicaid: This investigation is an example of the groundbreaking research partnership between GHS and Clemson University. In collaboration with Joel Williams, PhD, associate professor in Clemson’s Department of Public Health Sciences and an inaugural GHS/Clemson Faculty Fellow, and Ransome Eke, MD, PhD, a postdoctoral fellow and Embedded Scholar in our Department of Pediatrics, we are investigating the direct costs to SC Medicaid associated with caring for children with T1D. Results will help us better understand healthcare use as improved case management and clinical programs are developed to provide optimal, affordable care. Ellipse Trial: This pharmaceutical-sponsored study investigates liraglutide (VictozaTM) as a possible new therapy for children with T2D.

SEARCH: SEARCH for Diabetes in Youth is a multicenter study aimed at better understanding of diabetes among children and young adults in the US. SEARCH centers are located in South Carolina, Ohio, Colorado, California and Washington. Some centers have multiple sites within a state. SEARCH is funded by the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases. SEARCH helps ﬁnd answers about types of diabetes, diabetes complications, and how having diabetes affects children and young adults. TrialNet: Multicenter, national trial investigating the natural history of T1D and coordinated trials aimed at prevention or reversal of this disease. GHS is involved in three TrialNet studies: • Natural history of T1D: This study investigates siblings and family members of patients with T1D to better understand the natural history of the disease (who is at greatest risk, risk factors, timeline from initial identiﬁcation of risk and disease development). • Oral insulin: This trial investigates whether an insulin pill taken orally (that does not affect blood sugar) can prevent diabetes onset in individuals who are at risk but have normal glucose tolerance. • Tepluzimab: This trial investigates whether an immunomodulatory medication will prevent T1D in people at high risk for progressing to diabetes and already showing signs of abnormal glucose tolerance and elevated blood sugars. Welchol: This pharmaceutical-sponsored study investigates colesevelam use as a novel treatment for pediatric T2D.

CASE STUDY

Systemic Idiopathic Juvenile Arthritis An 11-year-old patient without significant past medical history presented to Children’s Hospital of Greenville Health System (GHS) from his primary care provider with chief complaints of headache, dizziness, fever and myalgia over a two-week span. At first, he complained of decreased activity and subsequent left-sided frontal headaches. His headaches worsened over the next few days, becoming generalized, and were associated with malaise and anorexia. Additionally, he complained of a sore throat and dizziness. Initial lab testing was negative for streptococcus pharyngitis and influenza. He was admitted to GHS because of dehydration. He then developed a fever and non-bloody, non-bilious emesis in addition to his previous symptoms. A head CT was performed, and he was diagnosed with sinusitis. CBC was found to show leukopenia and thrombocytopenia. After receiving IVF and antibiotics, he was discharged.

He continued to be febrile with a Tmax of 102F. In addition, he developed a flat, red, irregular rash starting in the axilla that would wax and wane with fever. Once admitted to GHS Children’s Hospital, he developed worsening muscle pain that limited his movement and ambulation. He denied that he had diarrhea, arthralgia or joint/muscle swelling. His parents denied recent travel or new/exotic food exposures, but he did state he often played in local wooded areas. Family history revealed significant rheumatologic pathology, including SLE, RA, Sjogren’s and hypothyroidism. On exam, the patient continued to be intermittently febrile with tachycardia. Exam findings included nondescript mild abdominal tenderness to palpation with soft liver edge 2cm below costal margin; diffuse muscle tenderness limiting active ROM; and a blanchable, erythematous, macular rash. He was also noted to have dermatographia. Lungs were clear and he did not have lymphadenopathy.

Initial evaluation included consideration for oncologic etiology, EBV-related HLH, bacteremia, viral illness, tick-borne illness and rheumatologic disease. Laboratory abnormalities included hyponatremia, hypochloremia, low albumin and total protein, mildly elevated liver enzymes, mild leukocytosis, elevated CRP and ESR, elevated LDH, elevated aldolase, elevated fibrinogen, and elevated ferritin. ASO, CPK, uric acid, blood and urine cultures, respiratory pathogen panel, and monospot were normal. Empiric IV antibiotic coverage was started with vancomycin, clindamycin and doxycycline. Myalgia improved with Toradol but his fever continued. While awaiting further lab results, the patient remained intermittently symptomatic with worsening symptoms occurring during febrile events. An echocardiogram was performed, and a mild inferior pericardial effusion with unknown clinical significance was identified. He was unable to complete activities of daily living without assistance, and his inflammatory markers trended upward. Infectious Disease and Rheumatology were consulted. He was found to have polyarticular arthritis with findings in his elbows, wrists and ankles. Both exam and history were consistent with systemic juvenile idiopathic arthritis (sJIA). During the period after diagnosis and before treatment, concern arose for developing macrophage activation syndrome (MAS) because of declining ESR. However, the patient soon started Anakinra, an IL-1 receptor antagonist, with prompt resolution of fever and rash and improvement in laboratory abnormalities. Arthritis resolved over the next six weeks with outpatient treatment, and the patient was transitioned to Canakinumab, a long-acting IL-1 receptor antagonist. He has remained in full remission on medications for nearly a year, with plans to begin weaning therapy in the coming weeks. A rheumatologic disorder affecting people of all ages, sJIA has peak prevalence between 1 and 5 years of age. It is characterized by arthritis in at least one joint, quotidian fever for at least two weeks and at least one of the following:

The rash typically is salmon-colored, with distribution to the trunk and proximal extremities. Hypersensitivity evokes a rash from trauma or heat in what is known as Koebner phenomenon. Systemic symptoms usually are present before developing arthritis. As seen in our patient, myalgia and a sore throat are other common symptoms. Severe headache is a usual symptom of sJIA. Lab findings typically include leukocytosis and increased inflammatory markers (CRP, ESR, ferritin and platelets). Patients with sJIA are at risk for developing MAS, which can be fatal. MAS is characterized by high fevers, lymphadenopathy, hepatosplenomegaly and encephalopathy. Typical lab values include thrombocytopenia, leukopenia, transaminitis, and elevated ferritin, LDH, and triglycerides. ESR begins to fall due to hypofibriniogenemia, and patients develop purpuric rash and mucosal bleeding. Emergent treatment with immune modulators is necessary in such cases. Of the various manifestations of JIA, sJIA is considered the most difficult to control. While 30-40% of patients have a monophasic course, approximately 50-60% develop a relentless form of polyarticular arthritis. Poor prognostic indicators include increased number of joints involved, prolonged duration of fever and prolonged elevation in inflammatory markers. Typically, sJIA is resistant to treatment from methotrexate or anti-TNF agents, and it requires IL-1 and IL-6 inhibitors. NSAIDs rarely help control symptoms. Longterm management includes yearly ophthalmologic evaluation for uveitis and nutrition counseling for adequate calcium, vitamin D, protein and caloric consumption. As this patient’s case demonstrates, sJIA is a disorder with a potentially great disease burden. However, prompt diagnosis and treatment can help markedly reduce morbidity and longterm complications. Therefore, sJIA and other rheumatologic disorders should remain on differential diagnosis in evaluation of patients with fever or arthritis, particularly those with a strong rheumatologic family history.

• Migratory erythematous rash • Generalized lymphadenopathy • Hepatosplenomegaly

Nicholas Kelley, MD, is a third-year Pediatric resident at GHS Children’s Hospital. His article is written under faculty direction of Sarah Payne-Poff, MD, medical director of Children’s Hospital’s Division of Pediatric Rheumatology.

• Serositis (pericarditis, pleuritis or peritonitis)

Prompt diagnosis and treatment can help markedly reduce morbidity and long-term complications.

SPECIAL PROGRAM Children’s Hospital of Greenville Health System (GHS) features a Pediatric Nurse Telephone Triage program that helps parents make decisions about health care for their child during evenings and on weekends.

Answering the Calls for Help Children always seem to get sick or injured outside of normal business hours.

Perhaps that’s what drove William F. Schmidt III, MD, PhD, medical director of GHS Children’s Hospital, to start a telephone triage program nearly two decades ago to assist parents with after-hours questions about their children’s health. The Pediatric Nurse Telephone Triage program began in 1999, with four nurses serving three GHS pediatric practices. Now, the program includes 12 nurses who team up to serve 21 pediatric practices—both GHS and non-GHS—throughout the Upstate. “Dr. Schmidt was a trailblazer, because there wasn’t a lot out there in the way of telephone triage,” recalled Rachel Edwards, who served as program supervisor until her recent retirement in October. “Now, the concept has expanded greatly.” The nurses—almost all have come to the program from GHS’ Children’s Emergency Center—handle about 90 percent of the after-hours calls without physician intervention. They follow protocols developed by Barton Schmitt, MD, a pediatrician with Children’s Hospital Colorado who has written several manuals and other resources on guiding parents through decisions about their children’s health care. Kevin Polley, MD, medical director of the Children’s Emergency Center and the telephone triage program, said being able to offer patient families after-hours access to nurses who are trained in pediatrics is a valuable service. “That’s a great beneﬁt, considering some of the other nursing call services don’t have pediatrics-speciﬁc nursing, per se,” Dr. Polley said. Two nurses take calls on weeknights, and two nurses are on call from 8 a.m. to 11 p.m. on weekends, with one nurse on call after 11 each night. After-hours calls go to the GHS Call Center, where an operator gathers information about the child and the complaint and then forwards that information to a nurse on call.

