Quality and Safety

Children's National Hospital

Safety at every level: a cultural transformation

Children's National Hospital

In early December, Children’s National Quality & Safety leadership team led participants through the hospital’s high-reliablility journey and actionable tools at the Institute for Healthcare Improvement National Forum in Orlando, Fla.

In early December 2019, leadership from Children’s National Hospital quality and safety team attended and presented at the Institute for Healthcare Improvement National Forum in Orlando, Fla. The presentation, titled Safety at Every Level: A Cultural Transformation, provided attendees with an overview of Children’s National Hospital’s high reliability journey and actionable tools they could use to improve quality and safety.

Rahul Shah, M.D., MBA., vice president and chief quality and safety officer, Lisbeth Fahey, MSN, RN., executive director of quality and safety, Kavita Parikh, M.D., MSHS, pediatric hospitalist, and Kathryn Merkeley, MHSA, RN, director of patient safety, led the participants through each step of our journey, highlighting where the organization started, key steps in the process and lessons learned along the way.

The presentation demonstrated the integration of safety tools such as error prevention training, safety briefings, safety event reporting, cause analysis, safety culture measurement and transparency with high reliability principles to produce tangible gains in safety, quality and organizational culture. Dr. Shah emphasized the overarching theme of continuous learning and iterative change that is needed to be successful with this type of work.

“We’re always learning and looking to make things better by benchmarking our work against other pediatric organizations,” Dr. Shah said. “It’s important to ensure that we use the best practices to make sure we have the latest, best and most-evidence based practices to remain a top performing pediatric hospital.”

In a pediatric setting, safety is the keystone for performance excellence. As organizations work toward becoming high-reliability organizations they become more sensitive to operations, committed to resilience and are more reluctant to simplify their observations. Through implementing these tools and continually evaluating and learning, Children’s National was able to institute the evolution of a new safety culture by being more systematic, proactive and generative.

“Our goal was to provide the audience with tools they could use on their own journey to high-reliability,” said Merkeley. “We not only wanted to share our successes in creating positive culture change, but also the many lessons we’ve learned along the way and the desire to always be learning and improving.”

newborn baby

Directly measuring function in tiny hearts

newborn baby

The amount of blood the heart pumps in one minute can be directly measured safely in newborns by monitoring changes in blood velocity after injecting saline, indicates the first clinical study of direct cardiac output measurement in newborns.

The amount of blood that the heart pumps in one minute (cardiac output) can be directly measured safely in newborns by monitoring changes in blood velocity after injecting saline, indicates a paper published online Dec. 17, 2019 in the Journal of Pediatrics and Neonatal Medicine. The research, conducted by Children’s National Hospital faculty, is believed to be the first clinical study of direct cardiac output measurement in newborns.

Right now, cardiac output is measured indirectly in the nation’s neonatal intensive care units (NICU) using newborns’ blood pressure, heart rate, urine output and other indirect measures. However, these techniques can produce imprecise readings in children. And the field lacks a feasible “gold standard” to measure cardiac output in newborns.

The COstatus monitor already uses ultrasound dilution – the expected decrease in the velocity of blood when saline is injected, producing a dilution curve. A Children’s National research team used ultrasound dilution in their small pilot study to gauge the feasibility of directly measuring cardiac output in newborns.

“Infants who stand to benefit most from directly monitoring cardiac hemodynamics are often so sick they already have central venous access,” says Khodayar Rais-Bahrami, M.D., an attending neonatologist at Children’s National and the study’s senior author. “Using the COstatus monitor in these children would enable the clinical team to personalize care based on the newborn’s current hemodynamic status, while introducing minimal fluid during measurements,” Dr. Rais-Bahrami adds.

COstatus monitor

The COstatus Monitor uses an extracorporeal loop attached to arterial and venous lines to measure cardiac output using ultrasound dilution. The research team injected 1mL/kg of body temperature saline into the loop and performed up to two measurement sessions daily.

The research team recruited 12 newborns younger than 2 weeks old who already had central venous and arterial access. The venous line of the arteriovenous AV loop is connected to the umbilical venous catheter while the COstatus monitor’s arterial line is connected to the umbilical arterial catheter. During measurement sessions, two injections of solution are injected into the venous loop, allowing for two measures of cardiac output, cardiac index, active circulating volume index, central blood volume index and systemic vascular resistance index.

Infants enrolled in the pilot study underwent up to two measurement sessions per day for up to four days, for a total of 54 cardiac hemodynamic measurements. The newborns ranged from 720 to 3,740 grams in weight and 24 to 41.3 weeks in gestational age.

The infants’ mean cardiac output was 0.43L/min and increased with gestational age. By contrast, the mean cardiac index was 197mL/kg/min and changed little with infants’ increasing maturity – either by gestational age or postnatal age. Two of the study participants were undergoing therapeutic cooling for hypoxic-ischemic encephalopathy and had their measurements taken during cooling and after rewarming.

“Although this study size is small, it demonstrates that this minimally invasive technique can safely be used in newborns to directly measure cardiac hemodynamics,” says Simranjeet S. Sran, M.D., a Children’s National neonatalogist and the study’s lead author. “This technology may allow for more precise and personalized care of critically ill newborns in a range of disease states – real-world utility in NICUs that serve some of the youngest and sickest newborns,” Dr. Sran adds.

The research team notes that direct measurement by ultrasound dilution revealed a stark increase in cardiac index as infants undergoing therapeutic hypothermia were rewarmed, raising questions about whether indirect measures using other technology, such as echocardiography, underestimate hypothermia’s effect on hemodynamics.

In addition to Drs. Rais-Bahrami and Sran, Mariam Said, M.D., also a Children’s National neonatalogist, was a study co-author.

expired drugs

Fewer than half of California pharmacies provide correct drug disposal info

expired drugs

Fewer than half of California pharmacies provided correct prescription drug disposal details, a percentage that dropped if “secret shoppers” made their call on a weekend, according to a brief research report published online Dec. 31, 2019, in Annals of Internal Medicine.

The callers pretended to be well-meaning parents who were trying to safely dispose of unneeded antibiotics and opioid-based prescription painkillers after their child’s surgery. Fewer than half of the California pharmacies they called provided correct prescription drug disposal details, a percentage that dropped sharply if the “secret shoppers” made their call on a weekend, according to a brief research report published online Dec. 31, 2019, in Annals of Internal Medicine.

“The Food and Drug Administration advises consumers about how to safely dispose of unneeded medicines and, because pharmacists can play an integral role in this conversation, the American Pharmacists Association says prescription medication disposal should follow FDA guidelines,” says Rachel E. Selekman, M.D., MAS, a pediatric urologist at Children’s National Hospital and the study’s first author. “We found very few California pharmacies permitted take-back of unneeded medications. There was also a striking difference in the accuracy and completeness of drug disposal information depending on whether they answered the call on a weekday or a weekend. That suggests room for improvement,” Dr. Selekman says.

The multi-institutional research team, led by Primary Investigator and senior author Hillary L. Copp, M.D., MS, at University of California, San Francisco, identified licensed pharmacies located in urban and rural settings in California. That state that accounts for 10% of all U.S. pharmacies. They wrote a script that guided four male and two female “secret shoppers” to ask about what to do about leftover antibiotics (sulfamethoxazole-trimethoprim tablets) and a liquid opioid-based painkiller (hydrocodone-acetaminophen). From late-February to late-April 2018, they called 898 pharmacies from 8 a.m. to 8 p.m., asking about the correct way to dispose of these medicines.

