Children’s Hospital & Medical Center

2.2012

Contents

4 Code Trauma

8 Targeting Cancer

12 Meticulous Planning Helps to Prevent Drug Shortages

15 Investing in Our Community

16 Leading Students from Stress to Success

20 Creating a Menu of Healthy Habits

24 A Hero for Children

28 The Best Place for Kids

Spira

Spira is the biannual magazine of

Children’s Hospital & Medical Center,

8200 Dodge St., Omaha, NE 68114.

Spira@ChildrensOmaha.org

SpiraMagazine.org

Children’s meets a number of strict criteria including:

❱ Experience in the care of the most complex and critically ill newborns.

❱ Subspecialists on-site and available 24/7 including heart surgeons, pediatric surgical subspecialists and pediatric anesthesiologists.

❱ The experience and expertise to provide surgical repair of complex congenital conditions including serious heart defects.

❱ The ability to transport critically ill newborns by ambulance, helicopter and fixed wing aircraft.

❱ And, the ability to facilitate and provide outreach education.

The new standards were published in the September 2012 edition of the medical journal, Pediatrics.

H i g H e s t L e v e L o f C a r e

New standards published by the

American Academy of Pediatrics

(AAP) establish Children’s Hospital

& Medical Center as the only Level

IV Regional Newborn Intensive

Care Unit serving Nebraska,

western Iowa and South Dakota.

Level IV is the highest level of care

as defined by the AAP.

“i’ve always been a firm believer that all children in our region belong at Children’s Hospital & Medical Center, and to carry that into the trauma arena only makes sense,” says shahab abdessalam, M.D., pediatric surgeon at Children’s.

“Kids are not little adults,” adds thomas Deegan, M.D., Children’s emergency medicine physician. “they have unique anatomy and physiology as well as different patterns and types of injury. therefore, the pediatric response to traumatic injuries and medical illnesses is different than adults. ideally, children should be in a children’s hospital where everything is pediatric-oriented.”

together, the two specialists lead Children’s pediatric trauma program which recently bolstered its credentials as the leading center for childhood trauma care by receiving american College of surgeons Committee on trauma (aCs-Cot) verification as a Level ii Pediatric trauma Center. it has been an intensive, three-year process.

“aCs-Cot trauma verification is a huge accomplishment. the aCs sets the standards for trauma care and has a very rigid review process. everything must be in place for at least a year prior to even applying for verification. so, you have to be doing it and doing it well prior to even being visited,” says Dr. Deegan.

the aCs-Cot program provides an objective, external review of trauma center resources while verifying compliance with aCs-Cot standards, considered the “gold standard” for a trauma center. the process included a thorough trauma verification review during which aCs reviewers focused on commitment, readiness, resources, policies, patient care and performance improvement.

“they looked at charts. they walked through the facility. they conducted interviews with people at all levels — nurses, physicians, administration,” explains Dr. abdessalam.

Code Trauma

To an adventurous 10-year- old boy, it seemed like a logical plan: an elevated backyard deck, a stiff Nebraska breeze and a couple of plastic grocery sacks that, surely, would serve as a parachute.

Kids will be kids — and, when their carefully thought-out plans go awry, the trauma team at Children’s Hospital & Medical Center is ready with comprehensive, multi-disciplinary care.

CHildreN’s TeaM

sTaNds ready for

THe UNexpeCTed

2.20124

Code Trauma

a community’s need for superior pediatric trauma care could not be more pronounced. traumatic injuries are the leading cause of death and disability in children. falls, sports-related injuries, bicycle accidents and motor vehicle crashes, including those involving all-terrain vehicles (atv), account for most of the traumas seen at Children’s.

Non-accidental trauma is also a somber reality for the trauma team, reveals Dr. abdessalam.

“Unfortunately, we also see a fair bit of child abuse. that’s generally restricted to those under the age of one.”

to ensure total care, the Children’s approach to treating all traumas is multi-disciplinary. the most serious cases may enlist the efforts of up to 75 clinicians. Phase one of care starts in the emergency room.

“You have pediatric emergency medicine physicians, pediatric respiratory therapists, and pediatric nurses. right away, they’re going to have access to the proper equipment, and they’re going to know something as simple as the iv rate and how to appropriately deliver oxygen for a certain-aged child,” Dr. abdessalam says.

Diagnostic imaging, including Ct scans and X-rays, comprise the second phase of trauma treatment.

“We have pediatric radiologists who know subtleties of bone development and anatomic variations that can look much different on X-rays and Cts in comparison to adults. it is important to know what is normal versus abnormal or traumatic in origin so the injury can be treated. a pediatric radiologist is trained to pick up these subtleties.”

the third phase, says Dr. abdessalam, is surgery.

“all of our pediatric surgeons, orthopedic surgeons and neurosurgeons are pediatric-trained and deal with children every day. equally as important, we have pediatric anesthesiologists specifically trained to handle difficult, small airways and manage the fluid/blood requirements.”

after surgery, treatment moves to the intensive care unit or general floor care.

“We have pediatric intensivists here that assist with our trauma care, along with nurses, mid-level partners, respiratory therapists and child care partners. everyone is geared toward taking care of children,” he says.

other components of care include child life, social work, pastoral care, behavioral health, physical therapy, occupational therapy and speech therapy. Keys, points out Dr. abdessalam, to helping the patient achieve the best possible outcome.

there’s also an inherent benefit that accompanies youth.

