Message from the in-chiefs
Living the healthiest lives possible
At Children’s Wisconsin, we are fully committed to the health and wellbeing of all kids, and we’re pursuing that goal through a wide range of surgical expertise.
Children’s Wisconsin has the full spectrum of pediatric surgical and anesthesia providers. All our surgeons have additional training and experience in pediatric surgery, and many of them are leaders nationally or internationally in their respective specialties. We apply this breadth and depth of experience across many specialties to provide the best in care for kids, no matter their age.
What you will see in the pages of this report is our commitment to providing excellent care while putting patients and their families first. We share examples of improvements in efficiency. For example, we now can provide access to immediate surgical treatment from our otolaryngologists with our fast track for ear tubes.
You also will learn about the complex care provided by specialists from cardiothoracic surgery to neurosurgery, and how our quality improvements include efforts to reduce narcotic prescriptions for patients after discharge while still providing excellent pain relief.
One aspect of pain management is addressed in the spine surgery article, where you will learn about an innovative behavioral approach that helps patients and their families prepare for spine surgery and its aftermath.
Throughout this report, you will see how we are growing as a group — in numbers as well as through new, evidence-based methodologies and treatments. We are focused on providing enhanced recovery after surgery (ERAS), where we attempt to minimize the physiologic changes that occur with surgery. Improving postsurgical recovery leads to better patient outcomes and shorter hospital stays.
We’re interested in performing surgeries in the least invasive way possible. Both pediatric general surgery and pediatric urology selectively use laparoscopic surgery or robotic surgery, which generally result in less pain and faster recovery after an operation.
Surgical Services continues to provide the best support possible by measuring our outcomes continuously, committing to care that’s based on the best evidence and measuring the cost of care so we can provide the best value and come within reach of every family.
Quality care must be made available to as many children as possible. We’re trying to ensure that patients have access to pediatric specialty care despite any socioeconomic challenges or geographic barriers that they may have. To that end, we’ve developed outreach programs and telemedicine to reach areas in the region that have a higher likelihood of socioeconomic barriers to health care.
We hope that Children’s Wisconsin will be known for developing an inclusive, nationally recognized pediatric research program, supported by outcomes data, that promotes innovation and clinical excellence and drives us toward our goal of making sure children in Wisconsin are the healthiest in the nation. Investment in the infrastructure to support that goal is a major priority. We want people to know that at Children’s Wisconsin we’re not only committed to providing exceptional service, but that we’re also investing in our faculty so they can pursue their interests and build programs that will be recognized as best in class.
Thank you for taking time to learn more about some of the many surgical services we offer. The physicians, staff and faculty of Children’s Wisconsin are ready to help kids live the healthiest lives possible.
David M. Gourlay, MD, FACS, FAAP
Surgeon-in-Chief, Marie Z. Uihlein Chair in Pediatric Surgery and Medical Director Children’s Wisconsin
Chief and Professor of Pediatric Surgery Medical College of Wisconsin
George M. Hoffman, MD
Anesthesiologist-in-Chief, Associate Medical Director (emeritus) of Pediatric Critical Care and James S. Tweddell Chair in Pediatric Cardiothoracic Research, Children’s Wisconsin
Chief and Professor of Pediatric Anesthesiology Medical College of Wisconsin
Nghia (Jack) Vo, MD
Diagnostician-in-Chief and Program Director of Pediatric Interventional Radiology Children’s Wisconsin
Chair and Professor of Pediatric Radiology Medical College of Wisconsin
A lasting legacy
A fond thank you to Keith Oldham, MD
After two impactful decades at Children’s Wisconsin and the Medical College of Wisconsin, Keith Oldham, MD — surgeon-in-chief, professor and chief of Pediatric General and Thoracic Surgery — has retired. A career such as his, spanning more than 40 years of medical practice, is difficult to adequately summarize. It is nevertheless well worth the effort to celebrate his accomplishments and legacy and to express gratitude.
A former president of the American Pediatric Surgical Association (2012–2013), Dr. Oldham also served on the board of directors for Children’s Wisconsin, Children’s Specialty Group, Global Initiative for Children’s Surgery and Children’s Research Institute.
An internationally recognized speaker and visiting professor, recipient of numerous grants and author of more than 100 published medical papers, Dr. Oldham also made time to provide encouragement and mentorship to colleagues and students. “He is someone who is viewed widely as a mentor to almost everybody that he comes into contact with, because of his natural
instinct to help others achieve what they want,” said David M. Gourlay, MD, FACS, FAAP, Dr. Oldham’s colleague at Children’s Wisconsin.
CAREER ACCOMPLISHMENTS
If there is one constant throughout his medical career, it is a sense of dedication to ensuring the health and welfare of children, including, and perhaps especially, the smallest and most vulnerable. To that end, Dr. Oldham was instrumental in creating and supporting numerous means to improve the standard of care. One of the many impactful accomplishments of his career was the development of the American College of
Surgeons (ACS) Children’s Surgery Verification Program. Dr. Gourlay added: “Several years ago, when he was president of the American Pediatric Surgical Association, in his presidential address, he shared a vision to help ensure that children who required surgery had their procedure in the right place, with the right people, at the right time. And from that vision, he launched a children’s surgical verification program that is sponsored by the ACS. And now, most pediatric hospitals across the country, like Children’s Wisconsin, have gone through a rigorous verification process where they are evaluated for their ability to meet a certain standard of care.”
He also directed and chaired the ACS Children’s Surgery Verification Program, the national Level 1 verification committee that has verified 35 children’s surgical centers. This national program helps ensure children’s specific providers and resources are available to the individual needs of every child needing surgical care. The ACS verified Children’s as a Level I Children’s Surgery Center — a distinguished rank for hospitals that perform pediatric surgery — thanks in no small part to Dr. Oldham’s efforts.
