June/July 2008

Medical Staff Bulletin

Contents

Message from the Chief of Staff
In 1992, Yale-New Haven Hospital implemented its first computerized clinical information and provider order entry system, locally named CCSS (Clinical Care Support System). The System was "turned on" unit-by-unit and, mild chaos notwithstanding, we have never considered returning to a paper-based provider order entry or information retrieval system. Over the last decade and a half, CCSS has been continuously updated and customized, and the features of the system at YNHH bore a unique YNHH signature. Several generations of house staff became expert users, together with some hardcore attendings who took considerable pride in their self-sufficiency.

CCSS, and the CIS stalwarts who supported and improved it, served us very well over these years. However, its structure embodied some important limitations and, for several years, we were told its manufacturer did not intend to continue system support. While CCSS could be over-layered with critical paths and practice guidelines, it did not have the potential to provide contemporaneous decision support. Moreover, potential for online documentation and interoperability with related systems was severely limited.

More than five years ago, YNHH began implementation of the Sunrise Clinical Manager (SCM) system. For the last two years, SCM has been the primary results retrieval system. Its utility quickly eclipsed that of CCSS as connectivity to PACS and Soft Med systems was added, permitting online viewing of radiology images and transcribed operative reports and discharge summaries. Most recently, led by Pediatrics, we have begun moving toward more online documentation as the truly electronic medical record begins to take shape.

The final phase of SCM implementation began in February 2008, with the transition to a new provider order entry system that embodies real-time decision support. In contrast to the CCSS phase-in, the implementation has been staged and well conducted by our IS&T Department. For sure, the new system will require significant additional modification, particularly to facilitate the discharge process; but there is almost universal agreement that computer support for patient care has considerably advanced.

A great deal of credit is due literally to hundreds of our staff who labored over the last three years. Included are physicians who served on the Steering Committee, meeting at 4 p.m. on Friday afternoons over many months (no joke). We were spectacularly represented and served by our two Chief Medical Information Officers, Drs. Allen Hsiao and Nidhi Shah. Holding all of us upright and to task were two remarkable and committed heroes, Marcia Dobrowski, RN, from CIS and her wonderful co-workers, and Lorraine (Lori) Lee from Pharmacy. Congratulations to them and the many, many others on their team who brought this project to fruition.

Performance management update

March 2008 Performance
AMI	#	YNHH%	Nat. 90%
ASA at arriv.	6/6	100	100
ASA at D/C	21/21	100	100
B-Block at arriv.	7/7	100	100
B-Block at D/C	19/19	100	100
ACEI at D/C	1/1	100	100
PCI <120 min	0/0	NA	98
Smoking cess.	7/7	100	100
CHF	#	YNHH%	Nat. 90%
LVEF assess.	23/23	100	100
ACEI at D/C	3/3	100	100
Smoking cess.	1/1	100	100
D/C instr. given	13/19	68	96
Pneumonia	#	YNHH %	Nat. 90%
02 assess. at arriv.	11/11	100	100
Pneum. vac. given	9/9	100	96
Abx given <4 hrs	7/9	79	94
Smoking cess.	2/2	100	100
Blood cx before abx	10/10	100	100
Initial (non-ICU)
Selection Abx	4/5	80	97
Influenza vaccine	8/9	89	98
SIP	#	YNHH %	Nat. 90%
Proph Abx 1 hr	34/34	`00	97
Abx selection	32/36	89	99
Proph Abx D/C	29/34	85	97
DVT proph ordered	21/26	81	97
DVT proph given	20/26	77	95
Hair removal	56/57	98	NA
Beta block rcvd	19/22	86	NA
Pedi asthma	#	YNHH %	Nat. 90%
Inpatient steroids	27/28	96.4	NA
Home mgmt plan	17/28	60.7	NA

At right are YNHH’s March performance numbers for our publicly reported measures. You will note we continue to perform very well in most of the domains, that there are some new measures reported, and that we have some familiar challenges.

