Transcript

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a Pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike!

Mike Patrick: Hello, everyone, and welcome once again to PediaCast, a pediatric podcasts for moms and dads. It is episode 204 from March 21st, 2012 and we’re calling this one The Children’s on Quality Mashup.

Now, you probably wondering what does a mashup mean. Well, PediaCast is not the only podcast here in Nationwide Children’s Hospital. We have others. And today, we are going to do our first ever podcast mashup and what that means is we’ve asked another podcast host from Nationwide Children’s to join us in the PediaCast studio so we can mash our shows together. So we’re going to check in with one another this week. It’s a little bit different but we’re excited about it.

01:19

Today’s mashup is going to be with Dr. Richard McClead. He’s the host of Children’s on Quality podcast here in Nationwide Children’s Hospital. So this means the show is not only an episode of PediaCast but a bonafide Children’s on Quality episode as well. So the show will be going out on both feeds.

And a couple of reasons for this, you know, it gives us a chance to kind of share between our audiences exactly what each show is about, who our audience is, what our content is, where we get our information. So we’re really excited about that. But the other cool thing is that each audience is going to be able to hear their host as the guest. So you’ll find out a little bit more about your host, why they got started podcasting, sort of the history of how things got going, how they do what they do, how they pick the content that they have.

02:15

So I think this will be interesting. They really hope you get to know us a little bit better, but also to talk about the shows in general. In particular, for those of you who don’t listen to one or the other, give you a chance to know little bit more about what’s happening podcast-wise here in Nationwide Children’s.

Before we get started though, I do want to cover our usual disclaimer. And that is the information presented in this podcast is for general education purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child’s health, make sure you call your doctor and arrange a face to face interview and hands-on physical examination.

Also, the use of this audio program is subject to the PediaCast terms of use agreement which you can find over at pediacast.org.

03:04

All right, so without further ado, let’s get started. And we’ll begin with Dr. Richard McClead in the hot seat.

Dr. McClead is a physician with the Section of Neonatology in Nationwide Children’s Hospital and a professor of Pediatrics at the Ohio State University College of Medicine. Dr. McClead also serves as the Medical Director of Quality Improvement for Nationwide and in that capacity hosts the Children’s on Quality podcast, which is why he’s joining us today.

So welcome to the PediaCast Studio, Dr. McClead.

Richard McClead: Thank you, Dr. Mike. I’m happy to be here.

Mike Patrick: We really appreciate you stopping by and I did a little calculating. We actually go way back. We first met when I was a fourth year medical student. So this was back in 1994. So 18 years ago and I was doing was called a sub-internship. So there are people lower than interns. At the time. I was one of them.

Richard McClead: Pretty close to Niagara Falls.

Mike Patrick: Yeah, in the Neonatal Intensive Care Unit here at Children’s. So 18 years ago, I thought… As I was calculating that, it made me feel old. But I suspected makes you feel a little older.

[Laughter]

04:11

Richard McClead: I’ve been here, you know. This is my 32nd year.

Mike Patrick: Yeah, a long time.

Richard McClead: And you know, it’s kind of funny because when I left my fellowship at Case, finished my fellowship and I came here to be a brand new attending, I figured I’d be here five years. Because by then, I’d probably be a Nobel laureate and have my academic career at the NIH or whatever. But of course, that didn’t happen and here I am still 32 years later and having a great time doing things.

Mike Patrick: It’s amazing how much the place has grown in those years.

Richard McClead: Well, most of the buildings that were here, even in ’94. Many of those buildings had been torn down. I mean, every building has a letter and A, B, C… I think A is still here but B, C, D and E and F were all gone, you know, but we put new ones up. They all got letters, too.

05:08

Mike Patrick: And we have a really big one that’s opening up in June in a couple of few months.

Richard McClead: Twelve-storey tower. You know, when you’re driving in town – they’re at the 70, 71 split – this is the biggest thing in this part of the town. It’s a huge tower.

Mike Patrick: Yeah. Yup, yup, it’s really impressive.

So, let’s talk about Children’s on Quality. What exactly is the podcast or what’s your audience and what kind of things do you talk about?

Richard McClead: Well, I’m trying to focus on bringing to the public, parents and others but also the medical public – the physicians who are interested in quality issues – but I’m trying to tell people about all the exciting quality initiatives we have ongoing at Children’s Hospital.

Hey, all hospitals have quality initiatives but they’re often not willing to talk to you about them in great detail. And so I thought, “Well, this is a new media that we could try to reach out to people and let them know about some of the great things that are going on and some of the not so great things.” I mean, it’s not that everything we do, we’re only telling you the good things. There are some things that we do that we’re working on. We know we’ve got opportunities improvement but…

06:26

Mike Patrick: But if you don’t talk about those things you’re not going to ever improve.

Richard McClead: It’s all about transparency. And I think this is probably one of the greatest struggles that healthcare is facing today is the reluctance to be transparent about quality issues.

Mike Patrick: Right.

Richard McClead: Everybody’s willing to say how great you are. But are you willing to share what you’re not doing well and what you’re working on? I don’t think people expect that we’re always going to be perfect but what they expect us to do is to work on our problems and make them better.

Mike Patrick: Yeah, absolutely. And if you don’t identify those and have that transparency, that’s not going to happen. Yup.

Richard McClead: Right.

07:06

Mike Patrick: Just in terms of some recent shows, you did a show on button batteries, hand hygiene here in Nationwide Children’s Pastoral Care. At Nationwide Children’s – reducing the frequency of pediatric pressure ulcers, breaking the language barrier where you talked about our interpretive services. So, lots of great content, very broad-based sort of stuff.

Richard McClead: I guess the whole issue of quality improvement covers the gamut of what we do in healthcare. So there’s just a lot of opportunity. The biggest problem that Kelly Nightingale, my producer, and I face is trying to narrow it down to what we can focus on and doing a 15-minute, 20-minute presentation.

Mike Patrick: Yup. You have a producer.

Richard McClead: Well, I do have a producer. So I guess, the trade-off between all the great audio equipment and having… I’d rather have a producer.

[Laughter]

Mike Patrick: We were just commenting before the show that the PediaCast studio, equipment-wise, is a little more high tech, but you have more people help.

Richard McClead: I have…

Mike Patrick: I really shouldn’t say that because we have some great folks on our interactive team, and just not a producer.

08:17

OK.

[Laughter]

Now, you talked about quality being important because that’s how you improve yourself. What are some other reasons you think that a culture of quality is important for today’s healthcare industry other than just improving yourself? What else?

Richard McClead: Well, I think we’re all aware of the financial struggles our country is in and a big piece of that is the entitlement associated with our healthcare coverage both from Medicare and Medicaid. And these are important services that we need to continue to provide, but there’s only so much money available. We need to focus on eliminating that which does not bring value to the healthcare delivery system to optimize outcome and reduce the cost.

Can we do the same thing even better and do it for less cost because I think the reality is we’ve got, 40% of our patients, I think, varies from unit to unit, but on average about 40% of patients are Medicaid patients. They’re government insured and there’s not going to be more money down the road.

Mike Patrick: Yeah.

09:43

Richard McClead: So we’re still going to have these patients to take care of whether the government cuts our budget or not. So we need to figure out how we can do things even better and there’s so much opportunity. We have to standardize our care and to create some efficiencies and we’ve just done so much here in the past 15, 20 years. It’s just amazing.

Mike Patrick: On a national level, here in Central Ohio, we don’t have a ton of competition. So if a child get sick here, it’s kind of a no-brainer. We’re going to take him to the Nationwide Children’s. But in some places and in the adult world where there is more of a competition issue, I guess quality in that case too, if you can present to the public, “Hey, we’re really working on being the best.” I mean, that may help you get more business that way, too.

10:30

Richard McClead: It is. But it is interesting though, and this is in Columbus, we are the only show in town when it comes to pediatric care. On the other hand, we’ve got a whole bunch of adult hospitals that are in competition for one another. And you can watch the television at night, everybody is advertising about how great they are but not a lot of data being put out there for the public to really compare. Although that’s changing with stuff coming out of CMS Medicare people. They’re starting put up those quality metrics for number of things. That should be helpful if the metrics are valuable.

11:20

Mike Patrick: Yeah, right.

Richard McClead: And are they informative? And are they worth paying attention to? And I’ve not always been convinced that some of those metrics are that valuable.

Mike Patrick: Yeah, kind of depends on who… Because you can spin metrics.

Richard McClead: You can.

Mike Patrick: Kind of watch where they’re coming from.

Richard McClead: They often have to be… A lot of those metrics that government reports about individual hospital – performance is based on what we call administrative data. These are the codes that we put in when we submit our bills for patient care. And a lot of times in pediatrics, those codes may not just quite fit.

Mike Patrick: Right.

