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Medical Staff Bulletin

February 2014

Contents

Message from the Chief of Staff

The general matter of specialty and subspecialty consultation at YNHH deserves attention from the Medical Staff. Our By-laws Rule No. 14 is minimally prescriptive on this topic. Questions frequently arise with respect to the appropriateness of consultation requests, but Rule 14 holds that "Judgment as to seriousness of the illness and the validity of diagnosis and treatment rests with the attending practitioner responsible for the care of the patient." Consultation should only be requested with the knowledge and consent of the attending practitioner. But with this knowledge and consent, there should not be efforts to deny or deflect the consultation request, particularly by residents-in-training. I frequently receive complaints that trainees demand extensive justification before acceding to a consult request, and this should not take place. If a fellow physician requests help, this should not be denied.

Rule 14 notes the timing of consultation is "dictated by the clinical urgency, but always within 24 hours."

Moreover, if documentation is provided by a member of the house staff, a clinical fellow, a physician assistant or an advanced practice nurse, the entry must be reviewed, edited if necessary, and authenticated by the attending consult practitioner. The attending consult practitioner must document the frequency of follow-up, findings and recommendations until signing off the case. Consultants may enter recommended orders either as "save work" or "sign and hold." However, except in cases of emergency, orders should not be entered by a consultant until review by the attending physician. This does not apply to pre-operative orders.

There have been frequent examples of delays in care or discharge while attending authentication of a consult is awaited. This is a particular problem in several services whose consultation is widely requested. Consultations also often result in recommendations for operative procedures. These should not be scheduled or performed, except in emergency and rarely, without direct (not chart) conversation with the attending of record.

Services should be sensitive to the consult load imposed on trainees and problems in demand, and responsiveness should be brought to the attention of the department clinical service coordinator. When trainees have simultaneous responsibility for emergency services, intensive care units, operating rooms and/or inpatient care or consultations, the burden cannot be unreasonable.

Reminder about DPH reportable adverse events

All adverse clinical events should be reported via the online event reporting system RL Solutions. RL Solutions may be accessed via the YNHH intranet or any Clinical Workstation. Certain adverse events are required to be reported to the State Department of Public Health (DPH) within seven days of the occurrence.

Examples of these are retained foreign bodies, perforations resulting in serious injury and wrong site procedures. For a full list of DPH reportable events, please refer to YNHH Administrative Policy C-I-3 or visit the DPH website http://1.usa.gov/LMHPv2. For more information, contact YNHH Legal and Risk Services, (203) 688-2291.

Performance Management Update

November 2012 - October 2013
CMS/TJC Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
297/297
100
100
ASA at D/C
275/279
99
100
B-Block at D/C
261/265
99
100
Statin D/C
269/275
98
00
PCI <90
34/35
97
100
       
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
341/341
100
100
ACEI at D/C
72/80
90
100
D/C instr. given
222/237
94
100
       
Pneumonia
#
YNHH%
Nat’l 90th%
Blood Cx before Abx
191/201
95
100
Initial (ICU and non-ICU)
Selection Abx
70/71
99
100
       
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
388/398
98
100
Abx selection
392/396
99
100
Proph Abx D/C
368/373
99
100
DVT proph ordered
399/400
99
100
DVT proph given
394/397
99
99
6 am glucose
110/118
93
100
BB Periop period
238/238
100
100
Foley removal POD2
384/399
96
100

Eleven Joint Commission surveyors visited Yale-New Haven Hospital between January 6-10, and accredited the hospital, and the ambulatory psychiatric and durable medical equipment programs at the same time. The Joint Commission survey was the first comprehensive, hospital-wide review since the integration of the Saint Raphael Campus, the establishment of the Yale-New Haven Children's Hospital at Bridgeport Campus and the addition of certain ambulatory and physician practices. The accreditation validated the SRC integration activities associated with safety, performance improvement, roles and responsibilities and the standardization of policies and practices.

The surveyors complimented physicians, nurses and staff on outstanding patient-centered care, citing patient safety and high-reliability organization, seamless patient transitions, effective hand-off communications, overall continuity of care and successful implementation of Epic. They also singled out the SRC integration as one of the finest they have seen across the country and were effusive in their praise of how far we have come as one hospital in 16 months.

The surveying team also recognized opportunity for improvements in some physician-driven practices, particularly related to perioperative/procedural and ambulatory services. In the perioperative and procedural areas recommendations for improvement include:

  • Informed consent documentation must be fully completed, including the risks related to not receiving the proposed intervention, with all medical record entries dated, timed and with legible signatures
  • "Day of procedure or within 24 hours update to the H&P" must reflect that the (within) 30 day H&P was reviewed, the patient examined, and document whether there were any relevant changes in the patient's condition or not since the 30 day H+P
  • "Brief operative/procedural note" must be fully completed and available in the medical record before the patient is transferred to the next level of care, unless the full operative/ procedural report is dictated, transcribed and in the medical record upon transfer (which is most unlikely)
  • High-level/sterilization disinfection practices, along with utilization and labeling of sample medications in the ambulatory areas.

