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Medical Staff Bullietin

October 2009


A message from the Chief of Staff

On October 21, we will dedicate Smilow Cancer Hospital at Yale-New Haven, recognizing a monumental construction effort undertaken just three years ago. In early 2006, many of us were losing hope that the Cancer Hospital would ever be a reality. Now it is, and the first patient in radiation oncology will be treated in the building's lower level on October 26. Over the next six months, the upper floors containing inpatient acute and intensive care units, outpatient treatment areas, operating rooms, and diagnostic radiology, will be brought on line. Shortly thereafter we will realign other services in our existing buildings and decommission a number of the nursing units in the East Pavilion. Overall, we will add 168 new beds including 30 additional critical care beds.

The majority of our cancer services, currently scattered throughout the Medical Center, will find a new home in Smilow. The space created in the West, South, and East Pavilions will permit geographical localization of other services that was impossible before Smilow. Heart and vascular related units will come together, the SICU will expand and develop new step-down capacity, transplant will join general surgery services in the West Pavilion, and Medicine will acquire many more private rooms in the East Pavilion as the era (thankfully brief) of triple rooms ends. Overall, the quality of space available for inpatient care will be greatly enhanced, as will our capacity to better match patient needs to nursing services.

This magnificent project came to fruition because of the work of hundreds of volunteers, hospital staff and construction workers. I must recognize and express deep gratitude to our campaign chairs: Jonathan and Jody Bush, Helaine and Marvin Lender, and Debra and Louis Chênevert. Norman Roth, with Bill Mahoney and Pat Luddy, provided oversight of all the construction and navigated some very difficult political waters. Hundreds of doctors and nurses contributed to the design of Smilow Cancer Hospital. CEO Marna Borgstrom and Dean Robert Alpern assured we never lost sight of the vision and purpose. Thousands of patients will benefit in ways we can only imagine.

Smilow Cancer Hospital employee and physician celebration

A celebration for employees and physicians will take place on Tuesday, October 20 from 2-5 p.m. in the Smilow Cancer Hospital lobby and the East Pavilion cafeteria special events area. An additional evening shift celebration will take place from 10:30 p.m. to midnight. Employees and physicians (with their I.D.s), can view the new lobby, the waterwall, a facsimile of the donor plaque for those who gave to the Smilow Physician's Campaign, enjoy music and receive a celebratory gift before moving to the East Pavilion cafeteria for refreshments. A press conference is scheduled the following day to formally dedicate the building, with invited donors in attendance.

'It's In Our Hands' video

The recent emergence of the H1N1 influenza has renewed YNHH's vigilance on improving hand hygiene compliance. The hospital has recruited volunteer hand hygiene coaches to support the inpatient units, motivating their colleagues to use personal protective equipment and hand hygiene. In addition, the hospital has created the "It's in Our Hands" video to demonstrate proper hand washing techniques to staff and show how quickly microbes can spread. The video, made in cooperation with operations support and epidemiology experts, shows viewers - both clinicians and non-clinicians - how easy it is to transmit infectious agents from one person to another and clarifies myths about hand hygiene. "It's In Our Hands" is on the hospital's intranet. Videos are at the top of the page.

Performance management update

At left are our familiar performance measures as they are reported to CMS and TJC for the month of June 2009. Our new fiscal year began on October 1, and this year we will report data on a total of 42 measures, with none of the current measures going away. We continue to perform well overall, with most measures in the national 90th percentile. Two areas of concern, PCI within 90 minutes and appropriate discharge instructions given for congestive heart failure patients, are special items on which we will focus intensely this year. We have very aggressive goals around improving both of these measures, bringing them up to parity with the rest of our measures.

Additional specific items in this year's plan, and also in this year's Performance Improvement Program (PIP) which is available to all eligible hospital employees, are improved performance with hand hygiene, aggressive throughput improvements (11 a.m. discharge), and compliance with all accreditation standards. In addition to measuring, improving and reporting on clinical quality in this column, we will also report on these operational measures throughout the year. If you have any questions regarding any of this data or related issues, please call Dr. Tom Balcezak at 688-1343.

H1N1 monovalent vaccine

The state of Connecticut will receive 2009 H1N1 monovalent vaccine during the month of October. It will be distributed to all 31 acute care hospitals, as well as to community health centers, private physicians' offices, visiting nurse associations, and schools. Live intranasal vaccine containing attenuated virus will arrive first. This may be used only by healthy individuals between the ages of 2 and 49. Inactivated H1N1 vaccine for intramuscular injection is expected near the end of the month and is more appropriate for older individuals who may have partial immunity.

CDC guidelines for the five initial target groups for H1N1 vaccine include: pregnant women; care providers of infants under 6 months of age; healthcare and emergency medical personnel involved in direct patient care; children between the ages of 6 month and 4 years, and children between the ages of 5 and 18 years who are at high risk of complication (chronic heart, lung, metabolic, renal and liver disease, cancer or immunosuppression). As additional vaccine arrives on a weekly basis during the next several months, healthy children and young adults, as well as adults between the ages of 25 and 64 at high risk for complication, will be targeted for vaccination. Children under age 10 will require two vaccine doses, and adults will require a single dose. 2009 H1N1 vaccine may be co-administered with seasonal influenza vaccine as long as both vaccines are not of the live attenuated variety.