At Children’s Wisconsin, Dr. Oldham created the prestigious Pediatric General and Thoracic Surgery and Pediatric Surgery Critical Care Fellowships and was involved in the formation of Children’s Specialty Group. Children’s Pediatric Surgical Clinical Outcomes Registry, which measures pediatric surgical care, was also Dr. Oldham’s creation.
DEDICATION TO CHILDREN
Dr. Gourlay, who succeeds Dr. Oldham as surgeon-in-chief, recognizes the foundation Dr. Oldham’s efforts laid and seeks to move ahead in the same direction.
“My vision is to build on what [Dr. Oldham] has done to combine our surgical quality program with our surgical research programs. We use our EMR data and information business intelligence to help drive our surgical quality programs in a way that leads to better, patient-centered care and provides better value for our patients.”
During his time at Children’s, Dr. Oldham spoke about what he loved about his vocation, saying: “In surgery, you intervene. You do something that most of the time yields a good outcome, and kids go on to lead full and normal lives. At birthdays and graduations and holidays, I get a variety of notes and cards, outlining how well people are doing in their lives. I love what I do.” He also appreciated the outlook he shared with his colleagues at Children’s, saying: “Everybody begins the day passionate about children.”
The staff and patients of Children’s Wisconsin wish Dr. Oldham the best in his well-deserved retirement and will miss his experience, dedication and mentorship.
Pioneer, friend, mentor
Remembering James S. Tweddell, MD
Lifesaving heart surgeon James S. Tweddell, MD, passed away in 2022 at the age of 62 after a battle with cancer. He had a considerable impact on the Herma Heart Institute during his 20 years of service.
Michael E. Mitchell, MD, Dr. Tweddell’s successor, spent nearly a decade working with Dr. Tweddell as a colleague.
“I was aware of his progress and development at the program from the time I was in medical school back in 1993,” he said. Dr. Mitchell joined Children’s Wisconsin in 2006, but he’d been paying close attention to Dr. Tweddell’s and the heart team’s work all along.
“He and the team here did phenomenal work on developing treatment for patients with hypoplastic left heart syndrome,” said Dr. Mitchell. “They drove the development of the program, which was achieving some of the best outcomes for the treatment of this lesion — better than many other centers around the country. That was a very exciting time for the program, and it really led to significant programmatic development.”
Dr. Mitchell added that beyond being a pioneer in surgical treatment, Dr. Tweddell was a strong champion for the team approach to patient care. “He had an approach that involves the surgeons working with the cardiologists, the anesthesia team, advanced practice providers and ICU nursing staff, all together as part of a team to generate the best outcomes for patients,” he said.
In addition to his talent as a heart surgeon, Dr. Tweddell was known and loved for his skill on the banjo, which he regularly shared on air during the annual Children’s Wisconsin Miracle Marathon radiothon.
“He was an excellent mentor and friend,” Dr. Mitchell said. His patients and colleagues, with whom he built strong bonds and lasting relationships, will miss him dearly.
Carrying on the legacy
In honor of Dr. Tweddell’s lifelong commitment to advancements in cardiac care, the James S. Tweddell Chair in Pediatric Cardiovascular Research has been established at Children’s Wisconsin. If you are interested in contributing to this endowed chair, contact the Children’s Wisconsin Foundation at foundation@childrenswi.org.
The first person to hold this position is George M. Hoffman, MD, anesthesiologist-in-chief and associate medical director (emeritus) of Cardiac Critical Care at Children’s Wisconsin, and chief and professor of Pediatric Anesthesiology at the Medical College of Wisconsin.
Leader and trailblazer
Remembering Marvin Glicklich, MD
Marvin Glicklich, MD, a beloved and influential surgeon at Children’s Wisconsin from the 1970s through the 1990s, passed away in 2022 at the age of 95.
Dr. Glicklich began his medical career after serving in the U.S. Navy toward the end of the second world war, where he developed a love of sailing that lasted his entire life. After studying medicine at the University of Wisconsin School of Medicine, he completed residencies in general surgery, pediatric surgery and thoracic surgery at the VA Medical Center in Milwaukee, Children’s Memorial Hospital in Chicago and Chicago Municipal Tuberculosis Sanitarium, respectively, becoming board certified in all three specialties.
In the 1960s, he began in private practice, pioneering research into microsurgical techniques now commonly used in kidney, heart, lung and gastrointestinal procedures. He joined Children’s Wisconsin in the early 1970s, where he would go on to work, teach and research for three decades. During those years, he cared for innumerable children and significantly furthered the field of pediatric surgery.
Dr. Glicklich was a leader and trailblazer. He developed programs, created subspecialties and mentored future surgeons. He also was a professor emeritus and chairman of Pediatric Surgery at the Medical College of Wisconsin. As a surgeon, his compassion and skill provided his patients and their families with hope and health. Children’s Wisconsin, thanks in no small part to
Dr. Glicklich’s vision and leadership, is recognized as among the top pediatric surgery programs in the country.
Dr. Glicklich retired in the late 1990s and traveled the world with his wife, Diann. He is survived by his children and many grandchildren.
His legacy as a surgeon and a mentor lives on. As Children’s first surgeon-in-chief, he was instrumental in growing our programs, creating subspecialties, recruiting, teaching and training future surgeons. The tradition of excellence that exists within our Surgical Services team is a testament to his vision and hard work. His skill and compassion touched the lives of many patients and families. As a pioneer in his field, his influence will be felt for generations to come.
The value of specialty pediatric anesthesia services
Pediatric Anesthesiology at Children’s Wisconsin provides periprocedural anesthesia, pain management and critical care service for about 22,000 encounters annually on both the Milwaukee campus and the Surgicenter, with a mission to deliver the highest-quality personalized care to all pediatric patients, from neonate to adulthood.
ABOUT THE ANESTHESIA DEPARTMENT
The division consists of more than 30 fellowship-trained pediatric anesthesiologists, as well as advanced practice providers (nurse practitioners, certified registered nurse anesthetists and anesthesia assistants), who work together to provide extraordinary care to every child. Anesthesia services are provided in operating room and nonoperating room locations, including diagnostic and interventional imaging.
