Transcription:
Pediatric Nephrology: From an APP Point of View

Tricia Williams: Hi guys. Welcome to the Advanced Practice Perspectives. I'm Tricia Williams.

Tobie O'Brien: And I’m Tobie O'Brien. This is a podcast created by advanced practice providers for advanced practice providers. We will be highlighting our amazing APPs here at Children's Mercy and do some education along the way.

Tricia Williams: We are so glad that you're joining us today. So sit back and tune in and let's get started.

Tobie O'Brien: Today, we are thrilled to interview Kat Mallett. She is a nurse practitioner in the Children's Mercy Kansas City Pediatric End-Stage Kidney Disease Program. Welcome to the podcast, Kat. Tell us about yourself.

Kathleen Mallett: Hey, guys. Thanks for having me. I'm really excited to be here. As you mentioned, I do work here at Children's Mercy. My role is to take care of patients who are on dialysis waiting for kidney transplant. And then I also get to continue taking care of them post-transplant on an outpatient basis.

Some background on me, I'm from a little town in North Central Missouri called Chillicothe. The home of sliced bread and the hornets and on the famous highway 36 where lots of famous people from Missouri are from, like Walt Disney and JC penny and General Pershing and Mark Twain. So kind of a little fun fact there.

Tobie O'Brien: Destined for greatness.

Tricia Williams: Sliced bread. The home of sliced bread.

Kathleen Mallett: Sliced bread, I know. The person who made the sliced bread machine lived in Chillicothe at the time of making that and patenting that invention. And so it's actually in the Smithsonian in Washington DC, and we get to borrow it from time to time at the Grand River Museum. So yeah, pretty cool.

Tobie O'Brien: Wow. Pretty cool.

Kathleen Mallett: Yeah. It's kind of fun because everybody knows "the greatest thing since sliced bread." So it's kind of a big deal. But I went to school, got my nursing degree at Missouri Western State College before it was the university. That's kind of how old I am. And then, got my master's degree and became a family nurse practitioner from UMKC. I won't say how long ago that was. But then I went straight into family practice, which is what I really thought I wanted to do. I'd been an ICU nurse and also worked PRN in GI lab that really loved doing primary care, because I'd also worked in a primary care clinic for about six years before I finally said, "Yep. That's exactly what I want to do."

And just to make things more interesting, I had told myself I'd never be a nurse. So next thing I know, I'm graduating from Missouri Western State College as a nurse. And then I decide, I think that I can do, you know, this extra role or have this extra responsibility of being a nurse practitioner. And so then I ended up doing that. And I really thought I would stay in family practice forever. But then this really great opportunity came up about six years ago here at Children's Mercy in the nephrology division. And I honestly did not think that I would get this job because, working in ICU, I knew that the nephrologists were some of the smartest people in the world and I had all adult and family practice, experience. So I wasn't really sure, but I thought I'm going to put my resume in and see what happens.

And now here, I am six years later and I really can't imagine not having these opportunities. It was just really a great turn of events. And I'm glad that I didn't have my entire life career completely planned out because I think I would have missed out on some opportunities.

Tobie O'Brien: Fantastic. So had you taken care of dialysis patients prior to coming to Children's or is this a new role?

Kathleen Mallett: Yeah, totally new role. And I was really worried being in a sub-specialty, especially that I would be losing some of my primary care skills and it turns out that couldn't have been farther from the truth.   In fact, many of our kids, we almost act as primary care for them because we see them so often, especially our dialysis patients. We see them at least three times a week. For some of the younger kids who require more dialysis, we see them up to five times a week. Our peritoneal dialysis patients, we see at least monthly. And then our transplant patients, you know, the closer they are to transplant, we see them more frequently. And then the further out they get, we see them about every three months.

