October 2008

Medical Staff Bulletin

Contents

Message from the Chief of Staff
In February 2008, YNHH had an unannounced, full accreditation survey by The Joint Commission (TJC). In March 2008, a full Medicare survey was conducted to assess compliance with Conditions of Participation as well as to conduct a Department of Public Health (DPH) license renewal inspection. TJC gave us four months to verify improvement in matters such as medication reconciliation, banned abbreviations, and the use of the universal protocol for "time outs." TJC determined that all the issues they identified were resolved after we submitted progress reports in July.

Corrective action plans were also developed and accepted by DPH for a number of different citations. The latter were embodied in the consent agreement signed by YNHH at the end of September. Many of the DPH issues related to documentation deficiencies on the part of both nursing and physician staffs. These included adequacy of pre- and post-operative anesthesia evaluations and updated histories and physicals before elective surgery. Other concerns related to retained foreign bodies and monitoring of ventilation after extubation.

One important citation related to our failure to prevent pressure ulcer development in a patient with a lumbar spinal fracture. This occurred in mid-2007 and illustrated a problem that has received a great deal of regional and national attention. Prevention of decubitus ulcers in immobilized patients, particularly those in ICUs on mechanical ventilation, has proved most challenging and has required new approaches and strict protocol adherence. For most of the last two years, pressure ulcer prevalence has averaged 7-10 percent among our patients as judged by quarterly surveys. During the current year, however, with the use of creative nursing approaches, the prevalence has fallen from 8.7 percent in the first quarter to 4.9 percent in the last. Because of advanced age and extreme skin fragility in many patients, it is acknowledged that pressure ulcer prevalence cannot be totally eliminated. At this juncture, however, our nursing staff has made outstanding progress.

Medical Staff co-sponsors Habitat for Humanity House
Yale-New Haven Hospital and the YNHH Medical Staff are co-sponsoring a Habitat for Humanity house located at 15 Wilson Street in the Hill neighborhood of New Haven, just a few minutes away from the hospital. Construction will begin later this fall and the house should be complete in spring 2009. Dr. Brett Gerstenhaber and Habitat volunteers Drs. Suzanne Lagarde and Michael Bennick were instrumental in the Medical Staff’s participation. YNHH and the Medical Staff are each contributing manpower and $25,000 to this effort.

Members of the Medical Staff and YNHH employees are invited to volunteer to work on the house, Tuesdays through Saturdays, from 9 a.m. to 4 p.m. No construction experience is necessary, as Habitat construction staff provide the necessary training. Habitat for Humanity of Greater New Haven is fully insured, and all volunteers are covered by an umbrella policy for disability and an accident medical policy. If you are interested in volunteering for a day (or more), please contact Jennifer Bowers in YNHH Employee Relations at 688-2402.

Performance management update
As you will see in the performance measures that we report each month to CMS/TJC, YNHH continues to perform very well in almost all situations. The big news this month is our performance in heart failure discharge instructions. For the first time, we have broken the 90 percent barrier. This impressive performance is due to a combination of work done within nursing discharge instructions and aligning the Discharge Instruction Med List with the Med List in the Dictated Discharge Summary. While there continue to be some technical difficulties in importing the Discharge Instructions into the Discharge Summary, this change in practice has resulted in a tremendous improvement in Medication List Concordance.

YNHH continues to perform sub-optimally, however, for the SCIP measure of antibiotic selection for certain surgical procedures. Analysis of our failures showed that pre-operative antibiotic selection has been incomplete in some cases (e.g. omission of metronidazole when using cefazolin for colorectal surgery) or does not conform to YNHH/CDC/CMS recommendations (e.g. incorrectly using ciprofloxacin instead of a cephalosporin/metronidazole combination for colorectal surgical patients without history of anaphylactic penicillin allergies). In the box below are YNHH Pharmacy and Therapeutics Committee approved guidelines for perioperative prophylactics for selected surgical procedures:

Finally, Medical Staff are reminded that prophylactic antibiotics for the above procedures must be discontinued within 24 hours (48 hrs. for CT surgical procedures) of the end of the surgical procedure to meet the CMS measure for duration of prophylactic antibiotics.

