2018-19 TOW #5: Water Safety and Drowning Prevention

Summer is a great time to review water safety, especially in Seattle where we have access to so much beautiful open water and sunshine to enjoy it. Safety around water is critical, as drowning is actually a leading cause of injury death for children. Seattle Children’s has partnered with community organizations through programs like Everyone Swims to develop materials and advocate for policy changes to prevent drowning, including contributions from our own residents.

Check out this week’s teaching resources here:

Take-home points for understanding drowning and promoting water safety:

  1. Epidemiology of drowning: Death from drowning is a top 3 cause of injury death in childhood. It is the leading cause of injury death for 1-4 year olds and the 2nd leading cause for 5-14 year olds. Unfortunately, it disproportionately affects minority children. Children can drown in only 1-2 inches of water. Adolescent males have a 10-fold increased risk of drowning compared to females. They have higher risk exposure, more risky behaviors (e.g., swimming alone and at night), and are more likely to drink alcohol in aquatic settings.
  2. Drowning definition: Drowning is no longer defined as death from submersion. The WHO defines it as “a process of experiencing respiratory impairment from submersion/immersion in liquid” and outcomes are classified as death, morbidity, or no morbidity.
  3. Risk reduction: Drowning can be prevented by many strategies including 1) adult supervision within arm’s reach, 2) life jackets, 3) pool fencing that encloses the pool and is at least 4 feet high, 4) swimming at lifeguarded areas, and 5) swimming lessons. The American Academy of Pediatrics (AAP) recommends children begin to learn to swim by age 4. In one study, taking formal swimming lessons was associated with an 88% reduction in drowning risk (Brenner et al. Arch Ped Adol Med 2009).
  4. Drowning prevention: Pediatricians have a role in helping prevent drowning. Screen for swimming ability at age 4-5 and refer to swim lessons (see pool info handouts on Everyone Swims tab on the SCH drowning prevention page). Discuss water safety with families and provide information, including handouts here: http://www.safekids.org/watersafety

2018-19 TOW #4: Sports Participation

Summer is primetime for pre-participation sports physicals. There has been much debate as to what should be included in routine testing and screening. Generally, we follow the AAP guidance for screening, and encourage use of the standardized tool adopted by multiple medical organizations, as below. We have a guideline developed for our UW General Peds division as well. Remember to refer to our wonderful local sports meds experts (like our esteemed APD, Dr. Celeste Quitiquit!) if you have questions.

Teaching materials for this week:

Take-home points for sports physicals:

  1. What are the key history questions we should include in sports physicals? Specific questions about key areas should include personal and family history, especially cardiac, bone and joint, asthma (and inhaler use), concussion or seizures, sickle cell, and infectious histories. Review weight and diet including attempted weight loss or gain, supplements to gain weight/muscle, and hydration and eating patterns. With females, review menstrual history.
  2. What are the components of cardiovascular screening? The American Heart Association recommends a 12-element screening tool that encompasses personal history, family history, and physical exam. This tool is incorporated into the Preparticipation Physical Evaluation, Fourth Edition (PPE-4) recommended by the AAP. A positive response or exam finding on any item should prompt referral to cardiology. A goal is to identify risk for and prevent sudden cardiac death, which happens in about 100 young athletes annually in the US. Unlike in other countries, we have not adopted routine ECG due to cost and number needed to screen.
  3. What are the critical parts of the exam? Vision, BP, thorough cardiac exam (murmurs-do valsalva, pulses, Marfan stigmata), musculoskeletal exam (strength, ROM, functional/sport-specific movements), neurologic exam (especially if previous concussion), and skin exam to look for infectious lesions.
  4. What are contraindications to full participation? These include
  • some cardiac diseases (discuss with cardiology)
  • Atlanto-axial instability (especially in Down syndrome or JIA)
  • Infectious diarrhea, conjunctivitis, or actively contagious skin lesions (e.g., HSV, MRSA)
  • Fever–increased risk of heat related illness and hypotension
  • Acute splenic enlargement-increased risk of rupture
  • Poorly controlled seizure disorder-especially for swimming, weight-lifting, sports involving heights
  • Hypertension–if> 5mm Hg above 99th percentile for age, avoid heavy lifting & high-static component sports

2018-19 TOW #3: Well child care/ health supervision

The beginning of the academic year is a great time to review our central tenets in providing effective well child care (WCC). WCC can be very rewarding as a pediatrician, especially if you have the right tools and knowledge. We all recognize that providing comprehensive WCC is difficult in a 15-20 minute visit, so we have to prioritize. We are also being called upon to consider new models of care to truly impact social determinants of health and chronic diseases over the lifetime, as one of our own amazing gen peds faculty, Dr. Tumaini Coker, discusses below and is actively researching.

Materials for this week:

Take-home points for this week:

  1. Why well child care? Through WCC visits, we have a unique opportunity to identify and address important social, developmental, behavioral, and health issues that can have significant and long-lasting effects on children’s lives into adulthood. Pediatricians provide the vast majority of WCC to children in the US, which differs from other countries’ health systems where general practitioners or nurses provide it. As society changes, one of our current pediatric challenges is to adapt WCC to better address issues that most impact adult health including poverty, low education, environmental exposures, and ACEs (Adverse Childhood Experiences). Newer models of care including the medical home with integrated care, group visits, home visitation programs, and health navigators are all being utilized and studied to improve WCC.
  2. What ages do we recommend WCC visits and why? We have >20 visits recommended with children between ages 0-18. Currently there are 6 visits recommended between birth to age 1 (newborn, 2-4 weeks, and 2, 4, 6 and 9 months). Visits are spaced out over the next 2 years (15, 18, 24, 30 months) and then annually after age 3. The timing for these has been largely influenced by providing vaccines, which is the most evidence-based prevention strategy we use in pediatrics; and by Bright Futures, developed by the maternal and child health bureau in the 1990s to standardize recommendations and care.
  3. How do we prioritize topics for WCC? For each recommended well child check from newborn to age 21, Bright Futures includes guidelines for screening and a “menu” of 5 possible anticipatory guidance topics. Even with these pared down, there’s a lot to cover, so we often still have to do more focusing. There’s some data that parents can only retain up to 3-4 recommendations from a visit. It’s also not just what we say, but how we say it that matters. To support parents feeling engaged and supported, we can use the tools of Promoting First Relationships in primary care. We can show we welcome parents’ concerns and acknowledge their needs and efforts. Through specific positive feedback, we can highlight what we see them doing well to engage in responsive parenting, recognize their child’s needs, and to find joy in interacting with their child.
  4. What’s the evidence for effective components of anticipatory guidance? Unfortunately, the studies are difficult to do and the data is limited. Because of this, the US Preventive Services Task Force often gives a Category 1 (Insufficient Evidence to Evaluate) rating to pediatric screenings, such as for lead, and cannot say whether outcomes are improved because of the intervention. There are several pediatric preventive health interventions with good supporting evidence including Reach Out and Read, promotion of breastfeeding, the “back to sleep” campaign, and avoidance of physical discipline.
  5. In the limited time we have, what’s most important to cover? Most important is that we address parents’ concerns and set an agenda with them. While I confess I don’t love or routinely remember mnemonics, “CHECUP” is a good list for basics to review that is more or less mapped to the order of topics in the visit, starting with parent concerns.
  • C – Concerns (or questions)
  • H – History (interval hx, past medical, birth, family, social)
  • E – Environment (home, typical day, nutrition, sleep)
  • C – Child (development, growth, voiding)
  • U – Unanswered questions (inquire about further concerns)
  • P – Prioritized anticipatory guidance

2018-19 TOW #2: Coding and Billing

Billing is such an exciting topic (said no one ever!), but it is a fact of life in our health care system, and oh so necessary to understand. Our Roosevelt crew has talked about the need to review this topic, so by semi-popular demand, here it is!

Materials for this week:

Key points:

  1. Why do we need to learn billing and coding? We will probably all be using E/M coding (Evaluation and Management) for the rest of our careers. Incorrect billing is considered fraud, and we have to be aware of the laws in order to do it accurately. UW faculty are required to update our billing compliance training annually to document we understand and are doing it appropriately. Best to learn it and do it right from the get-go.
  2. What are CPT codes? Current Procedural Terminology (CPT) codes or “procedure codes,” are published by the AMA to cover the services and procedures clinicians perform. They capture the human resources (time and cognitive effort) used to provide care and serve as the foundation for reimbursements. For office visits, two general features decide the type of code selected: 1) new vs. established patient, and 2) problem-oriented vs. preventive visit. There are also codes for immunizations and other common office procedures, (e.g., wart treatment, dental screening and fluoride varnish, etc).
  3. What is ICD-10? These are the “Diagnosis codes.” ICD-10 stands for International Classification of Diseases, Tenth Revision, Clinical Modification. The ICD was originally developed as a statistical tool for tracking diseases and trends worldwide. ICD-9 was published in 1978 by the World Health Organization, and used in the US for decades. ICD-10, developed in 1993, uses more codes to increase specificity and was adopted in most of the world before the US implemented it October 2015. We are supposed to be as specific as we can with ICD-10 and to use diagnoses rather than symptoms as often as possible (e.g., “strep pharyngitis” is preferred to “sore throat”).
  4. Do we ever combine preventive and problem-focused codes? Yes, BOTH can be coded when two or more types of E/M services are provided in the same visit. This requires use of a “modifier” – we use “Modifier 25” in primary care. When we see patients for well visits and also address their asthma or treat an ear infection, for example, we can use the CPT codes for “Preventive care, established patient and also add 99212- 99215 (as appropriate). We would include ICD-10-CM codes for both “well child” and the acute condition. Note: some offices have contracted not to use these modifiers because extra charges are incurred for patients; ask your clinic leadership when this is appropriate to use.
  5. What are the main CPT codes for problem-oriented visits? These are 99212-99215 depending on complexity and/or time. 99212 is ~10 minutes, very minor (rarely used), 99213 is ~15 minute visit and is our straightforward acute visit. The 99214 code is for ~25 minutes with more complexity (including prescriptions, referrals, medical decision making, etc.), and 99215 is ~40 minutes for complex visits (residents rarely bill this unless the faculty member has taken substantial time with the patient). Each of these comes with requirements for documentation, thus our EMR templates include appropriate documentation prompts such as for ROS.
  6. When is a patient “new”? This can be confusing. Technically, patients are new to us if our clinical system has not previously seen them for at least 3 years. A baby born in the nursery at UWMC will NOT be new to a clinic if they come to a UWMC-affiliated clinic (like Roosevelt and Harborview,) but they will be new to us if they were born at Northwest Hospital, which has a separate tax ID (ask your clinic manager if you are unsure). If a patient has not been to clinic in 3 years, they would be considered a new patient when we see them.
  7. Why do we need the billing modifier for faculty? This is explained in more detail here but basically, faculty have to attest to providing care with a resident by adding a “GC modifier” or a “GE modifier.” GC indicates teaching physician presence: “This service has been performed in part by a resident under the direction of a teaching physician.” GE indicates that the primary care exemption rule has been used to allow residents to see patients independently in primary care. This can be used for well visits and for acute visits up to a “level 3” (the 99213 code), but cannot be used for level 4 (99214) – faculty must see these patients. All interns must have attendings see their patients for the first 6 months of training.