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Medical Staff Bulletin

Contents - October/November 2013


A message from the Chief of Staff
Tom Balcezak and I are in the process of presenting grand rounds in most departments on the topic, "Keeping Patients Safe at Yale-New Haven Hospital." We are focusing largely on issues we need to address rather than program successes, which are many. We are also announcing YNHH's quest to become a truly high reliability organization. Following are details of our institutional approach which is in the advanced planning stage. This work is the underpinning for all we do and will require three hours of training for all members of the Medical Staff. As we evolve our safety culture, all levels of caregivers must commit to responsibility and accountability for the safety of our patients. Paraphrasing Donald Berwick, the basic ask of all patients is: "Don't hurt me, help me if you can, and please treat me with kindness."

We also are undertaking the last phase of our hand hygiene campaign to ensure that every clinician and support person disinfects their hands before contact with a patient or patient environment. There will be a special focus on the so-called off-shifts: evening, nights and weekends. These comprise the "other hospital" where we have not previously observed the hand hygiene habits of workers. Everyone should feel empowered to gently remind colleagues if they forget to decontaminate their hands and, indeed, to say "thanks" when reminded. Physician and nursing champions will lead this effort on every nursing unit, and we are grateful for their commitment.

YNHH honored by FDA
YNHH was honored in late October by the U.S. Food and Drug Administration's Center for Devices and Radiological Health with an "FDA Certificate for Outstanding Contribution in Promoting Patient Safety with Medical Devices." YNHH reported a major problem with a cardiovascular adult oxygenator which contributed to a Class II recall. The citation is the result of the work done by the YNHH licensed perfusionists as part of their response to a catastrophic device failure that occurred in the CTICU on the York Street Campus. Our team isolated the problem to a single product and sounded the alarm at the national level. Their rapid actions tangibly contributed to preventing harm to other patients. This is the third such award YNHH has received. Such recognition demonstrates the importance of staff involvement in recognizing and reporting any problems with medical devices that might lead to patient harm.

YNHH opens new blood draw station in Orange
YNHH opened a new blood draw station at 236 Boston Post Road in Orange. The blood draw station offers adult and pediatric blood draw services. No appointment is necessary and most major insurance plans are accepted. The Orange blood draw station is open Mon. —Fri., 7 am-5:30 pm (closed daily 12:30-1 pm) and Saturday from 8 am - noon.

July 2012 - June 2013
CMS/TJC Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
314/314
100
100
ASA at D/C
275/281
99
100
B-Block at D/C
310/318
99
100
Statin D/C
265/268
98
100
PCI <90
30/30
100
100
       
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
352/352
100
100
ACEI at D/C
80/88
89
100
D/C instr. given
216/231
89
100
       
Pneumonia
#
YNHH%
Nat’l 90th%
Blood Cx before Abx
182/192
95
100
Initial (ICU and non-ICU)
Selection Abx
73/75
97
100
       
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
364/376
97
100
Abx selection
369/374
99
100
Proph Abx D/C
346/350
99
100
DVT proph ordered
268/270
99
100
DVT proph given
394/397
99
99
6 am glucose
109/115
95
100
BB Periop period
236/236
100
100
Foley removal POD2
362/386
94
100

Performance Management update
With a new fiscal year, YNHH faces new challenges and new programs to propel the organization forward into 2014. One critical component of the FY 2014 corporate objectives and PIP is the initial steps we will be taking to become a high reliability organization (HRO). Healthcare has lagged behind many industries in understanding how to engineer human factors to improve outcomes.

In October, YNHH decided to make the commitment that many of our peers across the country and in Connecticut have taken to begin this journey. What does this mean? The Connecticut Hospital Association has engaged in a multi-year commitment of "getting to zero" in terms of harm to patients by partnering with a company called Healthcare Performance Improvement (HPI). HPI was founded by leaders from the nuclear power industry and are currently working with more than 500 hospitals across the United States to infuse key interventions into hospitals and ambulatory sites that improve the safety of patients. This is achieved by learning from our failures over the past two-three years, interviewing staff, understanding what our safety attitude survey tells us and then applying this knowledge to a custom curriculum for the organization to learn about safety science and the key behaviors that we must embody to improve the safety of our patients.

In late October, we began this diagnostic work. There will be more communication over the coming months about how medical staff will be trained and the interventions that we will all begin to practice to make our patients safer. If you would like to learn more about this program as it is being developed, or you would like to be part of the team of trainers, please do not hesitate to contact Kathleen Testa, Quality Improvement Support Services, at kathleen.testa@ynhh.org.