I really love that I was able to get into a role where I get to continue building those relationships and kind of watching them, you know, go through this journey and grow and thrive. And that was something I was really kind of nervous about because I had that relationship with my patients in family practice. And I saw young kids too in family practice, so that was great. But they were all pretty healthy, you know, I mean an occasional asthma, some ear infections, strep throat, those kinds of things.

It just was such a blessing to be able to have a role where I could continue having relationships with the patient and their families and still exercise a lot of primary care skills because as chronically ill these kids are, they still have common things happen like ear infections or GI disturbances and things like that. And they sprain their ankles too. Now, the way I deal with that might be a little differently in terms of having someone else look at it, because of my scope, but still it's good to have that background.

Tricia Williams: Sure. I would love to hear a little bit about what your work week looks like, because I feel like you take care of a very specialized group of patients, but in different phases of their disease process, if that makes sense. Would you mind kind of elaborating and shedding some light on what that role looks like for you?

Kathleen Mallett: There's kind of some structure in terms of having some routine meetings where the multidisciplinary team gets together and we're making sure that we're reviewing what's going on with these patients across the end-stage kidney disease spectrum, reviewing labs, what's their dialysis prescription, what's their immunosuppression regimen, is it still adequate? Those kinds of things. And then of course, we have a clinic day. But in between all of that, anything can happen. And so, I try at least on Monday, Wednesday, Friday, those are the most common days our kids come in for hemodialysis. So around in the morning, because we have two shifts, a group of kids comes in the morning and a group of kids comes in the afternoon.

So I do round on them each shift, just checking in with the nurses, checking in with the kids and young adults and asking, you know, how are they doing? How are they tolerating dialysis? Sometimes they come in too heavy, so they weigh too much and we have to pull extra fluids. So we have to have conversations about that. It's really strict diet that our peritoneal and haemodialysis kids have to be on. In terms of the things they can eat, solids, but also fluids, because their kidneys just can't, you know, get rid of all that extra fluid, that's why they're on dialysis. So we have to make those adjustments.

So there's a lot of conversations like that. Re-educating, encouraging, reinforcing. And then for the transplant patients, we do biopsies for them on intervals to make sure that their kidney doesn't have some signs of rejection that maybe we're not able to see on their routine labs, which unfortunately we have seen some kids with rejection where their labs looked great. So that's the reason why we do these surveillance biopsies so often. I'm doing history and physicals for them.

Tricia Williams: Do you perform the biopsies yourself or do you just get them ready to like going

Kathleen Mallett: the operating room?

No, I did not perform the biopsies, but there's a lot of collaboration. Nurse practitioners are care coordinators a lot of times, right? We're kind of the hub where we know what's going on and kind of all of our resources. Who do we talk to? Who do we make sure this box is checked and this person knows what's going on? Things like that. So that's a lot of what happens with those biopsies too, obviously in partnership with the transplant coordinators. So it definitely takes a village, but yeah.

And then things happen. "This patient's not feeling well on hemo. Can you come check on them?" Or, urgently, this patient is at home, a transplant patient and they don't feel well or they're being seen in their local emergency department, you know, we think need to be admitted, so jumping on that and getting care coordinated for that. And that's just the patient facing side of things.

So then there are plenty of projects. We're a very active division, always trying to work on things that improve care for these patients. So I weed a couple of projects through a national collaborative for dialysis, and weed some division-specific projects that we're working on. And finding time to do all that is sometimes a challenge, but it keeps me busy and I really love the variety and I like being busy.

Tobie O'Brien: Oh, wow. You are busy. Will you tell me a little bit about the nurse practitioner group or the advanced practice group within nephrology? It sounds like you mainly take care of dialysis patients and do lead these other projects. Is there a group that sees new patients coming in just for like, I guess, whatever your general nephrology problem might be?

