Brain Center

In the department of Department of Neurology, one of our quality goals is to make access to care easier for you and your child.

• NOW service:  When your child’s primary care physician recommends that your child see a neurologist very soon, we can arrange to have your child evaluated by one of our Neurologists or Nurse Practitioners within 24-48 hours.
• We have Neurologists serving the suburbs around Boston. The services offered in our satellites include our Headache Program, Sleep Studies, EEGs, Behavioral Neurology, Epilepsy and General Neurology Services.
• We offer interpreter services for all visits.
• Coordinated Care is available for patients with diagnoses that require a spectrum of specialty care including care in our Brain Injury Center, Neuromuscular Center, Learning Disabilities Program and Neonatal Neurology Clinic.

We want to listen to your concerns, teach and empower you in caring for your child and create a partnership between you and your neurologist.

• We are working to improve our teaching materials for patients and their families admitted to the neurology department.  Not only will you understand your child’s condition and how to care for your child once you are home, but with our “Ticket Home” you will understand what things need to happen during the hospitalization to ensure a safe discharge. Your questions will be encouraged at every step in the process.
• Communication with your care provider will become easier over the next 1-2 years with the introduction of an innovative web based tool that will allow you to complete forms online including medication lists, medical history and other documents required for your visit.  You will be able to submit updates to your physician on a regular basis and/or prior to each appointment.

We are committed to creating a safe environment.

• We continuously monitor any and all safety events that could potentially occur both in our inpatient and outpatient settings.
• Our physicians and nurses meet monthly to discuss safety and quality concerns that may arise.

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The Department of Neurosurgery at Boston Children's Hospital provides highly integrated care for children with diseases and malformations of the brain, spine and nervous system. Neurological disorders often have broad-reaching effects.

At Children's, we aim to understand and treat all elements of a child's condition.The department also maintains the highest expectations for the quality of care we provide to our patients. The department has a faculty of 6 full time board-certified neurosurgeons (ABNS - American Board of Neurological Surgeons and ABPNS – American Board of Pediatric Neurological Surgeons).

The department also includes 3 Nurse Practitioners (2 full time pediatric neurosurgery and one shared with the Trauma Program/Brain Injury).  We have one clinical  fellow in pediatric neurosurgery (Shillito Staff Associate) and 3-6 residents from the combined Children’s Hospital/Brigham and Women’s Hospital neurosurgery training program and multiple other programs from North America.

The team has the following membership:

• Physician-leader and director (Liliana Goumnerova, MD)
• Quality improvement consultant (Marie Lightowler, MPH, CHES)
• Nursing leader (Mary Pointer Reed, RN, Phdc, CNRN, ANP)
• Department Administrator (Norman Dean, MSF, CMPE)

The Department of Neurosurgery covers all major areas of pediatric neurosurgery. This includes:

• Hydrocephalus
• Congenital anomalies
• Brain tumors
• Vascular anomalies
• Spine
• Functional neurosurgery (epilepsy, spasticity)
• Trauma
• Craniofacial

The Department of Neurosurgery provides care for children as well as adults with “pediatric” problems. The faculty consults with colleagues at Brigham and Women’s Hospital on the care of adults who have transitioned their care to adult institutions.

There are a number of multidisciplinary programs within Children’s Hospital and Dana Farber Cancer Institute for which we are either co-leaders or integral members (Pediatric Neuro-Oncology, Myelodysplasia).

Procedures & Volume

The Department of Neurosurgery provides services both in the in-patient and out-patient settings at the Boston campus. For patients that would prefer to be seen closer to home we have clinics at Children’s Hospital satellite locations in Waltham, Lexington and Peabody.

Each year our neurosurgeons perform close 900 pediatric neurosurgery procedures, including many highly complex procedures:

• Over 100 Brain Tumor surgeries
• Over 50 Vascular cases including endovascualar procedures
• Over 50 Epilepsy cases including hemispherectomy

Our neurosurgery staff is continually working to develop new surgical techniques and approaches that will improve outcomes from surgery. One example is using Combined Endoscopic third ventriculostomy/choroid plexus cauterization to eliminate the need for shunts in infants. Research has shown that ETV/CPC can obviate the need for a shunt in infants with hydrocephalus.

We are internationally-recognized for our surgical innovations in the treatment of children with stroke due to vascular malformations of the brain and for conditions which narrow brain blood vessels (moyamoya).

Because of the installation of the intraoperative MRI unit, and our close relationship wth DFCI, we are an international referral center for the treatment of brain tumors.