“the beautiful part about pediatrics is that children have ‘plasticity.’ they are generally more healthy prior to their injury and can recover more quickly than an adult. their recuperative capacity is an unknown, but, in general, if you compare children to the adult population, their recuperative capacity is leaps and bounds above their adult counterparts,” he says.

“all of our pediatric surgeons, orthopedic surgeons and neurosurgeons are pediatric-trained and deal with children every day.” shahab abdessalam, M.d.

Consensus may be hard to come by in some areas of medicine, but there is no disagreement on this: the most effective way to deal with pediatric trauma is to prevent it. That’s why Children’s Hospital & Medical Center, in addition to its comprehensive, multi-disciplinary approach to trauma care, is squarely focused on injury prevention and child safety education.

“our emergency department treats hundreds of children each year who come in with preventable injuries,” says Tracy King, injury prevention coordinator at Children’s. “We feel that with good education and awareness, we can make a positive impact.”

Traumatic injuries are the leading cause of death and disability in children ages 1 to 14, killing more children each year than disease and drugs combined.

“all ‘trauma-tologists’ feel that trauma is a preventable ‘disease,’” explains

dr. shahab abdessalam, co-medical director of Children’s trauma program.

Now verified as a level ii pediatric Trauma Center by the american College of surgeons Committee on Trauma (aCs-CoT), dr. abdessalam believes Children’s injury prevention efforts will gain even more traction.

“Being a verified center, with that stamp of approval, it lends more credence to what you’re preaching — whether you’re saying no child under 16 should be on an adult-sized aTV or there should be no child out there riding a bike without a helmet.”

“Kids do crazy things. i don’t know if we’re ever going to prevent that,” says dr. abdessalam. “But, if we can prevent serious injury, which is what we hope to do, then children are going to live longer and become prosperous adults.”

Trauma: a PrevenTable “disease”

Now, with aCs-Cot trauma verification, the trauma team at Children’s is determined to keep pushing the bounds of superior treatment.

“the aCs reviewers made some recommendations on things we can do in the future, and we take those recommendations very seriously. We’re always looking for ways to improve,” explains Dr. abdessalam. “on an administrative level, we meet once a month to talk about issues: what’s good, what needs improvement and where do we want to go.”

Clinical skills are also sharpened through the use of simulation training. in the emergency Department, Dr. Deegan notes, quarterly mock codes deliver valuable preparation.

“fortunately, the highest level of trauma is few and far between. over the years, one thing that has helped in those high-risk, low-volume situations is providing simulation and doing mock codes. simulation can’t totally take the place of clinical experience, but if you do it the right way, you can get pretty close to the ‘walking through the door’ clinical experience. that’s become

increasingly important not only for us but also for trainees.”

all of this to ensure that the next ill-fated parachute endeavor, atv accident or trampoline spill will be met with the best care — and quickest recovery — possible in a child-friendly setting with an experienced team ready and waiting to care for and comfort kids in the wake of the unexpected.

Children’s is the proud leader of safe Kids omaha, a coalition of community groups dedicated to preventing childhood injuries. affiliated with safe Kids Worldwide, safe Kids omaha is helping raise public awareness among the general public and policy makers.

7

The bully snarls in cruel The bully snarls in cruel anticipation, its dark eyes anticipation, its dark eyes fi xed on its target — young, innocent, seemingly weak and alone. It is mistaken on two counts.

“Young cancer patients are amazing,” says Jill Beck, M.D., pediatric hematologist/oncologist at Children’s Hospital & Medical Center. “they are honest, funny — and really tough.”

and, far from being alone, they are surrounded at Children’s by a team of nationally-recognized champions, caregivers who stand up to the bully every day.

“those of us who treat kids with cancer do it because we feel the need to have some impact on this devastating disease, and we want to share in the visceral satisfaction of having done something important,” says Bruce gordon, M.D., faaP, professor and division chief, Pediatric Hematology/oncology & stem Cell transplantation.

the progressive, life-saving work performed at Children’s has received national recognition. Just this year, U.S. News & World Report ranked Children’s cancer program among the 50 best in the nation.

“it’s nice to be recognized, but even if we weren’t recognized, we would still get the satisfaction from doing this well,” explains Dr. gordon. “it’s what we come to work every day to do. We take care of kids the best way we know how.”

that includes an approach to cancer treatment that is multi-disciplinary, encompassing chemotherapy, radiation oncology, oncologic surgery and orthopedic surgery as well as child life and educational support, physical therapy,

occupational therapy, psychology and, if necessary, palliative care.

“When a child has cancer, there are a lot of people and services needed to take care of that child. it takes a whole lot more than a good doctor to help the kids heal. and it is important to remember that they are kids,” shares Dr. Beck. “Children’s oncology program has the people and services which allow curing cancer to be a team approach focused on kids and their families.”

it’s a way of thinking that Dr. gordon attributes to pediatric medicine as a whole.

“in pediatric oncology, we are more attuned to working as a team with ancillary services because that’s what we pediatricians do when treating all children.

C H I L D R E N ’ S A M O N G B E S T I N N AT I O NC H I L D R E N ’ S A M O N G B E S T I N N AT I O N

9

there is the mindset of the family as the recipient of care. and, when we take care of kids, including adolescents, with cancer, we’re more attuned to their needs outside the realm of medicine. We think they receive better care because we’re taking care of them as a whole person.”

a whole person who has the advantage of youthful strength and resilience. “a 16-year-old can tolerate much more than a 70-year-old,” he explains. “if you’re an adult oncologist and your training and your understanding is ‘i have to be gentle’ then you may not be treating the 16-year-old appropriately.”