According to the FDA, consumers should mix most unused medicines with an unappealing substance, like kitty litter, place it in a sealed container and toss the container in the trash.  Medicines that can be harmful to others, like opioids, should be flushed down the sink or toilet. Many pharmacies have programs or kiosks to handle unused prescription medicines.

Of the pharmacies surveyed in California:

  • 47% provided correct information about disposing of antibiotics
  • 29% provided correct information about how to dispose of both antibiotics and opioids
  • 19% provided correct information about how to dispose of opioids
  • 49% provided correct antibiotic disposal information and 20% provided correct opioid disposal information on weekday calls
  • 15% provided correct antibiotic disposal information and 7% provided correct opioid disposal information on weekend calls

Asked specifically about drug take-back programs, just 11% said their pharmacy had one that could be used to dispose of antibiotics or opioids.

“Unused prescription medications can be misused by others and can result in accidental childhood poisonings,” Dr. Selekman adds. “The bottom line is that we often talk about how to address the problem of too many unused medications lingering in homes. There are many reasons this is a problem, but part of the problem is nobody knows what to do if they have too many prescription medicines. Because of this research, we have discovered that pharmacies don’t uniformly provide accurate information to our patients. Patients, families and health care professionals who advise families should work together to help improve and expand safe disposal options for these powerful medications.”

In addition to Drs. Selekman and Copp, the research team includes co-authors Thomas W. Gaither, M.D., MAS, Zachary Kornberg, BA, and Aron Liaw, M.D., all of whom were at the University of California, San Francisco, School of Medicine, Division of Pediatric Urology at the time the study was performed.

Dr. Kurt Newman in front of the capitol building

Making healthcare innovation for children a priority

Dr. Kurt Newman in front of the capitol building

Recently, Kurt Newman, M.D., president and CEO of Children’s National Hospital, authored an opinion piece for the popular political website, The Hill. In the article, he called upon stakeholders from across the landscape to address the significant innovation gap in children’s healthcare versus adults.

As Chair of the Board of Trustees of the Children’s Hospital Association,  Dr. Newman knows the importance of raising awareness among policy makers at the federal and state level about the healthcare needs of children. Dr. Newman believes that children’s health should be a national priority that is addressed comprehensively. With years of experience as a pediatric surgeon, he is concerned by the major inequities in the advancements of children’s medical devices and technologies versus those for adults. That’s why Children’s National is working to create collaborations, influence policies and facilitate changes that will accelerate the pace of pediatric healthcare innovation for the benefit of children everywhere. One way that the hospital is tackling this challenge is by developing the Children’s National Research & Innovation Campus, which will be the nation’s first innovation campus focused on pediatric research.

Research & Innovation Campus

Children’s National partners with Virginia Tech

Children’s National Hospital and Virginia Tech create formal partnership that includes the launch of a Virginia Tech biomedical research facility within the new Children’s National Research & Innovation Campus.

Children’s National Hospital and Virginia Tech recently announced a formal partnership that will include the launch of a 12,000-square-foot Virginia Tech biomedical research facility within the new Children’s National Research & Innovation Campus. The campus is an expansion of Children’s National that is located on a nearly 12-acre portion of the former Walter Reed Army Medical Center in Washington, D.C. and is set to open its first phase in December 2020. This new collaboration brings together Virginia Tech, a top tier academic research institution, with Children’s National, a U.S. News and World Report top 10 children’s hospital, on what will be the nation’s first innovation campus focused on pediatric research.

Research & Innovation Campus

“Virginia Tech is an ideal partner to help us deliver on what we promised for the Children’s National Research & Innovation Campus – an ecosystem that enables us to accelerate the translation of potential breakthrough discoveries into new treatments and technologies,” says Kurt Newman, M.D., president and CEO, Children’s National. “Our clinical expertise combined with Virginia Tech’s leadership in engineering and technology, and its growing emphasis on biomedical research, will be a significant advance in developing much needed treatment and cures to save children’s lives.”

Earlier this year, Children’s National announced a collaboration with Johnson & Johnson Innovation LLC to launch JLABS @ Washington, DC at the Research & Innovation Campus. The JLABS @ Washington, DC site will be open to pharmaceutical, medical device, consumer and health technology companies that are aiming to advance the development of new drugs, medical devices, precision diagnostics and health technologies, including applications in pediatrics.

“We are proud to welcome Virginia Tech to our historic Walter Reed campus – a campus that is shaping up to host some of the top minds, talent and innovation incubators in the world,” says Washington, D.C. Mayor Muriel Bowser. “The new Children’s National Research & Innovation Campus will exemplify why D.C. is the capital of inclusive innovation – because we are a city committed to building the public and private partnerships necessary to drive discoveries, create jobs, promote economic growth and keep D.C. at the forefront of innovation and change.”

Faculty from the Children’s National Research Institute and the Fralin Biomedical Research Institute at Virginia Tech Carilion (VTC) have worked together for more than a decade, already resulting in shared research grants, collaborative publications and shared intellectual property. Together, the two institutions will now expand their collaborations to develop new drugs, medical devices, software applications and other novel treatments for cancer, rare diseases and other disorders.

“Joining with Children’s National in the nation’s capital positions Virginia Tech to improve the health and well-being of infants and children around the world,” says Virginia Tech President Tim Sands, Ph.D. “This partnership resonates with our land-grant mission to solve big problems and create new opportunities in Virginia and D.C. through education, technology and research.”

The partnership with Children’s National adds to Virginia Tech’s growing footprint in the Washington D.C. region, which includes plans for a new graduate campus in Alexandria, Va. with a human-centered approach to technological innovation. Sands said the proximity of the two locations – just across the Potomac – will enable researchers to leverage resources, and will also create opportunities with the Virginia Tech campus in Blacksburg, Va. and the Virginia Tech Carilion Health Science and Technology campus in Roanoke, Va.

Carilion Clinic and Children’s National have an existing collaboration for provision of certain specialized pediatric clinical services. The more formalized partnership between Virginia Tech and Children’s National will drive the already strong Virginia Tech-Carilion Clinic partnership, particularly for children’s health initiatives and facilitate collaborations between all three institutions in the pediatric research and clinical service domains.

Children’s National and Virginia Tech will engage in joint faculty recruiting, joint intellectual property, joint training of students and fellows, and collaborative research projects and programs according to Michael Friedlander, Ph.D., Virginia Tech’s vice president for health sciences and technology, and executive director of the Fralin Biomedical Research Institute at VTC.

“The expansion and formalization of our partnership with Children’s National is extremely timely and vital for pediatric research innovation and for translating these innovations into practice to prevent, treat and ultimately cure nervous system cancer in children,” says Friedlander, who has collaborated with Children’s National leaders and researchers for more than 20 years. “Both Virginia Tech and Children’s National have similar values and cultures with a firm commitment to discovery and innovation in the service of society.”

“Brain and other nervous system cancers are among the most common cancers in children (alongside leukemia),” says Friedlander. “With our strength in neurobiology including adult brain cancer research in both humans and companion animals at Virginia Tech and the strength of Children’s National research in pediatric cancer, developmental neuroscience and intellectual disabilities, this is a perfect match.”

The design of the Children’s National Research & Innovation Campus not only makes it conducive for the hospital to strengthen its prestigious partnerships with Virginia Tech and Johnson & Johnson, it also fosters synergies with federal agencies like the Biomedical Advanced Research and Development Authority, which will collaborate with JLABS @ Washington, DC to establish a specialized innovation zone to develop responses to health security threats. As more partners sign on, this convergence of key public and private institutions will accelerate discoveries and bring them to market faster for the benefit of children and adults.

