U.S. News &World Report. best children’s hospitalsby and ranked amongthenation’s Pittsburgh School ofMedicine Affiliated withtheUniversity of Fall 2019 •  •  •  •  •  In This Issue •  •  •  Podcast Series Pediatrics” Research Faculty Member Elastography Hydronephrosis andUltrasound Pediatric Urology CAUTI Rate Reductions and Pyeloplasty Division ExpandsWith New New Research Study: About theDivisionof A Focused Approach to New Research onPOCUS Division Publications UPMC Children’s “That’s UPMC Physician Resources Pediatric Insights

and follow-up ultrasounds postsurgery. patients have allhadthree to four clinicvisits a priorpyeloplasty for anUPJO. This seriesof small caseseriesof57 patients whohave had The current research project isexamining a the hospitalandclinic. amount oftimepatients needto spendin as opposedto radiology cancutdown onthe Performing theultrasound scansintheclinic satisfaction ishigh,” says Dr. Villanueva. in theradiology department, andthat patient safety oftheimagingissimilarto thosedone imaging isefficient and cost-effective, that “Our goal isto see ifourfollow-up ultrasound the radiology department. similar ultrasound procedures performed in for follow-upto diagnostics incomparison investigating theefficacy andsafety of POCUS M. Cannon, MD, divisionchief, have been Villanueva, MD, alongwithhismentor Glenn Second-year pediatric urology fellow Jeffrey pelvic junction obstruction (UPJO) anomalies. of pyeloplasty for thetreatment ofuretero­ of POCUSinrelation to follow-up care for cases One suchproject isaninvestigation oftheuse being usedfor ongoingresearch projects. in theprogram andhasanextensive patient data history onitsusethat is Division ofPediatric Urology isoneofthe14subspecialtiestakingpart the hospital-wide POCUSprogram encompasses 14subspecialties.The of-care ultrasound (POCUS) programs intheUnited States. Begunin2015, UPMC Children’s HospitalofPittsburgh hasoneofthemost extensive point- and Pyeloplasty New Research onPOCUS An Update From theDivisionofPediatric Urology

neurogenic bladder. surgical management ofchildren with procedures, aswell asthemedicaland special interest in minimallyinvasive fellowship training. Dr. Villanueva hasa before arrivingat UPMCChildren’s for his Medstar Georgetown University Hospital completed hisurology residency at the Massachusetts MedicalSchool,Dr. Villanueva Pittsburgh. A graduate oftheUniversity of instructor at theUPMCChildren’s Hospitalof pediatric urology fellow andjuniorclinical Jeffrey Villanueva, MD More AboutDr. Villanueva benefits,” says Dr. Villanueva. safety findingsandany patient-centered for apeer-review publication describingour annual meeting, andthenultimately submitted the next AmericanUrological Association written upandsubmitted asanabstract to “We expect to have ourpreliminary results , isasecond-year Continued on Page 5

2 Pediatric Insights: Pediatric Urology Fall 2019

A Focused Approach to CAUTI Rate Reductions

Urinary tract infections (UTIs) are one of the most common types of hospital-acquired infections. Upwards of 75 to 80 percent of all hospital-acquired UTIs are a direct result of Foley catheter use. Catheter-associated urinary tract infections (CAUTI) can lead to increases in morbidity, length-of-stay, treatment costs, and other complications.