Karin Collom, RN, walks a parent through the appropriate care steps during a call as part of the Pediatric Nurse Telephone Triage program at GHS Children’s Hospital.

Sarah Brem, RN, one of the nurses, said they call the parent back within as little as ﬁve minutes—but generally no more

than 20. By following protocols, the nurse can guide the parent to the appropriate course of action, from watchful waiting to an immediate trip to the emergency room. “These nurses work nights, every weekend and every holiday without fail,” Edwards emphasized.

Beneﬁts Abound The program has obvious beneﬁts, both for physicians and for their pediatric patients and families. Topping the list is keeping patients out of the emergency room. “The ER is the last place you want to end up, so the nurses do a fantastic job of handling the calls and helping about 90 percent of those calls avoid the ER,” Edwards pointed out. “Those patients could very easily end up in the ER. So that is a great service to them. In addition, the program helps make sure that the ER is used appropriately.”

The nurses who staff the Pediatric Nurse Telephone Triage program meet monthly to go over quality measures and other important information. Clockwise from left are six of 12 RNs: Program Supervisor Michelle Nicholas, Melinda Bennett, Wendy Watson, Karin Collom, Sarah Brem and Missy Wright.

At the same time, the program lets doctors enjoy a better quality of life during their off-hours. “The physicians and the nurse practitioners, all of them tell us that they get great feedback from their patients’ parents and that they are so thankful that we have this service,” Brem said. “They have complete trust in us. They’re not worried at night about somebody giving their patient the wrong answer.” The nurses also can offer parents a special level of compassion considering the program’s 12 nurses have more than 30 children between them. “As mothers, I think we bring to the table not just the medical, technical piece of the program for the parents, but the compassionate understanding, the ‘I’ve been there, done that,’ type of approach,” said Karin Collom, RN, who, like Brem, has been with the program since its inception. Collom continued, “When I took this position, my youngest was a year old. And they went all the way up to 9, so I had a lot of younger children. I have a lot of heart for the moms and what they are going through.”

‘Close’ Calls An additional service the program provides parents is quality assurance that involves following up on patients referred to the emergency room or an urgent care center—about 10 percent of callers. Brem said she calls these parents a day or two later to check on the patient and survey the parents’ thoughts on the care their child received.

“The parents report that it makes them feel special that somebody did call back to check on their child,” Brem said. “Not all pediatric groups follow up like that.” As the program has grown, it also has added a translation component through GHS’ Language Services Team to better serve non-English-speaking families, particularly the Hispanic community. Dr. Polley said one of the goals for the long-term is to incorporate a telemedicine component into the program. “This would be where you could actually have a video encounter with a patient and perhaps have an even better idea of what’s going on with a patient,” Dr. Polley said. “As technology improves and as we get better and better at these encounters, that’s certainly going to be on the drawing board.” The group of nurses meets monthly—often with Dr. Polley in attendance—to discuss unusual cases that team members handled, along with other important information. And because most of the work is done from each nurse’s home setting, the meetings provide an opportunity to come together and strengthen the nurses’ bond as a group. “We’re very close,” Brem noted. “We really do care about the patients and being professional and doing things correctly, but we also deeply care about each other. We’ve been together, close-knit like that, for many, many years.”

The program helps make sure that the ER is used appropriately. At the same time, the program lets doctors enjoy a better quality of life during their off-hours. 25

A S K T H E FAC U LT Y

Pre-participation Physicals Q: How useful are ECGs in identifying student-athletes who are at risk for sudden cardiac death? A: Pre-participation physicals play a key role in protecting student-athletes. One goal of the pre-participation physical is to identify individuals at increased risk for sudden cardiac death during physical exertion, which continues to be a problem for student-athletes despite widespread use of these physicals. Physicians continue to look for ways to improve the ability of the pre-participation physical to detect pre-existing cardiac abnormalities. One test frequently considered to help identify at-risk individuals is the electrocardiogram (ECG). ECGs are widely available, easy to perform and of minimal risk to the athlete. Theoretically, ECGs can detect excessive myocardial thickness as a sign of hypertrophic cardiomyopathy, the most common cause of sudden cardiac death in studentathletes. However, ECGs have historically had a very high false positive rate, particularly among such athletes, which hinders their usefulness as a screening tool. Student-athletes tend to have larger ventricular volumes, higher skeletal muscle mass, lower body fat percentage and thinner