One challenge — providing discharge instructions to patients with CHF — has been largely overcome as of April 15. Since that date, the discharge instructions given to the patient at the time of discharge are automatically added to the discharge summary, thus ensuring that the two documents contain the same information. This process then ensures that the patient, the attending physician, the referring physician(s), and the permanent medical record all have the same information and that this is consistent with what the patient has been told to do. This is a big step toward integration of our information systems and thanks go to Jen Travers and Jean Pawlich for putting it together.

New measures reported this month are additional SCIP metrics and pediatric asthma metrics. These pediatric metrics focus on providing appropriate beta 2-agonists and steroid therapy to inpatients and comprehensive asthma action plans upon discharge. The discharge action plan must contain information regarding medications to be taken, recommendations for modifying the home environment, and information regarding follow-up with a physician; and it is providing this physician follow-up information that is our single biggest missed opportunity. The Department of Pediatrics has made great strides toward improving this performance and we will do better. Drs David Hirsch and Michael Apkon have led improvement efforts in this area and are driving toward 90 percent compliance this summer. Many thanks to all the employees and staff for all the work aimed at improving these measures and improving the care and experience of our patients. If you have any questions, please call Dr. Tom Balcezak at 203-688-1343.

Dictation of consultations
One of the major short-comings of our current consultation documentation is the fact that the majority of hand-written notes remain buried in the old medical record. These cannot be electronically retrieved and generally do not serve patients after discharge or at re-admission. We announced, four months ago, that using "work type 15," it is now possible to dictate all consultations, which then are available in both Soft Med and SCM. We strongly encourage all specialists and sub-specialists to dictate consultation notes. The Medical Board will be considering a change in our rules and regulations to mandate dictation of consultations.

National Time Out Awareness Day noted on June 18
On June 18, YNHH staff joined with the Joint Commission, the Council on Surgical and Perioperative Safety (CSPS) and the Association of Perioperative Registered Nurses (AORN) to recognize National Time Out Awareness Day. The "time out" is one portion of the Joint Commission Universal Protocol which applies to all patients having surgical or invasive procedures.

Universal Protocol requires three separate steps:

1. 1. A pre-procedure verification of patient ID, and presence of appropriate chart documents, X-rays, implants and special equipment.
2. Marking the operative site to identify laterality, digits and spinal levels.
3. A final pause or "time out" immediately prior to the procedure. Teams are required to communicate, as a group, before every surgical or invasive procedure, to confirm key information about the patient, procedure, and any other information relative to the patient or procedure. Open and frequent communication helps to provide optimal safe patient care.

New sound-masking devices to be installed in EP patient rooms
As part of the Hospital’s Service Excellence initiative, the Quiet Team tested sound-masking devices in several patient rooms on EP 5-5 and 5-7 last year. Sound-masking devices generate soft background noise that helps muffle louder, more disturbing noises. In addition to lowering the noise level, sound-masking devises muffle conversations and help protect patients’ privacy and the confidentiality of clinical information. The results of the pilot were so successful that, beginning in late July, the entire East Pavilion will begin installation of sound-masking devices above each patient bed, on a floor-by-floor basis.

Smilow Cancer Hospital taking shape
Construction of the Smilow Cancer Hospital is on time and on budget and the building is up to the 12th floor. Over 1,900 truck loads of concrete have been poured, 3,200 pieces of steel laid, and 2,700 glass and metal panels will be installed to enclose the building with terra cotta panels. Below ground, workers are installing duct work, electrical wiring and plumbing and have constructed a tunnel to the area that will become the Hospital’s new loading dock, beneath the new building at 55 Park Street, just north of the Air Rights Garage. The final steel should be laid this summer and the building is expected to be completed in late 2009.

In addition, groundbreakings have been held for the two facilities that will support the new Cancer Hospital. The six-story Yale-New Haven Clinical Laboratory Building at 55 Park Street, which will be built and owned by Fusco Corporation, will house YNHH’s clinical laboratories, pharmacy services and shipping and receiving. The building will connect to the Smilow Cancer Hospital and the main Hospital complex through both an underground tunnel and a fourth floor enclosed walkway over South Frontage Road. The first floor will contain retail space. The Lot E parking facility s 2 Howe Street, being built by Intercontinental Real Estate Corporation, will include a six-story parking garage; a three-story mixed-use (retail/office) building; as well as 24 residential units.