Pediatric oncologists understand this, says gordon. they are specifi cally trained to deal with childhood cancers like neuroblastoma (a solid abdominal tumor) and Wilms tumor (a rare kidney cancer), and the childhood forms of lymphoma, Hodgkin’s disease and leukemia. in both good ways and bad, confronting childhood cancer is not the same as confronting adult cancer.

“a child with the threat of death is against the natural order. it’s a devastating

diagnosis — even more so than adults because of the relationships we have with children and the implications for the loss of long life. if a seven-year-old has cancer, you’re looking at gaining or losing 80 years of productive life.”

to the positive, Dr. gordon says childhood cancer typically responds better to treatment than adult cancer. “Childhood cancers are inherently more sensitive to chemotherapy, radiation, and, to a certain extent, surgery.

“We’ve made incredible strides in leukemia, lymphoma and Wilms tumor. Ninety-plus percent of kids with lymphoma are cured. Ninety-plus percent of kids with Wilms tumor are cured. in the 1950s and 1960s, essentially every child with acute lymphoblastic leukemia died. Now, we’re looking at 80-90 percent of those kids being cured. that’s what we focus on — the tremendous improvement in certain cancers.”

still, with other cancers like neuroblastoma, Dr. gordon admits progress has been frustratingly slow.

“We’re starting to think outside the box, outside the realm of just chemotherapy, and that’s where the strides have been made. We’ve got a lot of the best minds focused on that, on thinking about things other than the traditional approaches to cancer.”

Dr. Beck believes pediatric cancer diagnosis and treatment are moving toward a more personalized approach to tumor biology, which ultimately impacts treatment.

“We are learning about markers for diseases and how they affect the biologic pathways of a person’s cancer. this will eventually allow for better, more precise therapy,” she says.

since the populations they’re treating are children and adolescents, Children’s and the Children’s oncology group (Cog), an international pediatric cancer consortium, are very cognizant of the potential long-term implications of cancer treatments.

“as we get better at successfully treating kids with cancer, we have the luxury of worrying about long-term effects,” says Dr. gordon. “Wilms tumor is a classic example

“WE’RE STARTING TO THINK OUTSIDE THE BOX, OUTSIDE THE REALM OF JUST CHEMOTHERAPY, AND

THAT’S WHERE THE STRIDES HAVE BEEN MADE.”

Bruce Gordon, M.D.

“WE’RE STARTING TO THINK OUTSIDE THE BOX, OUTSIDE THE REALM OF JUST CHEMOTHERAPY, AND

2.201210

of this. We’ve gotten to the point where we’re curing the large majority of those patients. Now, we’re asking ourselves, ‘How do we cure them while exposing them to less and less therapy therefore causing the potential for fewer long-term effects?’”

Children’s works to ensure it’s always on the cusp of clinical care and best practices by continuing to participate in the Cog in a “real and meaningful way” and by recruiting strong, caring clinicians.

“We are also interested in recruiting smart scientists to advance our translational research. We’re interested in recruiting pediatricians who have an expertise and interest in bone marrow transplant to grow that program as well, to be able to offer cutting edge, nuanced therapies,” Dr. gordon shares.

Children’s is also working to develop a fellowship program which would bring in pediatricians fresh out of their residencies who are interested in becoming hematologists, oncologists and bone marrow transplant doctors.

Perceptions surrounding this fi eld of work can be challenging to overcome. Dr. gordon encounters people who question his own decision to devote his professional life to kids with cancer. Doesn’t it take a heavy emotional toll?

“i turn around and say, ‘You can tell the mother of a child with leukemia that there is an 80-90 percent chance their kid is going to grow up to be a happy, healthy adult.’ You take someone who has this horrible diagnosis, and you can fi x it 80-90 percent of the time. You tell me a better job than that.”

for Dr. Beck, pediatric oncology represented a perfect combination. “During residency, i was deciding between general pediatrics and pediatric intensive care, kind of two ends of the spectrum. Pediatric oncology allowed me the opportunity to take care of kids (and their families) when they are really sick, but i also got to develop a long-term relationship with them that lasts for years,” she says.

another benefi t is a stream of life lessons shared by young patients.

“they are wise beyond their years. My patients teach me patience all the time — to take things one day at a time and really appreciate the moments,” says Dr. Beck. “the kids and their parents let me into their lives at a time that is often rock bottom. i walk into the room and turn their world upside down, and then they give me the honor of going on the journey with them. i’m constantly learning how to make the journey the best it can be, considering the circumstances.”

the bully lands its devastating blows some days and is repelled on others. two things are certain: it will be back on the prowl tomorrow, seeking out another young victim — and Children’s experienced team will be there.

The cancer program at Children’s Hospital & Medical Center follows treatment and research protocols established by the Children’s oncology Group (CoG), a National Cancer institute-supported clinical trials group and the world’s largest organization devoted exclusively to childhood and adolescent cancer research. The CoG unites more than 8,000 experts in childhood cancer at more than 200 leading children’s hospitals, universities, and cancer centers across North america, australia, New Zealand, and europe. it is a “strength in numbers” approach to ensuring the most effective childhood cancer care.