“The Children’s National Research & Innovation Campus pairs an inspirational mission to find new treatments for childhood illness and disease with the ideal environment for early stage companies. I am confident the campus will be a magnet for big ideas and will be an economic boost for Washington DC and the region,” says Jeff Zients, who was appointed chair of the Children’s National Board of Directors effective October 1, 2019. As a CEO and the former director of President Obama’s National Economic Council, Zients says that “When you bring together business, academia, health care and government in the right setting, you create a hotbed for innovation.”

Ranked 7th in National Institutes of Health research funding among pediatric hospitals, Children’s National continues to foster collaborations as it prepares to open its first 158,000-square-foot phase of its Research & Innovation Campus. These key partnerships will enable the hospital to fulfill its mission of keeping children top of mind for healthcare innovation and research while also contributing to Washington D.C.’s thriving innovation economy.

doctor's stethescope coming out of a computer

Virtual cardiology follow-ups may save families time and money

doctor's stethescope coming out of a computer

Virtual cardiology follow-ups via computer or smartphone are a feasible alternative to in-person patient follow-ups for some pediatric cardiac conditions.

A poster presentation at the AHA Scientific Sessions shows successful implementation of virtual care delivered directly to patients and families via technology.

Health provider follow-ups delivered via computer or smartphone is a feasible alternative to in-person patient follow-ups for some pediatric cardiac conditions, according to the findings of a pilot study presented at the AHA Scientific Sessions this week.

“We’ve used telemedicine in pediatric cardiology for physician-to-physician communications for years at Children’s National, thanks to cardiologists like Dr. Craig Sable,” says Ashraf Harahsheh, M.D., cardiologist at Children’s National Hospital and senior author of the study. “But this is the first time we’ve really had the appropriate technology to speak directly to patients and their families in their homes instead of requiring an in-person visit.”

“We developed it [telemedicine] into a primary every day component of reading echocardiograms around the region and the globe,” says Craig Sable, M.D., associate chief of cardiology at Children’s National. “Telemedicine has enabled doctors at Children’s National to extend our reach to improve the care of children and avoid unnecessary transport, family travel and lost time from work.”

Participants in the virtual visit pilot study were previously established patients with hyperlipidemia, hypercholesterolemia, syncope, or who needed to discuss cardiac testing results. The retrospective sample included 18 families who met the criteria and were open to the virtual visit/telehealth follow up option between 2016 and 2019. Six months after their virtual visit, none of the participants had presented urgently with a cardiology issue. While many (39%) had additional visits with cardiology scheduled as in person, none of those subsequent in-person visits were a result of a deficiency related to the virtual visit.

“There are many more questions to be answered about how best to appropriately use technology advances that allow us to see and hear our patients without requiring them to travel a great distance,” adds Dr. Harahsheh. “But my team and I were encouraged by the results of our small study, and by the anecdotal positive reviews from families who participated. We’re looking forward to determining how we can successfully and cost-effectively implement these approaches as additional options for our families to get the care they need.”

The project was supported by the Research, Education, Advocacy, and Child Health Care (REACH) program within the Children’s National Hospital Pediatric Residency Program.

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Direct-to-Consumer Cardiology Telemedicine: A Single Large Academic Pediatric Center Experience
Aaron A. Phillips, M.D., Craig A. Sable, M.D., FAAP; Christina Waggaman, M.S.; and Ashraf S. Harahsheh, M.D., F.A.C.C., F.A.A.P.
Poster Presentation by first author Aaron Phillips, M.D., a third-year resident at Children’s National
CH.APS.12 – Man vs. Machine: Tech in Kids
AHA Scientific Sessions 2019
November 17, 2019
12:30 -1:00 p.m.

BPA analogues may be less likely to disrupt heart rhythm

Some chemical alternatives to plastic bisphenol-a (BPA), which is still commonly used in medical settings such as operating rooms and intensive care units, may be less disruptive to heart electrical function than BPA,

A poster at the AHA Scientific Sessions suggests bisphenol-s (BPS) and bisphenol-f (BPF) may have less impact on heart function than bisphenol-a (BPA).

Some chemical alternatives to plastic bisphenol-a (BPA), which is still commonly used in medical settings such as operating rooms and intensive care units, may be less disruptive to heart electrical function than BPA, according to a pre-clinical study that explored how the structural analogues bisphenol-s (BPS) and bisphenol-f (BPF) interact with the chemical and electrical functions of heart cells.

The findings suggest that in terms of toxicity for heart function, these chemicals that are similar in structure to BPA may actually be safer for medically fragile heart cells, such as those in children with congenital heart disease. Previous research has found a high likelihood that BPA exposure may impact the heart’s electrical conductivity and disrupt heart rhythm, and patients are often exposed to the plastic via clinical equipment found in intensive care and in the operating room.

“There are still many questions that need to be answered about the safety and efficacy of using chemicals that look and act like BPA in medical settings, especially in terms of their potential contribution to endocrine disruption,” says Nikki Gillum Posnack, Ph.D., the poster’s senior author and a principal investigator in the Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Hospital. “What we can say is that, in this initial pre-clinical investigation, it appears that these structural analogues have less of an impact on the electrical activity within the heart and therefore, may be less likely to contribute to dysrhythmias.”

Future studies will seek to quantify the risk that these alternative chemicals pose in vulnerable populations, including pediatric cardiology and cardiac surgery patients. Since pediatric patients’ hearts are still growing and developing, the interactions may be different than what was seen in this pilot study.

Learn more the impacts of exposure to plastics such as bisphenol-A and plasticizers such as DEHP and MEHP that are commonly used in medical devices:

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Bisphenol-a Analogues May Be Safer Alternatives For Plastic Medical Products
Rafael Jaimes, Damon McCullough, Luther M Swift, Marissa Reilly, Morgan Burke, Jiansong Sheng, Javier Saiz, Nikki G Posnack
Poster Presentation by senior author Nikki G Posnack
CH.APS.01 – Translational Research in Congenital Heart Disease
AHA Scientific Sessions
November 16, 2019
1:30 p.m. – 2:00 p.m.

doctor giving girl checkup

Decision support tool reduces unneeded referrals of low-risk patients with chest pain

doctor giving girl checkup

A simple evidence-based change to standard practice could avert needless referrals of low-risk patients to cardiac specialists, potentially saving nearly $4 million in annual health care spending while also easing worried parents’ minds.

Few events strike more fear in parents than hearing their child’s heart “hurts.”

When primary care pediatricians – who are on the frontline of triaging such distressing doctor visits – access a digital helping hand tucked into the patient’s electronic health record to help them make assessments, they are more likely to refer only the patients whose chest pain is rooted in a cardiac problem to a specialist.

That simple evidence-based change to standard practice could avert needless referrals of low-risk patients to cardiac specialists according to a quality-improvement project presented during the American Academy of Pediatrics (AAP) National Conference and Exhibition. This has the potential to save nearly $4 million in annual health care spending while also easing worried parents’ minds.

“Our decision support tool incorporates the know-how of providers and helps them to accurately capture the type of red flags that point to a cardiac origin for chest pain,” says Ashraf Harahsheh, M.D., FACC, FAAP, pediatric and preventive cardiologist and director of Resident Education in Cardiology at Children’s National Hospital. Those red flags include:

  • Abnormal personal medical history
    • Chest pain with exertion
    • Exertional syncope
    • Chest pain that radiates to the back, jaw, left arm or left shoulder
    • Chest pain that increases with supine position
    • Chest pain temporarily associated with a fever (>38.4°C)
  • A worrisome family history, including sudden unexplained death and cardiomyopathy.

“We know that evidence-based tools can be very effective in guiding physician behavior and reducing unnecessary testing and referrals which saves both the health care system in dollars and families in time and anxiety,” Dr. Harahsheh adds.