Yale-New Haven Hospital expects to begin administering the intranasal vaccine during the week of October 19, with initial priority given to healthcare workers in the emergency department, pediatrics and obstetrics. Administration of inactivated H1N1 vaccine is expected to begin during the first week of November to all healthcare workers with direct patient care responsibilities. Vaccine will be administered by designated staff in patient care areas, and will also be available at the Yale-New Haven Hospital Occupational Health Service, located on the first floor of the East Pavilion between 7:30 a.m. and 4:15 p.m. Monday-Friday.

Unanticipated outcomes causing significant harm must be disclosed

Pursuant to Administrative Policy C:D-1, it is the policy of Yale-New Haven Hospital to inform patients (and where appropriate their families) of unanticipated outcomes causing significant harm. This means, for example, that in the event a patient has a fall at the Hospital which results in harm and the patient is unable to receive this information, a telephone call should be made promptly to the patient's legal decision-maker or next-of-kin.

The responsibility for this disclosure generally lies with the patient's attending physician. If a non-physician is responsible for the unanticipated outcome, he/she should also be included in disclosure conversations.

For questions about making disclosures please contact Legal and Risk Services at 688-2291.

Should attending physicians adopt a dress code?

YNHH is in the process of finalizing standards of dress for all Hospital employees. A subcommittee of the Graduate Medical Education Committee, comprised of residents and led by Dr. John Moriarity, has drafted standards for physicians-in-training. These address visibility of name badges, hair, cosmetics and fragrances, jewelry, fingernails, undergarments, scrubs and footwear. Lab coats, ties, and overall professional dress are also addressed. Denims, sneakers (not walking shoes) and athletic attire are prohibited. From time to time, we see attendings making rounds, usually on weekends, who appear to have come directly from their gardens or a rugby match. Should attendings have some minimum dress standards? Please email your opinion to

Notice of possible change in reporting structure during a YNHH-declared disaster

Recent changes to The Joint Commission standards require that YNHH inform the Medical Staff of the reporting structure under which they would fall in the event of a hospital-declared disaster. The Hospital has a formal Emergency Operations Plan which is activated in the event of such an emergency, designating certain hospital leaders to fulfill specific roles within an incident command system. An incident commander coordinates all efforts hospital-wide, and the Chief of Staff serves as the YNHH incident command system's medical director.

In the event of a Hospital-declared disaster, the Chief of Staff or his designee is responsible for securing sufficient medical and affiliated medical staff to meet the current patient care needs. It is possible that as a member of the Medical Staff you may be asked to assist at the hospital in a role (such as emergency department triage) atypical for your usual practice. Under this structure, If you agree to do so, the chain of command would be altered slightly and you would be accountable directly to the Chief of Staff or his designee for the duration of your assignment.

According to the Medical Staff Bylaws, the normal chain of command for members of the YNHH Medical Staff is: Based on residency training, Medical Staff members are assigned to a clinical department and section (as applicable) and are accountable to the relevant clinical leaders in that department (chief, associate chief, section chief, associate section chief). The chiefs of each department report to the Chief of Staff. Clinical privileges are delineated accordingly, based upon training and experience.

In compliance with TJC, this notice conveys a possible change of reporting structure in the event of a declared emergency. If you have any questions concerning this information, contact Theresa Zinck Lederer, director, physician services at 688-2615.

YNHH applies for designation as Magnet hospital

YNHH has begun the rigorous two-year process of becoming designated a Magnet Hospital by the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association. The ANCC created the prestigious national Magnet designation program in the 1980s, after examining those hospitals that attracted and retained nurses and had outstanding patient outcomes. Today, only 305 American hospitals have Magnet status. Interestingly, the top five hospitals on the U.S.News & World Report Honor Roll are designated Magnet hospitals.

The Magnet recognition program focuses on advancing three goals: promoting quality in a setting that supports professional practice; identifying excellence in the delivery of nursing services to patients/residents; and disseminating "best practices" in nursing services. Although Magnet highlights nursing practice, this national hospital designation exemplifies increased engagement of physician and nursing relations and encourages collaboration among all departments.

Reasons for obtaining Magnet status include: increased quality and safety patient outcomes, decreased falls, pressure ulcer prevalence and mortality rates, increased patient and employee satisfaction, decreased nursing turnover and increased financial stability. For more information, contact Lori Hubbard, RN, Magnet coordinator, at 688-5715 or

Mandatory universal protocol compliance

The Joint Commission has made significant changes to it universal protocol or "procedure verification" process for 2009. These include carrying out the verification process, which includes site marking before the patient leaves the pre-procedure area, and the requirement for an alternative process for marking patients who refuse to be marked or cannot be easily marked. In those cases, at YNHH, we will place an ID band on the same side as the planned procedure with name, MRN or DOB, and the side/site.