“as a group, we address issues of clinical cancer care. We do large clinical trials,” says dr. Bruce Gordon, pediatric hematologist/oncologist. “Childhood cancer is relatively rare so any one of us will see a relatively small number compared to what an adult oncologist will see. so, the only way for us to take things from the laboratory and bring them to the clinics is to do so in the context of cooperative groups.

“We’ll do the same thing that Mayo Clinic is doing, that st. Jude’s is doing, that Memorial sloan-Kettering is doing. We’re all treating kids with cancer the same

way, and then all of our information, all of our experience is pooled together.”

Today, more than 90 percent of the 13,500 children and adolescents diagnosed with cancer each year in the United states are cared for at CoG-member institutions like Children’s. CoG research has turned children’s cancer from a virtually incurable disease 50 years ago to one with a combined 5-year survival rate of 80 percent today.

SHAPING THE FUTURE

11

learning that your child has acute lymphoblastic

leukemia, the most common childhood cancer, is enough

to traumatize any parent. But fi nding out that

methotrexate — the drug your child desperately needs — isn’t available because a primary supplier closed its manufacturing plant can be

beyond comprehension.

MetiCULoUs PLaNNiNg

drUG sHorTaGesHelps To preVeNT

2.201212

it’s a frightening and very

real situation that Children’s

Hospital & Medical Center

works very hard to prevent,

says pharmacy director

lisa Kwapniowski, pharm.d.

“We have key personnel in purchasing who work closely with our pharmacists to track our stock and monitor what is being used,” she says. “they are checking the wholesale system every day to see what is available, and routinely putting in back orders to avoid any shortages.”

still, it can happen, such as a recent incident involving a surgical anesthetic. “We had to contact the manufacturer to get an emergency shipment sent to us,” Dr. Kwapniowski says. “it was close but we got it in time.”

shortages result from a variety of reasons that, when combined, can severely limit an already thin supply. and while shortages occur in all drug categories, studies indicate oncology drugs account for the largest percentage.

in the case of the shortage of methotrexate in the fall of 2011, drug manufacturer Ben venue Laboratories voluntarily halted production of it and other drugs at its ohio plant due to product safety and quality issues. Methotrexate was already in short supply and the plant’s closing only worsened the situation.

Dr. Kwapniowski says other shortages can be triggered by a drug company’s decision to halt manufacturing due to low profi ts.

“although we now have a good supply of methotrexate, there are still probably 300 medicines on the food and Drug administration (fDa) shortage list,” she

13

says. “about 85 percent of those are injectables. that hits pediatric hospitals especially hard because those are what we use the most.”

Many of the drugs are generics, she says, which also lowers a company’s profi ts.

“there have been incidents where the fDa will come in and tell a drug company that its facilities need to be updated, but the company decides there isn’t a big enough profi t margin to support the changes so it ceases manufacturing,” she says. “that puts a strain on the two or three other suppliers and can create a shortage.”

through the Children’s Hospital association, Children’s networks with other pediatric hospitals across the nation to help monitor and maintain drug supplies. “it’s a system we have that allows us to reach out to each other,” Dr. Kwapniowski says. “they really assist us in trying to locate the drugs we need. it is also a communication network that we use to assist with

predicting items that may be in short supply before they become an issue.”

During the methotrexate shortage, “We contacted other local hospitals that assisted us in keeping a supply on hand,” she says. “there was even a hospital in central Nebraska that was willing to send us the drug after seeing a news story detailing the shortage’s impact on the hospital.”

there are other sources for drugs in short supply — but they are sources that Dr. Kwapniowski isn’t willing to trust.

“there is a black market out there,” she says. “We get calls from companies that say ‘We have this drug. We can get it to you.’ But these are secondary wholesalers that i don’t know and just won’t deal with.

“it’s a very scary situation. sometimes the drugs are the same as we’d get from primary suppliers, but there have been cases where the drugs are diluted down, and yet they still increase the price 300 to 700 times.”

it’s an issue she hopes the fDa will continue to investigate. “are they buying the drugs and then creating a shortage just to infl ate the price?” she asks. “that would be horrible.”

Dr. Kwapniowski notes that Congress has taken steps to pass legislation in 2012 to try and prevent critical drug shortages. the bill is aimed at requiring manufacturers to notify the fDa at least six months in advance when a life-saving drug may be in short supply. other prevention measures are also included in the bill.

avoiding shortages — and disreputable drug wholesalers — requires a collaborative effort at Children’s.

“our Purchasing and Pharmacy Departments stay in constant communication with drug suppliers to see what their stock level is so we can try to anticipate any shortages and avoid them,” Dr. Kwapniowski says. “Planning and staying aware of our supplies are the best ways to ensure our patients always have the medicines they need.”

“There are still probably 300 medicines on the fda shortage list. about 85 percent of those are injectibles. That hits pediatric hospitals especially hard because those are what we use the most.”lisa Kwapniowski, pharm.d.

2.201214

Seeing a child smile, sharing a fi rst word or providing comfort when there are tears; we’re honored to spend each and every day serving children and their families.

We witness milestones and inspirational recoveries; courageous battles and even the routine as we strive to make children, and our community, safer and healthier.

From an active stance to reduce preventable injuries to ongoing medical education and free classes for parents, Children’s Hospital & Medical Center is committed to addressing our community’s health care and educational needs. Guided by our community, we’re working to improve the lives and health of children across our region.