The abstract builds on a multi-institutional study published in Clinical Pediatrics in 2017 for which Dr. Harahsheh was lead author. More than 620,000 office-based visits (1.3%) to pediatricians in 2012 were for chest pain, he and co-authors wrote at the time. While children often complain of having chest pain, most of the time it is not due to an actual heart problem.

Over recent years, momentum has built for creating an evidence-based approach for determining which children with chest pain to refer to cardiac specialists. In response, the team’s quality-improvement tool, first introduced at two local primary pediatric offices, was expanded to the entire Children’s Pediatricians & Associates network of providers who offer pediatric primary care in Washington, D.C., and Maryland.

One daunting challenge: How to ensure that busy clinicians actually use the tool. To improve adoption, the project team embedded the decision support tool within the patient’s electronic medical record.  Now, they seek to make sure the tool gets used by more pediatricians around the country.

“If the chest pain decision support tool/medical red-flags criteria were adopted nationwide, we expect to save a minimum of $3.8 million in health care charges each year,” Dr. Harahsheh says. “That figure is very likely an underestimate of the true potential savings, because we did not calculate the value of lost productivity and other direct costs to families who shuttle from one appointment to the next.”

To ensure the changes stick, the team plans to train fledgling physicians poised to embrace the quality-improvement approach as they first launch their careers, and also look for evangelists within outpatient cardiology and pediatric clinics who can catalyze change.

“These types of quality-improvement projects require a change to the status quo. In order to be successful, we need members of the care team – including frontline clinicians and nurse practitioners – to champion change at the clinic level. With their help, we can continue to refine this tool and move toward nationwide implementation,” he explains.

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AAP National Conference and Exhibition presentation
Saturday, Oct. 26, 9 a.m. to 2 p.m. (ET)
H2086 Council on Quality Improvement and Patient Safety Program

Saturday, Oct. 26, noon to 1 p.m. (ET)
Poster viewing
“Reducing low-probability cardiology referrals for chest pain from primary care: a quality improvement initiative”
Ashraf Harahsheh, M.D., FACC, FAAP; Ellen Hamburger, M.D.; Lexi Crawford, M.D.; Christina Driskill, MPH, RN, CPN; Anusha Rao, MHSA; Deena Berkowitz, M.D., MPH

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Additional AAP 2019 activities featuring cardiology faculty at Children’s National Hospital include:

    • Rohan Kumthekar, M.D., recipient of the “Trainee Pediatric Cardiology Research Award” sponsored by the Children’s Heart Foundation
    • “Motion-corrected cardiac MRI limits anesthesia exposure and healthcare costs in children,” Adam B. Christopher, M.D.; Rachel Quinn, M.D.; Sara Zoulfagharian; Andrew Matisoff, M.D.; Russell Cross, M.D.; Adrienne Campbell-Washburn, Ph.D.; Laura Olivieri, M.D.
    • “Prevalence of abnormal echocardiograms in healthy, asymptomatic adolescents with Down syndrome,” Sarah B. Clauss, M.D.; Samuel S. Gidding M.D.; Claire I. Cochrane, BA; Rachel Walega, MS; Babette S. Zemel, Ph.D.; Mary E. Pipan, M.D.; Sheela N. Magge, M.D., MSCE;  Andrea Kelly, M.D., MSCE; Meryl S. Cohen, M.D.
    • “American College of Cardiology body mass index measurement and counseling quality improvement initiative,” Ashraf Harahsheh, M.D., FACC, FAAP; Arash Sabati, M.D., FACC; Jeffrey Anderson, M.D.; Clara Fitzgerald; Kathy Jenkins, M.D., MPH; Carolyn M. Wilhelm, M.D., MS, FACC, FAAP; Roy Jedeikin, M.D. FACC, MBA; Devyani Chowdhury, M.D.
Dr. Jonas and research collaborator Nobuyuki Ishibashi in the laboratory.

Cardiac surgery chief recognized for studies of surgery’s impacts on neurodevelopment

Dr. Jonas and research collaborator Nobuyuki Ishibashi in the laboratory.

Dr. Jonas and research collaborator Nobuyuki Ishibashi in the laboratory.

Richard Jonas, M.D., is this year’s recipient of the Newburger-Bellinger Cardiac Neurodevelopmental Award in recognition of his lifelong research into understanding the impact of cardiac surgery on the growth and development of the brain. The award was established in 2013 by the Cardiac Neurodevelopmental Outcome Collaborative (CNOC) to honor Jane Newburger and David Bellinger, pioneers in research designed to understand and improve neurodevelopmental outcomes for children with heart disease.

At Children’s National, Dr. Jonas’ laboratory studies of neuroprotection have been conducted in conjunction with Dr. Vittorio Gallo, director of neuroscience research at Children’s National, and Dr. Nobuyuki Ishibashi, director of the cardiac surgery research laboratory. Their NIH-supported studies have investigated the impact of congenital heart disease and cardiopulmonary bypass on the development of the brain, with particular focus on impacts to white matter, in people with congenital heart disease.

Dr. Jonas’s focus on neurodevelopment after cardiac surgery has spanned his entire career in medicine, starting with early studies in the Harvard psychology department where he developed models of ischemic brain injury. He subsequently undertook a series of highly productive pre-clinical cardiopulmonary bypass studies at the National Magnet Laboratory at MIT. These studies suggested that some of the bypass techniques used at the time were suboptimal. The findings helped spur a series of retrospective clinical studies and subsequently several prospective randomized clinical trials at Boston Children’s Hospital examining the neurodevelopmental consequences of various bypass techniques. These studies were conducted by Dr. Jonas and others, in collaboration with Dr. Jane Newburger and Dr. David Bellinger, for whom this award is named.

Dr. Jonas has been the chief of cardiac surgery and co-director of the Children’s National Heart Institute since 2004. He previously spent 20 years on staff at Children’s Hospital Boston including 10 years as department chief and as the William E. Ladd Chair of Surgery at Harvard Medical School.

As the recipient of the 2019 award, Dr. Jonas will deliver a keynote address at the 8th Annual Scientific Sessions of the Cardiac Neurodevelopmental Outcome Collaborative in Toronto, Ontario, October 11-13, 2019.

Tania Ahluwalia

Simulation curriculum for emergency medicine trainees in India

Tania Ahluwalia

“It is essential to equip emergency physicians in India with these necessary skills so they can provide the best acute care for children and help the country overcome its burden of pediatric illness. This project focuses on simulation training because it is a very effective way to practice clinical and communication skills,” says Tania Ahluwalia, M.D., FAAP.

India has a high burden of pediatric illness, and close to 1 million children die each year.

Despite those staggering public health challenges, pediatric emergency medicine training remains in its infancy in India. Tania Ahluwalia, M.D., FAAP, associate director of Global Health Programs, Division of Emergency Medicine and Trauma Services at Children’s National Hospital has been working with the Ronald Reagan Institute of Emergency Medicine to help address that training gap.

“It is essential to equip emergency physicians in India with these necessary skills so they can provide the best acute care for children and help the country overcome its burden of pediatric illness. This project focuses on simulation training because it is a very effective way to practice clinical and communication skills,” Dr. Ahluwalia says.