Over the last three years, a multidisciplinary was an outside assessment by the hospital’s “While the order for a Foley is always going team at UPMC Children’s Hospital of Pittsburgh catheter provider that looked at various to be physician-driven, we assessed the has developed and implemented a focused practices and procedures to help identify ability for our hospital to implement a nurse- approach to CAUTI rate reductions. Since the areas that could be targeted for some driven removal protocol and determined that program’s inception, CAUTI rates at UPMC intervention or process improvement. with the proper training and education, it Children’s have been reduced by more than would be a viable option. Assuming the “The assessment was very enlightening. It 50 percent through a number of initiatives. patient meets all the criteria of the protocol, showed us two big areas that we needed to Furthermore, the total number of Foley the nursing staff can discontinue catheter use address. The first was that our Foley catheter catheter days across the hospital has been without the need for direct permission from practices and steps in place at the time lacked cut by nearly 66 percent during the same the physician,” says Ms. Montoya. adherence. The second was that we realized three-year period. we were using older catheter technologies Changing the Maintenance Bundle “These successes across and that we could upgrade to a newer, closed and Audit the hospital and its system that would help cut down on infection various care units are rates,” says Ms. Montoya. Ms. Montoya indicates that one of the initiatives a direct result of the in the ongoing CAUTI fight launched in 2018 Later in 2017, new training was implemented collaborative effort we may have had the most significant impact at the same time a change was made to a developed between on CAUTI rates to date: changing the closed Foley system, and it was timed such nursing leadership, maintenance bundle and audits for Foley use. that it coincided with more robust annual pediatric urology, patient competencies for nursing staff. “We went from a three-point checklist to quality and safety, and specifically our one that now incorporates 11 specific points partners in the intensive care units where the “Closed systems are safer for patients since in the maintenance of Foley catheters. necessity of Foley catheter use is particularly there is much less manipulation to the The expanded checks include steps and high,” says Glenn M. Cannon, MD, chief of the catheter system once it’s been sterilely procedures such as documenting cleaning, Division of Pediatric Urology. inserted,” says Ms. Montoya. notes about why the catheter was in place, making sure it was necessary every day, and A New Committee and Outside Rewriting the Book on Catheter Policy other areas,” says Ms. Montoya. Assessment Lead the Way to Reform Coinciding with these initial first changes, Bag and line placement, such as their being Catheter Practices Foley catheter policy for the hospital was off of the floor, lines secured to the patient In 2017, Lindsay largely rewritten and expanded in a more for safety and comfort, intact seal present are Montoya, MPH, CIC, step-wise, instructional manner. While this some of the other aspects of the daily Foley a senior infection control was done at the same time as the change to audit now in place at UPMC Children’s. preventionist in the the new technology, other changes were Quality Services made to the electronic medical record to One impact over and above the reduction of Department at UPMC facilitate charting for nursing staff so they CAUTI rates of these initiatives has been a Children’s, worked to could more easily find and notate the daily reduction in the total number of Foley days reconstitute a committee care and even daily necessity for the catheter. across the hospital. It makes sense to assume to tackle CAUTI rates across the hospital. This latter point speaks to what was put One of the first steps in the process after in place to end Foley catheter use when it reforming the multidisciplinary committee is no longer necessary: a nurse-driven Continued on Page 6 removal protocol. UPMCPhysicianResources.com/Pediatrics 3

About the Division of Pediatric Urology

The Division of Pediatric Urology offers diagnostic evaluation and surgical treatment for children with genitourinary disorders, including ureteropelvic junction obstructions, vesicoureteral reflux, hydronephrosis, and other conditions. The Division supports robust clinical and research programs, as well as offering an accredited two-year fellowship program featuring an active basic science research laboratory experience.

Our Division is a national leader in providing UPMC Children’s Hospital of Pittsburgh is minimally invasive urologic surgical options one of the few pediatric hospitals offering Faculty and Staff for an array of urological conditions. Recon­ a multidisciplinary DSD clinic. Our multi­ Glenn M. Cannon, MD, Division Chief structive and extirpative techniques can be disciplinary Spina Bifida Clinic currently and Associate Professor of Urology accomplished laparoscopically, robotically, and follows more than 400 patients and offers endoscopically. Common conditions treated state-of-the-art reconstructive urologic Francis X. Schneck, MD, Clinical Director by these modalities include UPJO, duplication surgery and ongoing care. and Associate Professor of Urology abnormalities, reflux disease, and complex The UTI Center at UPMC Children’s takes a Rajeev Chaudhry, MD, Assistant stone disease. multidisciplinary approach to addressing and Professor of Urology Along with our nephrology and nutrition investigating pediatric urinary tract infections Janelle Fox, MD, FACS, CSSGB, colleagues, we are one of the few pediatric (UTIs). This creates a unique setting for Assistant Professor of Urology urology divisions in the country that offers a providing the highest level of clinical care and multidisciplinary approach to the treatment research. A resource for families and clinical Katharine Carter, PA-C of pediatric stone disease. partners, the Center focuses on UTI and the Dana Casciato, CRNP related conditions of vesicoureteral reflux and Disorders of sex development (DSD), formerly bladder and bowel dysfunction. With more Susan Kasubick-Tillman, PA-C termed “intersex conditions,” often require than two decades of experience caring for complex surgical reconstruction in addition to Kathleen Perich, CRNP children with UTI, our nationally recognized input from endocrinologists and psychiatrists. researchers have changed common practices for treating UTI, improving the lives of children in the process. 4 Pediatric Insights: Pediatric Urology Fall 2019