We’re online!Find Children’s full 2011 Community Benefi t and Annual Report at www.Childrenssnapshot.org

financial assistance Benefi tsUnpaid costs of Medicaid programs, uncompensated or discounted care for those unable to pay

Bad debt expenseLack of insurance reimbursement, unpaid care

Community Benefi t servicesOutreach programs and materials provided free of charge to patient families and community

Health professions educationThe cost of providing education to future physicians and health professionals

subsidized Health servicesClinical services provided despite a fi nancial loss to the organization

sponsorships and in-Kind donationsServices and support directly to the community, charity events and non-profi t organizations

researchHealth and research studies facilitated by the University of Nebraska Medical Center College of Medicine

Community-Building activities and assigned staff CostsStaff involvement in external outreach

$25.1 million

$2.1 million

$1.4 million

$6.7 million

$31.6 million

$747,000

$1.2 million

$69.1 million

$65,000

2011 Total Community Benefi t ( 29% of Children’s Total Operating Expenses )

investing in our Community

15

Leading StudentS from StreSS to

Year after year, the boy felt that he had the qualities and skills that

would make him a good leader for his school, characteristics he

wanted to share as a member of the student council.

But he also felt something else; something so overwhelming it prevented

him from even trying: anxiety.

“He always wanted to run for student council,” says Prairie Lane

elementary and Westside Middle school psychologist Karin Mussman,

ed.s. “But he was so afraid of standing up and giving the class speeches

that were required.”

all that changed after the boy became one of the fi rst students to take part

in an anxiety relief program piloted in the spring of 2010 by Children’s

Behavioral Health in the Westside Community schools (District 66).

Leading StudentS from StreSS to

ANXI ETY RE L I E F PROGRAM

SUCCESS

17

I n the program, schoolchildren use the “Wild Divine” biofeedback computer program to learn breathing techniques that help them manage stress in the

classroom by overcoming anxiety and diffi culty concentrating or relaxing.

“With Wild Divine, he learned how to calm down,” Mussman says of the student council hopeful. “He even practiced at home. once he got comfortable, he used the strategies from the program to fi nd the courage and self-confi dence he needed to give the class speeches.”

it worked. “He not only got through the speeches, he got elected and is still involved in student council today,” she says. “He isn’t using the computer program any more, but he learned the strategies it teaches and still uses them on his own.”

the boy’s success story is just one of dozens that are resulting from the program, which was expanded in the fall of 2012 to the Papillion-La vista school District.

tools such as the Wild Divine software kits and training for the program are provided by Children’s Behavioral Health, home of the anxiety Disorders Clinic at Children’s Hospital & Medical Center, the only pediatric clinic of its kind in the region.

“the anxiety Disorders Clinic started in 2007 and quickly proved to be successful,” says Behavioral Health manager Jody Kollath, LCsW. “We started with a donation from community philanthropists ellen and stavely Wright that helped fund the clinic. Because they continued to provide funding, we wanted to fi nd a way to go out into the community and reach as many children as possible.”

the Wild Divine computer program uses sensors that attach to three fi ngers and monitor the child’s breathing, heart rate and body temperature. the readings become part of a variety of interactive video games that encourage the child to use deep breathing exercises to relax. the better the child becomes at the breathing exercises, the farther they advance in the games.

“Wild Divine’s games are visually appealing, which really motivates the kids to practice the strategies,” Mcgill says. “they get feedback immediately which lets them connect it to what they just did, and then apply it later before a test or a performance.”

Mussman says the unique, interactive imagery “gives them something they can picture in their mind after they return to class. there are even non-verbal signals a teacher can give them to help remind them how to deescalate their anxiety.”

another tool employed in the program is the emWave hand-held device. it attaches to a thumb and measures body temperature, triggering a red light to indicate stress and anxiety, a blue light to signify a lower level of stress and a green light to show relaxation. the child can use the emWave in school and can take it home at night to practice relaxation techniques.

following a presentation on the program at an annual statewide conference in 2011, Kollath and Children’s clinical coordinator

In the Receding Waters game, students relax to lower their heart rate and drain the pool. A tunnel below the surface unlocks new worlds.

The Lotus Petals game introduces students to “butterfl y breathing,” encouraging them to breathe along with the rhythm of the butterfl y’s wings. As students relax, lotus petals appear on the water.

Students must energize or relax to control their heart rate and move a hot air balloon in Peril Footbridge.

2.201218

Kathy Brandt were approached by a behavior facilitator with the Papillion-La vista school district about expanding the program. “We trained their counselors and school psychologists and now there are 10 schools involved,” Brandt says.

Children’s Behavioral Health is also conducting research to determine whether the program is having a positive impact not only on relaxation techniques but also academic performance.

Kollath says that with Children’s anxiety Clinic, most of the children are referred by a physician. “one of the neat aspects of the school program is that it doesn’t require a referral,” she says. “the teachers, the school nurses or the parents see things that they think require attention and the child then visits with the counselor or school psychologist.

“We think having a presence in the elementary schools will help us identify and address anxiety issues at a much younger age.”

in addition to providing training, Brandt serves as a resource to the school counselors and psychologists. “she continues to support the program after the training is complete, visiting the schools, offering advice and consulting on the more diffi cult cases, situations where she can apply her clinical training,” Kollath says.