Richard McClead: And so if the government is taking those codes and evaluating the performance of a hospital based on their coding, they may be making some assumptions that are not valid and that’s frustrating.

So I think it’s important – decide what you want to measure and then go out there and do it. And then as much as possible, let the public know how you’re doing.

12:26

Mike Patrick: Yeah, yup. And you touch on outcomes, too. Of course, from a parent point of view, that’s really foremost on their mind. They want their kid to get better and they want it to be done in a safe, efficient manner. And so by kind of focusing on quality, we can improve care.

Richard McClead: Right.

Mike Patrick: So we don’t want to forget mentioning that.

Richard McClead: No, I mean, that’s kind of…

Mike Patrick: No brainer.

Richard McClead: Everyone of our quality projects has associated with it a balancing measure. A balancing measure is a measure that is our way of confirming that “improvement”, so called, that we’ve implemented is actually a change that is a true improvement and has not had a consequential adverse effect.

13:13

So, you know, a project that I’ve been working on now for two and a half years is reducing length of stay in the intensive care nursery. And a balancing measure for that is, of course, the readmission rate. If I send them out sooner, that’s great. But if they bounce back within 30 days, that’s not so great. Nobody expects to leave the nursery and then come back in 30 days unless there’s something that they have to do.

So, it’s important to have that. Quality is – we have to be focused on the same quality or better outcomes. But there’s so much variability in the systems that we have lots of opportunity to reduce that variability and improve the overall quality of patient care.

Mike Patrick: What specific quality initiatives are happening here? You mentioned the neonatal intensive care readmission rate. We mentioned hand hygiene before. What are some other sort of big package programs that are quality focused that are happening here in Nationwide Children’s?

14:15

Richard McClead: Well, I think that’s a great question. It’s actually, an opportunity for me to call attention to your audience of our website. If they will go to www.nationwidechildrens.org, all one word, to the website and then look for the Quality and Safety and pull that up, you can see that they have a quality and safety measures webpage. And so, there we publicly report adverse drug events. Medication errors are a significant cost of patient harm within any hospital and so we’re focus on eliminating, by 2013, our harmful events.

I have a podcast, hopefully coming out here in the next month, that’s actually going to talk about a little bit of our Zero Hero program that is focused on eliminating preventable harmful events that occur in our children that are under our care, within, by 2013.

15:20

But if you look at how children are harmed, about 50% to 60% of the cost, when we started this was due to medication errors. Errors, mistakes that are made in the medication management process that reached the patient and caused some degree of harm. We have a method to rank her injury.

In the most of more relatively minor things, if it gets the patient, maybe have increased monitoring a little bit whatever, rarely, and we haven’t had one for a long time. They cause really bad outcomes.

And so we track that, each event that is reported. Now, given this is based on our… We have various methods for monitoring adverse drug events but certainly the big part of it is our staff, their comfort level at reporting events. We’re trying to create a safety culture where people are focused on identifying an error that they made and then feeling comfortable about sharing that information with leadership so that we can set about fixing those aspects of the error that are system related and then can be prevented.

16:34

A lot of cultures come out… A lot of hospitals, especially, come out of an environment that it is a shame-and-blame environment where if somebody makes a mistake, they’re fired or they’re punished in some way. They’re put on administrative leave and things like that. We think it’s important to have a culture that is, you have to be accountable. If you’ve made a mistake and it’s because you chose to ignore some key safety measure intentionally, you have to be to be held accountable for that. But most of the errors that people make are in part related to the system problems. So adverse drug events is a major issue for…

17:17

Mike Patrick: For all hospitals, yeah.

Richard McClead: For all hospitals but we’re really and we’ve – I came from meeting this morning where we heard our current results to date. Our goal for… We started out… We did a podcast some time ago on adverse drug events, but at the time we were having – our peak was about 85 harmful events per quarter, every three months. And that’s based on about 140,000 doses per month. So 500,000 or so medications dispensed, we had 85 errors. Well, our goal for – and that was peak of 2010, February first quarter of 2010. First quarter of 2012 through February, we’ve had a total of 12 errors.

Mike Patrick: Wow.

18:05

Richard McClead: And we’re on track to hit our target of 20. And then, we’ll keep driving because the goal is to get zero. You just have to really focus on the systems. So that’s been a big measure.

Other elements of harm have to do with infection, a lot of things related. You mentioned hand hygiene is one of the process measures we track. But the outcome measure that we’re looking at are surgical site infection, ventilator associated pneumonia, and urinary tract infections, and the central line catheter infection, bloodstream infections. And we are having tremendous success at driving those infections down.

We haven’t totally eliminated, but for instance, in our NICU – the Neonatal Intensive Care Unit – the bloodstream infection which is, because we’re dealing with immuno-compromised population, it’s not surprising that it would be up. Ours is some of the best in the country. If you go to the website you can see how well we’re doing at Children’s Hospital with infections.

19:11

Asthma is another area, and then the overall serious safety event. And, I think, I really like people to take a look at this because you will not find very many hospitals in the entire country that’s willing to put a rate of how often they have a series safety event.

Now these are our pretty significant events that occur to patients, cause a great deal of harm. And fortunately, they don’t happen very often but we’re willing to talk about how often. And then, we’ll give you a little detail about the event and let people know about it.

Mike Patrick: Great. What did we learn from it, what did we change because of it.

Richard McClead: Exactly.

Mike Patrick: Now you’ve mentioned the Zero Hero program, what exactly is that?

Richard McClead: Well, the Zero Hero program was the vision of our new Chief Medical Officer, Dr. Rich Brilli who came in Fall of 2008. And his idea was to eliminate preventable harm.

20:17

I mean, there are some harm that is not preventable. But there are lot of things that happen to children that could be prevented if somebody… I mean, something as simple as acquiring central line catheter infection, hand washing is a key part of that. If you’re not washing your hands, your increasing the chance. So monitoring hand washing is an important element.

But his goals, his vision, was to eliminate preventable harm by 2013. That gave us, when we started and actually it went up being by the time we got it up and running, 2009. So within four years, we were going to… Our set of vision of something what is really… We talk about being audacious or bodacious. It’s just amazing to make that kind of commitment.

Mike Patrick: Yeah.

Richard McClead: It was hard to believe that we could do it. But now that we’ve been in it and we’ve seen the results, it’s happening. I don’t know that we’ll get to zero but we’re making great progress at eliminating all these different ways that children could be harmed while in our care.

21:24

Mike Patrick: Yeah, you know, I love the name, too. I don’t know who came up with that. But the idea being that you don’t want to be in a situation where you need a hero.

Richard McClead: Right.

Mike Patrick: Is that the … Or is this zero means we’re trying to get to zero events?

[Laughter]

Richard McClead: Well, we’re trying to get zero events but we want our heroes to be the staff that help us identify the various system problems that are contributing to errors and being willing to report.

Our Zero Hero Program was associated with a phenomenal training program in the culture, in patient safety. We created tools working with our consultants that people can use to help minimize the risk that they would make an error.

Mike Patrick: There is a lot of training that goes on. Anybody who’s a new hire to the hospital goes through Zero Hero training.

22:19

And one of the things that I like about it is the whole buddy system idea where you have sort of have someone that you’re accountable to and that’s kind of looking over what you’re doing. But then, you’re also looking over what someone else is doing. So that we’re all kind of a team and in this together and kind of have each other’s back.

Richard McClead: You know, we call that 200% accountability – that if somebody makes a mistake and I’m standing there watching them make mistake, I’m just as accountable as they are for making that mistake. So my role is to use my Zero Hero tools to tell my colleague that, “You know, I think you’re forgetting to do… Maybe you’re forgetting to put your mask on when you’re about to do an invasive procedure. That’s part of the checklist of things that we focus on to prevent infections. And you forgot to put your mask on. Would you put your mask on?” Just to remind people. We have to look out for each other to keep errors from happening.

23:22

Mike Patrick: Now, what are some areas where Nationwide Children’s could do better?

Richard McClead: I think we still have a ways to go with eliminating our harm. And I think that probably is the focus for attention – all these different ways that children can be hurt are areas that we want to continue improving. We’re making progress but it’s not zero. Until we get down to zero, that’s got to be our focus.

Mike Patrick: So just as new things come up, we need to…

Richard McClead: Yeah, we take care of… For instance, there are a number of projects I’ve been asked to take on because there’s a lot of variability in the various processes measures, outcome measures, and they may be very costly.

24:12

For instance, recently, I was asked to focus on one of the gases we use in the Critical Care unit. Very expensive gas, it has indications, but we use it for a lot of reasons. And there is not always the literature to support its use but the clinical impression of the physicians is that this is beneficial. So working with the doctors, we’ve established some standard pathways that they’re going to follow for the use of this particular gas. And we think, over time, use of good compliance with those protocols will lead to reduced variability in the usage.