Smilow Cancer Hospital fundraising campaign progresses
As the steel frame of the new Smilow Cancer Hospital begins to define the medical area skyline, a joint fundraising effort between Yale University, Yale School of Medicine and Yale-New Haven Hospital is similarly taking shape. With a goal of $100 million now within reach, efforts to engage supporters of this historic project are well underway. Buoyed by an extraordinary naming commitment from Joel and Joan Smilow, we have made remarkable progress on the campaign to date. But there is more work ahead.

The Hospital will bring the campaign to our Hospital community later this summer. As physicians who practice at Yale-New Haven, you clearly understand the value and importance of the Smilow Cancer Hospital. As you review your personal philanthropic goals, please consider a gift to support this project.

New hours for Shoreline ED
As of July 7, the Emergency Department at the Yale-New Haven Shoreline Medical Center (SMC) in Guilford, will be open 24 hours a day, in response to a steady increase in demand. When the SMC first opened in 2004, its ED was open for eight hours a day; in 2006, it expanded to 16 hours a day. But volume continued to rise over the past four years. In 2005, the SMC ED had 10,000 patient visits – two years later, in 2007, the number had almost doubled to 19,000.

ACR accredits Yale-New Haven in CT scanning and in cardiac MRI

The American College of Radiology (ACR) recently surveyed and accredited Yale-New Haven Hospital and Yale Diagnostic Radiology in CT scanning for a three-year term. ACR accreditation confirms high practice standards after a peer-review evaluation which assesses the qualifications of staff and adequacy of equipment.

ACR also recently accredited YNHH in cardiac MRI, making it one of only a handful of hospitals in the country to be accredited in this field. ACR accreditation in cardiac MRI requires strict standards for physician and technologist education, training and qualifications, as well as quality control programs, MRI safety policies and image quality specific to cardiac MRI. Cardiac MRI can evaluate heart function and detect or assess heart disease by examining the size, thickness and viability of the heart muscle and function of the chambers; it can also help detect tumors or areas of infection. Referrals for a cardiac MRI should be directed to Yale-New Haven’s MRI Center at 203-688-5739.

New food service program increases patient satisfaction
Since December 2007, when "At Your Request" room service was implemented Hospital-wide, patient satisfaction scores have climbed steadily. Press Ganey patient satisfaction scores show marked improvements in four measures of food service: overall meals, the temperature of food, the quality of the food and the courtesy of the server. Between the first quarter of FY07 and the second quarter of FY08, the overall score for adult patient satisfaction for food services went from 72.8 to 78.4. For pediatrics, it went from 71.6 to 80.4.

YNHH invested $2.5 million to design and install this new food service program, and patients have indicated they like ordering from a restaurant-style menu with more than 45 entrees anytime between 7 a.m. and 7 p.m. Physicians can help support this initiative by remembering to enter a diet order into the computer system when they admit a patient to YNHH. If the diet order is not entered into the system, no meal requests can go through.

Dr. Michael Simons hired as new chief of Cardiovascular Medicine
Michael Simons, MD, a distinguished heart researcher and physician, has been appointed section chief of Cardiovascular Medicine at YNHH and Yale School of Medicine. Dr. Simons was previously chief of Cardiology at Dartmouth-Hitchcock Medical Center, professor of Medicine, Pharmacology and Toxicology at Dartmouth Medical School, and director of the Dartmouth-Hitchcock Medical Center’s Cardiovascular Center and the Angiogenesis Research Center. While at Dartmouth, Dr. Simons received the Department of Medicine’s Excellence in Teaching Award.

