See page 4
The St. Louis Children’s and Washington University
Heart Center maintains a strong referral base
throughout Missouri and surrounding states. Five-yearold Porter Stone with Kelsey Wassmer, BSN, RN, 7 West
(left) and Yvonne Renick, BSN, RN, CICU (right), is from
St. Joseph, MO. Patients like Porter are referred to the
center with complex conditions that require expertise
and coordination beyond routine care.
St. Louis Children’s Hospital is
recognized among America’s best
children’s hospitals by Parents magazine
and U.S.News & World Report. For more
information about nursing opportunities
at a Magnet hospital, visit:
The Heart Center provides patients and families a collaborative approach to care
involving physicians, nurse practitioners, physician assistants, nurses, dietitians, physical
therapists, occupational therapists, speech therapists, pharmacists, respiratory therapists,
social workers and child life specialists — all with specific education and clinical expertise
in caring for heart patients.
Editorial board
Terry Bryant, MBA, BSN, RN, NE-BC
Professional Practice and Systems
Lisa Chapman, BSN, RN
Emergency Unit
Emily D’Anna, PharmD
Clinical Pharmacy
Doing what’s right for kids with heart disease . . . . . . . . . . . . . . 4
Angie Eschmann, RN
Clinical Operating Room
The winter surge of 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Robin Foster, MSN, RN, CPNP-PC, CDE, CPN
General Medicine
Jeanne Giebe, MSN, NNP-BC, RN
Newborn ICU
Peggy Gordin, MS, RN, NEA-BC, FAAN
Vice President, Patient Care Services
Nutritional screening and early intervention in
children with cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What a “NAVA” idea! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Meet Lauren Yaeger, medical librarian . . . . . . . . . . . . . . . . . . . 12
Beth Hankamer, MSN, BS, RN, CAPA
Clinical Education
Lisa Henry, MSN, RN, PNP-BC
Healthy Kids Express
Dora O’Neil, BSN, RN, CCRN
Cardiac ICU
Christina Patrick, MSN, RN, CPN
Clinical Education
Lara Smith, MSN, RN, CPNP
Pediatric ICU
Lisa Steurer, MSN, RN, CPNP-PC, CPN
Professional Practice and Systems
Pediatric Perspectives is published by the
St. Louis Children’s Hospital Communications
and Marketing department.
To add or remove a mailing address or make
a direct inquiry, please contact Arvella Robinson,
at 314.454.4086 or [email protected]
© 2012, St. Louis Children’s Hospital
The leadership team of the
St. Louis Children’s and
Washington University Heart
Center includes (from left)
Shelley Perulfi, MA, BSN, RN,
NE-BC, director; and co-medical
directors Pirooz Eghtesady,
MD, PhD, chief of Pediatric
Cardiothoracic Surgery, and
George Van Hare, MD, director,
division of Pediatric Cardiology.
Not pictured is Allan Doctor, MD,
director, division of Critical
Care Medicine.
See story on page 4.
Pediatric Perspectives
From Peggy
Extraordinary people, remarkable acts
What’s amazing to me
is how the staff at
St. Louis Children’s Hospital
continue to serve
patients and families.
I’ve come to understand
it’s just how we roll here.
Challenge has nearly become routine,
and the past nine months were an
exceptionally demanding time for
us. After the low volumes of 2011,
we were faced with the surge of 2012
and had to ramp up our staffing on
a dime. Every department across the
entire organization pulled together and
played a role — Materials Distribution,
Child Life Services, Nursing, Respiratory
Therapy, Pharmacy and Housekeeping
— just to name a few. The surge
arrived just as we were starting to use
Teletracking for bed management and
trialing a new Emergency Unit patient
throughput process. Hospital volumes
far exceeded what staff had planned for,
so new plans were put in place.
can take a great toll on employees and
their families, and the surge required
a tremendous amount of effort. I
truly appreciate what each and every
one of you did to get us through this
challenging time.
