June 6, 2013

Care coordination program eases children’s stress

When Melissa and Luke Allen of Cookeville learned that their five-year-old daughter, Annie Lou, needed eye surgery in addition to surgery to repair double hernias, they were overwhelmed.

When Melissa and Luke Allen of Cookeville learned that their five-year-old daughter, Annie Lou, needed eye surgery in addition to surgery to repair double hernias, they were overwhelmed.

“Just thinking about the fact that she needed two procedures made me nauseated,” Melissa said. “I was actually considering which surgery I could put off. Then, I thought, if there’s any way we can do this all at the same time, let’s do it that way.”

Any time a child undergoes a medical procedure — to say nothing of multiple procedures — families are stressed. Between worrying over a child’s safety and calming the young patient’s fear to juggling work schedules and arranging child care for other children, countless issues multiply the anxiety of an already challenging experience.

The care team at the Monroe Carell Jr. Children’s Hospital at Vanderbilt knows this. Through personalized intervention, they strive to minimize stress for patients and their families through a Complex Coordination of Care program (CCoC) for children requiring multiple procedures, so that only a single, continuous anesthetic is administered while needed care is performed.

Recent medical studies have raised concern about the possible impact of anesthetic exposure on developing brains, and though there is no definitive evidence of negative effects to date, doctors at Children’s Hospital make every effort to reduce anesthetic exposure.

The Complex Coordination of Care program was created in late 2011 by Jill Kilkelly, M.D., assistant professor of Clinical Anesthesiology. Hospital faculty and staff knew some patients were coming in for more than one procedure, such as an MRI and a minor surgery, often within the same month, but this was frequently discovered too late to combine care in a way that made sense for both the providers and families.

“What was happening was that different schedulers from different specialties were scheduling these services, and no one was seeing each other’s schedules,” Kilkelly said. “For example, kids were being scheduled for a tonsillectomy one day and then a GI evaluation eight days later. Parents have been so used to the separation of these services that they weren’t likely to ask about combining the two.”

Now, the Complex Coordination of Care team works with doctors, nurses and scheduling staff from all medical specialties to logically combine care whenever possible, and this was applied to Annie Lou’s case. A long-time patient of David Morrison, M.D., associate professor of Ophthalmology and Pediatrics at Children’s Hospital, Annie Lou had her first eye surgery to correct strabismus (misaligned eyes) when she was 3. While the family had been referred to a Knoxville urologist who could easily repair the hernia, the Allens had concerns.

“I was not comfortable with having to put Annie Lou under twice for different surgeries that could have easily been done at the same time,” Melissa said. “We love Dr. Morrison, and he knows Annie Lou, so we definitely wanted to stay with him.”

Melissa contacted the Pediatric Anesthesiology Division at Children’s Hospital, and was quickly connected with Kilkelly. John Thomas, M.D., assistant professor of Urologic Surgery, performed Annie Lou’s hernia repair. Emails flew between the CCoC team and the two physicians, and a care plan was designed that allowed both doctors to consecutively perform their surgeries in one operating room while Kilkelly and the anesthesia team delivered a single anesthetic.

The procedures went off seamlessly, according to all involved, and Annie Lou was released the same afternoon to recover at home.

“This process takes cooperation between everyone, and that is really the most special thing about this place,” said Thomas. “We enjoy working together, we’re all on the same page, and everyone has the same mission – providing the best care for our patients. It saves a child a second anesthetic, and that alone makes it worth it.”

Morrison agreed and said, “It is definitely worth it! If my child needed multiple procedures, I would like the providers to coordinate and do as much under a single anesthetic as they could, rather than to have them undergo multiple, separate events. The best way to care for children is to make sure the right hand knows what the left hand is doing, and that we all work together to provide the best care possible.”

Kilkelly has begun a post-procedure patient satisfaction survey with families who have experienced the CCoC process, and thus far, comments have been overwhelmingly positive.

She is also working with informatics technology personnel so notifications are generated when patients are scheduled for multiple procedures within a narrow time frame.

More than 115 patients and their families have benefited from this team effort. In addition to Kilkelly, the CCoC team is comprised of nurse practitioners and patient schedulers, including Jill Kinch, N.P., Betsy Beazley, R.N., Amanda Nesbitt and Brenda Sandlin, R.N.