Dr. Simons received his BS from Massachusetts Institute of Technology (MIT) and his medical degree from Yale. He completed his residency in internal medicine at New England Medical Center, Boston, before serving as a medical staff fellow and postdoctoral fellow, Laboratory of Molecular Cardiology, at National Heart Lung and Blood Institute at National Institutes of Health in Bethesda. Dr. Simons completed his fellowship in cardiology at Beth Israel Hospital, Boston, and the associate scientist program for excellence in molecular biology of the cardiovascular system at MIT. Dr. Simons was previously associate professor of medicine at Harvard Medical School and attending cardiologist and director of Beth Israel Hospital’s coronary care unit and its angiogenesis research center. His research interests include fibroblast growth factor (FGF) signaling in the vascular system, regulation of arterial development and endothelial signaling. He is also interested in the clinical applications of biological therapies — developing strategies for delivery and assessment of various biological agents, and how to identify novel biomarkers that predict individual responses to interventions that promote the growth of new blood vessels.

Reminder about YNHH media policy
Occasionally, members of the YNHH Medical Staff are contacted by the media to comment or offer expertise about a news-related topic. Hospital policy NC:R-2 "Release of information to the news media" reminds YNHH staff that they should contact the Department of Marketing and Communications before speaking with the media for the appropriate clearance and assistance. The full policy on the YNHH intranet, here. To reach YNHH Marketing and Communications, call the office during business hours at 203.688.2488 or through the Department’s 24-hour pager 203.766.1688. The YNHH media coordinator is Mark D'antonio — office: 203.688.2493; or cell: 203.506.5648.

Welcome new Medical Staff

April
Ya-Ching Chang, PA; Affiliated, Surgery
Ronnie Lynn Dubrowin, CNM; Affiliated, OB/GYN
Vishal C. Mehra, MD; Attending, Internal Medicine

May
Pauleen Reyes Consebido, CRNA; Affiliated, Anesthesiology
Suzzunne Nicole De Cruz, PA; Affiliated, Internal Medicine
Christopher Dill, PA; Affiliated, Surgery
Sasha Lee Durso, APRN; Affiliated, Child Psychiatry
Paul R. Fisher, MD; Attending, Diagnostic Radiology
Randall Mitchell Johnson, PA; Affiliated, Internal Medicine
Shaukat Ali Khan, MD; Attending, Psychiatry
Michal David Obrzut, MD; Attending, Diagnostic Radiology
Kimberly Ann Phillips, MD; Attending, Internal Medicine
Danielle Marie Tabaka, PA; Affiliated, Internal Medicine
Kendra Joy Towles, CRNA; Affiliated, Anesthesiology
Steven D. Vyce, DPM; Attending, Orthopedics
Alexander Brian West, MD; Attending, Pathology

June
Rebecca Debra Bonner, PA; Affiliated, Surgery
Wendy Diane Caruso, APRN; Affiliated, Surgery
Gilbert W. Moeckel, MD, PhD; Associate, Pathology
Heather Lee Paxton, MD; Associate, Psychiatry
Thomas Edward Quinn, APRN; Affiliated, Internal Medicine

Refer items for the next issue of Medical Staff Bulletin via phone, fax, e-mail or mail to:
Peter N. Herbert, MD
1063 Clinic Building
P: (203) 688-2604, F: (203) 688-7152
herbertpn@ynhh.org
or
Katie Murphy
Marketing & Communications
GB 443
P: (203) 688-2492, F: (203) 688-2491
Katie.Murphy@ynhh.org

Back issues of the Medical Staff Bulletin:

• April/May 2008
• March 2008
• January/February 2008
• November/December 2007
• October 2007
• August 2007
• June/July 2007
• May 2007
• March/April 2007
• February 2007
• January 2007
• November 2006
• September 2006
• July 2006
• June 2006
• May 2006
• March 2006
• January 2006
• December 2005
• November 2005
• September 2005
• August 2005
• June 2005
• March 2005
• January 2005
• December 2004
• November 2004
• October 2004
• September 2004
• July 2004
• June 2004
• May 2004
• April 2004
• March 2004
• February 2004
• January 2004
• January/February 2003
• October/November 2002
• August/September 2002
• April/May 2002
• February/March 2002
• January 2002
• November 2001
• July/August 2001

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Last revised: July 29, 2008 (dh)

Home page URL: http://www.ynhh.org

All information is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.