chest walls than their sedentary peers. These factors make the presence of tall R-waves in the precordial leads much more common in these individuals. Therefore, ECGs in studentathletes often appear abnormal secondary to voltage criteria for left ventricular hypertrophy. Cardiologists have attempted to revise the criteria for left ventricular hypertrophy in the ECGs of student-athletes; however, until recently, no speciﬁc criteria were widely accepted. In 2012, experts in sports medicine and sports cardiology convened in Seattle to discuss this conundrum. They devised new protocols aimed at distinguishing normal ECG changes in an athlete from changes likely to be secondary to a pathologic condition that would increase the risk for sudden cardiac death. These measures have come to be known as the Seattle criteria. The Seattle criteria are rapidly gaining acceptance among those working with collegiate athletes. However, it is not yet clear if the Seattle criteria are appropriate for high school and younger athletes. Greenville Health System (GHS) now is conducting a study of the Seattle criteria, “Improving standards in the prevention of sudden cardiac death in young athletes.”

Pediatric Specialty Services

This study is a collaborative effort among GHS’ Carolina Cardiology Consultants, Pediatric Cardiology, Family Medicine and Sports Medicine. We currently are performing ECGs to be interpreted by the Seattle criteria and then compared with echocardiographic findings at local universities. We hope to expand this investigation to local high schools soon. If this study and similar ongoing efforts around the world confirm that the Seattle criteria can appropriately identify pathologic ECG findings in athletes without an inappropriately high false positive rate, ECGs soon may be added to the pre-participation screening evaluation. While using the Seattle criteria—if evidence supports it—to more reliably identify at-risk individuals may prevent some incidents, several other conditions exist that increase the risk of sudden cardiac death and are more difficult to detect in the pre-participation physical. Many of these conditions are progressive in nature, which can make them even harder to pinpoint during a single examination. And they are so infrequent that physicians likely will screen a very large number of patients before identifying one at-risk individual. As a result, the immediate availability of an automated external defibrillator (AED) and trained users during competitions and practices will continue to be an important component of the safety net for student athletes.

References: 1. Drezner JA, Ackerman MJ, Anderson J, et al. Electrocardiographic interpretation in athletes: The ‘Seattle criteria’. Br J Sports Med. 2013;47(3):122-124. doi: 10.1136/bjsports-2012-092067 [doi]. 2. Drezner JA, Ackerman MJ, Cannon BC, et al. Abnormal electrocardiographic findings in athletes: Recognising changes suggestive of primary electrical disease. Br J Sports Med. 2013;47(3):153-167. doi: 10.1136/ bjsports-2012-092070 [doi]. 3. Drezner JA, Ashley E, Baggish AL, et al. Abnormal electrocardiographic findings in athletes: Recognising changes suggestive of cardiomyopathy. Br J Sports Med. 2013;47(3):137-152. doi: 10.1136/bjsports-2012-092069 [doi]. 4. Drezner JA, Fischbach P, Froelicher V, et al. Normal electrocardiographic findings: Recognising physiological adaptations in athletes. Br J Sports Med. 2013;47(3):125-136. doi: 10.1136/bjsports-2012-092068 [doi].

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For admission to Children’s Hospital: (864) 455-0000 This number connects you to GHS’ Patient Referral and Transfer Center, which can handle all arrangements for admission. You also may call 455-7000 and ask the operator to page the admitting resident. Neonatal Transport _________________________________ (864) 455-7165 To reach a Children’s Hospital doctor or program, call 1-800-4RBUDDY. Pediatric Outpatient Service Locations Call the appropriate Greenville number above for an appointment.

Article author Jon Lucas, MD, is a pediatric cardiologist at GHS Children’s Hospital.

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Exhibit Marks 20 Years of Keeping Kids Safe The Children’s Museum of the Upstate is featuring a special safety-themed exhibit—Buddy’s Safety Town—as part of the 20th anniversary celebration for Safe Kids™ Upstate, led by Children’s Hospital of Greenville Health System (GHS). This interactive exhibit helps children learn to stay safe at home, at school, on the water, in cars and on bikes. Children can participate in activities such as putting on the protective clothing that helps ﬁreﬁghters stay safe, practicing calling 9-1-1 in an emergency and donning the correct type of life jacket.

The Greenville exhibit runs through January 3. For more information about Safe Kids Upstate’s 20th anniversary, see Page 18.

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