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Pediatric Institute & Children’s Hospital

2008Outcomes

9500 Euclid Avenue, Cleveland, OH, 44195

© The Cleveland Clinic Foundation 2009

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

Please visit us on the Web at clevelandclinic.org.

65319_CCFBCH_Cover_ACG 1 7/8/09 11:28:04 AM

Pediatric Institute & Children’s Hospital 85

Resources for Physicians

Cleveland Clinic Secure Online Services

Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to GoogleTM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart.

DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].

MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

Critical Care Transport: Anywhere in the world

Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call 877.279.CODE (2633). For all other transfers, call 216.444.8302 or 800.553.5056.

CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.



Surgical OverviewTo promote quality improvement, Cleveland Clinic has created a series of Outcomes books similar to this one for many of its institutes. Designed for a physician audience, the Outcomes books contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a review of new technologies and innovations.

Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes for a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase

unavailable, we often report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques.

In addition to our internal efforts to measure clinical quality, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives:

(www.qualitycheck.org)

(www.hospitalcompare.hhs.gov)

Our commitment to providing accurate, timely information about patient care will also help patients and referring physicians make informed healthcare decisions.

quality/outcomes.

65319_CCFBCH_Text_ACG 1 7/8/09 11:14:34 AM

Dear Colleague,

On behalf of Cleveland Clinic, I am pleased to present our 2008 Outcomes books. The primary purpose of our annual Outcomes book initiative is to promote quality improvement at Cleveland Clinic, thereby optimizing the care we provide to our

accountability, transparency and results.

requiring hospitals to report more and more quality and patient safety data. We view our Outcomes books as voluntary supplements to the required public reporting and an opportunity to share selected innovations with colleagues across the country.

Designed for the physician reader, each book in the annual series focuses on care provided by one of our patient-centered

content informative.

CEO and President

Outcomes 20082


what’s inside

Institute Overview 06

Quality and Outcomes Measures

Pediatric Anesthesiology 10

Pediatric Otolaryngology 11

Pediatric Cardiology 12

Pediatric Behavioral Health 17

Pediatric Endocrinology 26

Innovations 62

Contact Information 80

3Pediatric Institute & Children’s Hospital


Outcomes 20084

Chairman’s Letter

Dear Colleague:

In 2009, healthcare organizations will continue to be challenged by increasing demand for

Cleveland Clinic Children’s Hospital is poised to meet these challenges.

congenital anomalies to deliver in the Children’s Hospital with immediate access to the full scope of our medical and surgical services.

include airway and swallowing disorders, asthma, general pulmonary diseases and children with special needs who are technology-dependent or who require mechanical ventilation.



his pioneering arrhythmia surgery in teens and young adults

infants and neonates, and pediatric coronary artery surgery and heart transplantation.

allowing us to double the number of satellite clinics we offer throughout Northeast Ohio.

Finally, it gives me great pleasure to announce

by 11,000 square feet.

Chairman and Physician-in-Chief

Calabrese Chair of Pediatrics

Cleveland Clinic Pediatric Institute & Children’s Hospital

5


Outcomes 20086

Institute Overview

Cleveland Clinic Children’s Hospital has been providing world-class, family-centered care to infants, children,

pediatric specialists and subspecialists within our Children’s Hospital provide state-of-the-art care for

pediatric specialists also care for children at family health centers throughout Northeast Ohio and at community hospitals, where we have dedicated Pediatric Emergency Departments, Neonatal Intensive Care Units and Pediatric

Our Children’s Hospital pediatricians and specialists provide the full spectrum of primary, specialty and

highlighted below:

Pediatric and Congenital Heart Diseases. In 2008, our heart surgeons performed 228 congenital heart operations,

Their surgical innovations address the unique needs of children as well as adults with congenital heart defects.

catheterization treatments, actively developing and testing less invasive ways and new devices to treat pediatric

procedures are combined for the best outcomes.

Neonatalology. In 2008, neonatologists in our Fetal

with antenatally diagnosed fetal anomalies. Working closely with high-risk obstetricians, pediatric surgeons and other Children’s Hospital specialists, they provided multidisciplinary counseling and coordinated care to achieve the best possible outcomes. The department also

introduced moderate whole-body hypothermia in 2008 for the

and created a multidisciplinary Neonatal Neuro-Intensive

neurological problems in newborns. A state-of-the-art mode of mechanical ventilation known as neurally adjusted ventilatory assist was also introduced to optimize management of respiratory failure in critically ill infants.

Hospital Medicine. Our pediatric hospitalists direct a child’s

initiative. Families are involved in daily bedside discussions with the child’s care providers, including specialists, residents and nurses, as they coordinate the care plan.

Critical Care Medicine. In our Pediatric Intensive Care Unit (PICU), Children’s Hospital critical care medicine specialists

admissions, remained well below the national standard. Our PICU staff maintained a catheter-associated bloodstream

had a single occurrence of ventilator-associated pneumonia or nosocomial viral infections for more than two years.

children and adolescents to our Children’s Hospital from across the country and around the world.



Digestive Disease. Our sophisticated, pediatric-only

streamlined detection technology, such as capsule

monitors that provide an unparalleled view of the digestive

and treat all gastrointestinal and liver disorders in infants, children and adolescents. We have one of the largest

As committed to research as they are to patient care, our pediatric digestive disease specialists are conducting groundbreaking studies funded by the National Institutes of Health (NIH) on fatty liver disease and obesity in children.

Epilepsy and Neurology. Cleveland Clinic Children’s Hospital neurologists and neurosurgeons are also recognized for the state-of-the-art care that they provide to more than 10,000 children annually. Our neurosurgeons

craniofacial procedures involving the skull, and surgery that relieves hydrocephalus and spasticity. They have

uncontrolled seizures and our epilepsy specialists see more than 2,000 children each year.

Cancer Care. Infants, children, adolescents and young adults with cancer or blood disorders require the best diagnostic tools and therapies available. Our pediatric oncologists care for young patients with leukemia, lymphoma, sarcomas, brain tumors, rare childhood cancers or other malignancies.

national study groups gives our patients access to more than 100 national trials of investigational cancer therapies at any

to support preclinical analysis of cancer vaccines derived from malignant brain tumor cells.

Transplantation. Cleveland Clinic Children’s Hospital is the only comprehensive pediatric transplant center in Northern Ohio, treating patients from infancy through young adulthood and offering heart, liver, lung and kidney transplantation. We are initiating a small bowel transplant program to help children with intestinal failure.

is consistently higher than the national average, and we are one of a select number of centers worldwide to have performed more than 100 pediatric heart transplants. We offer young patients waiting for transplant life-saving

surgeons are participating in a 10-year NIH program to

infant’s chest.

donor, split-graft and deceased donor transplants.

than any other program in Northeast Ohio, and is


Outcomes 20088

Institute Overview

Pediatric Anesthesia. Cleveland Clinic Children’s Hospital’s large team of dedicated pediatric anesthesiologists managed

and cardiac catheterization procedures.

Pediatric Surgery - Pectus Excavatum Program. Our

Pediatric Rehabilitation.Children’s Hospital is home to Cleveland Clinic Children’s

freestanding pediatric rehabilitation hospitals in the United

hospital stay, and for children with chronic illnesses or

Among the many other innovative Cleveland Clinic Children’s Hospital initiatives are the:

ADHD Center for Evaluation and Treatment. With its

children learn school skills and improve their social skills.