Throughout the weeks that turned into
months, no patient was ever turned
away. The staff knew that they had to
take care of our kids, and employees
stepped up to make that happen on
every shift, every day. Staff worked
longer, taking on more on-call duty
and additional shifts. Times like these
In early April the Trauma Program
hosted a visit from the American
College of Surgeons (ACS) to verify our
application for designation as an ACS
Level I Pediatric Trauma Center. This
visit also went successfully, and we were
recommended for verification. This was
quite an achievement and required the
Another note to recognize during the
early days of 2012 was the presence of
a survey team from the Commission on
Accreditation of Rehabilitation Facilities
(CARF). The hospital’s survey went very
well and staff continued to maintain
their commitment to patients and
families throughout the survey. We were
successfully re-accredited for another
three years thanks to the efforts of that
outstanding team!
collaboration of services from across
the hospital and Washington University
School of Medicine.
Not knowing what might lie ahead for
us, I know that the St. Louis Children’s
Hospital team will step up to meet any
challenge. I encourage you to read
more details about the surge plan
on page 6.
The other articles in this issue outline
several other programs, which represent
the kind of advancements St. Louis
Children’s Hospital has been known for
over the years. You continue to impress
me with your dedication to being your
best for every patient, every family,
every day!
Peggy Gordin, MS, RN, NEA–BC, FAAN,
is SLCH’s Vice President of Patient Care Services.
She can be reached at [email protected]
Pediatric Perspectives
Doing what’s right for kids
with heart disease
The St. Louis Children’s and Washington University Heart Center maintains the largest pediatric heart team in the region.
The St. Louis Children’s Hospital and
Washington University Heart Center
is the influential voice in the hospital,
the medical school and the region,
representing the best interests of
children with heart disease. Team goals
are to offer excellent pediatric clinical
cardiac care; advance the field through
innovation; provide clinical research and
laboratory investigation; and educate
the next generation of academic
physicians and clinicians.
The Heart Center was established to
encompass all aspects of the care that
patients and families receive while
dealing with heart disease. Previously,
activities and decision making had taken
place in multiple, disparate venues,
including hospital units, divisions and
departments. A broader perspective
was needed to achieve an inclusive,
efficient and transparent approach to
care and to collaboratively plan for the
future. The Center is led by co-medical
directors Pirooz Eghtesady, MD, PhD,
chief of Pediatric Cardiothoracic Surgery;
George Van Hare, MD, director, division
of Pediatric Cardiology; Shelley Perulfi,
MA, BSN, RN, NE-BC, director; and
Allan Doctor, MD, director, division of
Critical Care Medicine.
Moving forward
St. Louis Children’s Hospital and
Washington University are building
upon an already robust and prestigious
history of pediatric cardiac care.
Enhancing this history through the
development of the Heart Center
positions the hospital as a leader in
pediatric cardiac care for the future.
Strengths include:
• Active pediatric heart failure and
transplant program with 25 to 30
heart transplants annually
• Expanding pediatric ventricular assist
device program provides a growing
number of device implants each year,
including the Berlin, HeartMate II
and CentriMag. The program
also offers both neonatal and
pediatric Extracorporeal Membrane
Oxygenation (ECMO) support
• Continued expansion and
development of a comprehensive
adult congenital heart program
• Strong quality improvement
initiative related to patient safety
through monitoring and evaluation
of numerous indicators to enhance
patient outcomes
• Considered a high-volume center by
Society of Thoracic Surgeons (STS)
criteria with significantly better
outcomes than the STS national
average for complex cardiac
surgical cases
Pediatric Perspectives
The Heart Center team crosses
departments and includes all disciplines
that provide care to pediatric patients
with heart disease. Each individual
and team collaborates with the Heart
Center through participation on quality
improvement projects, the nursing
taskforce, and regular attendance at
leadership meetings. The blending of
the Cardiac ICU and 7 West patient
care staff is one of the immediate
challenges the team is facing to
enhance continuity of care.
To achieve its mission, the Heart
Center is developing an organizational
structure to enhance collaborative
working relationships across the
hospital and School of Medicine.
Increasing the breadth and depth
of pediatric heart services will help
accommodate increasing volumes
as the program’s national reputation
grows. For example, the Heart Center
received seven admits from Oklahoma
in January 2012 when previously three
admissions were the highest monthly
number admitted from this state.