The entire team must be present, interactive and attentive to the time-out procedure and all time-out elements must be performed and documented.

For procedures done in ORs and procedural areas, the "entire team" must include a practitioner credentialed through the Department of Physician Services (DPS) to do the planned procedure. The procedure shall not begin until the entire team completes the time-out. In situations where an additional credentialed practitioner is required to perform another procedure in the overall intervention and the practitioner is not present during the initial time-out, a second time-out must be conducted and documented.

When the practitioner arrives for bedside procedures, individuals normally involved in these procedures are accountable for documenting the time-out procedure on the standard form. All staff involved in any procedure must stop what they are doing during the time-out and be fully involved in the process.

Compliance with the elements outlined in the universal protocol will be audited randomly by independent reviewers.

YNHH nurses to begin wearing scrubs later this year

As part of our Service Excellence initiative, YNHH will be adopting staff uniforms later this year in several departments so that patients and families can better identify various caregivers, as well as to help create "a great first impression." A Standards of Appearance Team helped develop employee appearance standards and a nursing sub-committee solicited input from YNHH nurses and worked with a vendor to select a uniform style and suggest color choices for the hospital's 2,300 registered nurses. Nurses were able to vote online to choose the color.

Starting late this fall, all RNs and LPNs will begin wearing royal blue scrubs with the YNHH logo and "RN" or "LPN" embroidered in white. This includes all staff nurses, as well as patient service managers, clinical managers, off-shift administrators (when caring for patients) at YNHH, Temple, Long Wharf and the Shoreline Medical Center. The hospital will give each nurse a uniform subsidy, based on his or her full-time, part-time or causal status. A similar process is underway to select new uniforms for PCAs and BAs.

Early in the process, the YNHH Nursing sub-committee explored best practices for nursing uniforms at other hospitals. Many large academic hospitals - such as UCLA Medical Center, the Cleveland Clinic, Mayo Clinic and University of Chicago - have already converted to nursing uniforms.

New "diet choice" for YNHH patients

The Medical Board Executive Committee has recently approved a new "Diet Choice" option for YNHH and YNHPH patients. The hospital's room service diet techs will continue to monitor food choices made by patients, to determine whether these choices meet the standards set by the clinician's diet order. If the patient's choices exceed the therapeutic limits of the diet order, the tech will recommend more appropriate food choices. If the patient agrees with these recommendations, diet education will be provided and documented in the medical record.

If the patient continues to request choices which do not fit the diet order, the dietitian will be notified. The dietitian will discuss the patient's unwillingness to follow the ordered diet with his/her clinician. If the clinician agrees with diet liberalization, the patient will receive his/her choices. If the clinician feels that the ordered diet must be followed, the patient will be allowed only choices that fit the diet.

Guidelines for the 2009-2010 flu season

H1N1 influenza continued to circulate in the Northeast over the summer months albeit at lower levels than we experienced during late spring 2009. There is currently a lot of H1N1 flu activity around the U.S. and we expect to start seeing more cases in our area soon. There will likely be more cases of flu this season as there is no population immunity to the H1N1 strain and the vaccine is just starting to become available. The situation and guidance will likely change as the flu season progresses and so it is important to keep up with the most recent recommendations.

Current YNHH guidance and policies related to flu (e.g., laboratory testing, infection prevention precautions, vaccination, antiviral use, etc.) will be available online in an "Influenza" section being created on the Clinical Workstation.

With the official start of the 2009-2010 flu season, we would like to remind you of the following:

Patients from outpatient practices and community settings should not be sent to the YNHH ED for H1N1 testing unless they are seriously ill. The diagnosis of flu is a clinical one based on symptoms and specific testing for H1N1 or other flu viruses is not needed. YNHH is currently only performing H1N1 specific testing on admitted patients who have signs and symptoms of the flu.

Influenza-like-illness (ILI) is defined as fever (temperature of 100°F [37.8°C] or greater) and a cough and/or a sore throat in the absence of a known cause other than influenza. See the CDC website for the most up to date case definitions and treatment recommendations (

To avoid unnecessary testing that could compromise the function of the YNHH Emergency Department, we ask that non-acutely ill patients with a febrile respiratory illness be evaluated and managed in the outpatient setting in the usual manner (including the patient wearing a mask). Guidance for managing possible H1N1 flu patients in the outpatient setting is posted on the CDC website.

Patients with signs and symptoms of the flu who require emergency department-level care should be referred to the ED after you have:

  • Called the YNHH ED (adult: 688-2222, pediatric: 688-3333) prior to sending the patient to notify them of the patient's arrival.
  • Asked the patient to wear a mask that covers their nose and mouth and immediately go the triage desk upon arrival and avoid the waiting room and other public areas. If the patient does not have a mask, he or she should immediately ask for one upon arriving to the ED. Masks are available at the ED entrances.

Peter N. Herbert, MD
1063 Clinic Building
P: (203) 688-2604, F: (203) 688-7152

Katie Murphy
Marketing & Communications
GB 443
P: (203) 688-2492, F: (203) 688-2491

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