We are also national leaders in neuroendoscopy, the treatment of hydrocephalus and head trauma, and epilepsy.

Patient Access

The Department of Neurosurgery is dedicated to getting patients requiring care seen as quickly as possible. Most patients will be able to get an appointment with one of our neurosurgeons within 7 days. Conditions requiring immediate attention can be seen within one day.

Results from Outpatient Satisfaction Survey  

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Patient Satisfaction

The Department of Neurosurgery is dedicated to continually improving our patients and their families experience at Children’s Hospital Boston. The Department participates in the annual Outpatient Satisfaction Survey. We also conduct ongoing surveys for our inpatients and clinics.

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Comments Clinic Survey

“It was an excellent experience.  The doctor and her staff were compassionate, kind, thorough, and professional.”

“We are so pleased and grateful for the wonderful care our son received at Children's.  Thank you.”

“Dr. Warf and his staff were absolutely amazing.  It has been refreshing to deal with so many people eager to make my son's surgeries as easy as possible.”

Inpatient Comments

“CHB is the best hospital I've encountered. There is great access to doctors, general care from nursing, facilities and attention to detail."

“I rate my stay here a 10, the team was amazing and everything was really focused about children's care."

“We had great care and the nurses were awesome. The care was conservative, no excessive testing or labs. They did just want needed to be done.”

“Everyone was very informative, helpful and caring.”

Coordinated Care  

Our neurosurgeons work collaboratively with many services in the hospital, with specialty clinics and hospital service teams:

–      Neurology (stroke, epilepsy)

–      Oncology (brain tumors)

–      Plastic surgery (craniofacial disorders)

–      Orthopedics (spinal stabilization, spinal cord injury)

–      Otolaryngology (skull base tumors)

–      General Surgery (trauma, Advanced Fetal Care Center)

–      CCS, Orthopedics, Urology (spina bifida)

–      Radiology (Neurointerventional Radiology)

Education

We are working to improve our teaching materials for patients and their families admitted to the neurosurgery service.  Not only will you understand your child’s condition and how to care for your child once you are home, but with our “Ticket Home” you will understand what things need to happen during the hospitalization to ensure a safe discharge. Your questions will be encouraged at every step in the process.

Infection Data 

The department maintains databases on all major surgeries conducted within the department. We collect data regarding CSF leaks, wound infections, OR complications and unplanned reoperations. This data is used to reduce laboratory tests and imaging studies.

In August 2010, a standardized procedure for sampling CSF from external ventricular drainage systems was implemented.  Modeled after the successful central venous catheter blood sampling data, the procedure will be taught and followed by all neurosurgery nurse practitioners and rotating house staff to assure consistency with sample collection and will minimize hospital-acquired CSF infections.

In August 2008, a protocol for pre-operative assessment of patients with shunted  hydrocephalus was implemented to insure patient safety while avoiding resource over-utilization.  The algorithm provides a template of recommended imaging studies and a neurosurgery consult based on clinical indications.  The algorithm has decreased unnecessary studies and consults without compromising patient care.

Safety and Quality

There is a commitment to safety and quality that is clearly emphasized to all members of the department. There is a culture of cooperation/discussion and respect amongst the entire department that allows discussion of critical events and opportunity for improvement.

Nursing and physician training programs will incorporate quality and safety curricula and active participation in quality improvement projects. All staff will continue to attend mandatory training programs, competency assessments and reviews geared towards quality goals.

The department is focused on maintaining a professional practice and providing the best care for all patients.

The Psychiatry Quality Program (PQP)

We have the highest expectations for the quality of care that we provide. Safety and quality in mental health care are critical concerns shared by patients, families and clinicians today. Charged with providing oversight of the Department of Psychiatry’s patient safety, quality, and outcome initiatives, the new Psychiatry Quality Program at Children’s Hospital Boston works at the forefront of establishing best practices in mental health services for children and families.

We work with all departmental services to continually assess and improve the care we provide. Everyone in our Department plays a role in assuring that all patients receive the best possible care. We work to improve the systems in place in our hospital to ensure that best evidence and highest standards of practice are utilized.