All members of the procedural care teams are trained to meet the specific needs of children and their families. The periprocedural process begins with a comprehensive preanesthetic assessment. Children with complex considerations are evaluated by the Pre-anesthesia Evaluation Clinic, which has both virtual and in-person options. Child life specialists are available to help children prepare for surgery. Dedicated surgical nursing and technical staff assist with every procedure, and postprocedural recovery is performed by dedicated pediatric post-anesthesia care unit nurses.
Children’s Wisconsin anesthesiologists participate in surgical, imaging and interventional patient care. Each patient is evaluated for severity of presenting illness and comorbid conditions by performing a five-organ system assessment, which informs a global assessment of the patient called the American Society of Anesthesiologists Physical Status (ASA-PS) score. Once evaluated, the patient undergoes an anesthetic, with combined surgical, imaging and/or interventional care.
SAFETY IS OUR TOP PRIORITY
Major morbidity and mortality during anesthesia in children have declined over many decades with advancements in monitoring and pharmacology. However, these improvements in care delivery have not eliminated the risk of critical adverse events. Importantly, the risk of poor outcomes during surgical and diagnostic procedures is highest in children, especially infants.
Children have unique anatomic, physiologic, psychosocial and pharmacologic characteristics that impact anesthesia care. Respiratory events are most common in children, followed by cardiovascular events. Complications are most likely to occur during procedures that take place in settings outside of the operating room. Routine procedures (i.e., tonsillectomy, adenoidectomy, dental rehabilitation) in otherwise healthy children may be associated with poor outcomes in the absence of appropriate personnel and monitoring. The presence of qualified pediatric anesthesia services has been repeatedly linked to reduced incidence of periprocedural adverse events in children. Universal access to pediatric anesthesia services is critical to improving health care equity in this vulnerable population.
With completion of care, the patient is either awakened and recovered or transferred anesthetized to the intensive care unit, and care is handed off to the receiving team. Upon conclusion of the anesthetic encounter, the anesthesiologist must document their assessment of the anesthetic, identifying any perioperative safety events they were aware of. These events may occur in the immediate perioperative period or even extend out 30 days from the anesthesia encounter.
Perioperative events are categorized into one of five domains: neurologic, airway, respiratory, cardiovascular and other. The other category is further subdivided to stratify events that may include hospital-acquired conditions, human factors and metabolic issues. These events are then evaluated by an anesthesiologist not involved in the care of the patient who performs a scripted analysis of the case.
INCREASING ACCESS
Access to pediatric subspecialty care has been linked to improved outcomes and reduced costs, yet it remains a significant source of health care inequity. With this in mind, the American College of Surgeons developed the Children’s Surgery Verification (CSV) Program to match “providers and resources to the individual needs of every child needing surgical care” with the goal of achieving “optimal patient outcomes regardless of location.” The highest level of CSV verification is Level 1, and Children’s Wisconsin remains the only Level 1 Center in the state.
The division of Pediatric Anesthesiology at Children’s Wisconsin is committed to health equity within the state of Wisconsin and beyond. Serving an increasingly under-resourced and more complex patient population creates increasing demands on all aspects of the health care system, including the high-intensity perioperative and anesthesia environments. Both ASA-PS and social health factors are strong determinants of resource utilization and outcomes.
The goal to always provide safe and compassionate care, regardless of pre-existing conditions or resources, is increasingly challenging, and we are proud to provide the expertise of a highly trained pediatric anesthesia workforce to support our specialty partners and colleagues in service to Children’s Wisconsin’s mission for excellence in patient care, research, teaching and advocacy for children.
Innovation and teamwork
We have lofty goals for our pediatric cardiothoracic division at the Herma Heart Institute. I am extremely proud that over several decades we have published on numerous innovations, improvements and new approaches to the treatment of the most complex lesions in our specialty. Centers around the world have adopted our advances in the treatment of conditions such as atrioventricular canal defects, hypoplastic left heart syndrome, Ebstein anomaly and complex tracheal lesions, as well as improvement to the Norwood procedure and the Sano shunt.
For instance, we developed a novel arch reconstructive technique in the Norwood procedure. We applied the “dunk” technique for the Sano and used a hybrid approach for the highest-risk patients. We initiated a double switch operation to correct congenital transpositions. And we began using tracheal agenesis in neonates with associated cardiac defects. We also advanced the treatment of neonatal, infant and pediatric heart failure patients using aggressive ventricular assist strategies and brought valve-sparing aortic root operations and modifications of the Ross procedure to patients with complex congenital heart disease.
All of this has resulted in hundreds of presentations and publications within the U.S. and throughout the world. We provide consultations on managing the most complex congenital conditions in our field.
The Herma Heart Institute was one of the first programs to publicly report our outcomes data. We continue such transparency via public reporting through national and international registries. This reporting enables those who treat patients with congenital heart disease to learn from one another to achieve the best outcomes. These accomplishments are now the groundwork for our future.
KEY ACCOMPLISHMENTS
In taking on the highest-risk patients, surgical innovation is essential. Our goal is to achieve consistent outstanding outcomes every day. This defines us and will continue to distinguish our program. Achieving consistently excellent outcomes requires both innovation and surgical skill, but it also requires thoughtfulness and intense collaboration. It requires an extremely high-functioning team consisting of the focused and unified work of nurses and physician assistants, cardiologists and intensivists, anesthesiologists and perfusionists, and surgeons and scrub technicians.
Over the past several decades, we have woven these principles into the fabric of our program and our culture.
This year has seen significant improvement in survival in the most challenging cases. In fact, as of late October 2022, our STAT 5 survival rate was 100 percent for the most recent 420 days. We believe one reason for this is the team-based, protocol-driven algorithm we’ve developed that guides our approach based on the individual patient’s challenges. For instance, we work closely with our cardiac catheterization team to treat the smallest and highest-risk children with hypoplastic left heart syndrome.