For additional information, contact Shelley Perulfi
at [email protected]
Heart Center Team
❤ cardiac intensivists
❤ social workers
❤ perfusionists
❤ cardiac
❤ cardiologists
❤ nurses
❤ child life therapists
❤ pharmacists
❤ respiratory
❤ cardiothoracic
❤ pulmonologists
❤ patient care techs
❤ nurse practitioners
A nursing task force meets regularly to
guide Heart Center development and define
the recent combination of 7 West and the
Cardiac ICU (CICU). Members include (from
left): Rachel Miller, MSN, RN, CPN, 7 West
assistant manager; Elizabeth Risse, BSN,
RN, CPN, 7 West; Colleen Murphy, RN,
CCRN, CICU staff nurse; Kym Galbraith,
BSN, RN, CICU assistant nurse manager;
Anna Lawrence, BSN, RN, CICU staff nurse;
Avihu Gazit, MD, CICU medical director;
and Courtney Lazzara, MSN, RN, CCRN
staff nurse.
Pediatric Perspectives
The winter surge of 2012
Every winter, pediatric hospitals gear
up for high census related to viral
illnesses. In preparation for the winter
of 2012, St. Louis Children’s Hospital
proactively established a “surge”
committee during 2011 to plan for
these increased volumes. Based on
the typical winter bed availability
on the 10th floor surgical unit, the
interdisciplinary team developed plans
for patient placement, staffing, medical
coverage and communication.
During this time of the year, medicine
over-flow beds are usually available on
the 10th floor surgical unit; however,
the historical challenge has been
appropriate medical coverage in
order to tackle this issue. A model
was created that added 12 hours
of advanced practice nurse (APN)
day shift coverage to the 10th floor,
providing care for up to 10 general
medicine patients from mid-January
through March. A patient profile was
created to identify potential diagnosis
and appropriate age for this location.
Daily surge planning meetings were common on the 10th floor. From left,
Madeline Martin, BSN, RN, Amy Becker, BSN, RN, and Mary Kay Scanlon,
BSN, RN, administrative supervisor, discuss staffing issues to project needs
for upcoming admissions.
As surge plans were under
development, other organizational
changes were ongoing. Teletracking,
the new electronic bed management
application, went live in November
2011 to provide real-time views
of beds, pending discharges and
environmental services activities. In
addition, the Emergency Unit (EU)
was planning a “Fast Track” concept
using pediatric nurse practitioners to
facilitate EU patient flow. Both of these
initiatives supported patient throughput
efficiencies, especially in times of
increased census.
December 4, 2011 - March 3, 2012
Data reported weekly: week 1 is week ending Dec 10; week ends on Saturday
Then the winter surge hit, and plans
had to be revised. Cases of Influenza A
in the community peaked at the same
Pediatric Perspectives
January 15, 2012 - March 12, 2012
Beginning in January, surge planning
meetings were established weekly to
review the census, required resources
and equipment. After three weeks,
these meetings were changed to
daily meetings, when it was clear the
surge was actually increasing and not
stabilizing. Issues were identified with
updates provided the following day.
Peak census reached 262 patients at
10 a.m. on Feb. 22, 2012, but the census
each and every day was unpredictable,
requiring varying resources in each
department. Ancillary departments
such as Laboratory Services, Pharmacy,
Respiratory Therapy and Dietary had
to respond to the increase in tests,
medications, treatments and patient
meals. Additional physicians and
staff were needed to provide patient
care, but the volatility of the census
each day made this very challenging.
While increased demand on services
was challenging for all, not one child
was sent elsewhere for care. St. Louis
Children’s Hospital staff recognized
their unique role in the care of ill and/
or injured children as well as their
commitment to the community.
As with any plan and situation, there
were lessons to be learned. Earlier
Specialty Care Units
December 4, 2011 - March 3, 2012
time as Respiratory Syncytial Virus (RSV);
(see chart on page 6). Changes
included broadening the diagnoses
admitted to the 10th floor to include
respiratory illness. In addition, an
overflow area for the Pediatric ICU
(PICU) was created within the Newborn
ICU (NICU) because of high PICU
volumes. PICU nurse practitioners
provided medical coverage in
collaboration with PICU attending
physicians while the NICU nursing staff
provided patient care. Flexibility with
ever-changing plans was essential.