Kathleen Mallett: Right. So the way that the nephrology division utilizes advanced practice providers doesn't seem unique to me, but it might be for other people listening. So we have a nurse practitioner, Leslie Moale, who runs the hypertension clinic. We have a nurse practitioner, Ashley Auffert, who does a lot of kind of the enuresis bedwetting clinics; Lora Bear, who does a lot of regular renal, we call them regular renal kids that maybe have been referred from outside providers and they kind of need to be seen. There was a bump in their creatine, you know, things like that. And then is Tyson Moore, who is the other, there are two of us that do the end-stage kidney disease patient care on an outpatient basis.

Tyson and I do not have to do inpatient responsibilities, but the other three nurse practitioners do share that. We partner really closely with them because our kids are so complex. Oftentimes, they are admitted, you know, we're kind of people that they're coming to first. "Hey, what's their medications schedule? What's their story? What's their history?" And then again, we're participating in a lot of those kind of multidisciplinary meetings with inpatient team just to provide backgrounds and give insight into these kids that are very chronically ill.

Tricia Williams: It goes back to your theory of it takes a village to care for these patients, right? I would really like to loop back around. You said that you are working on a national collaborative. I would love to hear more about that and kind of your journey with that and what that entails.

Kathleen Mallett: This particular collaborative is through the Children's Hospital Association. It's called the SCOPE Collaborative and it's a collection of, I think we may have somewhere around close to 50 children's hospitals across the nation that take care of pediatric dialysis patients. So this is a dialysis-specific collaborative.

The project that I'm currently leading is related to exit site care for peritoneal dialysis patients. So peritoneal dialysis is where we use the membrane of the abdomen to kind of get that cleaning and that extra fluid off, that way the kids can do that at home. They usually do that every night while they're asleep. It takes a qualified family to be able to do that because they're the ones doing that at home. But it saves them from having to come into the dialysis unit several times a week and sit in a chair for several hours.

A very high risk issue for these patients is peritonitis. And one of the first things that is a risk factor is if they get these exit site infections where that catheter is coming out of their body. So the dressing changes are very important. The family's trained very specifically on how to do that. And then we evaluate that at least on a monthly basis.

Confusion around that is like how to score those. And if they look questionable and, "I don't know, it's a little red, but maybe it's not quite infected, you know, what are we going to do with that?" There are a couple of scoring systems out there, but none of them are validated in the pediatric population. So that's something that this collaborative and my innovation group is working on, is trying to standardize that, and give pediatric providers a validated, consistent, reliable tool so that we can see across the spectrum of presentations from the very healthy healed exit site to the ones that are obviously infected, but it's kind of the ones in the middle where it gets a little confusing and everyone's got their own subjective opinion on what that looks like. So very important work. Very exciting because if we can prevent peritonitis, then we can prevent hospitalizations and hospital costs from rising, especially in this population. So, very exciting.

Tricia Williams: Yeah, very important work. And I love that it's on a national level and that you're collaborating with other providers across the nation. That's fantastic.

Tobie O'Brien: Well, tell me a little bit about you being a certified nephrology nurse practitioner. Can you talk about that a little bit?

Kathleen Mallett: Yeah, so there's a nephrology nurse association called ANNA, the American Nephrology Nurses association, and they offer a specialized certification called the certified nephrology nurse practitioner. They have different levels, some for like dialysis technicians, also just like the RN level, the certified nephrology nurse.

So there are several of these nurse practitioners in the United States, but there are only three of us now that are in the pediatric study. So the first one was a colleague from Texas. And then I was number two and then my colleague, Tyson Moore, is the third one. So pretty exciting that two of us out of the three are from Children's Mercy.

It was kind of a tough certification because it's really geared more so towards adults. And so adult dialysis and transplant care looks a little different from pediatrics. So there's some basic information, but there are meds and things and other like HIV and hepatitis C and you know, things like that the adults may have more issues with that we don't really see in our pediatric population. So we had to be tested on those things too.

It's just such a small network of pediatric end-stage kidney disease providers in the United States, I mean, thankfully, right? But there's still never enough. There's not enough to say, "Oh, there's a specific certification for the pediatric nurse practitioners." So it is what it is, but it was still great go through that process. First test I've ever had to take twice and that was humbling.