Comprehensive Pediatric Obesity Prevention and Treatment Program work with the new Cleveland Clinic Department of Public

children and families in school, museum, library and Cleveland Clinic Family Health Center settings about

Pediatric Pain Rehabilitation Program. For children whose chronic pain affects school attendance and limits everyday activities, an intensive, two-week inpatient and

A multidisciplinary team provides individualized care that focuses on both child and family for the best long-term results.

Cleveland Clinic Lerner School for Autism. The newly

children with autism opened in 2008 in the new



Outpatient Visits

Allergy Behavioral Health 6,226 Cancer Center

Dermatology

167 Endocrinology Fetal Care/Developmental Follow-Up

12,787

Head and Neck Heart Center 11,921 Infectious Disease 679

711 Nephrology 2,782 Neurosciences 21,919 Ophthalmology Orthopaedics Other

1,006

6,797 Urology 6,690 Total Outpatient Visits 499,709Surgical Cases

Total Cases 1,584Pediatric Cardiology Cardiac Catheterization Procedures Pediatric Echocardiograms Other Diagnostic Procedures Total Cases 5,279Pediatric Gastroenterology Pediatric Endoscopy 1,008 Other Diagnostic Procedures Total Cases 2,278Patient Days (Main Campus) Hospital PICU NICU Total Days 76,526


creo

10

Surgical OverviewPediatric Anesthesiology

Pediatric PACU/ICU arrival temperatures

for pediatric anesthesiologists. The adult anesthesia/surgical literature has numerous reports on the detrimental effects of intraoperative hypothermia

cardiac outcome and three times the risk of surgical wound infection and increased blood loss, prolonged recovery and hospitalization.1

procedures and patients with a paper anesthetic record.

Pediatric General PACU/ICU Arrival Temperature (N=4,073) 2008

Anesth Analg

0

500

1,000

1,500

< 36.0 36.0 36.5 37.0 37.5 38.0 > 38.0

PACU arrival temperature, degrees C

Number of Patients

Outcomes 200810


11

Pediatric Otolaryngology

Post-Tonsillectomy Bleeding

Audit NP. Impact of NICE guidance on rates of hemorrhage after tonsillectomy: an evaluation of guidance issued during an ongoing national tonsillectomy audit. Qual Saf Health Care

Post-Tonsillectomy Bleeding Rate with or without Adeniodectomy (N=1,712) 2003 - 2008

Post-Tonsillectomy Bleeding Rate with or without Adeniodectomy (N=1,712) 2003 - 2008

10

8

6

4

2

0Return to OR Readmission with

Observation*National Average forReturning to the OR

Percent of Patients

4

5

2

1

3

0

Percent of Patients by Age Group

*0-4603N =

**5-12907

Age Groups (years)

***13-18202

Readmission with ObservationReturn to OR



The Children’s Hospital Critical Care Transport Team

wing transport for 2008

Pediatric Cardiology

The Children’s Hospital Cardiology Department offers a full spectrum of services to pediatric and adult patients with congenital heart disease and to pediatric patients with acquired heart disease. Fetal echocardiography is performed at the main campus, and at Fairview and Hillcrest hospitals. The number of fetal echocardiograms is increasing on a yearly basis and the accuracy of prenatal compared to postnatal diagnosis is in the 99 percent range.

baby are made based on the cardiac lesion, optimizing care for both mother and infant.

Our interventional team utilizes the latest technology in the catheterization laboratory. Intracardiac ultrasound is used to visualize the inside of the heart while closing atrial septal defects or dilating a stenotic aortic valve.

12 Outcomes 2008



Pediatric Catheterization Volume by Age (N=442) 2008

Pediatric Catherization Volume by Type (N=442) 2008

< 28 days >28 days, < 1 year

Age

>1 year

Cases

500

400

300

200

100

0

500

400

300

200

100

0

Cases

Diagnostic Therapeutic Electrophysiological


14

Pediatric Cardiology

There was no mortality, and the complication rate was lower than published norms (Schroeder VA, Shim D, Spicer RL, Pearl JM, Manning PJ, Beekman RH 3rd. Surgical emergencies during pediatric interventional catheterization. J Pediatr. 2002;140:570-5).

Quality measures have been instituted in the catheterization laboratory to ensure best and safest outcomes. In 2008, we began a policy of strict accounting for the amount of radiation exposure to the patient during a catheterization. The operator is alerted if exposure is approaching a level where complications could occur. Patient counseling and close follow-up are arranged in the rare cases where a threshold value is reached.

Pediatric Catheterization Complication (N=442) 2008

1.0

0.8

0.6

0.4

0.2

0

Percent

Minor Major Mortality

Complication Risk

Outcomes 2008


15

We have national expertise in the percutaneous treatment of congenital or acquired pulmonary vein stenosis. The most common form of acquired pulmonary vein stenosis at this time occurs in a small percentage of patients who have undergone pulmonary vein isolation, a type of ablation to treat atrial fibrillation. Although this is an acquired disease in mostly adult patients, our pediatric interventionalists have treated the largest number of patients nationally with this diagnosis with very low complication rates and no mortality. They have studied the long-term outcome of balloon and stent angioplasty for this disorder and shown that stenting, particularly for normal-sized veins, is superior. (Prieto LR, Schoenhagen P, Arruda MJ, Natale A, Worley SE. Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation. J Cardiovasc Electrophysiol 2008; 19:673-8).

Pulmonary Vein Stenosis - Patency Rates Based on Stent Size 2008


100

80

0

60

40

20

Percent

0 1 32 4 5 6 7

36 14 34 3 2 2 126 36 3 3 2 138

N = N = 15 26 2 1 124 29 2 2 1 1

Years since Catherization

≥ 10 Stent Diameter< 10 Stent Diameter


Outcomes 2008

Pediatric Cardiothoracic Surgery

Pediatric Cardiothoracic Surgery Complications

Diagnosis YearHeart Block

Post op bleeding

Death

2008 0 0 0 0

2007 0 0 0 0

TOF 2008 10 0 0 0 0

2007 8 0 0 0 0

Heart Block pacemaker

Bleed: Any patient having to go to the operating room for bleed

Stroke:

16



Pediatric Behavioral Health

Pediatric Pain Rehabilitation Program

(two weeks inpatient rehabilitation and one week day hospital) interdisciplinary pain rehabilitation approach that blends pediatric subspecialty care, behavioral health and rehabilitation therapies.

three-week pain rehabilitation program and at one-month follow-up.

Impact on Pain Severity (N=69) 2008

50

40

0

20

30

10

Rating

Pre-Treatment One-MonthFollow up

BEHAVIORAL HEALTH PATIENT CARE ACTIVITYQuality of patient care remains high. Productivity as measured by number of

liaison service on main campus completed

provided to established patients of the service.

17


18


61-item tool designed to assess the multidimensional impact of chronic pain on adolescents. BAPQ internal consistency, comparative validity and temporal reliability are established. The self-report version of the tool is administered at the beginning of the program and one month following its completion. The Physical Functioning, Pain

Impact on Physical Functioning (N=69) 2008

2008

100

80

0

40

60

20

Rating

Anxiety Social

Pre-TreatmentOne-Month Follow-up

40

0

20

30

10

Rating

Pre-Treatment One-MonthFollow up

Outcomes 2008



Motor Control Program

achieve the targeted movement pattern during a one-hour treatment session. Data

correct recruitment pattern is rewarded with activation of a video. The loss of the correct recruitment pattern terminates the video. In 2008, 10 patients were

beginning of treatment in the program.

