(Interviewer: Dana Whalen, SPUC Communications Committee member and Newsletter Editor)
In this issue’s podcast, we’re talking with Dr. Amy Romashko, of Children’s Hospital of Wisconsin in Milwaukee.
I’ve been asking everybody: How did you get interested in pediatrics? And how did you get interested in urgent care pediatrics?
Dr. Romashko: I’ve always been interested in peds. I went to med school thinking I would be a pediatrician; I’ve always loved children; I was a caretaker for children in college, and it’s just always been my passion to work with kids. Urgent care, I kind of stumbled into. I had come back to where my home was, with my husband, after he had finished his residency. I had been working in primary care for a couple of years, down in Chicago, and I just didn’t know if it was the right fit for me, with the hours and the call and the rounding in different hospitals. I have always enjoyed the faster pace of an ER setting, but not necessarily the greater acuity of an ER setting. I never did a fellowship. And when I came up here, a friend of mine recommended that until I kind of figured out what I wanted to do with my life that I “keep my foot in the door” — ha ha ha — in urgent care for children. And that was about twelve years ago now, so my foot is firmly planted. So it was a great fit for me, lifestyle-wise, the hours, the pace, the ability to do procedures, and then, also the people I work with. The team is incredible and I just quickly fell in love with the whole situation and haven’t looked back.
So, you moved from “foot in the door” to director of the whole shebang?
Dr Romashko: You have to find out about children in that situation that particularly appeals to you — or presents particular problems sometimes?
Dr. Romashko: I love their honesty. I love that if they don’t like you they don’t have to pretend to like you and if they’re uncomfortable, they let you know. And if they’re feeling better, it’s quite obvious. I love that they find joy in things and their curiosity. It keeps my job fun. I just did a shift yesterday, and it reinvigorates why you’re here, to be able to work with kids and their families. They come, and often in urgent care situations they’re nervous; they’re scared, and to be able to have that place in their lives, where you’re able to patch ‘em up and make them feel better and reassure people and give good teaching and make sure they’re routed back to their medical home. It’s just a good feeling, to be able to build that rapport and be that support to families after hours when they need it. Of course, the challenges. Nobody likes when kids are sick and nobody likes the challenges of sometimes difficult parents. But I think overall, our job is such a joyful one. And it’s just full of surprises and satisfying encounters. I just love it!
Is it a never-ending line of “new” children. Do children come back to urgent care over and over, and you see some children again?
Dr. Romashko: We actually have an amazing opportunity here. We have six different sites across the Milwaukee area and our volumes are ever-increasing. I think we saw 36-thousand kids last year in our sites alone. And about half of them are patients of the Children’s Hospital of Wisconsin Primary Care Group: there’s about 24 of those clinics now around the Milwaukee area. But the rest are patients of other primary care doctors in the area. And we see about a 30 to 40 percent new patient rate, which means new patients we haven’t seen in the last three years. So although we do get our fair share of repeat visitors that are fairly loyal and get to know us and my staff, we also have remarkable amounts of new patients that just, for whatever reason, need the care after hours and don’t want to go to the emergency room. I think more and more, as people are aware of high deductibles, and also just not wanting to go to an ER with something more minor, I think urgent care has become a really great way to serve the community in times of need.
How long has Children’s Hospital of Wisconsin operated urgent care centers?
Dr. Romashko: We’ve been open for over 25 years, probably closer to 30, How’re we’re set up has changed over time. We were kind of partnered with the ER initially, where we were like a “pod 2,” separate from the ER, but in the same location. And then as we moved off campus, it became much more apparent that we were a much better fit with the primary care world. So , although we’ve been around for a while, our growth has been really over the last five-six years or so, as we were adopted by the primary care umbrella of Children’s Hospital of Wisconsin. And I think that’s just because, rather than kind of just being a filter off the ER, we’re actually kind of a bridge to primary care and we’re able to support those medical homes in a way that we couldn’t do when we were on campus. When we’re out in the community, we can.
So, if it’s been the last five or six years, that’s been pretty much all during your tenure?
Dr. Romashko: We’ve grown a lot, but, as I said, it was really kind of coincidental with when we were kind of adopted by Primary Care. It really is such a nice fit and we actually were recently recognized as the first organization in the nation to get the patient-centered connected care recognition from the NCQA – the National Committee for Quality Assurance — because of our connection to primary care medical home and our support of that and our communication and our looping back. And so it’s just really, it’s kind of a magic formula, where we suddenly were able to partner so well with the primary care providers in our community as a support for them as opposed to a competition for patients.
What would you advise other operations around the country to take into consideration when they’re looking at that situation and working with pediatricians in their area who might be a little more skeptical?