It’s easy to start some of these medications but then the fear of stopping it because you’re not sure what’s going to happen, so if you a priori decide what are the stopping criteria and how are we going to wean this medication. And you get that all written down on paper and then you hold each other accountable for following it. And if you decide that you’re not going to follow the protocol, that’s OK, just tell us why so that we learn.

25:20

A lot of this improvement is about us, one, creating a belief that we can make a difference, and two, that the difference will have…

Mike Patrick: An effect, yeah.

Richard McClead: Have an effect later on.

Mike Patrick: I think some may be wondering in their minds. We’re talking about nitric oxide.

Richard McClead: Yeah, nitric oxide.

Mike Patrick: And there was a study that just came out. I forgot what’s the journal. But there was a study that looked at whether it’s really helpful or not. I think we have that lined in our future PediaCast.

Richard McClead: OK, great.

Mike Patrick: So, just in case parents are wondering what that’s all about.

So I’m just going to turn our attention here to the podcast itself. How did you get started podcasting?

26:09

Richard McClead: Well, when we started our program in Quality and Safety, the Zero Hero and eliminating harm, we kind of create this focus. One of the things we want to do was to begin the process of sharing our data publicly.

That was new for us and there were some concern that we wanted to make sure that the public understood what it is that we’re talking about. And so we decided that in addition to showing some of the data for different metric, we’d actually record an interview with experts to talk about what it is we’re doing and why we’re doing it.

So the marketing department asked me to be the interviewee and we hired a professional audio firm to come in and record these files of me interviewing various experts about the different metrics that we’re reporting publicly. And I thought, “Oh, this is kind of interesting.” It was very high quality. They’re still on the website. If you go and click on them, you can see those. They’re very high quality. They were somewhat expensive.

27:19

And I realized, “Wait a minute, I want to do something like this as a podcast. I can afford to pay somebody to record these things” So we kind of decided, “Hey, let’s try this and see what happens with it and we’d have the focus of each show a different aspect of some of the quality efforts we have going at Children’s Hospital.”

And that’s how it all kind of started. It came from that – how do we tell public about our metrics that we’re measuring?

Mike Patrick: Yeah. Because when you look at numbers, just the numbers, they can be misleading. You might not really understand the story behind the numbers and they gave you a chance to talk about that.

Richard McClead: Absolutely, yeah.

Mike Patrick: How do you choose which topics you’re going to talk about?

Richard McClead: Well, usually at the beginning of the year, Kelly and I will sit down and come up with a list of possibilities. I’m quite familiar with all the different things going on. So it’s not a problem of finding what to talk about. It’s a question of having enough time to put together a podcast for all the things we’d like to share.

28:20

Mike Patrick: Right.

Richard McClead: And then, trying to make some sort of a… Have it set up far enough in advance that we can kind of anticipate what the next one’s going to be. I got to line up individuals for the interview. I have to identify the expert, line them up, schedule the room where I’m going to do the recording and kind of go from there.

Mike Patrick: How often do you produce shows?

Richard McClead: I’m at best trying to do once a month. And with my busy schedule, it’s sometimes difficult to pull that off. Ideally, I’d like to do a podcast every week. I think we could do it. But I just…

Mike Patrick: It takes a lot of time.

Richard McClead: It takes the time. You know yourself, you get your audio file, then you got to edit it. So that takes a flicker of time. Then you need to have it vetted by the crew. So I’ll send it out to Kelly and she’ll have a listen. And then, sometimes I have to have other individuals take a listen to it to make sure they think it’s OK and then go from there.

29:26

Mike Patrick: Now, where can folks… Where’s the best place to connect with the Children’s on Quality podcast?

Richard McClead: Well, if you go that website of Children’s Hospital – www.nationwidechildrens.org – and then click on the tab at the top that says Quality and Safety, it will bring up the Quality and Safety Page where there’s an intro by Dr. Brilli that talks about our focus on quality and safety. And then on the left hand side, it lists the quality metrics. Then you can see from the Quality Metric Safety Measure, down just below that is the link for the Children’s on Quality blog and the audio file.

30:04

Mike Patrick: Sure.

Richard McClead: So this month, we’ve got surgical hypothermia as our topic that we’re covering. Because I got a team of anesthesiologists and perioperative quality improvement people that are working on trying to reduce the cold exposure, the unplanned cold exposure. Because sometimes we plan to make it cold as part of the surgery. But when it’s unplanned , it increases the risk of infection. So if we’re going to drive our surgical site infection rate down, we got to address the issue of surgical hypothermia.

Mike Patrick: Yup.

Richard McClead: And they have a big team around that.

Mike Patrick: Yup. That sounds interesting. And that show’s coming out later this month?

Richard McClead: It’s out now.

Mike Patrick: Oh, that one is the one that just went.

Richard McClead: Yeah, it is out there now. Yeah.

Mike Patrick: OK. And you can also hit childrensonquality.com. You guys have that as your kind of landing page.

Richard McClead: Right, exactly.

Mike Patrick: Just for the podcast itself with the Show Notes to let people know what particular topics. But again, the Safety and Quality tab is on the main website over at nationwidechildrens.org and people can look up links to both of those things in the Show Notes over at pediacast.org for folks at least who are going over there so they can find it as well.

31:14

All right. Well, this show is not only a PediaCast episode but it’s Children’s on Quality show as well, so it will be on both feeds. And even though, it may seem I kind of hijacked the operation here, I am going to turn the rings over to Dr. McClead. And for the first time in PediaCast history, I’m going to be playing the role of guest.

Take it away, Dr. McClead.

[Laughter]

Richard McClead: Well, I appreciate the opportunity to share in this mashup podcast. I think, 1994, you were the resident, Then you left and then, you were down in Florida?

Mike Patrick: Yeah, yeah, yes.

Richard McClead: And so you’re down there in private practice?

Mike Patrick: Great. You know, actually, I was working… I was in private practice in the city here in Ohio, in Springfield, Ohio, for 10 years. And I got kind of burnt out with private practice and was still trying to do PediaCast on top of a 40-hour work week. And an opportunity arose to go to Orlando and work with the Pediatric Urgent Care Group. So I did that for about three years.

32:18

Richard McClead: And the Urgent Care gives a little more…

Mike Patrick: A little more…

Richard McClead: Control of your time.

Mike Patrick: Yes. Yes. Yes.

Richard McClead: Well then, so the PediaCast began in Springfield.

Mike Patrick: It did, yes.

Richard McClead: And so what motivated… I mean, what we’re looking at, early 2000?

Mike Patrick: Yeah, it was 2006, July of 2006, when we first started.

Richard McClead: So what was the motivation to you to say, “Hey, there’s a need for a podcast for parents about pediatric health issues.”?

Mike Patrick: Well, I have to go back to when I was 10 years old. The reason for that is my parents at the time manage a skating rink. In fact, this is the late 70s, so roller skating was kind of a big thing and they were the professionals. You know, they did the classes and the people who were competing, they would coach them, so to speak. And then there were also managers at the skating rink.

33:18

So when I was 10 years old, I started to work as a DJ for the kid’s fun skate on Saturday mornings. And they paid me by letting me pick out from the concession stand anything that I wanted to eat after the skate session was over.

So that’s how I got started behind the microphone, when I was 10 years old. And throughout middle school and high school, I increased that, I kept doing it. It got to the point in high school, I was doing the Friday and Saturday night sessions, the all night skates. The skating rink then started to do other deejaying events. So I would go into pool parties, dances, kind of traveling DJ kind of gig.

And then I started working at a couple of radio stations, campus college kind of radio stations in Springfield. And then, when I went to college at Ohio Wesleyan, I worked at their radio station throughout college as well.

34:11

I liked it, but I wanted to do something where I was really helping people more than just doing broadcasting. And I was interested in medicine. No one in my family were doctors. I just thought it’d be kind of cool to be a doctor. I didn’t really look into it as much as I probably should have.

So I went to medical school, really forgot about broadcasting completely, went into pediatrics. And it was in 2005 when podcasting was born and I started listening to podcast. And I just kind of rekindled that, “You know, this is something I could do. It would kind of get me back behind the microphone again in a way that I could connect with parents.”

Because the problem that I find in private practice is you see a lot of the same things over and over again but you only have a snippet of time to be able to talk about it. So if a parent wants to know, “Why does my kid keep getting ear infections over and over again?” I mean to really explain on terms that they can understand but still going into the path of physiology of why this happens and why we need to do what we’re doing, it just takes up a lot time.

35:18

So I thought if I can come up with some sort of canned spiels that went into it in more detail, then I could say, “Here’s the quick story but if you go to this website, you can listen to me talk about it in a longer way to help you understand.” Because parents are, you know, they’re just thirsty for knowledge in whatever realm of medicine that’s affecting their child at that time. And getting good quality information out there is sort of hard to find.