Each October a team led by Dr. Ahluwalia teaches Pediatric Emergency Medicine modules in India based on a three-year curriculum.  In October 2019, they will focus on neonatology. And thanks to a 2019-2020 Global Health Initiative Exploration in Global Health Award presented during Research and Education Week at Children’s National, over two weeks Dr. Ahluwalia will visit various cities in India with a team that includes:

  • Kaitlyn Boggs, M.D., a second-year pediatric resident at Children’s National
  • Camilo Gutierrez, M.D., Children’s National Emergency Medicine and Trauma Services
  • Simone Lawson, M.D., Children’s National Emergency Medicine and Trauma Services
  • Shobhit Jain, Kansas City
  • Shiva Kalidindi, Nemours Children’s Hospital
  • Manu Madhok, Minneapolis

For the study, about 80 trainees participating in postgraduate emergency medicine training programs in India will practice skills, such as intubating a patient, using the same medical equipment and mannequins of the same size as pediatric patients. The trainees will review several pediatric emergency medicine cases that were developed based on a needs assessment at partner programs in India. First, visiting faculty members will watch videos developed by Dr. Ahluwalia, Michael Hrdy, M.D., and Rachael Batabyal, M.D., and will review literature on how to conduct simulation in a developing country.

Faculty teaching neonatology, use of simulation modules and other pediatric emergency medicine training topics will visit Bangalore, Bhubaneswar, Dehradun, Delhi, Kochi, Kolkata, Kozhikhode, Madurai and Mumbai. (Kate Douglass, M.D., of the George Washington University and Serkan Toy, Ph.D., an educational psychologist at John Hopkins University, have been heavily involved in this project but will not travel to India in October.)

“My passion is global education so, for me, this project will be a success if we improve the trainees’ comfort, knowledge and skill at providing patient care after undergoing this simulation-based curriculum. We also want to improve our faculty’s capacity to teach through these simulation modules, so there are definitely learning opportunities for both U.S. teachers and Indian trainees,” she adds.

WATCH: Introduction to simulation training
WATCH: Performing a simulation learning event
WATCH: Debriefing tools

Financial support for research described in this post was provided by the 2019-2020 Global Health Initiative Exploration in Global Health Award.

Pavan Zaveri

Children’s National Receives Accreditation Council for Graduate Medical Education (ACGME) Grant

Pavan Zaveri

“Providing educational opportunities to teach about safety, communication and leadership can be leveraged into quality & safety and process improvement,” said Pavan P. Zaveri, M.D., MEd, CHSE, medical director of the Simulation Program at Children’s National.

Recent medical innovations at Children’s National Health System have made it possible for the doctors and care teams to treat some of our most vulnerable patients. To support that technological innovation, Children’s National has received a grant provided by the Accreditation Council for Graduate Medical Education (ACGME) entitled, “Pursuing Excellence through Innovation”. This grant has utilized simulation and several other initiatives to achieve its aims toward quality, safety, interprofessionalism and more.

“A primary goal of the ACGME Pursing Excellence grant is to improve the clinical learning environment, specifically for the interprofessional education in clinical areas,” said Heather Walsh, MSN, RN, PCNS-BC CHSE CPN, Simulation Program manager at Children’s National.

The $300,000 grant supports 10 to 12 initiatives at Children’s National and is currently in its 3rd year. One of the major initiatives has been to incorporate simulation activities into more aspects of training and patient care. This growth has required the Simulation Program to expand its personnel, activities and abilities in multiple ways. With a team consisting of three educators, a program manager, two simulation technicians, a program coordinator and medical and nursing directors, their efforts directly support the simulation program as a whole.

“Providing educational opportunities to teach about safety, communication and leadership can be leveraged into quality & safety and process improvement,” said Pavan P. Zaveri, M.D., MEd, CHSE, medical director of the Simulation Program at Children’s National. “However, the focus of the work that we’re performing is focused on interprofessional care that is delivered at the bedside,” he added.

Through the Simulation Program, educators work to recreate situations by using manikins and supplies to replicate patient scenarios and function in a realistic situation. The cost of the manikins range from $5,000 to $50,000 and they perform a whole spectrum of presenting the pediatric patient including talking and providing vitals. This simulation provides doctors and nurses with the opportunity to perfect the care that they aim to deliver to patients at Children’s National.

In 2018, the Simulation Program was proud that 53% of simulations supported by the Children’s National team were interprofessional and 43% were conducted in clinical areas. Between 2016 and 2017, the Simulation Program led an initiative entitled “Code Response Training”, which focused on the use of safety communication techniques in critical situations.

“This was the largest simulation-based initiative in our organization, reaching 1,400 clinicians,” Walsh stated.

The following year, Children’s National implemented “Adaptive Response Training” that focused on teaching clinicians about the importance of safety event reporting, apparent cause analysis and root cause analysis. This initiative led 1,800 clinicians through a simulated apparent cause analysis and team simulation.

mannequin used in NICU evacuation training

Training teams for timely NICU evacuation

mannequin used in NICU evacuation training

From June 2015 to August 2017, 213 members of NICU staff took part in simulated drills, honing their skills by practicing with mannequins with varying levels of acuity.

In late August 2011, a magnitude 5.8 earthquake – the strongest east of the Mississippi since 1944 – shook Washington, D.C., with such force that it cracked the Washington Monument and damaged the National Cathedral.

On the sixth floor of the neonatal intensive care unit (NICU) at Children’s National in Washington, D.C., staff felt the hospital swaying from side to side.

After the shaking stopped, they found the natural disaster exposed another fault: The unit’s 200-plus staff members were not all equally knowledgeable or confident regarding the unit’s plan for evacuating its 66 newborns or their own specific role during an emergency evacuation.

More than 900 very sick children are transferred to Children’s National NICU from across the region each year, and a high percentage rely on machines to do the work that their tiny lungs and hearts are not yet strong enough to do on their own.

Transporting fragile babies down six flights of stairs along with vital equipment that keeps them alive requires planning, teamwork and training.  

“Fires, tornadoes and other natural disasters are outside of our team’s control. But it is within our team’s control to train NICU staff to master this necessary skill,” says Lisa Zell, BSN, a clinical educator. Zell is also lead author of a Children’s National article featured on the cover of the July/September 2019 edition of The Journal of Perinatal & Neonatal Nursing. “Emergency evacuations trigger safety concerns for patients as well as our own staff. A robust preparedness plan that is continually improved can alleviate such fears,” Zell adds.

Children’s National is the nation’s No. 1 NICU, and its educators worked with a diverse group within Children’s National to design and implement periodic evacuation simulations. From June 2015 to August 2017, 213 members of NICU staff took part in simulated drills, honing their skills by practicing with mannequins with varying levels of acuity.

“Each simulation has three objectives. First, the trainee needs to demonstrate knowledge of their own individual role in an evacuation. Second, they need to know the evacuation plan so well they can explain it to someone else. And finally, they need to demonstrate that if they had to evacuate the NICU that day, they could do it safely,” says Lamia Soghier, M.D., FAAP, CHSE, NICU medical director and the study’s senior author.

The two-hour evacuation simulation training at Children’s National begins with a group prebrief. During this meeting, NICU educators discuss the overarching evacuation plan, outline individual roles and give a hands-on demonstration of all of the evacuation equipment.

This equipment includes emergency backpacks, a drip calculation sheet and an emergency phrase card. Emergency supply backpacks are filled with everything that each patient needs post evacuation, from suction catheters, butterfly needles and suture removal kits to flashlights with batteries.

Each room is equipped with that emergency backpack which is secured in a locked cabinet. Every nurse has a key to access the cabinet at any time.

Vertical evacuation scenarios are designed to give trainees a real-world experience. Mannequins that are intubated are evacuated by tray, allowing the nurse to provide continuous oxygen with the use of a resuscitation bag during the evacuation. Evacuation by sled allows three patients to be transported simultaneously. Patients with uncomplicated conditions can be lifted out of their cribs and swiftly carried to safety.

Teams also learn how to calm the nerves of frazzled parents and enlist their help. “Whatever we need to do, we will to get these babies out alive,” Joan Paribello, a clinical educator, tells 15 staff assembled for a recent prebriefing session.