Separately, please remember that we are due for an unannounced Joint Commission survey anytime. For additional information, please do not hesitate to contact Tori Dahl Vickers of the Accreditation, Safety and Regulatory Affairs team. Please direct any questions to Tom Balcezak, MD, (203) 688-1343.

Kcentra now available through Epic
Kcentra™, a four-factor prothrombin complex concentrate (PCC) containing factors II, VII, IX, and X, is now available to order in Epic (search "PCC" or "Kcentra"). Kcentra has recently been FDA approved for Warfarin reversal in patients with life threatening major bleeding. Kcentra should be given after holding the patient's Warfarin dose and administering Vitamin K (10 mg, intravenous).

Kcentra dosing is based on the INR and the patient's weight:

Pre-treatment INR 2-<4 4-6 >6
Dosr (units/kg) 25 35 50
Max dose (units) Not to exceed 2500 Not to exceed 3500 Not to exceed 5000

At YNHH, all orders at for Kcentra must be approved by the on-call transfusion medicine physician, who can be reached at (860) 340-3411. After approval, the product will be reconstituted and available for pick-up in the blood bank.

Dual campus clinical planning continues
Year two of the integration with the Saint Raphael Campus will bring more specificity to the reconfiguration of clinical services on both campuses. Major medical/surgical services, emergency care, heart and vascular, neurosciences, cancer care and behavioral health will remain in place on both campuses. High-acuity services will remain at York Street; and there will be more of a focus on specialty services at SRC, such as the musculoskeletal center, low-risk/high-amenity obstetrics, comprehensive geriatric services and several specialized programs, a hernia center, digestive diseases and cardio-renal services.

Planning for the new musculoskeletal center at SRC continues, with the goal of making the patient experience there similar to the successful team approach at Smilow. The Grimes Center has undergone renovations to better meet the needs of rehabilitation and post-surgery orthopedic patients. In early 2014, elective and orthopedic spine patients will begin to move to Verdi 4 North on the Saint Raphael Campus, followed by the Acute Care for the Elderly Unit and other specialized programs. Details of other unit moves and transitions will be finalized once the major services for musculoskeletal, acute Geriatrics and low-risk Obstetrics are solidified on the Saint Raphael Campus. A number of other enhancements to clinical support services, such as the operating rooms, will occur in tandem with other inpatient unit moves.

Verdi 4 North ribbon-cutting is first step toward musculoskeletal center
Yale-New Haven Hospital took another step in the development of a musculoskeletal center on the Saint Raphael Campus on Oct. 14, with the dedication of a newly refurbished 29-bed unit on Verdi Four North, now designated the Dr. Robert J. and Lorraine D. Cronin patient care unit. In the first quarter of 2014, the new unit will begin to care for orthopedic patients as a first step toward creating the hospital's musculoskeletal center. Speaking at a brief ribbon-cutting ceremony were YNHH President Richard D'Aquila, Peter Herbert, MD, and Robert Alpern, MD, dean of Yale School of Medicine, as well as benefactor Lorraine Cronin, after whom the unit is named.

Plans for renovating the unit began shortly after integration in September 2012 with contributions from an interdisciplinary team from both campuses whose members worked to bring best practices from the construction of Smilow Cancer Hospital and prior renovations of units on York Street. Clinicians contributed to the design of the unit that would treat orthopedic patients and meet their special recovery needs.

Update on medical library access and study space at Saint Raphael Campus
A new study space for students, employees and physicians outfitted with computers, printers and work space will open by the end of the year. Access to the space, which is located on the first floor of the Orchard Medical Building on the Saint Raphael Campus, will be with your YNHH ID badge.

In addition, all members of the YNHH medical staff now have full use of the Yale School of Medicine's Cushing/Whitney Medical Library, including access to print and electronic resources, and professional staff assistance. All electronic resources, including ebooks, ejournals, databases and point-of-care tools, are available from a link on YNHH clinical workstations at both campuses. Within Epic, a dropdown "Library Services" tab allows users to easily access several popular point-of-care resources: UpToDate, Micromedex and AccessMedicine. Remote access to this vast array of online resources from home or office is available to all Medical Staff. Those with a Yale University affiliation can use their NetID to connect through the Yale VPN. Medical Staff without a university affiliation may request an account on the Medical Library Proxy Server. Details on remote access options are available at http://library.medicine.yale.edu/services/computing/remote.

For more information about remote access or any question about library resources and services, contact one of the clinical support librarians: Mark Gentry at mark.gentry@yale.edu, (203) 785-2163 or Denise Hersey at denise.hersey@yale.edu, (203) 785-6251.