So my OCD nature and my ADHD nature both kind of played a role here. I couldn’t just record spiels and put them out there. I had to really research this. So I started listening to podcast about how to make podcasts. What kind of equipment do I need? What kind of planning? What’s going to make it sound the best?

So l looked into all that. This is now late 2005 and in the early 2006. So I really had to have a plan. And as that came together, I thought, well, I don’t want to just make canned spiels. I want there to be a little bit of an entertainment factor involved, too.

36:20

So this idea came to cover news, answer list in our questions, do it more of an entertainment kind of show that still has a primary focus of education that people might be interested in listening too, and doing interviews. And so, when I started up in 2006, that was sort of the vision and just put it together and people started listening.

iTunes kind of grabbed a hold of it. Because it was still in the early days of podcasting. I think what helped me out was not submitting it as a medical podcast. I submitted it to the iTunes directory in the Kids and Family section, because that’s really where the audience is.

Richard McClead: Right. Yeah.

Mike Patrick: And so people started listening. iTunes, its still on their featured page. So if you go to iTunes, to Podcasts and click on Kids and Family, it’s right there on the front page of it.

So that’s really helped recruit the audience. So just been doing it and keep doing it and here we are.

37:13

Richard McClead: But it began as a way to actually improve…

Mike Patrick: The quality.

[Laughter]

Richard McClead: The quality of how you communicate with your families, because in your private practice setting, you didn’t feel like you have enough time to really provide the families what they needed.

Mike Patrick: Yeah.

Richard McClead: And that’s just great.

Mike Patrick: And, you know, it comes back down to the money factor. Because in order to operate a pediatric practice, you have to pay staff, you have to pay the bills and the rent and vaccines and all that. And so, in order to keep that going, you have to see X number of patients of day or you’re not going to have the income to pull it off.

And so, that’s really the pull – that you don’t have enough time to really sit down with parents and give them the information they want. And that’s happening in pediatric offices, and not just in pediatrics, in medicine in general all across the country. I mean, I’m sure doctors would love to see half the number of patients that they see in a day to be able to explain to parents exactly what’s going with their kids.

38:08

I know in our specialty clinics, you have a kid with a seizure disorder and they’re on their seizure medicines, they would want to know more than what the neurologist has a chance to sit down with them. But when you have a three-month waiting list to be able to get them to see the neurologist, they have to click along and see people quickly.

So I knew there was a need to get quality evidence-based information in the hands of moms and dads and this seem like a good way to do it.

Richard McClead: Wait, you remember our good friend, Dr. McClung.

Mike Patrick: Oh, yes. Yes.

Richard McClead: Years ago, he’s passed on now.

Mike Patrick: He’s a GI.

Richard McClead: A GI doc. But Dr. McClung had written one of the most popular articles – I think it was published in Pediatrics – forewarning the public about some of the bad information out there that they can get from the Internet that just isn’t correct.

Mike Patrick: Oh yeah. Yes.

Richard McClead: So he kind of given everybody a heads up.

39:04

Mike Patrick: Yeah. Anybody with an agenda can write anything they want and if it looks professional, in a blog, in parents, especially…

I guess a good example is the whole vaccine thing. When you have a kid who has autism, you want to know why. I mean, you want to be able to say, “Why did this happened? How can I prevent it from happening to my next child? How can I get the word out and prevent this from happening from other parents having to go through the same thing?”

And so when you get a hold of information that would suggest immunizations do it, I mean, you can understand from a parent’s point of view, you would become passionate about wanting to do this if you truly believe vaccines were the cause. So I think the Internet is really responsible for the misinformation that’s out there about vaccines.

So again, we’re just trying to make a place where parents can come and get the right information based on studies and science and experience.

Richard McClead: So how do you go about deciding? I mean, I have lots of things in Quality to talk about here but I just think about the myriad of possibilities to talk about with pediatrics health issues.

Mike Patrick: [Laughter]

Richard McClead: How do you go about deciding what your agenda’s going to be for the coming year?

40:16

Mike Patrick: You know, to be honest, I can’t even do an agenda for a year because I… I’d go out about three months or so. And the reason for that is because I wanted to be fluid in terms of what’s happening now.

Richard McClead: Right.

Mike Patrick: Sort of, what’s the mainstream media is talking about? What studies are coming out? What in pediatric medicine are the hot topics that we’re discussing? And so if you kind of plan out a year at a time, you’re going to miss the miss the boat on some of that stuff. So there’s a little bit of a shorter lead time for this show.

The first place I get ideas for topics is just people writing in. So we got lots of emails through the Contact page at pediacast.org where people have questions. So we try to be responsive to those first and foremost. So we’re here for the audience. If there’s particular issues you want to know about, we try to get those in the line up and talk about it.

41:08

Just an example, recently someone wrote in because they had broken a CFL bulb and they were worried about mercury exposure. So we got Dr. Marcel Casavant to stop in. We talked about mercury exposure just based because someone had written in with that particular topic. And we do funnel this a little bit to make sure it’s a topic that’s just going to appeal to…

Richard McClead: A wide audience.

Mike Patrick: Yeah.

And then, the next thing is to look and see, like what I said, what’s happening in the mainstream media. So if there’s… Dr. Oz comes out and talks about arsenic in apple juice, we’re going to talk about it and say, “Is this really a problem? Are kids really having symptoms of arsenic poisoning all across the country that we don’t know about?”

So any things that are kind of hot topics in the media, we try to pick those up. And then we also look at what kind of things, what kind of programs here at the hospital do we want folks to know about. I mean, there’s some great programs that we have. They’re maybe under utilized because people don’t know about them.

And we also, being a big tertiary care center, there are a lot of folks out there who don’t live next to big children’s hospital and so they have some choice where they want to go. So if you live in rural Iowa and you have a kid with Kawasaki Disease, you may want to take the trip up here to see one of our cardiologist to have your echo done. If it’s something you’re only going to be following up with once a year, it might be a place you want to be because we got the top folks here.

42:31

And so just getting that kind of information out into the hands of moms and dads.

And then, we also have a large international audience. When we were looking at our metrics from last year, PediaCast is actually heard in a couple hundred countries. And so, again, they don’t necessarily have access to great information in a lot of places so we try to provide that.

So we try to get more bread-and-butter pediatric topics in there too – eczema, asthma – just stuff that’s little easier to find but for other places, it may be more difficult. So we try to go into those things as well.

Richard McClead: And you’re producing a show weekly?

43:10

Mike Patrick: Once a week.

Richard McClead: Once a week?

Mike Patrick: Yeah. I had the good fortune to be with the Marketing Department a couple of days a week. To prepare a show with good evidence-based information, it’s anywhere from a half hour to sixty minutes per show. I mean, there’s a lot of prep time and of course, coordinating interviews and getting them to schedule and do them and all the post-production work.

And we’re now, and I think your podcast is too, we’re transcribing the podcast so that it’s not only an audio file but there’s actually a written documentation of what we’re talking about. And that’s, of course, helpful for Google because the search engines crawl and get all that information. So if someone searches for asthma, they’re more likely to get one of our shows that were talking about asthma a lot. Where if it’s just the audio file, that doesn’t…

Richard McClead: They might not pick that up.

Mike Patrick: Yeah. Right.

And there’s some people who just, you know, they prefer to read it.

Richard McClead: Yeah.

44:05

Mike Patrick: One of the things about podcasting that I really sort of fell in love with is that you can do other things. I mean, there are just so many things competing for our time these days but with podcasts, you can listen to them while you’re commuting, while you’re exercising, while you’re cooking dinner. So it doesn’t take a 100% of your time, but you can still get the information into your head.

[Laughter]

Richard McClead: Yeah, for sure.

Now, the program when it started in Springfield, was that immediately affiliated with Children’s Hospital? How that all come about?

Mike Patrick: No. I put together a studio in our basement and I was just doing it on my own. I was kind of a victim of my own success a little bit because I was with a host, where you have the audio files – and I won’t mention their name – but when it started to really pick up traffic, it was on a shared server and pretty much crippled their service. Which I didn’t realize it was happening.

So I got an email from these folks that says you have 24 hours to take your show off our servers. And at that point, I had a thousand listeners and it was in iTunes. And so I really had to switch to something that was more stable and would allow me to have higher traffic. That cost more money and I footed that for awhile.

45:27

In Springfield, we’re close enough to Nationwide Children’s. We have physician liaisons that came out to our office every few months. He would just kind of check in with us, what kind of services. And so I mentioned the podcast to him and just said, “Would you be interested in being a bandwidth sponsor, just helping me?” Because this has always been a free program and we never wanted to put that obstacle on there to make parents pay for it.

So I just mentioned, “Would you be willing to help foot the cost of it?” I don’t remember the exact… I want to say it was maybe late 2007 when we started with the relationship and so they were our bandwidth sponsor. And then, even when I moved to Florida, they continued to do that for me.