Motor Control Score (N=10) 2008

Beginning

End/current Status

1 2 3 4 5 6Patient

7 8 9 10

100

80

0

60

40

20

Motor Control Score

19



Summer Treatment Program

Overall Improvement (N=77) 2008

Effectiveness Compared to Other Treatments (N=77) 2008

from Program (N=77) 2008

4% Worse4% Worse4% Unchanged4% Unchanged

92% Improved92% Improved

100%100%

1% Less Effective1% Less Effective5% No Difference5% No Difference

94% More Effective94% More Effective100%100%

1% Little1% Little

19% Somewhat19% Somewhat

80% Much80% Much100%100%

20 Outcomes 2008



Fit Youth Program

Cleveland Clinic offers the comprehensive Fit Youth program, a 10-week program staffed by Cleveland Clinic professionals

program start.

Median BMI (N=64) 2008

40

30

20

10

0

Percent

Baseline End of Program Post program

Median Weight (N=64) 2008

0

200

150

100

50

Pounds

End of ProgramBaseline


Outcomes 2008


Median Waist Girth (N=64) 2008

Median Strength Indicators (N=64) 2008

0

50

40

30

20

10

Inches

End of ProgramBaseline

25

20

15

10

5

0

Number Exercises Completed

BaselineEnd of Program

Squats Pushups Crunches

BEHAVIORAL HEALTH GRAND ROUNDS, CONTINUING MEDICAL EDUCATION & OTHERTen staff members gave 40 Grand

Rounds, continuing medical education

presentations or other presentations

such as posters, at national

conferences, or community talks to

local organizations.

BEHAVIORAL HEALTH PAPERS PUBLISHEDThe staff published 18 (14 in 2007) scientific papers in peer-reviewed journals. In addition, six (five in 2007) staff members serve on editorial review boards or were ad hoc reviewers for 23 (20 in 2007) professional journals.

BEHAVIORAL HEALTH NATIONAL PRESENTATIONS & INVITED TALKSSix staff members gave 18 invited presentations (seven in 2007) as symposia participants and discussants at national conferences.

22



Autism Center—Diagnostic Program

Percent of Children Evaluated at Center for Autism Age Birth to Three Suspected of Having an Autism Spectrum Disorder 2008

Cleveland Clinic professionals and designed for children ages 12 months to

were assessed before and after initiation of Baby Day. The denominator is the number of children who were assessed, regardless of age.

After Introduction of "Baby Day"

Percent

Month

0

0.2

0.4

0.6

0.8

1.0

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Diagonoses given to Children referred for Baby Day 2008

3% Developmental Delay3% Developmental Delay3% Disruptive Behavior 3% Disruptive Behavior 3% Separation Anxiety Disorder 3% Separation Anxiety Disorder 11% Language Dysfunction11% Language Dysfunction

80% Autism Spectrum Disorders80% Autism Spectrum Disorders100%100%

23



24

Pediatric Feeding Disorders Program

After initial interdisciplinary evaluation, patients are seen in outpatient therapy using an interdisciplinary treatment approach with Psychology, Occupational Therapy,

again at the end of treatment.

continuing to meet criteria for failure to thrive (FTT) at end of treatment.

Growth Status for Premature Infant Population Failure to Thrive Status 2008

0

50

40

30

20

10

Volume NG/GT Supplementation

Post-TreatmentPre-Treatment

Outcomes 2008


25

NG/GT Supplementation for Premature Infant Population 2008

This graph represents the positive downward shift in the number of premature infants requiring a substantial percentage of caloric

the graph demonstrates the patient’s decreased reliance on

calorie intake over the course of oral feeding treatment.

100

80

0

60

40

20

Number of Premature Infants

> 75Kcals/Kg

50-75Kcals/Kg

25-49Kcals/Kg

< 25Kcals/Kg

Percent Calories Given by Tube

Post-TreatmentPre-Treatment



Outcomes 2008

Pediatric Endocrinology

Type 1 diabetes strikes children suddenly, makes them dependent on injected or pumped insulin for life and carries the constant threat of devastating complications. While diagnosis most often occurs in childhood and adolescence, it can and does strike adults. Type 1 diabetes is an autoimmune disease in which the body’s immune system attacks and destroys the insulin-producing cells of the pancreas. While the causes of this process are not entirely understood, scientists believe that both genetic factors and environmental triggers are involved.

Despite rigorous attention to maintaining a meal plan and

of insulin, many factors can adversely affect efforts to tightly control blood sugar levels, including stress, hormonal changes, periods of growth, physical activity, medications, illness/infection and fatigue.1

For people without diabetes, the normal range for the A1C test

an A1C less than 8 percent, although glycemic goals may be

risks for diabetic complications decrease for people with A1C levels in the goal range.2

1 2

26



Pediatric Endocrinology recorded the baseline HbA1c of 60 patients with type 1 diabetes who were new to our practice over the course of a calendar year. Eleven of those patients either transferred care to another physician or had not returned yet for the follow up visit,

follow-up visit.

diabetic educators in the department developed an education plan for families of children who were newly diagnosed with type 1 diabetes.

HgA1C Value at First Visit and One Month Follow Up (N=49) 2008

00 5 10 15 20 25

Patients

30 35 40 45 50

5

10

15

20

Percent

1st A1C Follow up A1C


Outcomes 2008

Pediatric Gastroenterology

and/or colonoscopy in the Pediatric Ambulatory Endoscopy Unit. All procedures were performed under general anesthesia administered by a pediatric anesthesiologist.

Patient records were reviewed to identify adverse events that occurred following the procedures, including hemodynamic instability, medication reactions, gastrointestinal bleeding and unanticipated admission of patients to the hospital secondary to

In addition, patient medical records were reviewed to identify post-procedure symptoms, as reported by the patient within seven days of their procedure.

abdominal pain, nausea, vomiting, diarrhea, dysphagia and fever.

construction and opening of our new endoscopy suite.

Pediatric Ambulatory Endoscopy (N=561) 2008

28

0

800

600

400

200

Number

0

8

6

4

2

Minor Complication Rate*

*Minor defined as nausea, vomiting, sore throat, abdominal discomfort

20082007

Post-Procedure Complication RateNumber of Endoscopies



Remicade® Administration Safety Monitoring® were administered

physician assessment, appropriate treatment and resolution of symptoms. No adverse

call to pediatric medical emergency response team or hospital admission were reported.

J Pediatr Gastroenterol Nutr.

Number 2007 2008

29



30

Pediatric Wireless Capsule Endoscopy

Wireless capsule endoscopy has become increasingly utilized in the evaluation of selected patients to identify small intestinal abnormalities. This procedure has been performed in children for the evaluation of symptoms including abdominal pain and gastrointestinal bleeding, for detection of

reviewed. Indications for wireless endoscopy in these patients included abdominal pain, diarrhea,

syndromes.

In this group of patients, 11 percent of the wireless capsules were deployed at the time of upper endoscopy, in patients who were not able to swallow the capsule. Capsules were swallowed

were complete to the cecum. Positive

percent of patients and included small bowel Crohn’s disease (68 patients),

lesions (seven patients) and isolated erosion/ulcer (nine patients). Capsule retention occurred in four patients

Endoscopies Cecum Findings Capsules

Outcomes 2008


Crohn’s Disease

tumor necrosis factor – (TNF- ), is available as an alternative to

was published in 2008. A retrospective chart review of pediatric

nine had ileocolitis. All patients had a history of attenuated response

follow-up, the median duration of treatment with adalimumab was

had no response to therapy. No serious adverse events requiring discontinuation of treatment occurred during therapy.

Adalimumab Treatment in Crohn’s Disease – Response to Treatment 2008

100

0Partial Response

2 Complete Response

7N =No Response

5

60

80

20

40

Percent

J Pediatr Gastroenterol Nutr



32 Outcomes 2008

Pediatric General Surgery

to achieve a goal of 100 percent on-time preoperative prophylactic antibiotic administration.