We created a pulmonary vein stenosis team, including our interventional cardiologists, and developed a protocol that enables us to take on cases other centers turn away. Correcting high-grade pulmonary vein stenosis, in which there is a blockage in the vessels that brings blood from the lungs back to the heart, is extremely difficult, with a high rate of mortality. However, we have demonstrated success in increasing life expectancy in these patients.
This year, we embarked on a program using analytics to drive quality improvement in much the same way sports teams use analytics to improve athletic performance. We have 50 years of data from multiple sources available to our providers through Cardiac Insight. By drilling down on factors that might significantly impact outcomes, and then identifying areas of improvement, we’re able to use a data-driven approach to address them in real time.
LOOKING TO THE FUTURE
While we continue to innovate and enhance the science of surgery, we recognize there are many components of our specialty that will remain art, which is something we embrace. This duality is what makes our work so wonderfully challenging and rewarding.
While we have accomplished so much as a program, we realize we have more work ahead of us. Our historic successes are just our beginning. We are now rolling up our sleeves and embracing innovation and teamwork as we tackle the work of the future.
TO REFER A PATIENT to the Herma Heart Institute at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer.
Improving care for acute appendicitis
By David M. Gourlay, MD, FACS, FAAP
As the most common diagnosis requiring surgery in the pediatric population, appendicitis is the most substantial contributor to cost variability in pediatric surgery. At Children’s Wisconsin, our Pediatric General and Thoracic Surgery team has focused considerable efforts on improving the quality and value of care for this common surgical condition. In particular, we have focused on minimizing radiation exposure, decreasing hospital length of stay, avoiding opioid overuse and providing high-value, family-centered post-operative care.
ULTRASOUND USE
For pediatric patients with possible appendicitis, it is recommended that ultrasound be used as the first imaging modality if diagnostic imaging is necessary to make the diagnosis. In comparison to computer tomography (CT), ultrasound is less expensive and does not expose patients to radiation. Ultrasound does require the hospital to have radiologists and ultrasound technicians who are trained and competent in performing ultrasound for appendicitis. At Children’s Wisconsin, we have radiologists and technicians available 24/7 to perform ultrasound for appendicitis. This has helped reduce our use of CT to less than 13 percent for patients who present to Children’s Wisconsin, compared to 25 percent for patients who are transferred from outside emergency rooms.
DECREASING HOSPITAL LENGTH OF STAY
Another area in which we have made significant quality improvement is decreasing the length of stay for patients undergoing a laparoscopic appendectomy for acute uncomplicated appendicitis.
As a first step, the barriers to discharge after surgery were closely evaluated. That project was recently published in the American Journal of Surgery. We then developed a workflow to address barriers and facilitate same-day discharge. This evidence-based workflow was developed using a multidisciplinary team, including representatives from hospital administration, pediatric general surgery, anesthesia, day surgery, acute care nursing and case management.
This project included the development of standard discharge criteria to decrease practice variability, elimination of unnecessary postoperative antibiotics and IV pain medications, and prompt resumption of an unrestricted diet.
Furthermore, we developed a process that permits discharge of patients from our surgical recovery area in order to streamline the patient experience. Patient movement pathways were developed to assist patients and families with navigating their way through the geographic locations of the different phases of care.
Finally, development of preoperative parental guidance regarding postoperative expectations was as an integral part of the success of this project. The anticipated plan of care, including the potential of same-day discharge, is directly communicated with families at the forefront of their hospitalization. A teaching sheet also supports the information that families receive about same-day discharge after appendectomy.
The same-day discharge program was implemented in spring 2021 and continues to be a success. The program has great impact on resource utilization — more than 500 appendectomies have been performed at Children’s Wisconsin over the past 12 months, and more than 72 percent of those patients met criteria for acute uncomplicated appendicitis. The number of patients meeting criteria for same-day discharge has steadily increased over the last year, facilitating a significant decrease in the average time to discharge. On average, the time to discharge following surgery has been just nine hours since implementation of the same-day discharge project.
REDUCING OPIOID MEDICATIONE EXPOSURE
In addition to decreasing the overall length of stay for patients, efforts to avoid prescribing opioid pain medications for this patient population at discharge have also been highly successful. A multimodal pain regimen was developed for use both intra- and postoperatively to include scheduled nonopioid pain medications, use of regional blocks and application of other non-pharmacologic therapies. Patients and families are educated about the importance of scheduling nonopioid pain medications in the days following surgery. Review of 30 randomized patients who underwent laparoscopic appendectomy for acute uncomplicated appendicitis showed a total of zero opioid prescriptions provided at discharge.
ENHANCED COMMUNICATION
Finally, the Pediatric General and Thoracic Surgery team leverages technology to enhance communication and decrease unnecessary postoperative visits for patients who underwent an appendectomy. Routine in-person postoperative clinic visits may be unnecessary for many common pediatric surgical procedures, including appendectomy for uncomplicated appendicitis. We created a family-centered approach to postoperative care that allows for variability based on both clinical need and families’ varying preferences regarding postoperative follow-up.
Epic’s online patient portal, called MyChart, allows our outpatient clinic staff to utilize questionnaires to address routine postoperative questions for patients and families. A short questionnaire is sent to families who are actively enrolled in MyChart within 72 hours following appendectomy. The questionnaire includes questions related to pain management and overall postoperative well-being. This tool has allowed
families to stay in close contact with the surgical team in the immediate postoperative period and has minimized unplanned visits.
In addition, MyChart is used as a means to complete postoperative follow-up visits. Families are contacted at 30 days with a MyChart message that includes five questions about their outcome. The responses are reviewed by our outpatient team, and for patients who have recovered uneventfully, the postoperative visit is eliminated, or the family is offered a video visit from home instead.