46:08

And then, what happened is, I found that even though I have less time working in Florida… I mean, really it was a better… Compared to private practice, it was fewer hours that I had to work. But when you live in Florida and you have kids and you live… Literally, we were five minutes from the Magic Kingdom at Disney World, I seldom have a lot of free time to do the podcast because we were going. We’d do a lot of fun things.

And then this opportunity came up though to actually make PediaCast a part of my 40-hour week job and I couldn’t resist, so that’s why we came back up.

Richard McClead: That’s pretty neat.

What do you think is the next big thing when it comes to social media that you might want to take advantage of?

Mike Patrick: Yeah. You know, this is still me talking to people at the end of the day. So folks can write in questions but it’s still not as interactive as I would like it to be. And I kind of envision the day when there’s something that we could do more live with people.

47:22

So folks, they have laptops with web cams on them. And so sort of a conference kind of thing where folks can show up and ask questions live. It can really be more interactive. I mean it is interactive in that people write in questions and we cover them and talk about them, but there’s still that production nature to it.

And I think, with social media, what that will open up in the future is for us to be able to be more interactive and actually be more one-on-one. More like a radio show, so to speak. Google Plus does have gatherings, I think it’s called, but there’s still a limit. I think it’s only 10 people or so that can do it at one time. So it wouldn’t work as well with a bigger audience. But I guess, that more interactive component to it is what I’m looking for, too. I think we’ll get there.

48:11

Richard McClead: Have you given any thought to actually having a broadcast video show?

Mike Patrick: We’ve talked about that as well. Again, I think… I don’t like the camera as well.

[Laughter]

I got a good face for a radio.

[Laughter]

So the camera, you know, is not my favorite thing. And I do think, I mean, eventually, we do have some plans with Facebook and video for later this year that we’re going to be discussing and working with. And that’s really at the pull of the marketing folks here. It’s not my initiative but we are kind of heading in that direction with video as well.

But again, I think that for folks who really are interested in in-depth information, the podcast is still the best way because we have more time. The video clips still have to be short, because when people are spending their whole time, video requires a 100% of your attention. You can’t do something else while you’re watching video.

49:15

And in our society today, people don’t want to sit and watch a video for a half an hour unless in front of their TV. And so, I don’t think that… I think we will have to have less depth if we go the video route.

And the whole reason for doing this was to be able to say, “Let’s explain why kids get ear infection. Let’s talk about eustachian tube, the cilia, how a virus infects those little cells so the cilia don’t work and bacteria.” You know, really getting more in-depth about why this happens so people can understand it. And I don’t think video lends itself to that quite as well as audio does. But maybe that’s old fashion of me and I’m going to get pulled into doing more video anyway.

[Laughter]

Richard McClead: There’s a video podcast, iPad Today, that I started watching. It’s an hour show and the problem I had is just to sit down for an hour, it’s not like watching a basketball game or something like that in television when you’re doing it. So I tried to do it and man, it just didn’t work.

50:26

I listen to a lot of podcasts. Most of the podcasts I listen to are business related because I happen to be chairman of the pension plan committee for our corporation. So I need to learn something about finances and things like that even though I’ve got some grad work in that area.

So I listen to Marketplace. I actually started off when it was free, listening to Bloomberg on the economy. But it was, you know, 15 to 20 minutes and that’s a drive in from home.

Mike Patrick: Yes. Yeah.

Richard McClead: I listen to, usually, two podcasts a day from various sources just driving back and forth to work.

Mike Patrick: Yeah. Yeah.

Richard McClead: And so it is a great tool for me to learn about some topic or some area of interest or to keep up in what’s happening in the economy today. And I’m sure it’s the same for parents who want to keep up with what’s happening with healthcare issues for their children.

51:23

Mike Patrick: Right now, we kind of have a hybrid audience in that still the majority of our listeners are parents. But we’re getting more listeners who are clinician. And so we have medical students. We have nurse practitioners, nurses, pediatrician, family practice doctors who write in. They make nice comments on iTunes, because we have iTunes reviews. So someone will say, “I’m a pediatrician. This is a great resource” kind of thing.

So I know we’re getting more of a professional audience. And that’s another reason to go more into details. So we had a Kawasaki interview here recently. We had a pediatric cardiologist and an infectious disease person, and I mean, we really unpacked Kawasaki Disease in detail. But we still kept the language where parents can understand.

52:09

But I do think that in the future, there’s interest I think in a podcast that’s aimed at pediatric professional. That kind of kicks it up a notch. We can use a little bit different language. And maybe even make it available for CME kind of stuff.

But as you know, there’s a lot more work that goes into that in terms of quality control and making sure that we’re hitting goals and there’s a way to evaluate. It’s more difficult. But I think doing a consumer podcast takes time. Doing that kind of thing will take you even more time. But I mean that’s a direction that we could head also in the future.

Richard McClead: It just occurred to me that with the interaction that you want to see happen, my role is Medical Director for Quality. I’m engaged in a lot of quality collaboratives around the country. So we might have 15, 20 hospitals all over the country that are participating in a specific quality improvement project.

53:11

And so, we have webinars that we use, the commercial platforms to… So it is not… There are some videos associated but usually it’s slides the people are presenting. And then, it’s hooked up to your phone lines so that I got an email that says, “At 9:00, we’re going to have a webinar. This is the number and the pass code” and things like that. Do you think that might play a role in creating the interaction that you might want to see with your audience?

Mike Patrick: Yup. And that kind of thing too then kind of get you into a little bit of a different audience in terms of more healthcare professional kind of stuff. So sure, yeah.

Richard McClead: That might work down the road.

Mike Patrick: All right. Well, I really appreciate you stopping by the studio today.

Richard McClead: It’s been fun.

Mike Patrick: I definitely has.

Before you go, there’s one more thing that I have to ask you. All of our guests that come in to PediaCast, we ask the same question. One of my passions – and the audience kind of rolling their eyes right now because they know exactly what I’m going to say. One of my passions is that families spend time together that doesn’t necessarily involve TV screens, video games, computers, just really quality time together. I think in our busy society, there’s less and less of that.

54:22

And in our house, one of the things that we like to do is sit down and play games – so board games and card games. And so every guest that comes by we just ask him, “Hey, what’s your favorite?” I think there’s a lot of folks out there who find new games through doing this. I know there’s been several games that we have played here recently that I have never even heard of but by asking folks I kind of found out about it. And it’s now a new favorite.

So what’s one of your favorite games.

Richard McClead: Well, let me preface things by saying my wife is a gamer.

[Laughter]

She is in the games and gets very upset if I don’t play with her. I guess she will play any games and it doesn’t matter what it is. But I prefer the card games, because there is usually some sort of challenges associated. It’s not so much about winning but the strategy involved in planning a set of cards. You know, something as old as euchre. I’ve never been a poker player but I’m kind of fascinated. I watch poker on TV. There’s Texas Hold Them, I guess, whatever it is called.

55:35

Mike Patrick: Yeah.

Richard McClead: But I think the card games, any of the card games…

Mike Patrick: Yeah, euchre, we love euchre. We thought our kids to play euchre at a young age. So they’re big euchre players and we do play that quite often.

I’m going to answer this question because, you know, since I’m one of the guests. We actually had Dr. Maya Spaeth. She’s a plastic surgeon here at Nationwide Children’s. She came by the studio last summer and talked to us about microsurgery. But she introduced us to Settler of Catan.

Richard McClead: OK.

Mike Patrick: Have you heard of that?

Richard McClead: No, I haven’t.

Mike Patrick: I hadn’t heard of it either and it is really fun. And there’s a ton of strategy involved. It basically is, there’s an island and you’re trying to set up a civilization. You have to get like 10 growth points and you can get those by building roads, by building cities, by having an army, different ways that you can get points.

56:32

And so all the players are trying to build their own civilization on this fairly small island. And you have to barter with one another. So you may need coal but you don’t own any property that has coal on it so you have to barter with other people. It’s really a lot of fun.

So anyway, it’s called Settlers of Catan. We got it for Christmas and we’ve been playing a lot since then.

Richard McClead: Do you play any of the interactive games?

Mike Patrick: I only play much to my chagrin – I probably shouldn’t do this as often as I do – the Words With Friends kind of thing like through Facebook. One of the nurse practitioners I work with introduced me to that and I wish she hadn’t.

Richard McClead: [Laughter]

It’s addictive.

Mike Patrick: It is. And so, right now…

Richard McClead: It’s another one of those Angry Birds.

57:15

Mike Patrick: Yeah, yeah, yeah. Exactly.