The graph above depicts the percentage of preoperative prophylactic intravenous antibiotics administered 0 to 60 minutes prior to surgical incision by month.

Preoperative Prophylatic Antibiotic Administration 2008

Month

80

100

60

0

40

20

Percent Compliance

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec GrandTotal



of our patients have been successfully treated with the minimally invasive approach known as the

2006 – 2008

100

0Complications within 30 Days of Surgery

Minimally InvasiveRepair Performed

Overall ComplicationRate

40

60

20

Volume

80

100

0

40

60

20

Percent

80PercentVolume


Outcomes 2008

Pediatric Hematology and Oncology

Infection is one of the most common causes of morbidity and mortality in pediatric hematology/oncology patients (Pizzo & Poplack, 2006). Fevers, especially in patients who are neutropenic, can quickly become

decreased morbidity and mortality (Pizzo & Poplack, 2006). At Cleveland Clinic Children’s Hospital outpatient hematology/oncology clinic, fever is the most common chief complaint for unplanned visits. A delay in

outcomes. This was determined to be a major patient safety concern and unacceptable practice. Causes for the delays included time to patient check-in, awaiting blood test results, prescriber not writing the orders quickly and pharmacy not sending the drug as soon as possible.

Neutropenia Fever – Time Frame for Antibiotics by Location (N=42) 2008

100

0< 60 min

40

60

20

Percent

80

> 60-90 min > 90-120 min > 120 min

Direct AdmitED Admit

Pediatric Hemotology/Oncology Clinic

34


35

In an effort to decrease the time to antibiotics, standardized fever

options for empiric antibiotics with doses included, supportive

fever orders also are applicable to oncology patients with non-

antibiotic administration in less than 60 minutes from arrival.

pharmacy staff satisfaction, as well as patient safety, by creating a consistent, clear order set with pediatric doses pre-printed, ensuring that all patients receive appropriate empiric antibiotics with



Outcomes 2008

2008

Hand hygiene is a high priority at Children’s Hospital. Pediatric Infectious Diseases has taken steps to improve it, including analyzing impediments on each unit, support of unit leaders, and unit physician support and education. This focus has resulted in one of the highest hand hygiene rates attainable, with recent levels approaching 100 percent consistently, measured by direct observation.

Month

80

100

60

0

40

20

Percent Compliance

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

36

Pediatric Infectious Disease


Outcomes 2008

children over 6 months of age. An internal study

of vaccination among our patients’ families showed the importance of prior commitment to vaccination. The results of this study will help us develop approaches to encourage parental compliance with the recommended universal vaccination of children.

38

Pediatric Infectious Disease



Lung Transplant

recipients. To date, this research has revealed the following:

In pediatric lung transplant recipients, risk factors for pulmonary fungal infections include: history of

and pre-transplant colonization with fungus. Pulmonary fungal infection was independently associated with decreased 12-month survival in pediatric lung transplant recipients.

occur after pediatric lung transplantation, with risk factors including younger age and non-cystic

pediatric lung transplantation.

One Year Survival After Pediatric Lung Transplant for Patients With and Without Pulmonary Fungal Infections 2008

100

80

0

60

40

20

Percent Survival

0 42 6 8 10 12

0

462

21

431

31

412

41

406

48

392

51

381

59

374

CumulativePFI Cases

Total Nat Risk

Months Since Transplant

PFINo PFI


Neonatology

NICU Central Line Associated Bloodstream Infection/1000 Central Line Days 2008

The overall mean National Healthcare Safety Network (NHSN) central line-associated bloodstream infection rate is derived by combining all birth weights and infection data from central line associated-bloodstream (CLAB) and umbilical catheter associated-bloodstream (UCAB) infections in Level III NICUs.

Reference Edwards JR, Peterson KD, Andrus ML, Tolson JS, Goulding JS, Dudeck MA, Mincey RB, Pollock DA, Horan TC (November 2008). National healthcare safety network (NHSN) report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control , 36 (9), 609-626.

CLAB: Central Line associated bloodstream infection UCAB: Umbilical Catheter associated blood stream infection CLABSI: Central Line Associated Bloodstream Infection CL: Central Line NHSN: National Healthcare Safety Network*

Central Line Associated Bloodstream Infection Rate = Number Central Line Associated Bloodstream Infections / Central Line Days X 1000

10

8

0

6

4

2

Rate

2005 2006 2007 2008

CLABSI Rate/1000 CL DaysNHSN Pooled Mean

Outcomes 200840

*There was no mean established in 2005.


Also in 2008, the Department of Neonatology introduced moderate whole-

encephalopathy and created a multidisciplinary Neonatal Neuro-Intensive

problems of the newborn. A state-of-the-art mode of mechanical ventilation, known as neurally adjusted ventilatory assist, was introduced to optimize the management of respiratory failure in critically ill infants.


2007 – 2008

have not been established; however, data collection and analysis of contributing factors is considered important for quality improvement and

rates have included trialing new ways to secure ET tubes and having two caregivers involved when repositioning intubated babies. The mean

ventilator days in 2008.

Numerator: Any unplanned removal of an endotracheal tube.

3

0

1

2

Rate per 100 Ventilator Days

4

5


Month

NICUMean Rate


42

Pediatric Neurology

Pediatric HeadacheOutcome Frequency/Treatment (N=46) 2008

Pediatric patients treated for headache in 2008 showed an improvement

and number of rescue medications needed over the past three months.

past three months. When comparing group means for headache frequency

50

40

0

30

20

10

Number

Peds MIDAS Headache Frequency Rescue Doses

Visit 2Visit 1

Absences Due to Headaches (N=17) 2008

the average number of school days missed in the preceding three

10

15

0

5

School Days Missed

Visit 1 Visit 2

Outcomes 2008



Some three percent of the population has unexplained neurologic and developmental symptoms including autism and epilepsy defined as idiopathic developmental delay. Until very recently, this population of children and adults, some with progression of their symptoms for unexplained reasons, remained largely without a diagnosis.

With advances in technology and improving diagnostic skills, the ability to reach a conclusive diagnosis in this population has steadily improved. While there is no national standard, tertiary care centers such as ours have the potential to reach a diagnosis 30 to 50 percent of the time.1

In 2008, our Neurometabolic Clinic evaluated more than 311 patients presenting with unexplained neurologic and/or developmental symptoms, and we were able to establish a diagnosis in 125 patients (40 percent). 1van Karnebeek CD, Scheper FY, Abeling NG, Alders M, Barth PG, Hoovers JM, Koevoets C, Wanders RJ, Hennekam RC. Etiology of mental retardation in children referred to a tertiary care center: a prospective study. Am J Ment Retard. 2005 Jul;110(4):253-67.

Pediatric Neurometabolic ClinicDiagnostic Yield (N=311) 2008

100

350

0

50

200

150

300

250

Number of Patients

New PatientConsults

Diagnosis EstablishedVia Muscle, Genetic

or CSF Testing

Pediatric Electromyography

Pediatric EMG

100

80

40

0

60

20

Number of Studies

2004 2005 2006 2007 2008

EMGs with OR/SedationTotal EMGs

Very few medical centers in the country provide high-quality electromyography (EMG) for the pediatric population with the option of EMG under sedation, resulting in a more comprehensive examination and less patient discomfort.