Dr. Romashko: Well, we had some skeptics, too, when we started out under their umbrella. I think good communication is huge. I did a lot of talking in front of groups; I did a lot of sharing our protocols. I think you build that trust, and then have an open mind for feedback. So when I have primary care doctors who see something that they’re not sure about that one of my providers did, or they’re confused as to why something happened, or if I hear it on my end that a parent says, “My primary care doctor said blah-blah-blah,” I loop back with those people and communicate really clearly, “How can we best help you? This is why we’re doing what we’re doing.” And we’ve actually found that in doing that, our clinical care, in general, for the whole primary care system, has really improved. We’ll find best practices in urgent care, and we’ll kind of be like: “This is why we’re doing this.” And the primary care doctors are like, “Well, that’s great. We should be doing that.” And so it has become a much more working partnership because of our communication and our openness about “Why are you doing it that way, and why are you not doing it this way?” I think every pediatrician, every doctor, wants the best and safest care for patients. I don’t think there’s a doctor alive that doesn’t want to do what’s best for their families and patients. I think just open communication, so that they understand our goal is really to support their patients, support the medical home. So, when we have asthmatics that come in — especially those we see often — we loop them back with their primary care doctor; we make sure they go back and talk about possible controllers. If we’re at all concerned about follow-up, we’ll call the primary care office and say, “You know, this family has been seeing us a couple of times for these asthma exacerbations; why don’t you reach out to them and make sure that they get hooked in We’ve told them to, but just make sure.” That way we can really partner for those families, and then we build that trust with the primary care doctor that we’re not trying to steal those patients.
You mention doing “it” — there’s sometimes an “it” that you’re doing that they learn from, or an “it” that they’re doing that you learn from. Do you have other examples that people might be interested in?
Dr. Romashko: Yeah, absolutely. So, for instance, you know when the AAP came out with their bronchiolitis recommendations about not going with Albuterol, unless there are other risk factors or a reason that you might think it might be helpful, we had this moment when we’d have families that would be frustrated with us because we wouldn‘t do Albuterol and they’d go to the primary care doctor and they would get Albuterol. And then they would be upset that they came to us and didn’t get that help. And so, by going through and showing them our guidelines and explaining the evidence behind them, and kind of sharing our protocols, they were able to see the evidence-based medicine we were practicing and then able to adapt some of that in their practices as well, as they talked amongst themselves. “You know what? We shouldn’t be doing this. This is what we should be following. “ So, kind of that example in the community, where we can show what we’re doing and show it’s based on evidence, and share that knowledge and trickle out . . . Medicine changes slowly and habits die hard and pediatricians are busy. And sometimes it’s hard to break habits that you’ve been doing for years. But when you’re working with someone who’s also seeing your patients who is delivering a message of improved care, it’s a little harder to ignore that in their world as well. And vice versa. You know we can learn from them as well, with the things that they’re doing in their groups. So, for instance, our guidelines. We have bronchiolitis guidelines, we’ve got all sorts of different guidelines for the things we do in clinic: things like alternating Tylenol and ibuprofen, which was a very common practice that has been disproven as something that is helpful for children for fever, and can sometimes really increase fever-phobia in families, thinking they have to control the fever. That’s another thing that we’ve kind of passed through and shown our evidence and explained why we’re not recommending that. Then when their families came back to them and say, “Well urgent care said we shouldn’t be doing this anymore, it kind of becomes this incentive for them to kind of: “Oh, yeah, you’re right, that’s probably not what we should be doing..” So it actually benefits care both directions as we open communication.
Earlier you mentioned, I think, 36,000 patient visits a year across six centers. Is it pretty much evenly divided? Do certain areas get more? Do you get different ages?
Dr. Romashko: We definitely have busier clinics, but for the most part, all of our sites are seeing the same amount of growth annually. We’ve been opening a new site every year for the last couple of years. We’ll be opening a new site in the South Side Milwaukee/Kenosha area in the next year. And I think there’s such an increased need for families that are busy, and an awareness of not wanting to go to the ER that I think is just a nice fit for people. We’re growing everywhere; it’s really kind of impressive.
What is your relationship with the ERs? How many cases might you send in a week or a month or a year?