New Research Study: Hydronephrosis and Ultrasound Elastography

UPMC Children’s Hospital of Pittsburgh Division of Pediatric Urology faculty member Rajeev Chaudhry, MD, has received Department of Urology funding to begin a new study using ultrasound elastography (UE) in patients with hydronephrosis caused by a ureteropelvic junction obstruction.

Hydronephrosis is the Dr. Chaudhry’s pilot study The MAG 3 Lasix renal scan provides essentially buildup of urine in the of hydronephrosis using two pieces of information to clinicians. The kidney that can be caused UE was conceived over first is that it can determine if a kidney is by a blockage (e.g., the last several years in obstructed by tracking the time it takes for kidney stone, tumor) collaboration with Judy the radiotracer to be excreted by the kidney. or congenital defect, Hereford Squires, MD, The second piece of information that the scan usually at the ureteral director of Pediatric can reveal is a measurement of renal function pelvic junction, that Ultrasound Imaging and in the obstructed kidney relative to the does not allow urine to flow properly into assistant director of Radiology Residency unobstructed kidney. The combination of the bladder and subsequently exit the body. Programs in the Department of Radiology at these two readings can lead to a diagnosis Hydronephrosis in the setting of obstruction UPMC Children’s. The pilot study began enrolling of an obstruction for which surgical can occur uni- or bilaterally, and if not patients in fall 2019; 10 to 15 patients are the intervention may be required. diagnosed and treated accordingly can target goal for enrollment in the pilot study. However, MAG 3 Lasix renal scans are not cause varying degrees of permanent renal as accurate in children (under the age of 2) dysfunction. At UPMC Children’s, pyeloplasty Study Aims and Design and neonates, specifically in those under the is the corrective surgical approach to most At its root, Dr. Chaudhry’s study is designed age of 3 months. Therefore, is there another cases of ureteropelvic junction obstruction. to see if UE can be a sensitive and specific imaging modality that can improve upon The procedure can be done in an open (and noninvasive) imaging modality for the accuracy of diagnosis for these young manner, or through a minimally invasive diagnosing and monitoring hydronephrosis, patients, and do so in a less invasive manner? robotic-assisted surgery (pyeloplasty is one particularly in very young children who are One that can be performed routinely in the of the top uses of robotic-assisted urologic under the age of 2. clinic or the radiology lab? surgery at UPMC Children’s). “Hydronephrosis, blockages, and kidney The study is designed to compare the UE is a relatively modern advance in the function can sometimes be difficult to assess, effectiveness of UE versus MAG 3 scans, with field of ultrasound imaging, one that allows and even more so in the very young, primarily each patient receiving two to three sequential for the noninvasive measurement of organ or due to their still-developing kidneys. The UE scans while they are being monitored for vessel elasticity to aid in the diagnosis and standard that we have now is the mercapto­ obstruction and hydronephrosis in addition assessment of disease states. Conversely, acetyltriglycine-3 (MAG 3) Lasix renal scan, to a MAG 3 scan. the imaging technology can detect levels of which is a nuclear medicine study. While we “We will compare the two studies to see if fibrosis in organs such as the liver or kidneys can determine several pieces of information UE correlates with the MAG 3 findings over and lesions in the breast, and it can aid from this study, it requires an IV, is time time and whether it helps us predict the prostate biopsies, among other uses. consuming, expensive, and requires small progression and time to pyeloplasty,” says doses of radiation. It is not a diagnostic Dr. Chaudhry. “Diagnosing some of these procedure that you can or would want to do obstructions and cases of hydronephrosis can every three months in an infant if you are be tricky. We do not want to do surgery if it monitoring a patient’s renal and urine is not warranted, particularly on very young function to determine if surgery is needed, neonates, if it appears as though their and identify when to avoid permanent loss function is not impaired or is improving. in kidney function,” says Dr. Chaudhry.