43

44

Pediatric Intensive Care Unit

Pediatric Central Line Associated Bloodstream Infection Rate/1000 Patient Days 2004 – 2008

Outcomes 2008

20072005 20082004 2006

8

6

4

2

0

10

Rate

The PICU continued its efforts in 2008 to reduce nosocomial infections. As shown above, we have maintained a catheter-associated bloodstream infection rate of less than three per 1,000 catheter days. This is below the national benchmark.

have also focused on preventing other nosocomial infections. We

child developed ventilator-associated pneumonia from August 2006

decreasing usage of urinary catheters. This has reduced the overall rate of hospital-acquired urinary tract infections. PICU has had only

days of 2008.


45

Numerator: Any unplanned removal of an endotracheal tube.

mortality was 0.72.


3

0

1

2

Rate

Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov

2007 2008

RateMean Rate


Outcomes 2008

Pediatric Nephrology

Hematocrit (N=11) 2008

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K/DOQ) guidelines have been widely adopted in the

used for quality improvement initiatives to improve the outcomes of patients who develop end-stage kidney disease. The unit has provided

areas for the last four years. The benchmarks are as follows:

30

0

10

20

Percent Hematocrit

40

50


Month

Average per MonthBenchmark > 32%

46

peritoneal dialysis services to children and adolescents through 21 years of age. The interdisciplinary team, comprising pediatric nephrologists, a nephrology nurse practitioner, nephrology nurses, renal dietitians, pediatric renal social worker, a recreation therapist, vascular surgeons, radiologists, transplant surgeons, psychiatrists and physiologists, make this department unique and help in the care of patients from diagnosis of end-stage renal disease to transplant.



Urea Reduction Ratio 2008

Urea reduction rates demonstrate the adequacy of the dialysis treatment. The Children’s Hospital Dialysis Unit consistently performs better than the national standard of seventy percent.

60

0

20

40

Percent of Urea Reduction

80

100


Month

Urea Reduction RatioBenchmark > 70%

Fistula Rate 2008

60

0

20

40

Percent

80

100


Month

Patients with FistulaBenchmark > 40%

47


Outcomes 2008

Pediatric Primary Care

The medical home is defined by the American Academy of Pediatrics as an approach offering accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective care. Our pediatricians are dedicated to the medical home as a vital component for the care of the children. Our general pediatricians are available in the office seven days a week, including evening hours on most days. Our pediatricians collaborate between all Cleveland Clinic offices to ensure the highest quality care. Utilizing our electronic medical record promotes appropriate communication between our offices and all Cleveland Clinic Health System Emergency Care facilities and Cleveland Clinic Children’s Hospital Specialists.

Appropriate Treatment for Children with a Viral Respiratory Infection (URI) (N=3,704) 2007 – 2008

Antibiotics have unquestionable value when used appropriately, but inappropriate use such as prescribing antibiotics for viral upper respiratory infections can have a negative impact, and may lead to bacterial resistance, making infections more difficult to treat. Antibiotic use is declining due to increasing appropriate utilization, and Cleveland Clinic Children’s Hospital pediatricians are leading the way.

80

100

60

0

40

20

Percent of Patients 3 Months to 18 Years Not Prescribed Antibiotics

20071967N=

20081737

48



throats, but are necessary for the treatment of strep pharyngitis. Our pediatricians ensure an accurate diagnosis of strep throat by obtaining a

were diagnosed with pharyngitis, received a group A streptococcus test and were dispensed an antibiotic (if necessary). A higher rate represents appropriate testing performed.

Appropriate Testing for Children with Pharyngitis (N=1,012) 2007 – 2008

80

100

60

0

40

20

Percent of Patients 3 Months to 18 Years Not Prescribed Antibiotics

2007458N =

2008554


Outcomes 200850

Pediatric Primary Care

Recommended Childhood Immunizations (N=9,542) 2005 – 2008

and the efforts of pediatricians to promote and provide the recommended vaccinations. Immunizations are given to children starting at birth and continuing through the teen years. Our immunization rates are consistently above the mean CDC rate.

The graph above shows the percentage of children who have had four diphtheria, tetanus and acellular pertussis

80

100

60

0

40

20

Percent of Children Who Received the Recommended Immunizations by Age 2

20052654N =

20082327

20062073

20072488

Children’s HospitalCDC Mean


52

Shaker Campus The Cleveland Clinic Children’s Hospital For Rehabilitation

and tracks the development of functional independence. Children treated in the rehabilitation program

The Children’s Hospital Median WeeFIM Score at Discharge 2006 – 2008

The Children’s Hospital Median WeeFIM Score Change (Gain) 2006 – 2008

80

100

60

0

40

20

Score

1Q12N =

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9

Children’s HospitalBenchmark

2007 20082006

80

100

60

0

40

20

Score

1QN = 12

2Q7

3Q14

4Q 21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q 9


2007 20082006

Outcomes 2008


53

Children treated in the rehabilitation program at Cleveland Clinic Children’s Hospital in 2008 gained more function over the course of

The Children’s Hospital Median Time from Onset to Admission 2006 – 2008

Because starting rehabilitation as soon as possible after an acute injury

closely with acute care facilities to transition children into rehabilitation quickly. The impairment-onset date is subtracted from the rehabilitation admission date. The onset time is calculated for each person, and the median time from onset to admission for all persons is reported. A lower number of days is better than a higher one.

80

100

60

0

40

20

Days

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006



Outcomes 2008


The rehabilitation length of stay is calculated by subtracting the admission date from the discharge date. If any program interruptions are recorded, these off-service days are subtracted from the total length of stay. The length of stay is calculated for each person, and the median length of stay for all persons is reported. Children treated in the rehabilitation program at Cleveland Clinic Children’s Hospital were generally discharged earlier from

The Children’s Hospital Median Rehabilitation Length of Stay 2006 – 2008

80

100

60

0

40

20

Days

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006

54



This measure is the change in functional status per day spent in the rehabilitation

persons is reported. A higher rate is better than a lower one.

2006 – 2008

2.0

2.5

1.5

0

1.0

0.5

Rate

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006

55


Outcomes 2008


The Children’s Hospital Median Functional Quotient Score at Discharge 2006 – 2008

This measure represents the discharge functional quotient of the children who undergo rehabilitation at the Children’s Hospital compared to children who undergo rehabilitation at similar facilities. Functional Quotient is a methodology of age-adjusting the data and comparing an observed rating vs. an age-

calculated for each person and the median functional quotient score for all persons is reported. A higher score is better than a lower one.

80

100

60

0

40

20

Score

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006

56



The Children’s Hospital Median Functional Quotient Score Change (Gain) 2006 – 2008

This measure represents the change in functional quotient between admission and discharge of children who undergo rehabilitation at the Children’s Hospital compared to children who undergo rehabilitation in comparable programs elsewhere. The functional quotient score change is calculated by subtracting the admission functional quotient score from the discharge functional quotient score. A functional quotient score change is calculated for each person and the median functional quotient score change for all persons is reported. A higher score is better than a lower one.

40

50

30

0

20

10

Score

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006


Outcomes 200858


2006 – 2008

Children treated in the rehabilitation program at the Children’s Hospital gained more function per therapy unit than those with similar conditions in comparable programs

reported for all persons. A higher rate is better than a lower rate.

0.4

0.5

0.3

0

0.2

0.1

Score

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006



The vast majority of the children discharged from the rehabilitation program at Cleveland Clinic Children’s Hospital were discharged to their home community. The community discharge rate is calculated by dividing the number of persons undergoing rehabilitation who are discharged to a community-based setting by the number of all persons undergoing rehabilitation.