Mussman says Brandt has helped develop assessment tools, performs data collection and provides supplemental materials. “she’s always available, whether we send her an email or call her on the phone,” she says. “giving us the tools, the training and Kathy as an ongoing resource really shows the extent of Children’s commitment to the program.”

Kollath says Children’s hopes to continue expanding the program. “We want to do more and with more schools,” she says. “the challenge for us is fi nding the resources.

“the program is working very well, beyond what we hoped for, even beyond what we dreamed. the more children we are able to help, the better.”

teaching them it is better to run for student council than to run away from anxiety.

“tHe Program iS WorKing VerY WeLL, BeYond WHat We HoPed for,

eVen BeYond WHat We dreamed. tHe more CHiLdren We are aBLe

to HeLP, tHe Better.”JODY KOLLATH, LCSW

19

Creating a Menu of

Healthy Habits

2.201220

Childhood obesity isn’t limited to a particular age, race or neighborhood. It isn’t determined by social status or income.

And it isn’t someone else’s problem.

according to a new health assessment co-sponsored by Children’s Hospital & Medical Center, a majority of omaha metropolitan area parents identify childhood obesity as the top health issue facing families today.

that fact provides both a challenge and an opportunity for Children’s, says Carl gumbiner, M.D., pediatric cardiologist and Chief Medical offi cer for Children’s.

“Being overweight or obese is more than a top concern for parents, it’s a primary concern for everyone at Children’s as well,” Dr. gumbiner says. “obesity can lead to a number of devastating and potentially fatal health conditions later in a child’s life. the time to act is now.”

Recognizing the problem isn’t enough.

21

“Children’s has already taken many steps in this direction,” he says, “and we will be taking many more.”

the 2012 Child & adolescent Community Health Needs assessment was based on a telephone survey of parents and discussion groups comprised of medical professionals, social service providers and business and community leaders.

obesity received the largest share of responses (38.8 percent) when participants were asked to name the number one health issue among children under the age

of 12, and when respondents were asked to name the number-one health issue among adolescents (26.2 percent).

substance abuse is the second highest concern among parents of adolescents, followed by sexually transmitted diseases and mental health issues.

an estimated 30 percent of metro area children ages 5 to 17 are likely overweight or obese based on height and weight measurements shared by parents.

surprisingly, the survey revealed that 68 percent of parents with overweight children and 43 percent of parents with obese children perceive their child to be “about the right weight.”

“those fi gures clearly illustrate the need for more community-wide education,” Dr. gumbiner says.

in its continuing effort to address this need, Children’s has launched a new community outreach program that teaches nutrition and emphasizes healthy habits and proper fi tness.

With a focus on prevention, the “Healthy Kohl’s Kids” program offers information that promotes making smart choices for healthy eating and exercise. through activities in

area schools and participation in community events, Children’s hopes to shape healthy habits and build healthier families.

funding for the program will come in part from Kohl’s Department stores. since 2000, Kohl’s has given more than $1.4 million dollars to Children’s through the Kohl’s Cares program.

Dr. gumbiner noted that nearly half of the parents surveyed said their children don’t eat the recommended fi ve servings of fruits and vegetables per day. and, 20 percent admitted that three or more of their child’s meals in the past week consisted of fast food.

“We can’t expect people to totally give up fast food but we can help steer them toward making healthier choices,” he says. “for example, selecting apples to go with your hamburger instead of french fries is a good way to start.”

Dr. gumbiner notes the work of Children’s Physicians pediatrician Cristina fernandez, M.D., who serves as medical director of the Healthy eating with resources, options and everyday strategies (Heroes) weight management program at Children’s that treated nearly 300 obese children in 2011.

“This is a call for Children’s to be seen as more than a health care provider,” Dr. Gumbiner says. “We want to be the community’s primary source for health education and information. By educating children and families regarding the need for good eating habits and daily exercise, we have an opportunity to prevent a weight issue from becoming a serious cardiac issue.”

Obesity38.8%

Colds/Flu15.6%

Nutrition7.1%

Exercise 4.6%

Abuse/Neglect 3.8%

Healthcare Access 3.8%

Allergies 3.7%

Asthma 3.6%

Mental/ADHD 3.1%

Other15.9%

Obesity26.2%

Alcohol/Drugs17.1%

STDs10.3%

Mental/ADHD

9%

Nutrition 5.1%

Colds/Flu 4.3%

Exercise 3.6%

Sources: 2012 PRC Child & Adolescent Health Survey, Professional Research Consultants, Inc. [Item 7]Notes: Asked of all respondents. Does not include respondents who were uncertain or could not give an answer.

Other24.4%

Perceived Number-One Health Issue Affecting Children Under 12 in the Community (Metro Area, 2012)

2.201222

“she has assembled educational materials and resources that address the issue,” Dr. gumbiner says. “it’s a road map to better health.”

to defi ne whether a child is overweight or obese, physicians use the Body Mass index (BMi) measurement, or the measure of weight adjusted for height using age- and gender-specifi c growth charts. for children, there are percentiles specifi c for age and gender to medically defi ne underweight, healthy weight, overweight and obese.