Continued on Page 6 UPMCPhysicianResources.com/Pediatrics 5

Division Expands With New Faculty Member

In September, the Division of Pediatric Urology at UPMC Children’s Hospital of Pittsburgh welcomed its newest faculty member, Janelle Fox, MD, FACS, CSSGB. Dr. Fox comes to UPMC Children’s after serving for six years as a pediatric urologist in the United States Navy, where she treated patients at the Naval Medical Center Portsmouth (Portsmouth, Virginia), Naval Medical Center Camp LeJeune (Jacksonville, North Carolina), and Joint Base Langley-Eustis (Newport News, Virginia). During her military practice, Dr. Fox was Assistant Department Head, Chair of Robotic Surgery, and Chair of the Performance Improvement Committee.

Dr. Fox earned her Clinical, Education, and Research Interests Clinically, Dr. Fox has particular expertise in medical degree from the diagnosing and treating refractory voiding Dr. Fox has diverse interests and long-term University of California dysfunction with concurrent behavioral plans now that she has arrived at UPMC San Diego and then diagnoses. She also brings with her the ability Children’s. Academic and resident mentorship completed her residency to offer tertiary therapy in the forms of Botox, is high on the list of priorities, specifically at the Mayo Clinic in parasacral TENS, percutaneous tibial nerve helping Urology trainees with research Rochester, Minnesota, stimulation, and sacral neuromodulation. opportunities, authorship, and opportunities to followed by fellowship present at national and regional conferences. Dr. Fox also has volunteered her expertise training at UPMC Children’s. Dr. Fox also is Dr. Fox also hopes to participate in ongoing and time to teach fellow urology colleagues completing a master’s degree in Healthcare point-of-care ultrasound (POCUS) comparative in other countries. In the past, she has Quality and Safety Management from effectiveness research from what is one of the volunteered for 12 humanitarian training Thomas Jefferson University in Philadelphia, largest pediatric urology series in the nation. missions to Senegal, Ghana, Liberia, Pennsylvania. In addition to her medical Dominican Republic, and Trinidad. She and health care training, Dr. Fox is a Six Quality improvement is another major area of will continue these efforts in the future as Sigma Green Belt with plans to pursue interest for Dr. Fox, and she hopes to take a part of the UPMC Children’s team. Six Sigma Black Belt certification while part in both division-level and system-wide working on quality improvement projects quality improvement and patient safety “While these trips are about helping those in with UPMC Children’s and the Division of efforts where she can leverage her expertise need, they also are about partnership to help Pediatric of Urology. and training in quality improvement to further our colleagues build their international improve surgical outcomes, safety, and quality. programs by sharing knowledge, research, “Having trained at UPMC Children’s for my and contemporary surgical techniques. The fellowship, I knew the system well and had Additionally, Dr. Fox will be involved in goal of surgical humanitarian missions should very positive learning experiences during my developing telemedicine initiatives for the be in supporting our colleagues and distant two years in fellowship. The mentorship that Division in hopes of enhancing access to and programs, such that our efforts will no longer I experienced with Division faculty here at experience of care for patients in distant be needed someday. It is challenging work, UPMC Children’s, and more broadly in the locations who require subspecialty pediatric but one that has so many benefits both adult urology program led by Dr. Joel Nelson, urologic care. She has prior experience personally and professionally,” she says. was so beneficial to my early career,” with both asynchronous and synchronous says Dr. Fox. telehealth consultation in the military.

POCUS and Pyeloplasty Continued from Page 1

More About the POCUS Program at UPMC Children’s is currently led by emergency medicine physician and Point-of-Care Ultrasound Medical Director Jennifer Marin, MD, MSc. Point-of-care ultrasound (POCUS) is a focused ultrasound exam performed directly at the bedside by clinicians. POCUS exams improve The goal of the POCUS program is to improve patient care across the accuracy, quality, and efficiency of clinical care by bringing the a mix of diverse clinical specialties by standardizing the performance diagnostic imaging modality directly to the patient. of point-of-care diagnostic and procedural ultrasound for many conditions and care scenarios. The hospital-wide POCUS program at UPMC Children’s Hospital is one of only a handful in existence in the United States. The program 6 Pediatric Insights: Pediatric Urology Fall 2019