Paul Taheri, MD, named CEO of Yale Medical Group
Paul Taheri, MD, MBA, is the new chief executive officer of Yale Medical Group (YMG), and a deputy dean at the Yale School of Medicine. He is also a YNHH attending surgeon in the section of Trauma. Dr. Taheri joined YMG from University of Vermont (UVM), where he was president and CEO of the UVM Medical Group in Burlington, and senior associate dean for clinical affairs, as well as a professor of Surgery. Before that he was division chief of Trauma, Burn and Critical Care, and then vice chair of Surgery at University of Michigan in Ann Arbor, where he completed his MBA at the Ross School of Business. Dr. Taheri completed his medical degree at New York University and his general surgical residency at Tulane University. He is the past chair of the Group on Faculty Practices for the Association of American Medical Colleges, an examiner for the American Board of Surgery, and has lectured broadly on various business topics, including cost of care, physician leadership and system optimizations.

YNHH house staff starts Gold Humanism Honor Society chapter
The Arnold P. Gold Foundation Humanism Honor Society (GHHS) honors medical students, residents, role-model physician teachers and other exemplars recognized for "demonstrated excellence in clinical care, leadership, compassion and dedication to service." Humanism in medicine describes relationships between physicians and their patients that are respectful and compassionate. It is reflected in attitudes and behaviors that are sensitive to the values, autonomy and cultural and ethnic backgrounds of others.

About two years ago, Rosemarie Fisher, MD, director/associate dean, Graduate Medical Education, was on a Gold Foundation strategic planning committee that was discussing ways to bring residents into the humanism in medicine model. They developed a proposal to create Gold Humanism Honor Society chapters for residents. Dr. Fisher, along with Leonard Moore, MD, second-year primary care resident; Jing Luo, MD, third-year primary care resident; and Rajitha Devadoss, MD, a third-year pediatrics resident, submitted a grant proposal for a YSM/YNHHS Gold Humanism in Medicine Resident Chapter, and last fall, the medical school and Yale New Haven Health System became one of 10 organizations nationwide awarded a pilot grant.

The mission of the Yale Resident Chapter of the Gold Humanism Honor Society (GHHS) is to enhance humanism in personal, professional and community roles and encourage and honor residents who demonstrate a capacity for humanism and patient-centered care. In May, the first chapter was inducted — 56 individuals selected from among the system's 1,100 residents through peer nomination and review by members of the chapter's organizing committee. The chapter has been involved in various projects that contribute to the community, enhance humanistic practice of healthcare providers and strengthen the doctor-patient relationship. They have planned a humanism-in-medicine lecture series; participated in community health fairs and held a silent auction to raise awareness funds for health care for the underserved.

Gregory Germain, MD, named associate chief of Pediatrics
Gregory Germain, MD, has been named associate chief of Pediatrics at Yale-New Haven Children's Hospital. Dr. Germain is an associate clinical professor at Yale School of Medicine and an assistant clinical professor at the University of Connecticut School of Medicine. He is an attending physician with the Yale Pediatric Endocrine Clinic and is in private practice with Pediatric and Medical Associates, P.C. He earned his medical degree from the University of Connecticut School of Medicine and completed a residency at Yale-New Haven Hospital.

Michael DiLuna, MD, named chief of Pediatric Neurosurgery
Michael DiLuna, MD, has been named chief of Pediatric Neurosurgery for the department of Neurosurgery and Yale-New Haven Children's Hospital. Dr. DiLuna completed his undergraduate and medical degrees at Yale, and his residency in neurosurgery at YNHH. After completing a fellowship in pediatric neurosurgery at the Children's Hospital of Philadelphia in 2010, he returned to Yale-New Haven as assistant professor of neurosurgery and pediatrics. He assumes his new role at a time of expanding development, clinical program growth and enhanced efforts around quality, safety and patient experience for the Children's Hospital.

Special thanks to Dr. Charles Duncan for his many contributions as the founding Chief of Pediatric Neurosurgery. His leadership of the section and commitment to the care of children has had a profound effect on our institution, for which we are all most grateful.

David Caminear, DPM, becomes associate chief of new Podiatric Surgery and Medicine
David Caminear, DPM, has been named the associate chief of Podiatric Surgery at YNHH. He is an attending physician at YNHH and was section chief of podiatric surgery at the former Hospital of Saint Raphael. He joins Steven Vyce, DPM, who recently became the first chief of YNHH's new department of Podiatric Surgery and Medicine. Dr. Caminear is an assistant clinical professor, department of Orthopaedics and Rehabilitation at Yale School of Medicine and is in private practice with Connecticut Orthopaedic Specialists.