An “X” on the door designates rooms already evacuated. A designated charge nurse and another member of the medical team remain in the unit until the final patient is evacuated to make a final sweep.

The simulated training ends with a debrief session during which issues that arose during the evacuation are identified and corrected prior to subsequent simulated trainings, improving the safety and expediency of the exercise.

Indeed, as Children’s National NICU staff mastered these evacuation simulations, evacuation times dropped from 21 minutes to as little as 16 minutes. Equally important, post evacuation surveys indicate:

  • 86% of staff report being more comfortable in being able to safely evacuate the Children’s National NICU
  • 94% of NICU staff understand the overall evacuation plan and
  • 97% of NICU staff know their individual role during an evacuation.

“One of the most surprising revelations regarded one of the most basic functions in any NICU,” Dr. Soghier adds. “Once intravenous tubing is removed from its pump, the rate at which infusions drip needs to be calculated manually. We created laminated cards with pre-calculated drip rates to enable life-saving fluid delivery to continue without interruption.”

In addition to Zell and Dr. Soghier, study co-authors include Carmen Blake, BSN; Dawn Brittingham, MSN; and Ann-Marie Brown, MSN.

View slideshow: Disaster preparedness: In the NICU

Dr. DeBiasi

Staying one step ahead of deadly Ebola

Dr. DeBiasi

An ongoing outbreak of Ebola virus since 2018 in the Democratic Republic of the Congo that has resulted in millions of travelers being screened at checkpoints, hundreds of thousands of vaccinations and thousands of deaths is a stark reminder of the need to remain one step ahead of the deadly disease.

To that end, one-half dozen personnel from Children’s National in Washington, D.C., including infectious diseases experts, critical care nurses and laboratory personnel traveled to New York in mid-August for an interactive workshop sponsored by the National Ebola Training and Education Center. They covered how to correctly don and doff protective gear, safely collect, handle and process specimens and discuss the special circumstances that arise when caring for pediatric patients, among other topics.

“Since 2014, Children’s National has evaluated 6 children with exposure as Persons Under Investigation of  Ebola virus disease, 4 of  whom required extended inpatient hospitalization under full isolation precautions,” says Roberta L. DeBiasi, M.D., MS, chief of the Division of Pediatric Infectious Diseases. “As a designated Ebola Treatment Center, we must continue our preparedness to care for additional patients with suspected and proven Ebola infection.

“Hands-on training and  drilling offer Children’s National personnel an opportunity to continue to test, evaluate and optimize our institutional Ebola response plan and procedures to maintain our preparedness for the needs of future patients,” adds Dr. DeBiasi.

In addition to Dr. DeBiasi, members of the Children’s National Special Pathogens Isolation Unit team who attended the Emerging Infectious Disease Workshop included:

  • Zohreh Hojjati, Laboratory Medicine.
  • Kristin Elizabeth Mullins, Clinical Lab Director, Laboratory Medicine.
  • Daniel Schroeder, Registered Nurse II, Pediatric Intensive Care Unit (PICU).
  • Melissa Taylor, Registered Nurse II, PICU.
  • Heather Wellman, Registered Nurse II, PICU.

“Among the keys to Children’s National serving as a national exemplar for pediatric Ebola care, is the stability of our multidisiciplinary care team and our institutional commitment to ongoing training,” Dr. DeBiasi adds.

During a Grand Rounds presentation at Children’s National in mid-August, Dr. DeBiasi provided updates about recent global infectious disease outbreaks affecting pediatric patients including Ebola, measles, acute flaccid myelitis and Zika Virus. An interdisciplinary panel of Children’s National experts, including nurses, transport specialists, infectious disease and intensive care experts directly involved in caring for Ebola Persons Under Investigation, demonstrated personal protective equipment and fielded questions from staff. The overview also outlined Children’s National institutional expertise and response, including the Congenital Zika Virus Program, the Acute Flaccid Myelitis Task Force, the Special Isolation Unit for Ebola and other highly contagious infectious diseases.

View Ebola preparedness photo gallery.

Murray Pollack

Exploring accurate data use that supports clinical judgment

Murray Pollack

A new research collaboration between Children’s National Health System and KenSci seeks to understand how current data streams in health care can be used to enhance clinical decision making. The partnership seeks to develop personalized data-driven dynamic outcomes prediction for individual patients.

“These data are all around us in clinical medicine,” says Murray Pollack, M.D., MBA, of Children’s National Center for Translational Research. “Our goal for this project is to apply machine learning and statistical modeling to apply that data in ways that will enhance the work of the patient’s medical providers.”

“Since the mid-80s we have been able to predict mortality risks in pediatric ICUs using risk scores. In most cases these scores are used for quality assessment.,” Dr. Pollack continues. “Our collaborative goals are to study the temporal variation in data, taking the first step towards dynamic risk scoring for pediatric ICUs.”

“We see tremendous possibilities for how this wealth of data can be used safely and securely to supplement the clinician’s judgment,” says Hiroki Morizono, Ph.D., director of Biomedical Informatics at the Children’s National Center for Genetic Medicine Research. “This type of modeling, if successful, could perhaps predict an individual patient’s likelihood for deterioration or improvement.”

Over the course of one year, the two groups will come together and apply KenSci’s prediction platform to test different models and compare their accuracy to previous iterations developed at Children’s National.

Ankur Teredesai, KenSci’s co-founder, chief technology officer and professor at the University of Washington Tacoma, acknowledged the strategic nature of this collaboration, “Time is our best ally if integrated appropriately with other variables in healthcare machine learning and AI. Adding dynamism holds tremendous promise to be assistive for critical care. Caregivers in Pediatric ICUs serve the most vulnerable patients in our population, and this collaboration advances KenSci’s vision to be the best system of intelligence for healthcare.

Read KenSci’s press release about the partnership.

Preemie Baby

Optimizing pediatric quality & safety in the NICU

Preemie Baby

Children’s National doctors are optimizing pediatric quality and safety by working to decrease the rate of hypothermia in the Neonatal Intensive Care Unit.

Jessica Cronin, M.D., an anesthesiologist at Children’s National Health System, is working closely with staff and researchers to optimize pediatric quality and safety at the hospital. One of the projects Dr. Cronin is assisting with helps some of the smallest and most vulnerable patients that need surgery. Specifically, she is working to decrease the rate of hypothermia in the Neonatal Intensive Care Unit (NICU).

“It’s a significant problem that children may become cold during the surgery and immediately afterwards,” said Dr. Cronin. “There are a number of complications associated with that occurrence and our doctors and researchers are looking for solutions to combat that issue,” she added.

The hospital staff has instituted several interventions by making data available to the anesthesiologists responsible for temperature management and receiving feedback every month on the types of incidences that are happening. From when a baby is in the NICU, moved to the operating room and when they get transferred back, the doctors at Children’s National have created a checklist of tools to keep babies warm and monitor their temperatures during the perioperative period.

The NICU team has also worked closely with Dr. Rana Hamdy, M.P.H., M.S.C.E., who leads the antimicrobial stewardship team, Sudeepta Basu, M.D., a board certified neonatologist at Children’s National, and the pharmacy team to decrease out antibiotic utilization rates. To achieve its goals, the hospital has implemented the use of real-time check-ins during rounds, new algorithms, de-escalation of antibiotics and the frequent auditing has significantly reduced the unnecessary use of vancomycin.

This project is currently being tested in other parts of the hospital. Furthermore, the Children’s National team recently won an award from the District of Columbia Hospital Association (DCHA) to develop and implement interventions including clinical practice guidelines, educational initiatives, pharmacy-initiated prompts on rounds to de-escalate or discontinue vancomycin review from the antimicrobial stewardship team and provide documentation of culture volumes.