CAUTI Rate Reductions Continued from Page 2

that the fewer days catheters are placed, the critical issue for the entire hospital. I think One such project in the planning phases, lower the likelihood of infection occurring. their level of involvement and support got according to Dr. Cannon and Ms. Montoya, While the CAUTI team does not have specific people’s attention and created a desire to be is a urine testing protocol — not just for Foley benchmarks for a reduction of Foley days, successful,” says Ms. Montoya. catheter patients but for any specimens Dr. Cannon explains that in 2017, there were collected across the hospital. A new reflex more than 6,000 days across the hospital. In On the Horizon test is being assessed for use where urine

2018, that number was down to around 3,500. While the initial steps in reducing CAUTI analysis is done first, and cultures are subsequently done only if analysis shows “Along with everything we have been able to rates at UPMC Children’s have been quite signs of infection through white blood cells accomplish, I do not think we would have been successful, there is still more that can and will or other inflammatory markers. This process as successful in our efforts so far without be done to lower incidence even further, will help to eliminate testing and obtaining the full support and confidence of hospital improve patient care and safety, and drive false-positive cultures on what could likely be leadership, who made it known this was a costs out of the system. asymptomatic colonization of the urine.

UPMC Physician Resources

For the latest news, events, videos, and free CME courses Video Rounds presented by UPMC clinicians and researchers, visit Video Rounds is a series of short, informative, and educational videos created for physicians and covering a variety of medical and surgical UPMCPhysicianResources.com/Pediatrics. disciplines. Current topics in urology include:

CME Courses • OncoFertility Program with Glenn M. Cannon, MD Kidney Transplantation in the Pediatric Patient • Robotics in Pediatric Urologic Surgery with Glenn M. Cannon, MD Presented by Armando Ganoza, MD

Hydronephrosis and Ultrasound Elastography Continued from Page 4

However, we also do not want to wait too long patients are so young, any permanent kidney UPMC Children’s. Dr. Chaudhry earned his and risk permanent renal injury if surgery is damage sustained may be a life-long issue medical degree from the Warren Alpert warranted. With the ultrasound, we can take with potentially life-altering consequences. Medical School of Brown University. Dr. readings virtually anytime the patient is in the Having a noninvasive, cost-effective, Chaudhry completed a residency in urology clinic — monthly, for example — and very repeatable monitoring framework and and a urology research fellowship at Duke closely monitor their status.” algorithm in place should UE ultimately prove University Medical Center in Durham, North efficacious would be a practice-changing Carolina. He then completed a fellowship in Time will tell if UE is a viable monitoring development for pediatric urologists. pediatric urology at UPMC Children’s prior methodology for these hydronephrosis to joining the Division as a faculty member. patients; if the pilot results are promising, More About Dr. Chaudhry Dr. Chaudhry’s research interests include the Dr. Chaudhry and his collaborators will seek application of bioengineering and robotics in to expand their study into a larger trial with Rajeev Chaudhry, MD, is an assistant surgery, disorders of sexual differentiation, more power to show efficacy. professor of urology in the Department of Urology at the University of Pittsburgh and neurogenic bladder. His clinical interests Avoiding renal injury in these cases takes on School of Medicine and a pediatric urologist include pediatric robotic surgery and complex special significance. Because many of these in the Division of Pediatric Urology at reconstruction in patients with spina bifida. UPMCPhysicianResources.com/Pediatrics 7

UPMC Children’s “That’s Pediatrics” Research Podcast Series

UPMC Children’s Hospital of Pittsburgh medical podcast series for physicians, scientists, and other health care professionals features compelling interviews with the hospital’s leading researchers and clinicians discussing innovative basic, translational, and clinical research. New episodes are released every two weeks.