Since implementation, 20 percent of patients have chosen to follow up by MyChart alone. The Children’s Wisconsin Pediatric General Surgery team’s experience using video visits was recently published in the Journal of Surgical Research.
Due to the success of these quality improvement efforts, other surgical specialties at Children’s Wisconsin have gained interest and will be applying similar concepts and strategies, in particular the implementation of same-day discharge after similarly uncomplicated procedures. The Pediatric General Surgery team
continues to evaluate other opportunities for quality improvement in our perioperative care processes for children receiving surgical care at Children’s Wisconsin.
TO REFER A PATIENT to the General Thoracic Surgery Program at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer.
Hand and Upper Extremity Program expands access to specialty care
Jessica Hanley, MD
Jessica Hanley, MD
The Orthopedics department at Children’s Wisconsin has repeatedly been recognized by U.S. News & World Report as one of the nation’s best providers of orthopedic care for kids. Within the Orthopedics Department, the Hand and Upper Extremity Program offers rare specialty care for kids with traumatic hand injuries and congenital conditions of the upper limbs.
Because the anatomy of the shoulder, arm, elbow, wrist and hand is complex, injuries and conditions can be overlooked or misdiagnosed. That’s where the program’s expertise is particularly valuable. Led by Jessica Hanley, MD, a fellowship-trained orthopedic surgeon, the Hand and Upper Extremity Program is the only practice of its kind in Wisconsin.
“We’ve grown tremendously in just three years,” Dr. Hanley said of the program that launched in 2019. In that time, the team that started with Dr. Hanley, a pediatric hand therapist and an athletic trainer, has grown to include a second hand therapist, a physician assistant, a nurse and, soon, another full-time surgeon.
TEAMWORK
Congenital upper extremity patients present with a wide variety of issues, including polydactyly (extra digits), syndactyly (fusion of the skin between the digits) and missing limbs or digits. The Hand and Upper Extremity Program can see patients close to home in the pediatric setting.
Typically, the team sees more than 100 patients each week in the hand clinic. The program’s hand therapists also have begun serving a population beyond orthopedics, including burn patients, which has been beneficial for the hospital and the patients.
The Hand and Upper Extremity Program works closely with other specialties throughout the hospital to make sure their patients get the best care. This involves coordinating treatments and surgeries with other surgeons when possible to minimize anesthesia and being available for consultation or patient follow-up with emergency department and urgent care physicians. “I find that having this multidisciplinary approach makes it easier for us to treat those complex clinical issues while ensuring that each child is getting the most appropriate, individualized care and timely treatment,” said Dr. Hanley.
PRESENT AND FUTURE
The Hand and Upper Extremity Program started with two clinic locations and recently added a third. Dr. Hanley plans to continue growing the program.
In the future, she hopes to start a congenital upper extremity camp where kids can meet and interact with other kids with upper limb differences. “There has been a lot of excitement from patients and parents when they hear about ‘hand camp,’” she said. “That is something we would like to make happen in the next few years.”
Dr. Hanley and her team contribute to research by keeping a registry of children with congenital upper limb conditions at Children’s Wisconsin. This can eventually be integrated into the national Congenital Upper Limb Differences (CoULD) Registry. The goal of this research is to look at patient outcomes after surgical and nonsurgical treatments and track a variety of outcomes — not just medical, but also social and emotional impacts of congenital conditions.
Ultimately, Dr. Hanley’s goal is to expand access to care for children with upper extremity injuries or conditions. “There is always more we can do, and we will continue to work hard to meet the needs of the community and beyond,” she said.
TO REFER A PATIENT to the Orthopedics Program at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer.
Providers aim for rapid access for recurrent ear infections
Otitis media can have a negative impact on a child’s quality of life, and recurrent ear infections can result in missed school for affected children and missed work for caregivers. Repeated exposure to antibiotics for otitis media can have a number of side effects, such as skin reactions and upset stomach. Overuse of antibiotics can lead to increased bacterial resistance in a child, making ear infections increasingly more difficult to treat. Recurrent ear infections and chronic middle ear effusions also can have a negative impact on a child’s hearing and speech development.
Every year, it is estimated that more than 700 million episodes of acute otitis media are diagnosed around the world, making it the most common reason for medical visits and antibiotic prescribing in children. The economic burden of otitis media in children is staggering: It is estimated that between $4 billion and $5 billion are spent each year in the United States on ambulatory care of children with ear infections.
The placement of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States and is an effective tool to relieve the burdens associated with recurrent and chronic otitis media. Ear tube placement is a quick ambulatory procedure, typically performed under a minimal general anesthetic. The result is commonly a child with healthier ears who is able to return to daycare or school the day after the procedure.
FAST TRACK EAR TUBE PROGRAM
Throughout the years, the Pediatric Otolaryngology team at Children’s Wisconsin has continued to strive to provide efficient, equitable and evidence-based care to our children in need of relief from recurrent ear infections, particularly when antibiotic resistance has made effective medical treatment difficult. In 2017, Children’s Otolaryngology introduced the Fast Track Ear
Tube Program, a quality improvement project aimed at improving access for these children who needed ear tubes as soon as possible.
Before the Fast Track Ear Tube Program, the time to next appointment for new patient referrals was typically 14 days, with another 2–4 weeks before surgery could be performed. This 4–6-week span from referral to surgery sometimes meant a high likelihood that children would be diagnosed with another ear infection and need another round of antibiotics, adding to the overall disease burden.
The Fast Track Ear Tube Program aimed to reduce this by reserving new patient appointments with an otolaryngology nurse practitioner within one week of referral from the primary care provider for select patients and allowing for surgical scheduling 48 hours after the patient was seen by the otolaryngology nurse practitioner and confirmed to be a candidate for ear tubes.