So I got games going with my wife and with my kids. And there’s a new one called Picture This, I think. It’s like a Pictionary game but it’s also through Facebook. And so you draw picture and they have to guess what it is. But it’s kind of fun because then, when it’s you’re turn again, it actually draws what you drew in real time and shows you how long it took them to guess. And any move that they made, so if they started to guess something wrong, you’ll see that. Kind of records what their screen is doing. And then they’ll draw something that you have to guess. You hook up to it like you do with Words with Friends.

But again, there’s so many things that want your time, you know what I mean. So I try to stay away from online gaming as much as I can.

Richard McClead: I’ve never been in the online gaming. But my wife would play Words of Friends, or I think it’s one of the word games, with my daughters who were out and about.

58:10

Mike Patrick: Well, my daughter’s going to college in the fall. And my wife in particular already told her, “You know, you have to keep playing Words With Friends when you go away.”

[Laughter]

So I’m not sure if that was a good thing for my daughter or not. But we’ll find out.

All right, well, again, really appreciate you stopping by. And on behalf of Dr. Rick McClead and myself, thanks for joining us for Children’s on Quality and PediaCast for our first ever mashup.

I know it’s been a little different from our regular shows and we hope you enjoyed it. Don’t forget to tell your families and friends, also your healthcare providers, about both of these great shows from Nationwide Children’s.

Remember, it’s easy to get in touch with us again. If you just head over to pediacast.org, we have the contact link there. And for Children’s on Quality, you can go to childrensonquality.com. Or better yet, go to nationwidechildrens.org and click on Safety and Quality. It’s a big tab, you can’t miss up. You can hook up with the Children’s on Quality podcast that way as well.

We’re also available in iTunes. And for PediaCast specifically, if there’s a topic that you want us to talk about, you can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That’s 347-404-K-I-D-S.

59:23

And until next time, this is Dr. Mike along with Dr. McClead saying stay safe, stay healthy and stay involved with your kids. So long everybody.

[Music]

When a person is under anesthesia, he or she loses the ability to regulate body temperature. This means that his or her body temperature mirrors that of the room. If the body cools down so much as to lead to mild hypothermia, this restricts the movement of white blood cells, which are important for fighting off bacteria. If white blood cells can’t travel where they need to, this increases the chance of a surgical site infection.

The staff at Nationwide Children’s has been implementing various interventions to eliminate the occurrence of mild hypothermia. Some of these include warming the operating room before the patient arrives and maintaining it during the procedure, using warming blankets during travel and warming the mattress that patients lie on during the operation.

Listen in as Dr. Tom Taghon, director for Anesthesia Services, and Mike Fetzer, quality service line coordinator for Perioperative Services, talk specifics on how Nationwide Children’s Hospital is combating the cases of mild hypothermia, and how this is improving overall quality of care.

Transcript

[Music]

Rick McClead: Several research studies have demonstrated that various complications developed when surgery patients become cold while in the operating room. Surgical wound infection, increase surgical blood loss, cardiac arrhythmia, and prolonged post-operative hospitalization to name just a few, yet the operating rooms are really cold. What was being done to keep the kids warm while they’re in the operating room. Mild surgical hypothermia, next on Children’s on Quality.

[Music]

Welcome on Children’s on Quality. With me to discuss the problem in surgical hypothermia is Dr. Tom Taghon, Quality Director for Anesthesia Services at Nationwide Children’s Hospital. And Mike Fetzer, Quality Service Line Coordinator for Perioperative Services. Welcome to Children’s on Quality.

Dr. Tom Taghon: Thank you. It’s a pleasure to be here.

Mike Fetzer: Thank you.

01:00

Rick McClead: Dr. Taghon, I’d like to begin with you for our listeners. Please describe what we are talking about when we discuss hypothermia as a complication of surgery?

Tom Taghon: Sure. General anesthetics decrease your ability to maintain body temperatures. So, you essentially become poikilothermic, which is just a term that means you assume the temperature of the environment that you’re in. So, if we don’t take precautions to keep that room warm, and keep our patients warm, they will assume a very cold temperature during the case.

Rick McClead: And what kind of temperature ranges are we talking about?

Tom Taghon: So, we usually -our goal is to keep our patients above 36 degrees, between 36 and 38 degrees Celsius. So, we will take whatever precautions we need to maintain that range.

Rick McClead: Normal body temperature is 37..

Tom Taghon: 37.

Rick McClead: or 98.6. So, a degree or so on each side of that is what we’re looking at for a normal temperature.

Tom Taghon: That’s correct.

Rick McClead: What we’re not talking about is therapeutic hypothermia, correct?

Tom Taghon: You’re correct we are not. In this case is we’re taking advantage of hypothermia for its neuro protective and cardio protective effects.

02:06

And quite often in the cardiac case we have a profusionist there who can regulate the body temperature very precisely, so they can warm those patients up at the end of the case.

Rick McClead: Well, I commented in the intro that the operating rooms are really cold. Why are they so cold?

Tom Taghon: That’s a great question. I think we like to say that perhaps being cold will inhibit bacterial growth. But I think it’s also a function of comfort for the staff, surgeons, and scrub nurses are typically wearing heavy gowns and gets very hot in those lights.

Rick McClead: Well, in the opening I mentioned a few of the complications that describe in the literature that result from mild surgical hypothermia, however most of the literature is based on adult experiences. What do we see in kids? What do we need to be concerned about with our children in the operating room?

Tom Taghon: Well, many of the same things like we’re concerned about surgical site infection for example. We’re concern about thermal discomfort in the recovery room. If you ask adults, if they were to rank their discomfort in the recovery room, they will frequently rate thermal discomfort, or the discomfort from being cold even over their incisional pain.

03:08

So, we don’t want our kids certainly to suffer through that. And as you mentioned there are issues with blood clotting. So, we certainly can’t see the same complications in children, although the risk the data are not as strong.

Rick McClead: Well, one of the complications that’s been noted primarily in the adult literatures is the issue of post-operative shivering due to hypothermia and how that can increase the risk of mal-cardio schema or heart attacks. That’s not I think we need to worry about the kids isn’t it?

Tom Taghon: Typically not, Rick. It’s true that when you shiver you can increase your mild cardio oxygen consumption by sometimes up to 200%. Many of our children do not have coronary heart diseases, so they may not be at the same risk level for that. But there are other complications that we need to prevent.

Rick McClead: Are the kids more likely to have complications from their surgical hypothermia than an adult?

04:02

Tom Taghon: I don’t know if they are more likely. But I think they are certainly at the same risk.

Rick McClead: What kind of factors play into a child becoming hypothermic as far as what characteristics do they have physically that might contribute to them getting cold easily?

Tom Taghon: Well, I think that the biggest thing is, as you know they have a very high surface area to weight ratio which leads them to have a lot of exposed surface area. Because again as I mentioned before, the changes that occur due to the anesthetic, they can’t regulate their body temperature at all.

Rick McClead: Well, Mike Fetzer, before you explain how mild hypothermia came on the quality radar screen, would you share with our listeners a little bit about your background. Because you’re not a clinician, and yet you’re involved in the quality of health care at Nationwide Children’s Hospital. Tell us a little bit about that.

Mike Fetzer: Yeah, that’s true. I have a non-clinical background. Actually I have a degree in Industrial and Systems Engineering. And I worked for several years as a quality manager in a manufacturing setting. But currently I’m working as the Improvement Coordinator in our perioperative are and also in pediatric surgeries.

05:03

And what I do is I facilitate our teams with the use of improvement methodology, so we can move quality improvement projects forward. We work very closely with physicians, nurses, and leaders in those areas to facilitate those teams.

This particular project of -got on the quality radar screen as were looking at surgical site infections, and how we could try to reduce our surgical site infections, specific population. And we saw that there was an opportunity for us to decrease hypothermia in the OR.

Rick McClead: So, there is this relationship between this model hypothermia and possible wound infections developing after surgery in at least some populations of patients.

Tom, can you explain how mild hypothermia could increase the risk of wound infection or surgical site infection?

Tom Taghon: Yeah. It’s an interesting question. That the leading theory is that when you get hypothermic, you actually develop some basal constriction in the subcutaneous tissues.

06:04

And what that does is decrease oxygen delivery to those tissues and that inhibits the function of neutrophils which can kill organisms using oxydated mechanism. So, if you interfere with that mechanism of white blood cells, and neutrophils, you can increase the risk of your infection.

Rick McClead: So, the white cells won’t gobble up the bacteria very well?

Tom Taghon: That’s correct.

Rick McClead: So, we need to set about minimizing this mild hypothermia? Michael, what was your approach to do that?

Mike Fetzer: Well, initially we brought a team together, and we wanted to determine our baseline of hypothermia. Well, in doing so, we found that our ability to measure temperature following surgery was quite variable and it was quite inconsistent.