Thomas Sweeney named associate chief of Surgery
Thomas Sweeney, MD, an attending physician at Yale-New Haven Hospital for more than 35 years, has been named associate chief of Surgery. Dr. Sweeney is also medical director, Surgical Services, Saint Raphael Campus, and associate chief of Vascular Surgery at YNHH. He is an assistant clinical professor of surgery at Yale School of Medicine and is in private practice with Connecticut Vascular Center, P C.

Dr. Sweeney earned his medical degree from Yale School of Medicine and completed an internship and surgical residency at YNHH, where he was chief surgery resident. Dr. Sweeney, a past president of the Medical Board at YNHH, was named outstanding surgical teacher at the former Hospital of Saint Raphael in 1992.

Naftali Kaminski named head of section of Pulmonary Critical Care
Naftali Kaminski, MD, has been named chief of the section of Pulmonary Critical Care and Sleep Medicine at YNHH and Yale School of Medicine, and the Boehringer-Ingelheim Professor of Internal Medicine. Before joining YNHH, Dr. Kaminski held numerous positions at the University of Pittsburgh School of Medicine, including professor of medicine and associate professor of computational biology, human genetics and pathology. He was also director, Lung, Blood and Vascular Center for Genomic Medicine; director, Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, and the Simmons Center Endowed Chair for Pulmonary Research.

Dr. Kaminski earned his MD from Hebrew University-Hadassah Medical School, Jerusalem; completed a residency in internal medicine at Hadassah Mount-Scopus University Hospital, Jerusalem; a fellowship in pulmonary medicine at Sheba Medical Center, Tel-Hashomer, Israel; and post-doctorate work in cellular and molecular biology, functional genomics and microarray technology at the University of California, San Francisco.

YNHHS adopts new mission, vision and values statements
Yale New Haven Health System has refined its mission and vision, and has identified five core values, to guide our organization, provide the framework to anticipate and proactively prepare for the future, and move forward in as strong a position as possible in this enormously challenging environment. Having a single mission, vision and set of values for our System — including the three hospitals and Northeast Medical Group (NEMG) — provides a clear direction and common focus and helps unify the system, and supports evolution to the desired culture identified by staff and physicians.

Mission: YNHHS is committed to innovation and excellence in patient care, teaching, research and service to our communities. The mission reflects the purpose and the underlying commitments that have been a hallmark of YNHH and YNHHS.

Vision: YNHHS enhances the lives of those we serve by providing access to integrated, high-value, patient-centered care in collaboration with others who share our values. The vision is aspirational, reflecting the imperative that patient care must provide the value — high quality, patient-centered, cost-conscious — that patients and payers expect. It also acknowledges the need to carefully choose partners to achieve our goals.

Vision: Our new system-wide values reflect responses for a "desired culture" from more than 7,600 YNHHS employees, leaders and physicians on the 2012 Values Assessment Survey. The values, which are expected to be demonstrated in both individual and organizational behaviors, are: patient-centered, accountability, integrity, respect and compassion.

YNHHS will be moving to ICD- I0
The federal government is requiring providers and payers to transition from ICD-9 codes, used nationwide since 1979 for all diagnoses and inpatient procedures, to a new coding system — ICD-10. Over the next year, Yale New Haven Health System will update systems using the outdated ICD-9 codes with more specific ICD-10 codes for patient diagnoses and surgical codes for inpatient surgeries.

Because ICD-10 codes are more specific, the number of codes healthcare providers use will increase from around 14,000 to around 70,000. For example, there are nine ICD-9 codes for a pressure ulcer diagnosis, including one for "pressure ulcer, lower back." There are 150 ICD- 10 codes for pressure ulcers that are more specific, such as "pressure ulcer of right lower back, stage 2." Improved documentation, updated software applications, and organization-wide educational efforts are underway.

All physicians throughout the Health System and Northeast Medical Group, as well as Yale Medical Group, will be trained in 2014. Additional training for Health Information Management (HIM) will also be required. Other employees will receive more general training and information. Twelve subcommittees have formed to support this multidisciplinary, system-wide effort, led by Cindy Zak, director of HIM and Coding. The ICD-10 conversion will also require changes to Epic.

Hospitals and other healthcare organizations that do not implement the ICD-10 codes by October 1, 2014 will not receive full reimbursement from the government or private payers.

Watch for more communications about this project, including training schedules.