The team has the following membership:

• Physician-leader and director (Giuseppe Raviola, MD)
• Quality improvement consultant (Katie Gallagher, MA)
• Nursing leader (Sally Nelson, RN, MEd)
• Practice administrator (Patrick McCabe, LICSW, MBA)
• Informatics specialist (Jason Kahn, PhD)

Our Psychiatry Quality Program:

• Oversees the Department of Psychiatry’s patient safety, quality, and outcome initiatives
• Assesses the quality of care delivery, with a  focus on improved clinical outcomes
• Ensures that care is safe, timely, effective, equitable, efficient, and patient-centered
• Monitors adverse events when they happen and collaborates with departmental services to develop plans for improvement
• Offers training and education to affect clinician behavior in using evidence-based practices
• Follows best practice for quality as outlined by national organizations:
  • Institutes of Medicine (IOM)
  • Agency for Healthcare Research and Quality (AHRQ)
  • American Academy of Child and Adolescent Psychiatry (AACAP)

Outpatient Psychiatry Service

Nearly 15,000 visits take place each year within the Outpatient Psychiatry Service, which includes Neuropsychology, Psychopharmacology, and Psychosocial Treatment programs.  We strive to provide patient-centered care that respects patients’ values, preferences and expressed needs, and provides physical comfort, emotional support, and the involvement of family.

Top Outpatient Diagnoses

1. Anxiety disorders
2. Attention deficit disorders
3. Depressive disorders
4. Bipolar / mood disorders
5. Psychotic disorders

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Inpatient Psychiatry Service  

The 16 bed Inpatient Psychiatry services sees over 200 patients per year.  Of those patients, 15.7% had at least one co-existing chronic medical condition severe enough to require specialty pediatric care.

Top Inpatient Diagnoses

1. Depressive disorders
2. Bipolar / mood disorders
3. Eating disorders
4. Anxiety disorders
5. Adjustment disorders
6. Disruptive behavior disorders

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Emergency Psychiatry Service

In recent years, the Emergency Department at Children’s Hospital Boston has seen a significant increase in patients who are assessed to need psychiatric hospitalization but for whom no inpatient psychiatric beds are available.  These patients end up either staying in the Emergency Department or on a medical floor while waiting for transfer to an available psychiatric bed.  In response to this, the Emergency Department has been using a family-based crisis intervention for suicidal adolescents and their families in the Emergency Department in order to try to send more of these patients home from the ED, rather than having them wait for an inpatient bed.

In a pilot study, when the family based crisis-intervention was used, only 36% of the suicidal adolescents were hospitalized from the ED.  This can be compared with a matched group of adolescents, in which 55% of the suicidal adolescents were psychiatrically hospitalized.  All the adolescents in the pilot who returned home from the ED with their families received regular follow-up telephone calls for six months.  Most families needed no help from the clinician calling them for follow-up and most were very grateful that their child had not been hospitalized.

Psychiatry Consultation Service

The Psychiatry Consultation Service completes over 1000 medical consultations per year on the inpatient medical and surgical floors throughout the hospital.  This is one of the first pediatric programs of its kind in the country, and we strive to lead the field in providing, safe, high-quality, consultations. Clinical protocols and practice guidelines are currently being developed to standardize care delivery. Additionally, preliminary data from an ongoing quality survey indicates that the earlier the psychiatry consultation service is consulted on a patient on the medical floor, the shorter the overall length of hospitalization following the psychiatry consultation.

Dr. David DeMaso, Psychiatrist-in-Chief, coauthored the AACAP Practice Parameter for the Psychiatric Assessment and Management of Physically Ill Children and Adolescents (2008). Numerous projects are ongoing to monitor types of patients seen, factors related to higher service usage, patient and parent satisfaction, and outcomes of care. Despite increasing desire for psychiatry services across the hospital in response to growing mental health needs, the service strives to remain responsive while providing quality care with over 80% of patients seen within 24hours of the consult request.

Children's Hospital Neighborhood Partnerships

Children’s Hospital Neighborhood Partnerships (CHNP) works to “reach students where they live and learn” by providing a range of mental health services onsite in schools, key natural environments in which to address the social-emotional-educational needs of children.

• Crisis response.  CHNP clinicians responded to crisis situations in a mean time of less than 5 minutes, with the large majority of cases being seen immediately. This is a highly significantly reduction in wait time compared with services in an emergency room setting, where nearly half of families report waiting for an evaluation for 1-4 hours.
• Individual psychotherapy.  The average wait time to start this treatment was only 13 days compared to community rates of 6-7 weeks to start treatment. 75% of students demonstrated improved adaptive functioning with a marked decrease in disabling mental health symptoms.  Teachers report that 77% of students who receive CHNP therapy services demonstrate decreased difficulties in the classroom. Students and parents reported very high levels of satisfaction with CHNP therapy services.

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