So, therefore we had to improve our ability to capture an accurate temperature following surgery. So, we did this by introducing new digital thermometers for use in the PAC-U, and this really resolved our issue with variability, and inconsistency as it related to capturing the correct temperature following surgery.

07:06

Rick McClead: The PAC-U is the Post Anesthesia Care Unit, that’s where a patient will go after they’ve been taken out of the operating room to recover from surgery. It’s still a recovery room?

Mike Fetzer: Yes. That is correct. And then once we corrected our gauge error if you will, we were then able to understand our true baseline and really start focusing on reducing hypothermia. We were able then to analyze our data using quality improvement tools such as Pareto diagrams and honing in on the largest portion of hypothermia based on the population of patients that we see in the operating room.

Rick McClead: And what was that?

Mike Fetzer: It was really with the kids that were having orthopedic surgeries. Surprisingly it was a group of teenagers.

Rick McClead: It was the older kid population?

Mike Fetzer: Yes.

Rick McClead: And that surprise me. Why do you think Tom, the older kids seemed to be having more of a problem in this than the babies?

08:06

Tom Taghon: So, we were surprised by that. And we fully expected to see a higher instances in the young children because of that surface area, it’s the body weight ratio that we discussed. But what we suspect is that we were very attuned to the possibility of hypothermia in young infants and children, and it maybe a little lax in our approach to the older children. And I think that was reflected in our data.

Rick McClead: OK. All right. So, you defined the population of patients you really needs to target to get their risk for developing hypothermia during surgery. So, what was your next step?

Mike Fetzer: Well, we then wanted to try some different interventions to see if we could effectively reduce hypothermia. And some of the interventions that we tried, we started with the variation of temperature management bundle. Those included certain devices that are used in the operating room to keep patients warm.

09:00

We also looked at room temperature, we looked at the use of various different blankets throughout the perioperative travel. We considered using warm fluids for specific cases. We also worked with our pre-operative technicians to ask them to change their process, so they could place warming devices in the OR pre-operatively.

Therefore making it easier for the staff in the OR to use those devices. We’ve also considered perioperative warming gowns. So, this were some of the ideas and interventions that we tried.

Rick McClead: All improvement involves change, but not all changes in improvement. So, those various interventions that you listed, which were the ones that you think seemed to make a big difference, Tom?

Tom Taghon: So, I think Max surprisingly we found that warming the room before the patient arrives and maintaining the room at a very warm temperature until the time that the patient is draped was one of the key interventions that helped. And it’s a pretty basic thing, but we were able to show that through our PDSA cycle and show that, that was very effective.

10:09

We also found that the use of the bear hugger routinely which is a force the air warming device we use in the operating room, it’s kind of like a big hair dryer, but the warm air goes into a mattress that the child lays down, or we can place over them as a blanket.

That device was very effective. And then again, warming the room up at the end of the case before we take the drapes off of the patient. And what I think was really needed about this project is those are all simple interventions.

They are all things that we know work, but when we’re able to put them together as bundle and eliminate the variability in our practice, we saw good results.

Rick McClead: That’s interesting though that both of the intervention before warming up the OR and the intervention at the end allowing it to return to those temperatures, that’s all occurring at a time when the staff is not likely to be fully gowned and where they’re going to be uncomfortable.

11:04

Tom Taghon: That’s right.

Rick McClead: Beginning of the case, and they haven’t really gowned up yet, and at the end of the case, they’re taking all the gowns off?

Tom Taghon: Right. That’s a good point and that’s correct. And as we mentioned before one of the reasons the rooms are cool I think is for the comfort of the staff. And so, sometimes when the staff -when they feel particularly warm, we like to point out that if we’re good before the case and at the end of the case we can cool there off in the middle and still keep the patient warm.

Rick McClead: That’s interesting. What do you think the next steps are for this particular project?

Tom Taghon: Well, I think most importantly we’ve made some gains, we’ve decreased our incidents of hypothermia by about half, and we’d like to maintain that.. So, we’re sort of in a maintenance mode there and we really want to hold those gains.

And secondly, we’d like to get to zero percent hypothermia, so we’re trying to identify those children that were still struggling with and seeing if there’s any trends there. And we’d identified a few that we’re going to go after and try to target some interventions to those populations.

12:03

Rick McClead: Do you have thoughts at this point as to why some children are just more difficult to maintain normal thermic during the operating?

Tom Taghon: Certainly. You know, I think there are some children who I think have neurological conditions that probably diminish their ability to maintain their body temperature without anesthesia. So, if we can identify those children perioperatively and start actively warming them before they even come to the operating room, we might be able to make some gains there. And so, that’s one of our trials right now that we are using some gowns that we can actually start actively warming children before they come to the OR.

Rick McClead: Well, we are out of time for this edition of Children’s on Quality. I thank my guest Dr. Tom Taghon, and Mike Fetzer. I also thank my listeners. Children’s on Quality is produces by Kelly Nightingale. Our theme music was composed by Ryan McClead. Next time on Children’s on Quality, we hope to finally bring you our podcast on the luminating arm at Nationwide Children’s Hospital.

13:03

Until then, this is your host, Dr. Rick McClead wishing you the best of good health.

[Music]

For more information and to listen to the rest of Susan Saudaukas’s story, check out our video news release here: http://www.nationwidechildrens.org/news-room-articles/physicians-at-nationwide-childrens-hospital-warn-consumers-of-the-dangers-of-button-batteries?contentid=97339

For tips on preventing button battery injuries, check out this website: www.poison.org/battery/tips.asp.

Transcript

[Music]

Susan Sadalco: I never would have thought that he could have gotten this little case off of this battery and ingest something like that. And they are everywhere

Rick McClead: That was Susan Sadalco who’s son Max ingested a small battery from a remote control device. Each year more than 3500 cases of button battery ingestion’s are reported to the poison control centers.

This harmless appearing nickel size batteries can cause terrible damage and can lead to death of not removed within a few hours of ingestion. The dangers of button batteries next on Children’s On Quality.

[Music]

Rick McClead: Welcome to Children’s on Quality. This is your host Dr. Rick McClead, Medical Director for Quality at Nationwide Children’s Hospital. With me to discuss the problem of button batteries is Dr. Kris Jatana, assistant Professor of Otolaryngology at Ohio State University.

01:05

And then Ears, Nose, Throat Specialist here at Nationwide Children’s Hospital. Kris, welcome to Children’s on Quality.

Kris Jatana: Thank you for the opportunity to be here.

Rick McClead: I’d like to begin by having you describe what it is that we are talking about when we refer to a button battery.

Kris Jatana: So, button batteries are very common today and they were first introduced to the consumer community back in the late 1950s. And since that time they evolved, the batteries if today are much different than the batteries of several decades ago.

And most in the part to improving the technology of them, making them more powerful, more slim, sleek design. They are batteries that typically power watches and calculators, hearing aids, there are musical greeting cards, toys, games, thermometers, and a lot of electronic devices are now powered by this.

02:04

Given that they’re more powerful than they were before, the increase in number of consumer electronic products that were on the market that contains this batteries, this is really a growing problem that we’re seeing with kids either placing this inside their bodies, in their ear canal or nose, or swallowing the batteries.

Rick McClead: You know I had looked back -the first reports of these batteries being a problem would go back in the late 70s. And yet following the literature along, there seem to be some controversy whether this was or wasn’t a problem or not because early batteries are different than the ones today.

They were less powerful, but they also maybe were incorporated mercury, as a component of the battery and that pose some toxic hazards as well. It seems as if the controversy is somewhat abated, this is clearly a problem.

03:00

Kris Jatana: Absolutely. This batteries have been a problem for several years, decades of time on fact. And the mercury containing batteries that you’re referring to are now off the market as an act in the mid 90s that has banned those types of batteries from the consumer products.

But there’s still the concern that number of electronic devices is really rapidly increasing on the consumer market. These are small coin shaped batteries that kids find attractive, they are shiny, kids very commonly will swallow coins. And it’s one of those hazards that parents don’t think about that’s in every home in the country.

Rick McClead: Well, tell me about how these batteries can cause a problem if a child ingest them.

Kris Jatana: Sure.

Rick McClead: How do they work to cause damage?

Kris Jatana: So, the biggest problems with these batteries occurs when the batteries get stuck or lodged in a specific location.

04:02

The electric current that generates around the battery causes an alkaline or hydroxide ion to form at the negative poll of the battery. And so, this creates a very rapid tissue burn, tissue injury.

And if you think about a chemical burn with alkaline materials, this is basically a chemical burn that’s powered with electricity. And so, it occurs very rapidly and even within two hours of the button battery being placed inside the body, that current can cause severe injury.

Rick McClead: Now, this things are pervasive throughout a home, how might I know that a child of mine has actually ingested one of these batteries? What would be the signs and symptoms of an ingestion that a parent should look for?