The Children’s Hospital Community Discharge Rate 2006 – 2008

0.5

1.0

1.5

0

Score

1QN = 12

2Q7

3Q14

4Q21

1Q11

2Q20

3Q19

4Q15

1Q7

2Q14

3Q9


2007 20082006


Outcomes 200860

Patient Experience

that elevates Cleveland Clinic’s reputation as one of the world’s best hospitals.

and family-based programs that support this mission.

Outpatient – Children’s Hospital & Pediatric Institute

100

80

0

60

40

20

Percent

Excellent Very Good Good Fair Poor

S Q li D M i l h i l d

2008 (N = 2,236)2007 (N = 2,373)

100

80

0

60

40

20

Percent

Excellent Very Good Good Fair Poor

Source: Quality Data Management, a national hospital survey vendor

2008 (N = 2,236)2007 (N = 2,373)

Overall Rating of Outpatient Care and Services 2007 – 2008

Rating of Outpatient Provider 2007 – 2008



Recommend Outpatient Provider 2007 – 2008

100

80

0

60

40

20

Percent

ExtremelyLikely

Source: Quality Data Management, a national hospital survey vendor

Very Likely SomewhatLikely

SomewhatUnlikely

VeryUnlikely

2008 (N = 2,236)2007 (N = 2,373)

100

80

0

60

40

20

Percent

Rate Hospital Would Recommend

% respondentschoosing 9 or 10

% respondents choosing'definitely yes'

Source: Quality Data Management and Press Ganey, national hospital survey vendors

2008 total survey respondents = 6042007 total survey respondents = 590

49%57% 56% 51%

Overall Assessment 2007 – 2008

Inpatient – Children’s Hospital & Pediatric Institute


Outcomes 2008

Innovations

Pediatric Endocrinology

In conjunction with the Diabetes Clinic, we have initiated a

to better manage our insulin pump patients.


developed and published details on a non-invasive process to diagnose non-alcoholic steatohepatitis, also known as

disease, often associated with obesity, that can begin even in childhood and progress to severe chronic liver disease in adulthood.

transplantation as an option for pediatric patients with

program.

Pediatric Urology

in children and laparoscopic varicocelectomies.

62



Nursing Innovations

Through the development and implementation of a pediatric rapid response team, Cleveland Clinic Children’s Hospital sought to improve the quality and safety of pediatric patient

comprises a pediatric senior resident, pediatric intensive care unit charge nurse, respiratory therapist and attending physician.

respiratory distress, seizure)

the PICU

63


Outcomes 2008

Selected Publications

64

The Pediatric Institute

staff authored 122 publications in 2008. For a

complete list go to

www.clevelandclinic.org/

quality/outcomes

analysis of the autism diagnostic interview-revised. J Autism Dev Disord

Peterson Jmeconium are associated with poorer neurodevelopmental outcomes to two years of age. J Pediatr

Vogel NM childhood asthma. J Asthma

Knapp JA in a neurodevelopmental outpatient clinic. Appl Neuropsychol

and reading disorder using symptom validity measures. Arch Clin Neuropsychol.

neurocognitive performance in pediatric bipolar disorder. J Child Adolesc Psychopharmacol.

Richards MMself-reported coping strategies using a cluster analytic approach. J Child Fam Stud. 2008

Richards MMnonclinical sample: consistent and inconsistent reports of child psychosocial functioning across informants. J Pers Assess

Manos MJ

J Am Acad Child Adolesc Psychiatry. 2008

Turell DC. Advances with surfactant. Emerg Med Clin North Am

Goldfarb J, Desai N, Levine MA. Preimplantation genetic diagnosis for severe albright hereditary osteodystrophy. J Clin Endocrinol Metab

Levine MAhypoparathyroidism: a molecular and biochemical study. J Clin Endocrinol Metab. 2008

Rogers D. Final diagnosis: transient pseudohypoaldosteronism (TPH) caused by UTI without concordant obstructive uropathy. Clin Pediatr (Phila



Levine MA, Hillhouse EW,

Cell Signal.

lung transplantation. J Heart Lung Transplant. 2008

. Bronchoalveolar lavage fungal antigen detection in critically ill children. Journal of Bronchology

Foster CBand risk of advanced distal colorectal adenoma. Cancer Epidemiol Biomarkers Prev.

, Sabella C

Pellett PE, Goldfarb J. Beta-herpesviruses in febrile children with cancer. Emerg Infect Dis

Luciano M

ventriculostomy for the treatment of hydrocephalus. Eur J Obstet Gynecol Reprod Biol

Di X, Luciano MG, Benzel EC. Acute respiratory arrest following partial suboccipital cranioplasty for cerebellar ptosis from Chiari malformation decompression. Neurosurg Focus.

Luciano MG. Chronic hydrocephalus-induced

vessel density in hippocampus. Neuroscience

Wyllie E, Gupta A. Interictal hypermetabolic

Neurology

Parikh SCohen BH

of suspected mitochondrial disease. Mol Genet Metab. 2008

Ruggieri P Foldvary N, Wyllie E, Kotagal P, Bingaman B, Dinner D,

Temporal lobe neoplasm and seizures: how deep does the story go? Epileptic Disord

Kotagal P Bingaman W, Wyllie E. Discontinuation of medications after successful epilepsy surgery in children. Pediatr Neurol

Kotagal P, Gupta A, Bingaman W, Wyllie E.

Epilepsy surgery in epidermal nevus syndrome variant with hemimegalencephaly and intractable seizures. J Neurol

Friedman NR, Ruggieri PM, Marcotty A, Sears J, Traboulsi EI. Pituitary stalk duplication in association with moya moya disease and bilateral morning glory disc anomaly - broadening the clinical spectrum of midline defects. J Neurol

Luciano M.

complications. Surg Endosc. 2008 Aug;22(8):1866-1870.

Parikh S, Cohen BH, Gupta A, , Wyllie E, Kotagal PPediatr Neurol

Cohen BH

in autism spectrum disorder patients: a cohort analysis. PLoS ONE


Outcomes 200866


Knapp JAneuropsychological assessment in a neurodevelopmental outpatient clinic. Appl Neuropsychol

Rome E,

in adolescent females using injectable or oral contraceptives: Fertil Steril. 2008

Dec;90(6):2060-2067.

Macknin ML

professionals: a prospective randomized controlled trial. Am J Infect Control

Traboulsi EI. The value of keratometry and

central corneal thickness measurements in the clinical diagnosis of marfan syndrome. Am J Ophthalmol. 2008

Phelps T, Wexberg S, Foley C, Lock JC, ,

innovation is a panacea: a case series in quality improvement for primary care mental health services. Clin Pediatr (Phila).

Traboulsi EIUnited Arab Emirates families with achromatopsia. Mol Vis.

Hashkes PJ, Uziel Y. Differentiation of post-streptococcal reactive arthritis from acute rheumatic fever. J Pediatr

Traboulsi EI. Hypermetropia and esotropia in myotonic dystrophy. J AAPOS. 2008 Feb;12(1):69-71.

Wyllie E, Gupta A. Interictal hypermetabolic

Neurology

Morrison SC

Emerg Radiol

Hashkes PJ. A call for increased adult-pediatric collaboration in rheumatology. Curr Opin Rheumatol.

Traboulsi EI. The value of keratometry and

central corneal thickness measurements in the clinical diagnosis of marfan syndrome. Am J Ophthalmol. 2008

. Plasma chitotriosidase in lysosomal storage diseases. Clin Chim Acta

Kotagal P, Yardi N. The relationship between sleep and epilepsy. Semin Pediatr Neurol

Traboulsi EI

effect on secretion of the full-length enzyme. Hum Mutat.

Hashkes PJpain syndrome of early childhood. Nat Clin Pract Rheumatol.