The DCHA serves as the unifying voice working to advance hospitals and health systems in D.C to strengthen systems of care, preserve access and promote better health outcomes for patients and communities. The Children’s National NICU team has been recognized for their outstanding work.

“The work that Dr. Cronin and the rest of the anesthesia team are performing is outstanding,” said Lamia Soghier, M.D., F.A.A.P., C.H.S.E., neonatologist and medical director of the neonatal intensive care unit (NICU) at Children’s National. “Our doctors have cut our rates of hypothermia for postoperative NICU infants by 60% and this project marks one of our major successes!”

Holly Meany

TAA-Ts as therapy for tumors

Holly Meany

“The T cell immunotherapy regimen resulted in prolonged disease stabilization in patients who previously experienced rapid tumor progression,” says Holly Meany, M.D. “The therapy could prove to be an important component of immunotherapy for patients with solid tumor malignancies.”

In a study published in the Journal of Clinical Oncology, researchers from Children’s National Health System uncovered tumor-associated antigen cytotoxic T cells (TAA-Ts) that represent a new and potentially effective nontoxic therapeutic approach for patients with relapsed or refractory solid tumors.

The Phase 1 study led by Children’s National pediatric oncologists Holly Meany, M.D., and Amy B. Hont, M.D., represented the first in-human trial investigating the safety of administering TAA-Ts that target Wilms Tumor gene 1, a preferentially expressed antigen of melanoma and survivin in patients with relapsed/refractory solid tumors.

“These are exciting clinical results using a novel ‘first in-human’ T cell therapy,” said Catherine Bollard, MB.Ch.B., M.D., director of the Center for Cancer and Immunology Research at Children’s Research Institute. “This T cell therapy was safe and appeared to prolong patients’ time to progression which suggests that we can now use this novel treatment as a combination therapy to hopefully achieve long-term remissions in pediatrics and adults with relapsed/refractory solid tumors.”

During the Phase 1 trial, TAA-Ts products were generated from autologous peripheral blood and were infused over three dose levels. Patients were then eligible for up to eight infusions that were administered four to seven weeks apart.

Of the 15 evaluable patients, 11 were with stable disease or better at 45 days post-infusion and were defined as responders. Patients who were treated at the highest dose level showed the best clinical outcomes, with a 6-month progression-free survival rate of 73% after TAA-Ts infusion, an improvement as compared with prior therapy.

Overall, the Phase 1 trial of TAA-Ts resulted in safely induced disease stabilization and was associated with antigen spreading and a reduction in circulating tumor-associated antigen DNA levels in patients with relapsed/refractory solid tumors before infusion.

“The T cell immunotherapy regimen resulted in prolonged disease stabilization in patients who previously experienced rapid tumor progression,” said Dr. Meany. “The therapy could prove to be an important component of immunotherapy for patients with solid tumor malignancies,” she added.

The other researchers that contributed to this work are as follows: Amy B. Hont, M.D.; C. Russell Cruz, M.D., Ph.D.; Robert Ulrey, M.S.; Barbara O’Brien, B.S.; Maja Stanojevic, M.D.; Anushree Datar, M.S.; Shuroug Albihani, M.S.; Devin Saunders, B.A.; Ryo Hanajiri, M.D., Ph.D.; Karuna Panchapakesan, M.S.; Sam Darko, M.S.; Payal Banerjee, M.S.; Maria Fernanda Fortiz, B.S.; Fahmida Hoq, MBBS, M.S.; Haili Lang, M.D.; Yunfei Wang, Dr.PH.; Patrick J. Hanley, Ph.D.; Jeffrey S. Dome, M.D., Ph.D.; Catherine M. Bollard, M.D.; and Holly J. Meany, M.D.

illustration of brain showing cerebellum

Focusing on the “little brain” to rescue cognition

illustration of brain showing cerebellum

Research faculty at Children’s National in Washington, D.C., with colleagues recently published a review article in Nature Reviews Neuroscience that covers the latest research about how abnormal development of the cerebellum leads to a variety of neurodevelopmental disorders.

Cerebellum translates as “little brain” in Latin. This piece of anatomy – that appears almost separate from the rest of the brain, tucked under the two cerebral hemispheres – long has been known to play a pivotal role in voluntary motor functions, such as walking or reaching for objects, as well as involuntary ones, such as maintaining posture.

But more recently, says Aaron Sathyanesan, Ph.D., a postdoctoral research fellow at the Children’s Research Institute, the research arm of Children’s National  in Washington, D.C., researchers have discovered that the cerebellum is also critically important for a variety of non-motor functions, including cognition and emotion.

Sathyanesan, who studies this brain region in the laboratory of Vittorio Gallo, Ph.D., Chief Research Officer at Children’s National and scientific director of the Children’s Research Institute, recently published a review article with colleagues in Nature Reviews Neuroscience covering the latest research about how altered development of the cerebellum contributes to a variety of neurodevelopmental disorders.

These disorders, he explains, are marked by problems in the nervous system that arise while it’s maturing, leading to effects on emotion, learning ability, self-control, or memory, or any combination of these. They include diagnoses as diverse as intellectual disability, autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder and Down syndrome.

“One reason why the cerebellum might be critically involved in each of these disorders,” Sathyanesan says, “is because its developmental trajectory takes so long.”

Unlike other brain structures, which have relatively short windows of development spanning weeks or months, the principal cells of the cerebellum – known as Purkinje cells – start to differentiate from stem cell precursors at the beginning of the seventh gestational week, with new cells continuing to appear until babies are nearly one year old.  In contrast, cells in the neocortex, a part of the brain involved in higher-order brain functions such as cognition, sensory perception and language is mostly finished forming while fetuses are still gestating in the womb.

This long window for maturation allows the cerebellum to make connections with other regions throughout the brain, such as extensive connections with the cerebral cortex, the outer layer of the cerebrum that plays a key role in perception, attention, awareness, thought, memory, language and consciousness. It also allows ample time for things to go wrong.

“Together,” Sathyanesan says, “these two characteristics are at the root of the cerebellum’s involvement in a host of neurodevelopmental disorders.”

For example, the review article notes, researchers have discovered both structural and functional abnormalities in the cerebellums of patients with ASD. Functional magnetic resonance imaging (MRI), an imaging technique that measures activity in different parts of the brain, suggests that significant differences exist between connectivity between the cerebellum and cortex in people with ASD compared with neurotypical individuals. Differences in cerebellar connectivity are also evident in resting-state functional connectivity MRI, an imaging technique that measures brain activity in subjects when they are not performing a specific task. Some of these differences appear to involve patterns of overconnectivity to different brain regions, explains Sathyanesan; other differences suggest that the cerebellums of patients with ASD don’t have enough connections to other brain regions.

These findings could clarify research from Children’s National and elsewhere that has shown that babies born prematurely often sustain cerebellar injuries due to multiple hits, including a lack of oxygen supplied by infants’ immature lungs, he adds. Besides having a sibling with ASD, premature birth is the most prevalent risk factor for an ASD diagnosis.

The review also notes that researchers have discovered structural changes in the cerebellums of patients with Down syndrome, who tend to have smaller cerebellar volumes than neurotypical individuals. Experimental models of this trisomy recapitulate this difference, along with abnormal connectivity to the cerebral cortex and other brain regions.