A pilot study of 45 families who went through this program in 2017–2018 quickly revealed what a huge success this was, with 100 percent of families agreeing that the Fast Track Ear Tube program was timely and effective, and that they would recommend it to other families in need of relief for their children suffering from recurrent ear infections. When asked about their perceptions of the Fast Track Ear Tube Program, referring providers echoed the positive sentiment of their patients’ families. Providers were overall very satisfied with both the ease and accessibility of the referral process and the advantage of avoiding extra antibiotic burden for their patients.
EXPANDING ACCESS
After an immensely successful pilot, the Fast Track Ear Tube Program expanded its access, with otolaryngology providers at multiple Children’s Wisconsin clinic sites now reserving slots for Fast Track Ear Tube referrals, and more than 325 children have been referred for expedited ear tube placement in the last year alone.
If the program has saved each child one ear infection, on average, with a health care cost of about $200 per episode of otitis media, the Fast Track Ear Tube Program has potentially saved the health care system in Wisconsin $65,000 in the last year alone. However, this financial victory pales in comparison with the satisfaction of our families and referring providers.
TO REFER A PATIENT to the Otolaryngology Program at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer.
An evolving treatment paradigm for Robin Sequence
Mandibular hypoplasia, retrognathia (posteriorly displaced mandible) and micrognathia (undersized mandible) are commonly encountered problems in pediatric plastic surgery — with potentially devastating complications for the growing child. Robin Sequence (RS) represents a rare congenital birth defect with an estimated frequency of 1 in 8,500–14,000 births. Isolated RS occurs from de novo genetic mutations, while the sequence may be a feature of an overlying syndrome and subsequently inherited in an autosomal dominant manner.
ISSUES IN CHILDREN WITH RS
The term “sequence” refers to the sequential events occurring in utero that stem from mandibular hypoplasia, including tongue displacement and airway obstruction. Often, children with RS develop large U-shaped cleft palates, as the underdeveloped mandible displaces the tongue posteriorly and prevents descent of the palatal shelves to form the secondary palate during embryogenesis.
Children born with RS clinically manifest with early feeding issues, repeat ear infections and a spectrum of breathing difficulties. This spectrum spans snoring and stridor to hypoxemia and hypercarbia, resulting in failure to thrive, developmental delays and cor pulmonale (a condition that causes the right side of the heart to fail).
TRADITIONAL THREATMENT FOR RS
Treatment strategies rely on interpretation of sleep study data used to corroborate clinical signs and symptoms of obstructive sleep apnea (OSA). While milder phenotypes may be managed nonoperatively with prone positioning, nasopharyngeal airways and supplemental oxygen, those with more severe phenotypes often require ventilatory assistance and possible tracheostomy.
The ideal management of these severely affected children remains to be elucidated.
- Tracheostomy offers a definitive and reliable airway but results in significant morbidity.
- Tongue-lip adhesion (TLA), introduced in the 1940s as an alternative to tracheostomy, relies on subsequent “catch-up growth” of the hypoplastic mandible and simply affixes the tongue anteriorly to mitigate airway obstruction as the child continues to grow.
- Mandibular distraction osteogenesis (MDO), pioneered in the 1990s and utilized in a variety of craniofacial surgery applications, offers a surgical solution to lengthen the underdeveloped mandible. Yet, the risk profile of MDO continues to evolve, and its long-term durability and safety remains in question. Specifically, iatrogenic complications of distraction include damage to the permanent molars, temporomandibular joints (TMJ), inferior alveolar nerve, marginal mandibular nerve and cutaneous facial scarring.
STUDY ON TLA AND MDO
The surgical management of RS presenting with severe neonatal airway obstruction at Children’s Wisconsin has continued to evolve since the introduction of mandibular distraction. To better assess mid-term surgical outcomes and inform decision-making, we performed a retrospective cohort study of age and disease severity-matched subjects with RS and cleft palate undergoing either TLA (n=29) or MDO (n=40) over a 17-year period.
Using sleep study data [i.e., Apnea-Hypopnea Index (AHI)], we hypothesized MDO offers a faster resolution of OSA when compared to TLA but leads to increased iatrogenic complications and morbidity. Our results demonstrate improved initial postoperative AHI, significantly decreased intensive care length of stay in subjects undergoing MDO and a decreased rate of
reintubation (2.2 percent versus 10.3 percent), but comparable subsequent AHIs in the MDO and TLA cohorts, suggesting mandibular “catch-up” growth in the TLA cohort. Moreover, only a minority of patients in either cohort required postoperative enteral nutrition (MDO 5.4 percent v. TLA 9.1 percent).
Of the subjects who initially underwent TLA, 20 percent required revision or conversion to MDO, while 14.7 percent of subjects in the MDO cohort required repeat distraction. However, iatrogenic injury in the MDO cohort included facial nerve asymmetry or paresthesias (14.7 percent), TMJ injury/ankylosis (3.0 percent) and extensive cutaneous scarring (4.3 percent). These data
suggest structural alteration of the hypoplastic mandible in RS using MDO remains an imperfect surgical solution with early postoperative benefits that may later become overshadowed by deleterious mid-term outcomes. Are there evolving treatment modalities to address the shortcomings of both MDO and TLA?
PROMISING RESULTS FOR ORTHODONTIC AIRWAY PLATES
Initially introduced in Europe, orthodontic airway plates (OAPs) were recently brought to the United States for the nonsurgical treatment of severe airway obstruction in children with RS. These plates consist of traditional acrylic-based appliances with intraoral, intrapharyngeal and extraoral components. The pharyngeal component is placed in the pre-epiglottic space to elevate the epiglottis and prevent posterior displacement of the tongue.
Promising results in Germany with the Tuebingen palatal plate to treat patients with RS and severe airway obstruction have led to its early adoption stateside. A multidisciplinary team at Stanford University recently published on the efficacy and safety of OAPs for the treatment of severe airway obstructive in patients with RS.