Kotagal P Wada memory asymmetry scores and postoperative memory outcome in left temporal epilepsy. Seizure. 2008 Dec;17(8):691-698.



. Double outlet right ventricle: aetiologies and associations. J Med Genet

Parikh S, Cohen BH, Gupta A, , Wyllie E, Kotagal PPediatr Neurol

Hashkes PJ, Hom C,

in children with juvenile idiopathic arthritis: a randomised, double-blind, placebo-controlled withdrawal trial. Lancet.

Spalding SJ, Hashkes PJ. The role of tonsillectomy in management of periodic fever, aphthous stomatitis, pharyngitis, and adenopathy: Unanswered questions. J Pediatr

Gupta AClinical problem-solving: island intruder. Neurosurgery. 2008

Traboulsi EI

Am J Ophthalmol.

Traboulsi EI

Am J Ophthalmol. 2008

Ugokwe K, Chahlavi A, Bingaman W, Gupta A

day. Neurosurgery

Hashkes PJ

articular injection in juvenile idiopathic arthritis. Pediatr Rheumatol Online J. 2008;6:1

in autism spectrum disorder patients: a cohort analysis. PLoS ONE

Iben SC

respiratory drive in a rat pup model. Pediatr Res. 2008

Mossad E

infants, and children. J Clin Anesth

Cole-Kelly K, Rosen KR. A theme-based hybrid simulation model to train and evaluate emergency medicine residents. Acad Emerg Med

Lorber R

with an interarterial course: should family screening be routine? J Am Coll Cardiol

Duncan BW, Rosenthal GL

sinus myectomy for pulmonary atresia with intact ventricular septum. J Thorac Cardiovasc Surg

Chhatriwalla AK, Prieto LR

accuracy of rubidium-82 cardiac PET perfusion imaging for the evaluation of ischemia in a pediatric population. Pediatr Cardiol


Outcomes 200868


Latson LA. Causes of recurrent focal neurologic events after transcatheter

occluder. Am J Cardiol

Latson LA. Endovascular stent grafts for large thoracic aneurysms after coarctation repair. Ann Thorac Surg

Latson Ldefuse some ticking time bombs. Catheter Cardiovasc Interv.

Latson L. The roads less traveled. Catheter Cardiovasc Interv

Latson LA. New look at an old ring. Catheter Cardiovasc Interv

Latson LA. Percutaneous closure of patent foramen ovale: have we achieved the ‘utopian’ ideal? Nat Clin Pract Cardiovasc Med

Mavroudis Csurgery in patients with and without congenital heart disease. Ann Thorac Surg

, Rosenthal G, Qureshi A, Prieto L, Preminger T, Lorber R, Latson L, Duncan BWshunt promotes growth of diminutive central pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and systemic-to-pulmonary collateral arteries. Ann Thorac Surg

Phillips KP, Natale A, Sterba R

pericardial instrumentation for catheter ablation of focal atrial tachycardias arising from the left atrial appendage. J Cardiovasc Electrophysiol

Prieto LR Arruda MJComparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation. J Cardiovasc Electrophysiol

Sterba Rnovel mobile cardiac outpatient telemetry for children and adolescents with suspected arrhythmia. Congenit Heart Dis.

Krogmann O, Deal B, Mavroudis C

complications associated with the treatment of patients

Congenital Heart Disease. Cardiol Young. 2008 Dec;18

Mavroudis Cin single ventricle patients. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu

Duncan BW, Rosenthal GL ,

sinus myectomy for pulmonary atresia with intact ventricular septum. J Thorac Cardiovasc Surg

Mavroudis CTask force 9: training in the care of adult patients with congenital heart disease. J Am Coll Cardiol

Mavroudis C.

based on objective data. Cardiol Young. 2008 Dec;18



Mavroudis CArrhythmic complications associated with the treatment of patients with congenital cardiac disease: consensus

Pediatric and Congenital Heart Disease. Cardiol Young.

Mavroudis Carrhythmia surgery in patients undergoing repair of congenital heart disease. Pacing Clin Electrophysiol

Mavroudis C

surgical treatment of congenital cardiac disease--an updated primer and an analysis of opportunities for improvement. Cardiol Young

Mavroudis C,

for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease - the perspective of cardiac surgery. Cardiol Young

Mavroudis Cwith continuous cardiopulmonary bypass for the bidirectional cavopulmonary anastomosis. Cardiol Young. 2008

Mavroudis Cfor Fontan patients: state of the art invited review. Eur J Cardiothorac Surg

, Rosenthal G, Qureshi A, Prieto L, Preminger T, Lorber R, Latson L, Duncan BWshunt promotes growth of diminutive central pulmonary arteries in patients with pulmonary atresia, ventricular septal defect, and systemic-to-pulmonary collateral arteries. Ann Thorac Surg

Duncan BW, Fukamachi K. The Cleveland Clinic PediPump:

reconstructions of cardiac computed tomography scans. ASAIO J

Mavroudis C, Correa A. The importance of nomenclature for congenital cardiac disease: implications for research and evaluation. Cardiol Young

Kurosawa H, Mavroudis C

paediatric and congenital cardiac disease across the World: a

Cardiol Young

Duncan BWarray analysis of a rat model of pulmonary arteriovenous malformations after superior cavopulmonary anastomosis. J Thorac Cardiovasc Surg

Duncan BW,

ASAIO J


Outcomes 200870


Davis D, Davis S Kenny D, Harrison AMdelay in children with hypoplastic left heart syndrome versus d-transposition of the great arteries. Pediatr Cardiol. 2008

Kay M, Wyllie R. Endoscopic appearance of an esophageal squamous papilloma in a pediatric patient. J Pediatr Gastroenterol Nutr. 2008

Alkhouri N, Kaplan B, Kay M

World J Gastroenterol

Atay O, Radhakrishnan K, Arruda J, Wyllie Rchest pain in a pediatric ulcerative colitis patient after

World J Gastroenterol. 2008

Carter-Kent C Feldstein AE. Cytokines in the pathogenesis of fatty liver and disease progression to steatohepatitis: implications for treatment. Am J Gastroenterol

Carter-Kent C Mahajan L J Pediatr Gastroenterol Nutr

Feldstein AE. Cytokeratin 18 fragment levels as

a noninvasive biomarker for nonalcoholic steatohepatitis in bariatric surgery patients. Clin Gastroenterol Hepatol. 2008

Feinberg AN, Feinberg LA, Atay OK. Disability in adolescents with chronic illness: Nutrition and gastroenterology issues. Int J Disabil Hum Dev. 2008

Feinberg AN, Feinberg LAof children and adolescents with developmental disabilities. Pediatr Clin North Am

Feinberg L, Mahajan L, Steffen R. The constipated child: is there a correlation between symptoms and

J Pediatr Gastroenterol Nutr. 2008

Hanouneh IA, Feldstein AE

syndrome in the setting of chronic hepatitis C virus infection. Clin Gastroenterol Hepatol

Hanouneh IA, Feldstein AE

of metabolic syndrome in the setting of recurrent hepatitis C after liver transplantation. Liver Transpl. 2008

Feldstein AE.

Hepatology

Wyllie R,

Crandall W. Effect of early immunomodulator use in moderate to severe pediatric Crohn disease.

Wieckowska A, Feldstein AE. Diagnosis of nonalcoholic fatty liver disease: invasive versus noninvasive. Semin Liver Dis.