Although the cerebellum is a pivotal contributor toward these conditions, Sathyanesan says, learning more about this brain region helps make it an important target for treating these neurodevelopmental disorders. For example, he says, researchers are investigating whether problems with the cerebellum and abnormal connectivity could be lessened through a non-invasive form of brain stimulation called transcranial direct current stimulation or an invasive one known as deep brain stimulation. Similarly, a variety of existing pharmaceuticals or new ones in development could modify the cerebellum’s biochemistry and, consequently, its function.

“If we can rescue the cerebellum’s normal activity in these disorders, we may be able to alleviate the problems with cognition that pervade them all,” he says.

In addition to Sathyanesan and Senior Author Gallo, Children’s National study co-authors include Joseph Scafidi, D.O., neonatal neurologist; Joy Zhou and Roy V. Sillitoe, Baylor College of Medicine; and Detlef H. Heck, of University of Tennessee Health Science Center.

Financial support for research described in this post was provided by the National Institute of Neurological Disorders and Stroke under grant numbers 5R01NS099461, R01NS089664, R01NS100874, R01NS105138 and R37NS109478; the Hamill Foundation; the Baylor College of Medicine Intellectual and Developmental Disabilities Research Center under grant number U54HD083092; the University of Tennessee Health Science Center (UTHSC) Neuroscience Institute; the UTHSC Cornet Award; the National Institute of Mental Health under grant number R01MH112143; and the District of Columbia Intellectual and Developmental Disabilities Research Center under grant number U54 HD090257.

spectrometer output

Understanding low cardiac output after surgery

spectrometer output

Rafael Jaimes, Ph.D., created an algorithm that is being tested in a pre-clinical model to characterize the light absorbance spectrum from different heart regions using a spectrometer.

After intense cardiac surgery, sometimes a patient’s heart is unable to effectively deliver oxygenated blood and nutrients throughout the recovering body. Known as inadequate or low cardiac output, the condition occurs in about a quarter of patients following surgery with cardiopulmonary bypass, including young children who require complex procedures to correct congenital heart defects at Children’s National Health System.

Researchers at the Sheikh Zayed Institute for Pediatric Surgical Innovation are exploring several facets of this challenge, with the goal of better understanding post-operative recovery trajectories in pediatric patients. Rafael Jaimes, Ph.D., a staff scientist at the institute, leads this work to identify when and how low cardiac output occurs, pinpoint the physical hallmarks of this condition and use that information to prevent long term damage and complications after surgery, including cardiac arrest.

“More research needs to be done to understand the cause of this overarching and multi-faceted syndrome,” says Dr. Jaimes. “I’m interested in understanding how metabolic insufficiency contributes to this condition, and also exploring how we can use current imaging and diagnostic tools to measure, track and treat the insufficiencies that contribute to low cardiac output.”

Tracking inadequate oxygen and nutrient delivery to the parts of the heart that have been repaired is one avenue under exploration. Currently, a cardiac-specific real-time device to measure the oxygen state of the heart, while a patient is in post-operative critical care, is under development.

The heart’s complexity has made using current oxygen measurement devices, such as spectrometers, very difficult. To date no tool exists that effectively screens out artifacts and noise to allow clear visualization. However, during his post-doctoral work, Dr. Jaimes has created a new algorithm that may be the first of its kind to accomplish this feat.

This work on low cardiac output recently received a Congenital Heart Defect Research Award, which is a collaborative program of the Children’s Heart Foundation and the American Heart Association that supports innovative research, seeking to understand and treat congenital heart defects.

A new research study will build on his previous studies by using the algorithm to characterize the absorbance spectrum from different heart regions in a pre-clinical model. The data collected will serve as the baseline for development of a prototype spectrometer software, capable of tracking changes in heart oxygenation before, during and after surgery.

The end goal is to more effectively identify when parts of the heart are deprived of oxygen and nutrients and prevent resulting impacts on cardiac metabolism and output. Doing so will decrease short term mortality and morbidity and may also improve circulation systemically, potentially reducing long term health impacts of reduced oxygenation, such as neurodevelopmental disorders.

Denice Cora-Bramble with the Mayor’s Commission on Healthcare Systems Transformation

Denice Cora-Bramble, M.D., MBA, selected for Mayor’s Commission on Healthcare Systems Transformation

Denice Cora-Bramble with the Mayor’s Commission on Healthcare Systems Transformation

Photo credit: Executive Office of the Mayor

Denice Cora-Bramble, M.D., MBA, chief medical officer and executive vice president of Ambulatory and Community Health Services at Children’s National, has been selected to serve as a member of the Mayor’s Commission on Healthcare Systems Transformation. Established by Mayor Muriel Bowser, the commission will make recommendations on strategies and investments necessary to transform health care delivery in the District of Columbia.

Dr. Cora-Bramble is one of three representatives appointed to the commission from specialty hospitals in the District. “I am honored to have been invited to participate in the commission’s important discussions,” she says.

While D.C. has many resources related to health care and is home to several acute care hospitals, residents still need help accessing services. The 27-member commission will work to alleviate these challenges and over the next six months they will develop recommendations for improving access to primary, acute and specialty care services, addressing health system capacity issues for inpatient, outpatient, pre-hospital and emergency room services and maternal health.

The commission will also work to promote equitable acute care and specialty services in communities east of the Anacostia River.

“I’m looking forward to serving as a resource to citizens living within the District,” says Dr. Cora-Bramble.  “I am hopeful that the group’s recommendations will improve the delivery of health services, particularly for vulnerable and underserved populations.”

Dr. Cora-Bramble joined Children’s National in 2002. In her role as chief medical officer, she leads the tri-state clinical operations of Children’s National primary and specialty sites, including regional outpatient centers, emergency departments, community health centers, pediatric practices, school-based health centers, mobile medical units and nursing services in D.C. Public Schools and Public Charter Schools. She also oversees the telemedicine program and the Children’s National Health Network.

Children’s National ranked No. 6 overall and No. 1 for newborn care by U.S. News

Children’s National in Washington, D.C., is the nation’s No. 6 children’s hospital and, for the third year in a row, its neonatology program is No.1 among all children’s hospitals providing newborn intensive care, according to the U.S. News Best Children’s Hospitals annual rankings for 2019-20.

This is also the third year in a row that Children’s National has been in the top 10 of these national rankings. It is the ninth straight year it has ranked in all 10 specialty services, with five specialty service areas ranked among the top 10.

“I’m proud that our rankings continue to cement our standing as among the best children’s hospitals in the nation,” says Kurt Newman, M.D., President and CEO for Children’s National. “In addition to these service lines, today’s recognition honors countless specialists and support staff who provide unparalleled, multidisciplinary patient care. Quality care is a function of every team member performing their role well, so I credit every member of the Children’s National team for this continued high performance.”

The annual rankings recognize the nation’s top 50 pediatric facilities based on a scoring system developed by U.S. News. The top 10 scorers are awarded a distinction called the Honor Roll.

“The top 10 pediatric centers on this year’s Best Children’s Hospitals Honor Roll deliver outstanding care across a range of specialties and deserve to be nationally recognized,” says Ben Harder, chief of health analysis at U.S. News. “According to our analysis, these Honor Roll hospitals provide state-of-the-art medical expertise to children with rare or complex conditions. Their rankings reflect U.S. News’ assessment of their commitment to providing high-quality, compassionate care to young patients and their families day in and day out.”

The bulk of the score for each specialty is based on quality and outcomes data. The process also includes a survey of relevant specialists across the country, who are asked to list hospitals they believe provide the best care for patients with challenging conditions.

Below are links to the five specialty services that U.S. News ranked in the top 10 nationally:

The other five specialties ranked among the top 50 were cardiology and heart surgery, diabetes and endocrinology, gastroenterology and gastro-intestinal surgery, orthopedics, and urology.