“We have instituted a new policy throughout the Children’s organization requiring that all children we encounter have a BMi assessment,” Dr. gumbiner says. “each one who measures above a certain percentile will be given and introduced to the list of resources we have.”

to help shape overall health awareness and prevention, Children’s has also

partnered with Healthteacher to share a comprehensive online wellness education curriculum with more than 47 school districts and youth programs in a nine-county region of eastern Nebraska and western iowa. Healthteacher provides educators with immediate access to a full range of interactive lessons and classroom tools focusing on stress relief, injury prevention, nutrition, healthy behavior, and more.

regarding other health issues, a majority of families (86.5 percent) surveyed rated their children’s overall health as excellent or very good. Nasal and hay fever allergies (23.8 percent) were considered the most prevalent health condition, followed by other allergies (16.2 percent), speech/language problems (10.8 percent), aDHD (9.4 percent) and asthma (8.7 percent).

the assessment also identifi ed access to health care as an issue. Nearly 21 percent

of parents reported a diffi culty or delay in obtaining health care services for their child in the past year. twelve percent said inconvenient offi ce hours prevented them from taking their child to the doctor, while seven percent of parents said they do not have a “medical home” (primary place) for care.

the assessment’s fi ndings are not all negative, Dr. gumbiner says. “there are many areas where programs are succeeding,” he says, “and some where we still have work to do.”

By targeting the community’s needs, Children’s can take the lead in promoting the health and well-being of all children.

“We have the resources, the specialists and the facilities to care for the very sickest of children,” he says. “We also need to be the go-to resource for all other aspects of children’s health, including public health initiatives, safety initiatives and legislative initiatives.

“thinking about pediatric health and wellness should immediately bring Children’s Hospital & Medical Center to mind.”

Obesity38.8%

Colds/Flu15.6%

Nutrition7.1%

Exercise 4.6%

Abuse/Neglect 3.8%

Healthcare Access 3.8%

Allergies 3.7%

Asthma 3.6%

Mental/ADHD 3.1%

Other15.9%

Obesity26.2%

Alcohol/Drugs17.1%

STDs10.3%

Mental/ADHD

9%

Nutrition 5.1%

Colds/Flu 4.3%

Exercise 3.6%

Sources: 2012 PRC Child & Adolescent Health Survey, Professional Research Consultants, Inc. [Item 7]Notes: Asked of all respondents. Does not include respondents who were uncertain or could not give an answer.

Other24.4%

Perceived Number-One Health Issue Affecting Teens (13-19) in the Community (Metro Area, 2012)

“We can’t expect people to totally give up fast food but we can help steer them toward making healthier choices.”Carl Gumbiner, M.D.

23

2.201224

A HERO“I’ve always thought that working hard and doing the

right thing was the basis of success.”Cristina Fernandez, M.D., pediatrician and medical director, Children’s HEROES program

A HEROfor Children

Cristina fernandez, M.D., has a very real contentment about her.

“i love my job and my family,” she says.

But contentment should not be mistaken for complacency.

Dr. fernandez is fi ercely dedicated to the well-being of children and to confronting one of the biggest health threats facing kids today. obesity now affects 17 percent of all children and adolescents in the United states — triple the rate from just one generation ago, according to data from the National Health and Nutrition

examination survey. as medical director for Children’s Heroes (Healthy eating with resources, options and everyday strategies) program, fernandez is leading a multi-pronged effort to get overweight or obese children on the path to proper health.

“everybody has to put their hands in and work together,” she says. “i love the Heroes program because it is a multi-disciplinary team where all the members have the same level of input in patient care. they are outstanding providers, and they have a passion for fi ghting childhood obesity.”

the Heroes program is the only high intensity childhood obesity program in the area. it combines medical management;

required nutrition, behavior and fitness classes; behavioral health therapy and consultations with medical specialists. Children must undergo an evaluation by the multi-disciplinary Heroes team to determine if they qualify for the six month (or longer if necessary) program.

“in our environment here, everyone has the same struggles. over the course of the program, you can see the children’s self-confidence increase. You can watch them blossom,” says Mary Jane Hawkins, rN, one of two clinical nurses who serve on the Heroes staff. the team also includes a dietitian, a social worker, a recreational therapist, a psychologist and a physician assistant.

the goal of the program isn’t quick weight loss; it’s long-lasting lifestyle changes.

“Dr. fernandez has helped us to see this as a chronic issue,” says social worker shana romero, LCsW.

“We recently had a patient come in with a Body Mass index (BMi) of 52,” says Dr. fernandez. (Normal BMis for boys range from 13.8-16.8 for a 5-year-old, 14.2 to 19.4 for a 10-year-old, and 16.5-23.4 for a 15-year-old.) “We are sure we can help him improve his quality of life and issues related to his obesity. We expect his BMi to improve over time.”

originally from Cali, Colombia, this mother of a 15-year-old son connected to the issue of childhood obesity while doing a residency in the Bronx, a low-income borough of New York City.

“i spent a lot of time in the child abuse clinic where i saw the suffering of children and learned about the problems that are really prevalent in low-income communities, including obesity and asthma,” she says.

When her career brought her to omaha in 2004, she realized that about 40 percent of her young patients here were also obese. for her, it was a call to action. Dr. fernandez began collaborating with a group of residents, nurses and the Nebraska Department of Health and Human services. they created a tool for health care providers to raise awareness about childhood obesity and the most effective way to target it in a clinical setting.