Feldstein AE. Increased hepatic and circulating interleukin-6 levels in human nonalcoholic steatohepatitis. Am J Gastroenterol



Kay M, Wyllie R, Mahajan L.

with Crohn disease. J Pediatr Gastroenterol Nutr. 2008

Kodish Eprotocol. Lancet

Kodish E. Correspondence between objective and subjective reports of adherence among adolescents with acute lymphoblastic leukemia. Child Health Care

Kodish ED. Anticipatory guidance to improve informed consent: a new application of the concept. J Pediatr Oncol Nurs

Andrish J. The management of recurrent patellar dislocation. Orthop Clin North Am

Ching CB, Palmer JSPediatric Health. 2008 Apr;2(2):

Soldes OS

peritonitis. Pediatr Surg Int

Palmer JSBJU Int.

Ross JH. Prenatally detected ureteropelvic junction obstruction: clinical features and associated urologic abnormalities. Pediatr Surg Int

Luciano M.

shunt complications. Surg Endosc. 2008 Aug;22(8): 1866-1870.

Palmer JSoutpatient procedure. J Urol

Palmer JSbetamethasone for treating phimosis: a comparison of two treatment regimens. Urology

Ross JH. Timing of the

repair in pediatric patients. J Urol. 2008 Oct;180

Andrish JT

anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg

Andrish JT

cruciate ligament reconstruction rehabilitation: part II:

electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg

Whittemore K, Discolo C. Nonsteroidal anti-

adenotonsillectomy in pediatric patients. Arch Otolaryngol Head Neck Surg

. Complete bronchial stricture and airway management challenges. Am J Otolaryngol


Outcomes 20087272

Staff Listing

Institute Chairman and Physician-in-Chief

Calabarese Chair of Pediatrics

Institute Vice Chairmen

Section of Adolescent Medicine

Center for Pediatric Allergy

Center Head

Department of Pediatric Anesthesiology

Chair; Director, Pediatric Anesthesia Fellowship Program



Center for Pediatric Behavioral Health

Center Head

Deborah Baum, PhD

Cara Cuddy, PhD Director, Feeding Disorders Program

Kristen Eastman, PsyD

Thomas Frazier II, PhD

Eileen Kennedy, PhD

Dunya T. Yaldoo-Poltorak, PhD

Section of Pediatric Cardiothoracic Anesthesiology

Department of Pediatric Cardiology

Transplant Program

Department of Pediatric and Congenital Heart Surgery


Outcomes 20087474

Staff Listing

Department of Critical Care Medicine

Chair; Director, PICU

Director, Pediatric Transport

Center for Pediatric Endocrinology

Center Head

Section of Pediatric Epilepsy and Sleep Disorders

Head, Center for Pediatric Neurology

Department of Pediatric Gastroenterology

Chair

Director, Pediatric Hepatology and Transplantation

Department of General Pediatrics



General Pediatrics - Urgent Care

Genetics

Section of Pediatric and Adolescent Gynecology

Department of Pediatrics Hematology/Oncology

Chair; Co-Director, Pediatric Brain Tumor Program

Center for Pediatric Hospital Medicine

Center Head

Center for Pediatric Infectious Diseases

Center Head


Outcomes 20087676

Staff Listing

Pediatric Liver Transplant Team

Director

Section of Pediatric Nephrology and Hypertension

Director, Power Dialysis Unit

Department of Neonatology

Chair

Center for Pediatric Neurology

Center Head

Section of Pediatric Neurosurgery

Section of Pediatric Ophthalmology and Strabismus



Section of Pediatric Orthopaedic Surgery

Section of Pediatric Otolaryngology

Pediatric Plastic Surgery

Section of Pediatric and Adolescent Psychiatry

Patricia Klaas, PhD

Center for Pediatric Pulmonary Medicine

Center Head

Pediatric Radiation Oncology

Section of Pediatric Radiology

Section of Pediatric Rheumatic and Immunologic Disease

Department of Pediatric Surgery

Chair


Outcomes 20087878

Staff Listing

Pediatric and Adolescent Sports Medicine

Center for Pediatric Urology

Center Head

Department of Developmental and Rehabilitative Pediatrics

Chair

Department of Community Pediatrics

Chair

Cleveland Clinic Avon Pointe

Cleveland Clinic Beachwood

Cleveland Clinic Brunswick

Cleveland Clinic Elyria at Chestnut Commons

Cleveland Clinic Independence



Cleveland Clinic Lakewood

Cleveland Clinic Lorain

Cleveland Clinic Solon

Cleveland Clinic Strongsville Diane C. Cutter-Ali, DO

Cleveland Clinic Willoughby Hills

Cleveland Clinic Wooster David A. Burke, DO

s may practice in multiple locations. For a complete list including staff photos, please visit clevelandclinic.org/staff


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Contact Information

General Patient Referral

Main Campus

Cleveland Clinic Children’s Hospital for Rehabilitation, Shaker Campus

Outpatient Appointments/Referrals

Cleveland Clinic Children’s Hospital for Rehabilitation, Shaker Campus Outpatient Medical Clinic Appointments/Referrals

Center for Autism

Feeding Disorders Program

OT/PT/SLT and Motor Control Programs

Dialysis

On the Web at clevelandclinic.org/peds

Center near you, visit clevelandclinic.org/fhc

Additional Contact Information General Information

Hospital Patient Information

Patient Appointments

Medical Concierge

Complimentary assistance for out-of-state patients and families

or email [email protected] Global Patient Services/International Center

Complimentary assistance for international patients and families

or visit clevelandclinic.org/gps Cleveland Clinic in Florida

For address corrections or changes, please call



Institute Locations

Main Campus

Shaker Campus

Fairview Pediatric Subspecialty Clinic

Hillcrest Pediatric Subspecialty Clinic

Huron General Pediatric Clinic

216.761.7281 Marymount General Pediatric/Cardiology Clinic

Therapy Services Therapy Services-West

826 Westpoint Parkway

Therapy Services-South

Therapy Services-East


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Institute Locations

Family Health CentersAvon Family Health Center

Beachwood Family Health and Surgery Center

Brunswick Family Health Center

Elyria Family Health Center, Chestnut Commons

Independence Family Health Center

Crown Center II

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Lorain Family Health and Surgery Center

Solon Family Health Center

Strongsville Family Health and Surgery Center

Willoughby Hills Family Health Center

Wooster Family Health Center

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Cleveland Clinic Overview

In 2007, Cleveland Clinic restructured its practice, bundling all clinical specialties into integrated practice units called institutes. An institute combines all the

under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the patient. From access and communication to billing and point-of-care service, institutes will improve the patient

acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs

hospital and clinic in Weston, Fla.; and health and wellness centers in Palm Beach, Fla., and Toronto, Canada. Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to open in late 2012.

of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total

federal agencies, non-federal societies and associations, endowment funds and other sources. In an effort to bring research from bench to bedside, Cleveland Clinic

at any given time.

offers all students full tuition scholarships. The program will

Cleveland Clinic is consistently ranked among the top hospitals in America by and our heart and heart surgery program has been ranked No. 1

For more information about Cleveland Clinic, please visit clevelandclinic.org.



Resources for Physicians

Cleveland Clinic Secure Online Services

Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to GoogleTM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart.

DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/drconnect or email [email protected].

MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and life-altering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

Critical Care Transport: Anywhere in the world

Cleveland Clinic’s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call 877.279.CODE (2633). For all other transfers, call 216.444.8302 or 800.553.5056.

CME Opportunities: Live and Online

Cleveland Clinic’s Center for Continuing Education’s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.



2008Outcomes

9500 Euclid Avenue, Cleveland, OH, 44195

© The Cleveland Clinic Foundation 2009

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

Please visit us on the Web at clevelandclinic.org.


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