Data reported weekly: week 1 is week ending Dec 10; week ends on Saturday
recognition of equipment and patient
furniture needs was needed. In addition,
staff were not clear on the exact timing
and process of supply distribution. For
example, inventory par level information
was sent to the warehouse at 1:45 p.m.
each afternoon. If departments stocked
their areas after this time, the need for
replacement supplies was not known
until the following day, leading to a
lower inventory than required to meet
the peak demand.
Volumes continued to be strong
even into April. However, the lessons
learned during this surge season will be
documented and used to plan the next
sustained increase in census. It’s not “if”
it happens again, but “when” it happens
again…..and the staff will be ready!
For additional information, contact
Terry Bryant at [email protected]
Pediatric Perspectives
Nutritional screening and early
intervention in children with cancer
The overall survival rate for a child
or adolescent newly diagnosed with
cancer is now almost 80 percent.
Although cure rates are high, the
side effects of chemotherapy are
still significant and include nausea,
vomiting, mouth sores and loss of
appetite. These side effects, as well
as pain and fatigue, can impact a
child’s nutritional status. The risk of
malnutrition associated with treatment
for childhood cancer is estimated to
be as high as 60 percent. Children are
more vulnerable to malnutrition than
adults due to their increased caloric
requirement and decreased caloric
reserve. Malnutrition during treatment
for childhood cancer increases
children’s risk of infection, decreases
their tolerance to treatment, and can
impact their overall survival. Published
guidelines recommend children and
adolescents with cancer be screened
for malnutrition risk at diagnosis and
monthly throughout treatment.
Deborah Robinson, DNP, APRN,
PNP-BC, CPON, 9 West, and Marsha
Flowers, MHS, RD, LD, clinical
nutrition manager, conducted a study
funded by the American Cancer
Society to assess nutritional screening
performed at baseline and for the first
six months of treatment for children
and adolescents with cancer during
active treatment with chemotherapy
and/or radiation. In addition, the
study determined if children with a
positive screen (at risk for malnutrition)
received timely intervention. Based
on the published literature, a tool
was developed to record monthly
objective criteria to determine the risk
of malnutrition. This included baseline
weight, monthly weight, and percent
Marsha Flowers, MHS, RD, LD, clinical nutrition manager, (center) and Deborah Robinson,
DNP, MSN, RN, APRN, BC, PNP, CPON, 9 West, (far right) counsel Braden Darty and his
mother Heidi about Braden’s daily diet, calorie intake and nutritious snacks.
of weight loss from baseline. In
addition, serum albumin was recorded.
If children had a negative screen, no
further data was obtained. If children
had a positive screen, subjective data
and co-morbidities were documented
at the time of the visit, including
documentation of mouth sores, pain,
infection, nausea, vomiting, and
reported decrease in oral intake.
Disease status was recorded as stable
or progressive (not responding to
Seventy-nine children and adolescents
met the inclusion criteria (age > one
year and treatment > 6 months) in
2010. All children on active treatment
plans had monthly visits with the
pediatric oncology team, and
objective measurements for risk of
malnutrition (height, weight, body
surface area (BSA), body mass index
(BMI), and serum albumin) were
recorded on all patients. Sixty-two
percent (n = 49) of patients had a
positive screen, which showed a risk
for malnutrition defined as greater
than or equal to 5 percent weight
loss from baseline weight or previous
month. In addition, a serum albumin
less than 3.2 grams/dL was also a
primary risk factor for malnutrition.
Of the 49 patients with a positive
screen, 38 received timely intervention
(78 percent). Timely intervention
(within 24 to 48 hours) included
medical care or a referral to the
Pediatric Perspectives
• • •
Children are more
vulnerable to malnutrition
than adults due to
their increased caloric
requirement and
decreased caloric reserve.
Malnutrition during
treatment for childhood
cancer increases children’s
risk of infection, decreases
their tolerance to
treatment, and can impact
their overall survival.
• • •
Since being diagnosed with acute myeloid leukemia in January, Braden has
experienced multiple hospital stays including a month in the Pediatric ICU.
A sixth grader at Wentzville Middle School, Braden has improved his nutritional
status and hopes to return home soon to enjoy summer.
dietitian for a full nutritional assessment
and plan. Medical care included antiemetics, IV hydration, pain medication,
or treatment for mouth sores or infection.