“Going back to the polio In addition to Dr. Williams, “That’s Pediatrics” Current episodes of “That’s Pediatrics” in vaccine, Pittsburgh has hosts are: urology and related topics include: always been a hub of Carolyn Coyne, PhD, director of the • Falling in Love With the Bladder with very innovative research, Center for Microbial Pathogenesis, UPMC Carlton Bates, MD and in recent years has Children’s Hospital really become a nexus Stephanie Dewar, MD, director of Pediatric for some groundbreaking Subscribe to “That’s Pediatrics” in iTunes Residency Training Program, UPMC research in pediatric or Google Play Music to have new episodes Children’s Hospital medicine,” says automatically download to your phone for John Williams, MD, chief of the Division Brian Martin, DMD, vice president, Medical free when they become available. To see of Pediatric Infectious Diseases at UPMC Affairs, UPMC Children’s Hospital the current list of archived podcasts, visit Children’s and one of the podcast hosts. CHP.edu/health-care-professionals/podcast. “There is a spirit of collaboration here in Pittsburgh that makes it somewhat unique nationally and we really want to explore the research that is happening here and how we have a real opportunity to change the way pediatric medicine is practiced around the world.”

Division Publications

Valli-Pulaski H, Peters KA, Gassei K, Hugar LA, Chaudhry R, Fuller TW, Cannon GM, Berklite L, Witchel SF, Yatsenko SA, Steimer SR, Sukhwani M, Hermann BP, Schneck FX, Ost MC, Stephany HA. Urologic Schneck FX, Reyes-Múgica M. Early Bilateral Dwomor L, David S, Fayomi AP, Munyoki SK, Phenotype and Patterns of Care in Patients Gonadoblastoma Associated With 45,X/46,XY Chu T, Chaudhry R, Cannon GM, Fox PJ, Jaffe With Megacystis Microcolon Intestinal Mosaicism: The Spectrum of Undifferentiated TM, Sanfilippo JS, Menke MN, Lunenfeld E, Hypoperistalsis Syndrome Presenting to a Gonadal Tissue and Gonadoblastoma in the Abofoul-Azab M, Sender LS, Messina J, Major Pediatric Transplantation Center. First Months of Life. Pediatr Dev Pathol. 2019 Klimpel LM, Gosiengfiao Y, Rowell EE, Hsieh Urology. 2018 Sep; 119: 127-132. Jul-Aug; 22(4): 380-385. MH, Granberg CF, Reddy PP, Sandlow JI, Villanueva J, Killian M, Chaudhry R. Robotic Baker BH, Fox JA, Womble PR, Stromberg IH, Huleihel M, Orwig KE. Testicular Tissue Urologic Surgery in the Infant: a Review. Grossgold ET, Walters RC. Optimizing Opioid Cryopreservation: 8 Years of Experience From Curr Urol Rep. 2019 May 18; 20(7): 35. Pain Medication Use After Vasectomy. A a Coordinated Network of Academic Centers. Prospective Study. Urology. 2019 Nov 25. pii: Hum Reprod. 2019 Jun 4; 34(6): 966-977. Mohapatra A, Chaudhry R, Picarsic J, Schneck S0090-4295(19)31030-1. Epub ahead of print. FX. A Rare Case of Uterine Torsion With Jimbo M, Granberg CF, Osumah TS, Bandari J, Juvenile Granulosa Cell Tumor in the Pediatric Smart VA, Roger EI, Ricca RL, Spitzer TL, Fox JA. Cannon GM, Routh JC, Gargollo PC. Discrep­ Patient. Urology. 2019 Jun; 128: 87-89. Fibroepithelial Vaginal Polyps in a Newborn ancies in Self-Reported and Actual Conflicts Female. Urology. 2019 Oct; 132: 161-163. of Interest for Robotic Pediatric Urological Surgery. J Urol. 2019 Feb; 201(2): 393-399. 4401 Penn Ave. Pittsburgh, PA 15224

About UPMC Children’s Hospital of Pittsburgh Regionally, nationally, and globally, UPMC Children’s Hospital of Pittsburgh is a leader in the treatment of childhood conditions and diseases, a pioneer in the development of new and improved therapies, and a top educator of the next generation of pediatricians and pediatric subspecialists. With generous community support, UPMC Children’s Hospital has fulfilled this mission since its founding in 1890. UPMC Children’s is recognized consistently for its clinical, research, educational, and advocacy-related accomplishments, including ranking 15th among children’s hospitals and schools of medicine in funding for pediatric research provided by the National Institutes of Health (FY2018) and ranking on U.S. News & World Report’s Honor Roll of America’s Best Children’s Hospitals (2019–20).

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