Dr. Romashko: I don’t remember the exact numbers, but we do have a percentage. Under two percent, our transfer rate to the ER. So, It’s not high numbers. We do transfer kids who need full work-up, evaluations, rule out appendicitis, some of our traumas. It’s interesting what can show up in urgent care these days, as people are trying to avoid those ER co-pays. We have an under-two-percent transfer rate and we do have a good relationship with our ER. It’s really nice they are a Level 1 Trauma Center, they’re a very good ER for peds, and it’s nice to know that when you’re sending your pediatric patients to the ER that they’re getting excellent ER care as well. I work closely with their medical director, to iron out issues with hand-offs some things with that as well. We all share a medical record, an electronic medical record, which is also very helpful. So they can see our vital signs, our treatment, all that kind of thing in our medical record, as can all the primary care doctors that work for Children’s. And so, it’s an unusual relationship in that we can give them a call and even say, “Hey, I’ve got this kid, what do you think? Is this something you guys would do more with?” In addition to transferring, we often share advice, and kind of learn from one another that way as well. It’s really handy, and we’re lucky enough to be associated with a peds hospital, so we also have access to all the specialty care as well. So if we get a complicated kidney kid, or a complicated hem/onc kid that comes in, we can actually call the service and talk to the resident on call, or even the attending on call and get feedback on what we should be doing, what they feel would be best and safest for that patient. It makes our job a lot easier to provide the best possible care, because we’re all partnered so closely.
As you prepare the seventh center, have you learned anything from the first six– is there going to be anything different in the staffing or the layout? There’s been discussion on some of the SPUC e-mail boards about equipment. What are you looking at as you prepare your seventh?
Dr. Romashko: We have learned a lot, especially over the last five to ten years we’ve really started standardizing our sites and defining our scope of care. I think it’s helpful for the community to know what our scope of care is, so that pediatricians don’t send the wrong thing to the wrong place. Nobody wants parents to be frustrated with that. I think the one thing we’ve really learned is that we need space to expand. We’ve been growing so quickly, and we’ve unfortunately not had the vision to see how fast that would happen. So we’ve outgrown some of our spaces rather quickly. We want to make sure we have the right number of exam rooms. We like to have a kind of workspace where we can see where everyone is. We’ve been in clinics before where we’re more of a primary care site, where, when someone’s in a room you have no idea where they are. Most of our sites now are set up in such a way so there’s a central workstation. And we can do alot more multi-tasking and teamwork when we can all see where everyone is and everyone knows where everybody is. So, definitely that.
I think for our emergency care, our goal, since we have such great access to our ER (our response times are usually within five minutes from the different centers around us to get kids to the ER,) we really want to focus on what we need to do to keep the patient safe and stable before they get transported. And so, we have standardized our emergency kits, and actually, that is rolled out through all the primary care sites as well, which is kind of exciting at Children’s, where they all have the same equipment, the same protocols, the same supplies that they would need for an emergency, so that everyone is very prepared for what comes in.
I think space, and the other thoughts right now: we’re mostly open nights and weekends because we haven’t wanted to compete with the primary care medical home. But we’re starting to see that extended hours might be helpful, especially as primary care sites book their clinic slots pretty early. So, we don’t open till 5:00. But often, by 2:00 or even 1:00 in the afternoon, a lot of the primary care acute visits are booked. So we’re kind of thinking about making sure that we have space we can — right now we’re sharing in a lot of spaces so we can’t necessarily open earlier, but at future sites we’re looking for opportunities for that, where we might be able to extend our hours a little bit, and even give more access to the families that need us.
How many and what kinds of medical professionals at any given center?
Dr. Romashko: We have a team of — let’s see, how many do we have now; we’re growing so fast. We have 28 physicians right now and 17 nurse practitioners. We’re at least double-staffed at every site; we have at least a doctor and a nurse practitioner working side-by-side, if not two doctors, or two doctors and a nurse practitioner. So, we’re either double or triple staffed everywhere. And we flex our staffing based on anticipated volume; there are certain days of the week at different sites that tend to be busiest. We want to make sure that we have the providers that we need. We also have at least two nurses at every site — RNs, we feel that’s very important, especially in the triage abilities. As we’re walk-in centers, we often get more volume than we can handle in any given hour and having actual RNs that can help to do our triage and assessment helps make sure that we’re not missing emergencies and we’re getting the kids moving where we need them to be. And then we also employ MAs, to help with meds and assist the nurses. So at sites that are triple-staffed with providers we often will have two nurses and an MA; we tend to try to match the nursing/MA staff with our provider staff so there is good support on both sides. And then we also have a registration staff at the front desk that then helps out when they need to, but mostly is doing the registration of all of our patients on the front end.
As the Society for Pediatric Urgent Care moves forward, what kind of interests do you have in the organization and what should they be focusing on?
Dr. Romashko: I’m so excited to have the Society for Pediatric Urgent Care. When I first heard about it, it was just a couple years into my medical directorship and it was just so refreshing to have a group of people that were focused on the same issues and problems and opportunities that we were. And I think that offering that community of like-minded professionals to share ideas and support growth and development of our field is so important and exciting. And I think, especially as we’re moving forward with all of our quality improvement projects and that kind of thing, a place to have some standards and some benchmarks offered to the group, and mostly just kind of a support- and idea-factory is just such an exciting thing about having a group like the Society for Pediatric Urgent Care.