The success of this Joint Commission accreditation was a credit to the entire patient care team and support services. Thanks to the medical staff employees for and their continuous commitment and dedication to high-quality, patient-centered care aligning our efforts to becoming a destination hospital.

Adult and pediatric rapid response teams

YNHH has rapid response teams (RRTs) for both adult and pediatric patients.

The indications for calling an adult RRT are:

  • Heart rate of less than 50 or greater than 130
  • Respiratory rate of less than 8 or greater than 25
  • Systolic blood pressure of less than 90 or greater than 200
  • Oxygen saturation of less than 90% on prescribed oxygen
  • Change in mental status
  • General concern / worry about a patient for any reason

Any member of the healthcare team can activate the adult RRT by contacting the pager operator (dial 155). Make sure you have the name and location of the patient.

The indications for calling a pediatric RRT are:

  • Respiratory distress of any kind
  • Acute/sustained change in respiratory rate: Less than 12 or greater than 80 breaths per minutes in an infant (less than one year old), less than 10 or greater than 60 breaths per minute in a child (one to ten years old); less than 8 or greater than 50 breaths per minute in an adolescent (older than 10)
  • Acute change in oxygen saturation
  • Asthma score of greater than 6 or difficulty speaking
  • Acute / sustained change in blood pressure after treatment: systolic less than 60 or diastolic less than 30 in an infant; systolic less than 80 or diastolic less than 40 in a child or systolic less than 90 or diastolic less than 45 in an adolescent
  • Acute / sustained change in heart rate or abnormal heart rate: less than 80 or greater than 200 in an infant; less than 60 or greater than 180 in a child; less than 40 or greater than 130 in an adolescent
  • Acute loss of urine output (less than 0.5 ml/kg/hr for four hours
  • Mottled, cool skin, prolonged capillary refill
  • Neurologic concerns (e.g. unexplained decrease in consciousness, repeated or prolonged seizures, change from baseline seizures)
  • General concern / worry about the patient for any reason

Any member of the heath care team can activate the pediatric RRT by contacting (203) 688-2323 (Pediatric ICU). Make sure you have the name and location of the patient.

Ongoing support available for Epic

Ongoing support and training for Epic are available to members of the Medical Staff who have questions, challenges or want to improve proficiency. To contact the Epic Enhanced Clinical Support team, call (203) 688-0279 on the York Street Campus or (203) 789-3958 at the Saint Raphael Campus weekdays between 7 am and 3 pm, and between 7 am and noon on weekends.

This team can help with the Epic EMR, both inpatient and ambulatory workflows, and provide assistance in person or over the phone with remote access to your computer. Advanced training classes are also being offered to help clinicians take their Epic skills to the next level. Providers have found learning more about workflows such as communication (letters, referrals), inbasket and note writing to be very useful and big time savers. For more information or to register for a class, go to https://ynhhs.skillport.com, and enter your Epic username and password "epictrain."

Medical staff "high reliability" training to begin this spring

For the last three years, Connecticut hospitals have been working with CHA and Healthcare Performance Improvement (HPI) on a statewide initiative to become high reliability organizations (HROs) — organizations that operate successfully in high-risk industries. Nearly 250 hospital leaders — including 100 from YNHH — have participated in HRO training at the Connecticut Hospital Association. The program focused on methods and practices for instilling safety as a core value.

The goal is to build a culture of collegial teamwork where sound practice habits are adopted, resulting in a culture of safety. The leadership program focused on how to set the tone of safety as a core value, find and fix barriers to effective performance, and build and reinforce accountability. Training for members of the YNHH Medical Staff is being developed now and will begin in early spring. YNHH's effort, which is called "Getting to Zero Events of Harm," relies on much of the CHA/HPI training materials, including a mnemonic device to remember five key safety behaviors: CHAMP, which stands for:

C Communicate clearly
H Handoff effectively
A Attention to detail
M Mentor each other — 200% accountability
P Practice and accept a questioning attitude


Update on United Healthcare contract


For the past four months, Yale New Haven Health System has been working to negotiate a new contract with UnitedHealthcare/Oxford Health Plan, and renewal terms have been completed for Bridgeport Hospital, Greenwich Hospital and Northeast Medical Group. We have also reached an agreement for clients with United commercial insurance at Yale-New Haven Hospital and Yale Medical Group, but not for those with Medicare Advantage health insurance.

As of April 1, YNHH and YMG doctors will now be considered out of network for clients with Medicare Advantage. Those clients will lose in-network access and face higher out-of-pocket costs to receive care at YNHH or with any of the 60+ Yale Medical Group facilities and 1,200 doctors in the medical group. Unless CMS intervenes, United patients with Medicare Advantage should consider choosing another plan to retain in-network benefits for YNHH and YMG.

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