Project Access-New Haven celebrates third anniversary
With dedicated physician volunteers, support from YNHH and a network of community partners, sponsors and donors, Project Access-New Haven (PA-NH) has marked a successful three-year anniversary, with more than 700 low-income, uninsured patients receiving over $9.5 million in medical care and services. More than 300 physicians see patients free of charge through the program, a community-led effort designed to expand healthcare resources for underserved patients and increase access to urgent medical care for those most in need. YNHH donates diagnostic testing, inpatient and surgical facilities and other services at its York Street and Saint Raphael campuses. Community partners donate everything from orthotics and prosthetics to taxi rides.

Since it opened with one referral site and two staff members in September 2010, PA-NH has grown substantially — adding staff and expanding to six primary referral sites in the Greater New Haven community. PA-NH's healthcare delivery model centers around a team of patient navigators who coordinate care and help patients overcome access barriers. Key program successes include reduced medical appointment wait times and a no-show rate of 3 percent. Patients also report improved health and quality of life, increased access to care, and high satisfaction with the program.

Other community partners include Fair Haven Community Health Center, Cornell Scott-Hill Health Center, Yale University-Robert Wood Johnson Foundation Clinical Scholars Program, Community Foundation for Greater New Haven, New Alliance Foundation, Connecticut State Medical Society and New Haven County Medical Association.

Starting in January, Yale-New Haven Hospital will have one version of the basic consent form needed for all surgical or invasive procedures including interventional radiology, placement of central lines, chest tubes and biopsies. The new Form 1696 will replace both the older Form 1696 as well as the one-page surgical consent that is used in some of our ambulatory locations, AF1019.

The biggest change to the form is in the section regarding transfusion of blood products. It requires the patient to initial either the line agreeing to blood products or the one refusing them. This change will be accompanied by the introduction of a new informed consent form for transfusions being given for reasons not associated with surgery or other procedures. That form will need to be signed once per admission for any patients receiving blood products. Outpatients who return regularly for infusion of blood products will need a new form every 90 days.

Bylaws changes to "Refer & Follow" medical staff category
At the October Medical Board meeting, a change to the Medical Staff Bylaws relating to the "Refer & Follow" medical staff category was approved. The recommended change will allow physicians in this category to refer patients for "laboratory or radiologic studies, infusion therapy or other similar such outpatient procedures at the hospital." This modification is currently out for vote with the active medical staff and expected to be finalized by the Board of Trustees at the end of November.

Announcement of massive transfusion protocol optimization
Effective immediately, the massive transfusion protocol (MTP) will no longer include recombinant Factor VIIa (Novo7). This change is due to concerns of prothrombotic tendencies in off-label use. The adult MTP will now offer the option of tranexamic acid for massively bleeding trauma patients who arrive within 3 hours of the time of injury. This product is located in the Pyxis in areas that activate the MTP. Please contact the Blood Bank physician on call (860) 340-3411, with any questions or concerns.

YNHH breaks ground with Radium 223
In July, YNHH became the first hospital in Connecticut to treat patients with radium 223. Radium 223, or Xofigo, is a new radiation oncology therapy that is giving renewed hope to patients with stage 4 hormone-refractory prostate cancer (HRPC), and can improve survival and palliate bone pain. Daniel Petrylak, MD, led this multidisciplinary effort, that included medical oncology and urology, to bring the compound to YNHH and to treat advanced prostate cancer. Dr. Petrylak has directed international studies in prostate cancer treatment and is a recognized thought leader in that field. Greenwich Hospital's radiation oncology team started treating patients with radium 223 shortly after YNHH. Looking ahead, Dr. Petrylak and team will be conducting a randomized phase 2 trial to determine if combining radium 223 with another proven drug treatment will improve outcomes. The study will compare combining radium 223 with Abiraterone or MDV 3100 and enrollment is expected to begin early next year.

New leadership at Fair Haven FQHC
YNHH Gastroenterologist Suzanne Lagarde, MD, is the new chief executive officer at the Fair Haven Community Health Center, one of New Haven's federally qualified health centers for underserved populations. Dr. Lagarde earned her MD from Cornell University Medical College and completed her residency and gastroenterology fellowship at Yale-New Haven Hospital. Before joining Fair Haven Community Health Center, she was in private practice of Gastroenterology in Southern CT. She is a founding member of Project Access-New Haven and currently serves as immediate past President of the Board of Directors. Dr. Lagarde is also licensed in Mississippi and until recently made quarterly trips to Biloxi, working with mostly uninsured patients at Coastal Family Health Center, a clinic serving more than 30,000 patients, most of whom are uninsured. In April 2010, Dr. Lagarde received the Biloxi Health Volunteer of the Year Award for her work.

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