Tricia Williams: Humbling, yeah.

Kathleen Mallett: Yeah. But I'd already put all the time in, you know, and so I was like, "I'm passing this."

Tobie O'Brien: Oh, yeah. For sure.

Tricia Williams: Well, you know, congratulations to you and your colleague, Tyson, for first of all being brave enough to take that test. Sounds like it's pretty adult-based. I know in our otolaryngology world, we have a certification exam as well, but it's very adult-based. And a lot of us shy away from that exam because of it. And I have talked to colleagues across the nation about this, that we won't set for it, because of that. So we are currently looking into possibly developing a pediatric-focused certification exam for us, instead of the adult-based. But that's just really in its mitosis and meiosis stages of development.

So really I congratulate you for being brave enough to step up and take that. I know that you're really a huge advocate for advanced practice providers in the nephrology, arena. And I would love to talk to you about a book chapter. I know that you have written a book chapter in regards to this, and I would love for you to talk to us about your book chapter, because that's a huge success story for you.

Kathleen Mallett: It is. And gosh, like I said before, if I had planned out my career path the way I thought it was going to go, I would be in sports medicine, you know, or still in family practice. And certainly, all the things I've been able to do, I'm just excited and blessed and I'm like, "Wow, I never would have guessed. This is where I would be." But now that I'm taking care of this population, I love it so much. And yes, I will shout it from the rooftops, you know, that there's a place for the nurse practitioner for sure in this population.  

I've also been blessed, as I've heard in some of the other podcasts about having a cheering section that supports you and believes in you. I mean, our division is so great at supporting each other and I have a great boss, Brad Warady, who has really helped me have a lot of opportunities too. And one of them is this book chapter. He and a couple of his colleagues are the editors for what's considered the pediatric dialysis Bible. So it's kind of like everyone covets this book and wants it. And he said, "Hey, why don't you and Jessica," which is my colleague from Texas, "You guys should write a chapter about how APPs function in the pediatric dialysis unit." And I was like, "You want me to do what? Write a book chapter?"

Tricia Williams: You said yes that.

Kathleen Mallett: Okay. I've never done that before, so let's try it, you know? It was just really a great honor. I mean, we really got to highlight our role in being first-line providers, being able to start ordering tests if something doesn't look right, being able to be the first ones there at the chair side when our patients might not be feeling well on dialysis or if their line isn't functioning or they're having a reaction to dialysis. I mean, there's lots of acute and chronic things that we're first-line providers for.

We're also the common thread for these patients between the physicians and the nurses and, you know, just a piece of the multidisciplinary pie, but we're pretty consistent in coordinating their care and visiting with them all the time. So that was one thing we were able to highlight. And also just all the quality improvement projects we can do in terms of meeting measures for making sure their anemia is well-controlled or they're getting immunized appropriately, so that they're getting ready for transplant. How do we help them build good transition programs so that they can transfer to an adult dialysis setting if they're not transplanted first? How do we help ease that transition as they go from the milder stages of chronic kidney disease towards that dialysis and transplant spectrum, where their kidney function is so poor that they really need those interventions? How do we educate them on that?

So there are so many wonderful ways that we get to perform and it's not the typical, you know, seeing patients in clinic several days a week. It's just a little more behind the scenes, a little less tangible maybe, you know, from what other people are used to. But it was really great to be able to sit down and brainstorm and go, "Gosh, we really do a lot." I mean, nurse practitioners tend to be a little humble and a little self-deprecating like, "Oh, don't look at me. And it's just what we do." And that's okay to a point, but, man, it was just really great to sit down with Jessica Geer and say, "Wow, we really fill a lot of gaps." And this is important. This is what improves our patient outcomes. Like the exit site care that I'm taking part in, you know, how do we continue to improve outcomes for these patients? And there are so many different ways that we're able to do that. So grateful for the opportunity to put that in a book that's used internationally. I mean, it's really phenomenal. And I'm talking about it, but I still can't even like wrap my head around the fact that this has happened.