In many cases, the medical intervention
reversed the risk of malnutrition and
the patient’s weight stabilized or
improved. Nutritional interventions
included nutritional counseling and oral
supplements. Some children did require
more aggressive nutritional support
including total parenteral nutrition (23
percent) or enteral feedings (10 percent).
Data from the participants who had a
positive screen (n= 49) were analyzed
further to determine if variables such as
age, gender, diagnosis, treatment type,
head and neck location and disease
status impacted the risk for malnutrition.
The only variable that was statistically
significant was disease status. Children
and adolescents with progressive
disease had a significantly higher risk
of malnutrition. In addition, individual
risk factors were analyzed to determine
if children with these factors were more
likely to need a nutritional referral and
nutritional plan. Children who had any
one of these risk factors were more likely
to receive a nutrition referral as compared
to those children who had weight loss but
no additional risk factors or symptoms
present. In addition, the number of risk
factors present increased the overall risk
of a positive screen for malnutrition.
Future studies will include determining
what type of nutritional strategies
are effective in reversing the risk of
malnutrition and if early intervention for
malnutrition impacts the patient’s quality
of life and overall outcome.
For additional information, contact
Deborah Robinson at [email protected]
or Marsha Flowers at [email protected]
Pediatric Perspectives
Meet Lauren Yaeger, medical librarian
Lauren Yaeger serves as the medical
librarian at St. Louis Children’s Hospital
in partnership with Washington
University School of Medicine,
providing information and research
support to the hospital staff and
the Department of Pediatrics at
Washington University.
What is your role?
I am the go-to-person in the hospital
for library resources and information
support. I instruct clinicians, often
one-on-one, about how to access
evidence-based information to support
their practice. I assist employees who
are studying for advanced degrees
and nursing students on rotation at
the hospital. I also teach classes on
library resources, such as searching
skills, accessing full text articles, using
PubMed and other specific needs.
Lauren Yaeger, the go-to person for library resources and informational support.
• • •
It makes me happy
when people have
that ‘ah ha’ moment
about using the
right resources
to get needed
information to help
them perform their
job better.
• • •
I participate on multidisciplinary
teams within the hospital, such as
the Craniofacial and Cleft Palate
Research team meetings. As a member
of the Ethics Committee, I provide
research support for the consult team
and general information support. I
am working with a multidisciplinary
team that is running a pilot program
integrating decision support tools and
library resources into the electronic
health record in the Emergency Unit.
In addition, I support the residents,
the 8 West Unit-Based-Joint-Practice
team, and recently provided a two-part
information series for the Physician’s
Education Committee. Whenever
possible, I attend clinical rounds to
provide point-of-care information
support as well as become better
acquainted with the clinical environment,
pace, language and needs.
Another aspect of my role is to provide
systematic review searching to the
Department of Pediatrics. As a librarian,
I have the skills and knowledge to
perform the comprehensive search
needed for a systematic review article
where the goal is to have a “sensitive
search,” not to miss any article. I
recently partnered with Child Health
Advocacy and Outreach (CHAO)
to present a paper at the National
Association of Children’s Hospitals
and Related Institutions (NACHRI)
conference; I also presented two
posters and a paper at the national
Medical Librarian’s Association (MLA)
conference in May.
What is your background and
educational preparation?
I have a Master of Arts (MA) in English
Literature from Saint Louis University.
Pediatric Perspectives
What a “NAVA” idea!
Mechanical ventilation has seen
significant advancements for the
hospital’s pediatric and neonatal
patients. The ultimate goal, however,
has not changed; to provide effective
ventilation with the least amount
of trauma and extubate as soon as
clinically indicated.
Different forms of ventilation have
been developed to provide adequate
ventilation for patients. Initially,
intermittent mechanical ventilation
(IMV) was available. During IMV, a
patient received a set number of
breaths per minute, regardless of the
patient’s own respiratory breath cycle.
Improvement came with the use of
synchronous intermittent mechanical
ventilation (SIMV), in which the
ventilator would be triggered to deliver
a breath when the patient initiated
a breath (began to inhale). However,
many patients continued to experience
asynchrony, which is thought to
contribute to patient discomfort, alter
a patient’s work of breathing and lead
to diaphragmatic dysfunction. Research
has shown as high as 25 percent of
patients exhibit asynchrony, which can
cause increased duration of mechanical
ventilation, ineffective triggering
resulting in ventilation mismatch,
hypoxemia and ineffective diaphragm
activity. For patients, this leads to an
increased need for sedation, oxygen
requirements and ventilator support.