With the recruitment of fellowship-trained craniofacial orthodontist Cleo Yi, DMD, we are excited to be one of a few centers nationally to offer this nonsurgical treatment modality through our multidisciplinary craniofacial team. As we begin to enroll patients, we plan to prospectively assess its efficacy when compared to traditional TLA and MDO in managing severe airway obstruction in patients with RS. We are hopeful OAPs will serve as the next paradigm shift in the management of RS, both in Wisconsin and afar.
TO REFER A PATIENT to the General Thoracic Surgery Program at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer.
Multidisciplinary work group ensures seamless Imaging services
In early spring 2022, the Chinese government implemented a lockdown in Shanghai related to COVID-19. As a result, there became an acute and abrupt shortage of iohexol (Ominpaque)
iodinated contrast media (ICM) commonly used for diagnostic imaging studies (such as computer tomography and fluoroscopy studies) as well as interventional procedures.
This shortage had a nearly immediate impact, both locally and nationally, for health care providers and organizations on how they care for patients requiring imaging and interventional services. By early May 2022, our suppliers informed our team that the supply chain for our typical supply of ICM would be ceased.
ASSESSING CURRENT STATE AND FUTURE IMPLICATIONS
Our leadership team quickly convened a multidisciplinary and collaborative work group of stakeholders to assess the current state and immediate implications for patient care, and to develop a system-wide mitigation strategy with the goal of maintaining the best and safest care, and maintaining high-quality service, while minimizing impact on patients and our referring providers.
As a team, we immediately accounted for and identified the inventory within the entire system and cross-referenced the current inventory compared to typical monthly utilization. This permitted us to project how much ICM was available based on multiple scenarios and assumptions to include the potential for no resumption of routine supply chain for 3–6 months or access to any alternative ICM supplies.
Our pharmacy and supply chain partners were then free to be proactive in acquiring appropriate alternative ICM sources when available. Pharmacy and supply chain demonstrated clear and concise communication with Imaging leadership, keeping the entire team abreast of daily changes and product availability during daily morning huddles. Supply chain was successful in obtaining alternative contrast substitutes, 500mL vials of ICM, alongside the guidance of Imaging leaders.
Immediate strategies included:
- Identifying alternative ICM options, supply sources and integration into clinical use
- Preserving current supply and minimizing waste of current inventory
PROCESS FOR ENSURING SEAMLESS IMAGING SERVICES
Our process for ensuring seamless imaging services amidst the ICM shortage included the following:
- We initially determined there was up to 1.5 months’ supply of ICM in inventory based on traditional monthly utilization projections.
- We defined the initial status as “medium” and did not include a requirement to alter routine imaging services or utilization of ICM for diagnostic or interventional procedures.
- We developed a collaborative process for ICM daily distribution and to minimize waste.
- We held morning huddles Monday through Friday to project ICM required for the day and prior day utilization and impact on
inventory. - Pharmacy investigated and developed a daily process of drawing up from the acquired 500mL vials under the hood into 20 individual vials (25 mL) to ensure the least amount of
medication waste and safest administration practices. - We determined distribution of contrast aliquots to Imaging, Cardiac Catheterization Lab and Surgery based on the day’s scheduled studies and procedures. This would decrease utilization of single-patient 100 mL vials of iohexol ICM, which could have typical waste up to 50 percent. If required, Pharmacy would prepare a second distribution in the afternoon based on continued real-time need. During after-hours and on weekends, the single-patient vials could be used to minimize delays and alterations to routine process.
- We held weekly team meetings to review current inventory, supply chain status and workflow to determine if further mitigation measures would be required.
As a result of the collaborative effort, imaging services and availability were seamless for patients and referring providers. Throughout the potential ICM shortage crisis, no patient or provider was required or asked to consider a delay or alternative for routine diagnostic imaging or interventional procedures.
TO REFER A PATIENT to the Imaging Program at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer
A behavioral health approach to surgical optimization
In 2020, the Children’s Wisconsin Spine teams saw a unique opportunity to improve multidisciplinary care for patients undergoing posterior spinal fusion (PSF), addressing behavioral health factors that complicate surgery. “At first blush, people typically think about how a major surgery affects the mental well-being of patients,” said Nick Young, PhD, pediatric health psychologist in Children’s Wisconsin Orthopedics. “But it’s more complex than that.”
Dr. Young explained things can be better understood with a “biopsychosocial” view — dynamics between physical, psychological, and social-environmental factors all influence the surgery and recovery experience. “For example, the combination of high pre-surgical pain and unmanaged anxiety can increase risk of developing chronic pain.”
Many patients with spine deformities and conditions experience behavioral health problems like this. The demands of a major surgery further complicate things and may lead to other issues, such as longer and more costly hospitalizations.
This is where Dr. Young comes in — identifying and mitigating behavioral health factors that affect surgery and aftercare.
HEALTH OPTIMIZATION: NOT JUST MENTAL
Once surgery is indicated, patients are referred to various specialties based on their health history. However, Children’s Wisconsin Spine teams jumped at the opportunity to integrate Dr. Young into the PSF optimization process. A pre-surgical behavioral health evaluation is now routine for PSF candidates.
“We cover a lot of ground in those visits,” said Dr. Young. “We certainly review overall psychological functioning. But there’s substantial discussion of key health behaviors and cognitions. Do patients have unrealistic expectations that their bodies will be perfectly symmetrical after surgery? Do parents observe behaviors that could amplify pain?”
Patients and caregivers start the evaluation by completing informant measures on things like pain, physical activity and surgery expectations. The results help identify potential risks and guide the clinical discussion.
One especially notable area addressed in his visits: substance use and exposure. “Nicotine in the system increases risk of pseudarthrosis. We’ve all seen the issues with young people vaping,” Dr. Young said, noting that caregivers sometimes see risk from secondhand exposure as motivation to quit themselves. “Connecting caregivers to quit resources in the interest of both their child’s health and their own is a huge bonus.”
The rest of the visit functions much like any other routine medical appointment. Dr. Young gets a detailed history, observes the patient’s psychological/functional status, and communicates impressions and recommendations.