Tobie O'Brien: How long did it take you? I'm so curious, how long did it take you guys to write this chapter?

Kathleen Mallett: Yeah. So I think all told it took us about a year to write the chapter. And then of course, all the other chapters in the book, this is the first year for this chapter, by the way, in this first edition for it.

Tobie O'Brien: Amazing!

Kathleen Mallett: Right. So all the other chapters had to be reviewed, make sure everything's still current in terms of the information that's in there. So the book finally came out and is published that I have a hard copy. I just got it in March, I think. So I actually wrote the chapter almost three years ago, so it's definitely not a oh-you-write-it-and-instant-gratification.

Tricia Williams: Yeah, publication doesn't happen that way, does it?

Kathleen Mallett: No. No, it doesn't.

Tricia Williams: You said a couple of things. It's a very common theme that as nurse practitioners, we are very humbling and we do not like to shout out our accolades and say how fantastic we are. But Kat, you need to know that what you did for your subspecialty and the APRNs and the physician assistants in your sub-specialty is amazing. It is amazing. You're getting your voices heard. You're telling people, physicians, other providers, general practice, what the relevance and importance of your role is in your subspecialty. So kudos to you and shout from the rooftops of how amazing you are.

Tobie O'Brien: Yeah, I agree. Tricia.

Kathleen Mallett: Yeah, thank you. It's so exciting. I mean, I also gave a talk on this at a dialysis conference right before COVID happened. And it's just so fascinating because I've had other dialysis directors, pediatric dialysis directors, reach out to me and say, "You know, I think we need to incorporate a nurse practitioner or a PA into our dialysis program. And so how did you do that?" Or other nurses have said, "Hey, we really want to incorporate that role. Can you give us kind of a framework for what that looks like, where you are so that we can take this to our administration and really advocate for this role?" And so, I mean, wow. And I love that because I love us and I will not really toot my own horn, but I will to everyone else's, you know, and I'm a cheerleader at heart, and so let's collectively do this together.

Tricia Williams: I'll toot your horn for you. You're a trailblazer, sister. Toot toot.

Tobie O'Brien: For sure.

Tricia Williams: Nicely done.

Kathleen Mallett: Thank you.

Tobie O'Brien: Absolutely. Kat, thank you so much for joining us today. We loved hearing about your role in nephrology and all of the things that you do in your group and of course your book chapter, which we are obviously so proud of you for.

So we end each episode with the same question we ask everybody. So we want to know, and it does sound like, again, you did not think your life was going to go this way. If you had planned out, it would have been something different. So we want to know what advice you would give to your old self, like yourself right after you graduated with your family nurse practitioner degree? What advice would you give yourself self?

Kathleen Mallett: I think just to continue to be open to opportunities, even if you're not really sure how it's going to work out. I mean, take the chance.. Figure out what inspires you, what drives you and then take some chances|. You might surprise yourself where you'll land and what your opportunities will be. And I think I would tell anybody that, "Gosh, if you're just not sure, you know, and something comes up, take a chance." If you're invited to give a talk or you're invited even just within your division, take the chance

Tricia Williams: yeah. It's important to take the chance and say yes if somebody sees value in you and ask you to do something like write a book chapter and sees your value on that, you say yes and do that. So Kat, it has been an absolute delight to talk with you this afternoon. Thank you so much for joining us. And listeners, stay tuned because coming up on our next episode of the Advanced Practice Perspectives, we have a special treat for you. So you have to tune in to know what that special treat is.

Tobie O'Brien: If you have a topic that you want to hear about or you want to be a guest, we'd love to have you, so please email us at tdobrien@cmh.edu or twilliams@cmh.edu. And once again, thank you so much to Kat. We loved hearing from you and thank you for our listeners for tuning into the Advanced Practice Perspective podcast.