In spring 2008, a new mode of
ventilation became available known
as Neurally Adjusted Ventilatory
• • •
With NAVA,
there has been
a reduction in
sedation use, and
patients exhibit
better tolerance
and quicker
recovery time.
• • •
—continued on back page
It was there that I discovered my love
of mining databases to find the jewels
of information I seek. This discovery
led to my decision to obtain a master’s
degree in Library and Information
Science (MLIS) at the University of
Illinois at Urbana-Champaign and
become a librarian.
What brought you to your
current position?
Luck!! I was working at St. Luke’s
Hospital as a librarian hoping for an
academic librarian position to open
where I could mix my love of literature
and library sciences. During that time,
I applied for my current position and
cannot believe what a perfect fit it has
become. I love working in the hospital
and supporting the people who do so
much good for kids. It’s humbling.
What is the most rewarding part
of your job?
with a hundred opportunities every day,
I want to do everything I can to help.
Education. It makes me happy when
people have that ‘ah ha’ moment
about using the right resources to
get needed information to help them
perform their job better. In turn,
being in the clinical environment is
educational and teaches me how to
better serve my customers. I learn
something new every day, and I hope
I do the same for my community.
I really enjoy working with the
residents; they are all amazing
people with bright futures.
For additional information, contact
Lauren Yaeger at [email protected]
What is the most challenging
part of your job?
Trying to be everywhere and support
everyone. There is only one of me and
Pediatric Perspectives
What a “NAVA” idea!
Assist (NAVA). NAVA synchronizes the
ventilator to the diaphragmatic activity
of the patient allowing for breath-tobreath variance based on the patient’s
individual needs.
Understanding how NAVA works
In collaboration with a respiratory
therapist, an individualized plan of
care is first required, which requires
at least 30 to 45 minutes for set up.
A catheter, specifically designed for
NAVA, is inserted nasally or orally by
the bedside nurse to the level of the
diaphragm. Placement is verified using
the NAVA positioning screen, often
requiring frequent reassessments to
ensure catheter migration has not
occurred. Once the catheter is in place,
the type of NAVA support needed
is determined by using the preview
screen. Back-up settings and alarms
are then determined. The ventilator
in NAVA mode generates a peak
continued from page 11
inspiratory pressure (PIP) based on the
amount of electrical activity generated
by the diaphragm. PIP is continued until
the electrical activity of the diaphragm
decreases by 40 to 70 percent, then the
breath is terminated and the patient
exhales. The patient will determine the
PIP and the inspiratory time (i-time)
of each breath on a breath-to-breath
basis. Every breath can be different;
this is normal. For example, it is known
that suctioning may cause atelectasis.
In SIMV mode, the patient is unable to
receive larger breaths to recover after
suctioning unless the actual ventilator
settings are adjusted. NAVA allows for
the patient to adjust himself or herself
so once the positive end-expiratory
pressure (PEEP) and oxygen level are
set, all other parameters including the
initiation of the breath, i-time, rate, PIP,
and termination of the breath are
controlled by the patient.
The Newborn ICU began using NAVA
in April 2011. With NAVA, there has
been a reduction in sedation use,
and patients exhibit better tolerance
and quicker recovery time with care.
Also noted was an improvement in
oxygenation and blood gases.
Several patients were successfully
extubated directly from the NAVA
mode of ventilation. As noted in
previous studies, apnea was the
biggest contributor to failure. There
is a continued learning process related
to all the intricacies of the system,
including the fact that NAVA is not
MRI compatible.
NAVA is a new and exciting concept
of ventilation for patients, continuing
to help staff strive to do what’s best for
every patient, every family, every day.
For additional information, contact Julia Huck at
[email protected] or Dan Murphy at [email protected]
is a NAVA
In order for a patient to be
considered a candidate for NAVA,
a patient must have an intact
respiratory and neurological
system and therefore, should
not be heavily sedated. Backup modes are set initially to a
pressure support mode in the
event the patient becomes
apneic and then full back-up
if the patient’s diaphragm does
not trigger a breath.
Photo courtesy of MAQUET Medical Systems USA.