Kris Jatana: And that really highlights the biggest problem we have with this is it’s hard to make the diagnosis as a parent, it’s hard to make a diagnosis even as a physician seeing a child in the emergency room because the signs and symptoms that go along with the button battery ingestion example being lodged in the esophagus are no different than the symptoms we see with the common cold or viral illness in children.

05:18

So, a lot of them will have fever, will just be more irritable, not eating as much, vomiting, and these symptoms are really hard to distinguish from the common viral illness we see in children.

So, it really presents a challenge for both parents as well as physicians to make this diagnosis. The diagnosis can be made by obtaining both lateral and interior-posterior view x-ray.

And on the x-ray in particular what to look for is on the anterior-posterior view you’ll see a ring or halo sign around the battery which differentiate’s it from a coin. And on the lateral view you’ll usually see a little notch or step off that’s consistent with the battery.

06:04

But the challenge that emergency room physicians, pediatricians, and urgent care physicians, we are seeing these children initially is we can’t get x-rays on every child with these symptoms. And it’s hard to make the diagnosis without getting the x-ray. So, with the rising incidents of consumer products that contain this battery this is really a growing problem that you see in the community.

Rick McClead: So, we really have to have high index of suspicion for that.

Kris Jatana: Absolutely.

Rick McClead: From a parent’s perspective besides the symptoms which there could be no symptoms at all, a finding might be a remote control device that’s been taken apart, bits and pieces laying around, a musical greeting card that has been opened up.

Any of the thoughts about what a parent could look for that might make them suspicious that the child could have consume something like this.

07:00

Kris Jatana: Absolutely. There are a number of children that will be completely symptomatic and the clock is ticking from the moment that battery is placed inside the body. And that’s why this is just such a huge problem for children is it’s hard to make the diagnosis quickly.

Majority of the children that have suffered serious complications or fatal complications from button battery ingestion had a delay in diagnosis. And really prevention is the biggest key that we need to focus on. Certainly if you see any electronic devices that have been disassembled, then you can’t find the battery, that would be concerning, do bring your child to the emergency room for evaluation.

However, prevention is really the key. And I think several steps that can be taken within the household setting would include just going through just like when you child proof your home early in life, or electrical outlets and things like that.

Really go through and look at every battery powered device that you have in your home. And make sure that that battery is kept in a secure location.

08:03

And something that would be considered more secure is for example a screw back compartment where a child would have to take a screw driver to take the battery out of the device. And make sure that there’s no lose battery just laying around on the counter or on the coffee table that are used for these types of devices.

They should be kept in a secure location and treated just like a hazardous chemical in the home. The batteries are really everywhere and something that should be taken into account during that child proofing process.

Rick McClead: On our Children’s on Quality website we have a link to our brochure with tips for parents to prevent button battery injury. This is from the National Poison Control Center. That link is www.poison.org/battery/tips.asp. I wanted to also touch just briefly in looking at the literature about the button battery ingestion.

09:04

There seemed to be some size differentiation, things really became increasingly a problem when they started making the batteries about 20millimiters which is between the size of a dime and a nickel is that correct? Because that’s the size of tins that gets stuck.

Kris Jatana: Sure.

Rick McClead: But I was also surprised to learn that this little tiny hearing aid batteries can be a problem as well. So, grandma and grandpa they’ve got a hearing aid, they’re taking their batteries out weekly or every 10 days or something like that, and replacing them.

A child could pick one of this up or an adult mistaking this for a pill accidentally ingest. Talk to me a little bit about how these very tiny batteries could pose a hazard to both the child and adult?

Kris Jatana: Absolutely. So, the size of the battery really does make a difference. And of the major and fatal outcomes that we’re seeing in children and majority of these batteries have been the 20 millimeter lithium batteries.

10:04

And they’re big enough to get stuck, they’re more powerful than some of the other batteries, and so they can cause very rapid tissue injury. The batteries that don’t tend to cause as much injury are the smaller batteries because they don’t tend to get stuck in the esophagus.

However they can cause serious injury if they’re place into the ear canal or the nasal cavity where they can get stuck in those locations. And in particular with children who commonly place objects in their nose and their ear canals, this can cause serious injury within the nasal cavity. This can cause perforation of their nasal septum.

This can cause infection and cellulitis around the eye. And the ear canal, it can cause hearing lose, it can cause eardrum rupture, it can cause facial nerve paralysis. And this have all been reported in children. As far as the adult population, it is very common given provision to mistaken a battery that is used for the hearing aid device for a pill.

11:07

And that’s one of the most common causes of button battery ingestion in the United States is older adults who accidentally swallow this batteries. Fortunately these batteries were small, they typically will pass through the gastro intestinal system without any complications, and don’t cause a serious injury.

However, grandparents who wear hearing aids who have these batteries around the house definitely poses a risk to grandchildren that come over and could have access to these batteries and particularly placing them in their nasal cavity or ear canal.

Rick McClead: You know, I never thought much about what the significance of the identification code on the batteries represent. But in fact there’s information that’s there that a parent could communicate to the Poison Control Center or to the emergency room physician. Could you explain how those letters and numbers correlate to the problem that we’re concern about?

12:08

Kris Jatana: Absolutely. The first two letters correlate to the type of chemical that the battery contains. The four numbers typically correspond to -the first specifically the two first digits corresponded the diameter of the battery. So, if it says 2023 that means that it’s a 20 millimeter diameter battery, and the 32 actually what refers to the thickness or height of the battery in tens of a millimeter.

So, it’s a little bit confusing the way that they label because the first two digits is using the unit of millimeters and the second two digits were actually tenths of a millimeter. So, 2032 would mean a 20 millimeter diameter battery with a 3.2 millimeter thickness.

Rick McClead: So, a parent who maybe have a number of these batteries around is familiar with what battery is going in to a particular device that a child has ingested.

13:09

If they could find a similar battery and just communicate that number to the emergency room staff when they bring the child in for x-ray, that could be pretty valuable.

Kris Jatana: It’s helpful to know a little bit more information about that and particularly for studies that looked back at the ingestion of these and what children are more commonly swallowing. But really the concern of having battery ingestion no matter what shape of size the battery is, is really an emergency. And so, parents should bring the child to the emergency room immediately if they suspect ingestion of any type of battery.

Rick McClead: Well, solution to the button battery problem would appear to be a product or a package we design. You had mentioned the -a ore secure battery compartment. What are the manufacturers of the batteries and the products that use the batteries doing to make these products or these batteries less accessible to children/

14:07

Kris Jatana: That’s a very good point that you brought up. I think that there are a number of devices out there on the consumer market that are not necessarily marketed for young children. And so, those were the devices that are the highest risk for children that get access to them.

And so, if an older sibling or parent has these devices, these are the devices that are not necessarily regulated like a child’s toy. And I’ve been involved with the national advocacy effort, was involved with presenting to the U.S. Consumer Product Safety Commission this past year on this very topic.

And figuring out ways that we can strengthen the product safety standards for devices that contain these batteries . There’s an act in Congress that still in sub committee review at this moment, that is entitled “The Button Cell Battery Safety Act of 2011″.

15:03

And it was introduced in June of 2011 to the Senate subcommittee and is still in review. There have been no updates as far as where that’s going to go from there once the discussion is completed.

But that basically allows for the consumer product safety commission to have oversight over products that contain these button cell batteries as well as the companies who manufacture the batteries, and making sure that the packaging is adequate. And that warnings are adequate on both the product and the battery when they’re sold in the consumer market.

And these are really measures that I think are really very important because we have a situation where children are otherwise healthy, these are devices that are in every home. And children are really suffering life long consequences from button battery ingestion, it’s not just a one time injury.

16:06

And several of these children have had to require feeding tubes to be placed directly into the stomach for nutrition. Tracheostomy tube placed into the airway passages in order to breath. And the complications that we’re seeing from these batteries are much more significant than 30-40 years ago, and they’re just everywhere.

Rick McClead: Well, that is all the time we have for this edition of Children’s on Quality. I thank my guest Dr. Kris Jatana. And I thank you my listeners. Children’s on Quality is produced by Kelly Nightingale, our theme music ‘Fleeing Moments’ was composed by Ryan McCleod.

Next time on Children’s on Quality, we shall discuss the problem of hypothermia during surgical procedures. Until then, this is your host Dr. Rick McClead, wishing you, the best of good health.

[Music]

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In the fall of 2008, Nationwide Children’s Hospital broke ground on a new 12-floor main hospital that is scheduled for completion in 2012. This new tower will be 750,000 square feet and will be surrounded by six acres of green space featuring parks and healing garden spaces for patients and families. The new building will open with more than 450 patient rooms that are 40 percent bigger and an emergency/trauma center that is twice as big as the current facility. It will also have a new pediatric intensive care, cardiac intensive care and transplant unit. Learn about the new patient care tower on this edition of Children’s on Quality.