“We created a PaN (Physical activity and Nutrition) assessment and a great workshop that we did several times in different areas of Nebraska. Within two years, around 1,000 practitioners were trained. We received help from activate omaha and Livewell omaha Kids, the Metro omaha Medical society and the american academy of Pediatrics to spread the training,” Dr. fernandez explains.

the project was presented as a workshop at the Pediatric academic societies Conference — the most prestigious

“I love to teach. My priority is to teach students, residents and patients — all at different levels — but with good care.” Cristina Fernandez, M.D.

pediatric conference — in 2007 in Canada. Building on that momentum, Dr. fernandez said she felt pulled to work in omaha’s Latino community.

“We were able to do a great job there with one program, the first of its kind in the omaha area, called Healthy families,” she says.

the 12-week program taught Latino families how to eat healthier and be more physically active.

“the patients loved it and the results were great with BMis that either decreased or held stable,” says Dr. fernandez.

three years ago, she was invited to participate as a committee member in the creation of the Heroes program and clinic at Children’s. early last year, she took over as medical director.

“it has been a great experience belonging to a weight management program that has all of the elements for success,” she says. “it is a great team of practitioners with outstanding knowledge and passion for this issue.”

in addition to her work with Heroes, Dr. fernandez also sees patients three-and-a-half days a week at the Children’s Physicians office located within alegent Creighton Health Creighton University Medical Center.

“the general pediatric office is like a family where you get involved with patient development and growth, and their family grows with you. it is humbling to know somebody put the health of their child in your hands,” she says.

on top of her clinical work, Dr. fernandez serves as an associate professor of pediatrics for the Creighton University school of Medicine’s Pediatric residency Program.

“i love to teach,” she says. “My priority is to teach students, residents and patients — all at different levels — but with good care.”

Her passion for teaching has earned the admiration of her colleagues at Creighton. they recently selected her to receive a Distinguished CMe (Continuing Medical education) educator award.

Between treating and teaching, fernandez also writes, participating last year in the authorship of a new book titled “obesity: epidemiology, Pathophysiology and Prevention, second edition.” the book has five chapters with authors from Children’s and Creighton. Dr. fernandez contributed to three of those chapters.

“it is a busy time, and i work hard like any physician. the key to success is to enjoy it,” she says.

Her biggest champion, she adds, is her husband, fernando Zapata, M.D., a pediatric gastroenterologist at Children’s Hospital & Medical Center.

“He understands how important all these projects are for me, and he supports me 100 percent.”

right now, Dr. fernandez and the rest of the Heroes team are working with the Children’s Hospital association and the University of Nebraska Medical Center College of Public Health to improve the quality of the Heroes program, conduct research and evaluate the results. the overarching goal is healthy children — with brighter futures.

“it is great for all of us in the Heroes program to see how the kids get better, how their quality of life improves and how the effects of obesity recover with treatment,” says Dr. fernandez. “it is amazing how small changes can bring big rewards!”

and how a passion for the well-being of children coupled with the support of loved ones can inspire someone to confront a nationwide health threat — and transform them into a hero.

27

The Best place for Kids

2.201228

What drives us each and every day at Children’s Hospital & Medical Center? What energizes and inspires us? What pushes us to continually provide the highest level of care, and constantly re-evaluate that benchmark?

the answer is cemented in the very foundation of this institution. it is the firm belief, dating back to 1948, that we are caring, quite literally, for the future. When you’ve been given that monumental charge, there is no giving less than your absolute best — all day, every day.

this dedication, this singular focus on caring for children, has earned us national recognition for quality and excellence. Just this year, U.S. News & World Report ranked Children’s Hospital & Medical Center among the 50 best in the nation in two specialties: cancer and cardiology/heart surgery.

More importantly, our dedication to children has earned us the confidence of parents. in the omaha region so far this year, 70 percent of families seeking care for their children have turned to us, increasing our market share to a record high for a fifth consecutive year. in 2011, patients and families from throughout the city, the region and the nation sought care at Children’s through more than 350,000 hospital, clinic and emergency room visits.

We do not make this statement lightly — it is too bold for that — but we do believe it in our core: Children’s Hospital & Medical Center is the best place for kids.

Caring for children is what we do, and all we do. Children’s is the only full-service pediatric specialty health care center in Nebraska with the region’s only dedicated pediatric emergency department.

We know children. We know they require:

❱ the full continuum of individualized care, primary and acute.

❱ talented, experienced, pediatric-trained caregivers. since 2008, the number of Children’s specialty physicians has grown from 120 to 140.

❱ specialized medications, treatments and equipment.

Patients who come to Children’s are among the most severely ill, and our clinicians are saving their lives.

in all we do, the patients and families we serve provide a constant stream of inspiration as we challenge ourselves and our organization to always provide the highest level of care and demonstrate, time and again, that we are the best place for kids. We also find inspiration

in our founders — Omaha World-Herald publisher Henry Doorly and Dr. C.W.M. Poynter, dean of the University of Nebraska College of Medicine — who, almost 70 years ago, laid out their vision for a world-class hospital dedicated solely to the care of children, regardless of a family’s ability to pay.

With a nod to the past, we look forward to a future of a sustained, high quality service. We will continue to nurture our partnerships within the omaha medical community, maximizing strengths and sharing expertise to do what is best for the patient. We are proud of our critical care partnership with Creighton and our pediatric affiliation with the University of Nebraska College of Medicine, enterprises which encourage breakthrough educational, research and clinical outcomes.

Born to serve children, passionate about the future and those who will lead it — that is Children’s Hospital & Medical Center, the best place for kids in the region.

Commentary by gary a. Perkins, faCHe President and Ceo Children’s Hospital & Medical Center

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