Dr. Young commonly follows patients throughout surgery and recovery for short-term care focused on any number of health-related issues. Common examples include non-pharmacological pain management skills, treating procedural anxiety and supporting return to activity after surgery. That care is coordinated with relevant outpatient and inpatient teams as needed. Much of the work focuses on what happens prior to
surgery. “I describe it as ‘pre-hab’ and contrast it to rehab. I emphasize the importance of prevention to families.” The end goal is always the same: Optimize health for surgery.
Dr. Young explains the connections between anxiety and musculoskeletal pain
Dr. Young explains the connections between anxiety and musculoskeletal pain
TRANSFORMING CARE
Surgery teams speak to the benefits of this novel multidisciplinary care. “It’s completely changed the way we do things for the better,” said Channing Tassone, MD, medical director of Orthopedic Surgery and clinical vice president of Surgical Services at Children’s Wisconsin. “Recoveries are enhanced. Families have a smoother experience.”
Dr. Young expressed his own sentiments: “I want to make everyone else’s jobs easier, so they can focus on doing what they do best. I would trust any of our surgeons with my daughter in a heartbeat. I want our families to feel the same way.”
Expansion to other musculoskeletal procedures is underway. Dr. Young is running ongoing program evaluation and cross-specialty research projects to further improve care. Preliminary results from a recent project suggest certain types of pre-surgical anxiety may be associated with postoperative opioid consumption. Findings like this could help better anticipate and prevent problems. “There’s already plenty of research and clinical justification for what we’re doing, but there’s always room to grow,” Dr. Young said.
TO REFER A PATIENT to the AIM Spine Center at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer
Building partnerships to study pediatric kidney disease
Jonathan S. Ellison, MD
Jonathan S. Ellison, MD
The combination of innovative concepts and teamwork often drive improvements in surgical outcomes. The most impactful projects require hard work and are frequently resource-intensive. But the result of these initiatives — namely, better care of our patients and our families — make such projects worth the cost.
With all the thought and effort put into surgical outcomes research, how can we ensure the outcomes that matter most to patients and their families?
This question has been at the core of our Children’s Wisconsin Pediatric Urology research team for several years. The solution, as we saw it, was both simple and profound: We would ask the patients and families. However, we wouldn’t simply ask them. Rather, we would embark on a program of patient partnership in our research endeavors, starting with pediatric kidney stone disease. With this goal in mind, Jonathan Ellison, MD, associate professor of Urology at the Medical College of Wisconsin, has established several key initiatives in patient-engaged research to enhance surgical outcomes and disease management for our patients.
Anna Kurth, pictured meeting with Dr. Ellison, has been a valuable part of the PKIDS trial and an important voice for children and adolescents with kidney stone disease.
Anna Kurth, pictured meeting with Dr. Ellison, has been a valuable part of the PKIDS trial and an important voice for children and adolescents with kidney stone disease.
A COLLABORATIVE APPROACH
Pediatric kidney stone disease has risen rapidly over the past several decades, with adolescents representing the fastest-growing demographic across the lifespan of disease. Up to one-third of children, adolescents and young adults with kidney stones may need surgery, with each surgical option offering a trade-off of surgical success, postoperative pain and risk of complications. Because high-level evidence (i.e., “gold standard” research studies) supporting the choice of surgical intervention for children with kidney stones does not exist, researchers at Children’s Wisconsin were founding members of the Pediatric KIDney Stone (PKIDS) Care Improvement Network — a collaborative learning health network comprising 30 pediatric health systems dedicated to improving the care of children with nephrolithiasis.
As an executive PKIDS site, our Children’s Wisconsin research team has been instrumental in the development of the PKIDS Trial — an expansive three-year prospective study to investigate the outcomes and lived experiences of children undergoing kidney stone surgery. This trial, funded by the Patient Centered Outcomes Research Institute (PCORI), has enrolled more than 1,000 participants and will provide invaluable information regarding surgical outcomes. Several patients and caregivers who comprise the PKIDS Patients and Family Partners group co-produced this study. The Patient and Family Partners contributed key collaborations to the research design and focus of the PKIDS Trial, including choice of patient-reported outcome measures and timing of postoperative trial-based assessments.
Recognizing the importance of patient engagement in research, Dr. Ellison, who is also associate director of the PKIDS Network, secured funding from PCORI to build further capacity for stakeholder engagement. This project will work with the newly founded Kidney Stone Engagement Core — a team of researchers, patients, caregivers and kidney stone advocates — led by Dr. Ellison to develop a prioritized research agenda for kidney stone disease.
A ROAD MAP FOR PROGRESS
To date, this team has engaged more than 100 individuals who live with or care for someone with kidney stones in order to best understand the day-today issues that should be the focus of future research endeavors. This work, to be completed in 2023, will provide a road map for funding agencies and researchers to develop studies that kidney stone patients have identified as important. Additionally, the Kidney Stone Engagement Core will provide important collaboration, supporting patient insight on outcomes and study design.
Partnering with patients on ambitious research endeavors adds value, ensures patient voices in the process and may also help with study recruitment and retention. Partnerships founded on trusting relationships ensure productive experiences for everyone involved. Research partners are often paid for their time and included on equal footing in meetings with the traditional research team. Researchers must have a focused strategy to engage stakeholders while listening and incorporating their feedback on the proposed projects. By taking the time and effort to include patients and caregivers in their work, research teams can achieve a high level of success while also strengthening valuable and rewarding relationships with their stakeholder collaborators.
TO REFER A PATIENT to the Urology Program at Children’s Wisconsin, call (414) 607-5280 or toll free (877) 607-5280, or visit childrenswi.org/refer
Contact us
We welcome the opportunity to partner with you to serve your patients and deliver the very best outcomes possible. We are happy to answer any questions you may have. Please email us at mdconnect@childrenswi.org.
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