Thank you for your attention to these important matters. If you have any questions regarding these measure sets or performance, please do not hesitate to contact Tom Balcezak, MD.

Information about flu vaccines for medical staff and patients
Medical Staff members can receive a free flu vaccination in the East Pavilion cafeteria special events area on November 5 from 10 a.m.-5 p.m., November 6 from 9:30 a.m.-5 p.m., and November 7 from 6:30 a.m.-2:30 p.m. No appointments are necessary.

The Medical Staff is reminded that influenza and pneumococcal vaccination of inpatients are publicly reported CMS measures for pneumonia patients. As of October 1, 2008, YNHH re-instituted annual screening of inpatients for receipt of influenza vaccine. Using the Nursing Admission Assessment in SCM, all inpatients are screened for vaccine indications, contraindications, as well as their vaccine history. This information is transmitted to the pharmacy to enter a protocol order for vaccination, if appropriate.

If an inpatient has received influenza vaccine as an outpatient since September 1, 2008, or pneumococcal vaccination within the last five years, please note this in the medical record and inform the patient’s nurse so the vaccine can be charted in SCM with the notation of "Not given due to prior receipt of vaccine." This way, the charting of the vaccine removes the order from the patient’s profile and allows appropriate documentation of why the vaccine was not administered during the inpatient stay.

Demand management update
As previously noted in Medical Staff Bulletin, Carpedia International is engaged with Yale-New Haven Hospital to improve patient flow and throughput. While the opening of Smilow Cancer Hospital will add needed inpatient capacity, we have substantial challenges to manage growing demand before then. There is crowding in the Emergency Department; delays in admitting patients; difficulty in moving patients through critical points in the hospital (the operating room, diagnostic radiology, etc.); and delays associated with discharge.

We are now 11 weeks into a 40-week engagement and have reached a couple of milestones. In the past 11 weeks, teams including members of the Medical Staff, employees and consultants have observed patients, staff, physicians and ancillary caregivers for hundreds of hours. These teams have collected many ideas to improve the flow of patients — or "method changes."

As a next step, which started the week of September 29, the Hospitalist team and others in the department of Internal Medicine will be working together to implement many of these "method changes" on a trial unit, East Pavilion 5-5. This unit was chosen for its high volume of patients, its highly committed and flexible staff, and a strong and dedicated leadership. By the end of three weeks, we should have a good sense of what improves the quality of experience for our patients and our staff, and what doesn’t. We subsequently will be adopting many of these changes in other units.

There may be some short-term difficulties while trialing new processes, but we are committed to improving overall patient flow. If you have any questions about this, please do not hesitate to contact Sandy Bacon, RN, at 688-9432 or Tom Balcezak, MD, at 688-1343.

Mortality and HCAHPS data posted to YNHH website
The federal government, through the Centers for Medicare & Medicaid Services (CMS), has developed a survey instrument to collect information on patients’ perceptions of the care they receive while in the hospital. This information — called HCAHPS, for Hospital Consumer Assessments of Healthcare Providers and Systems — is readily available to the public. YNHH has recently posted the data on its website.

The most recent HCAHPS results for YNHH (January-December 2007), while disappointing, do not reflect the Service Excellence efforts that have taken place over the past year. These will hopefully be reflected in the next set of HCAHPS results.

A sampling of some of the questions show:

• How often did nurses communicate well with patients? 72 percent answered "Always," compared to the US average of 74 percent
• How often did doctors communicate well with patients? 75 percent answered "Always," compared to the US average of 80 percent
• How often was patients' pain well controlled? 64 percent answered "Always," compared to the US average of 68 percent
• How often did staff explain about medicines before giving them to patients? 54 percent answered "Always," compared to the US average of 59 percent
• Were patients given information about what to do during their recovery at home? 78 percent answered "Always," compared to the US average of 80 percent

To view the results in more detail, go to the YNHH website and click on "Quality" in the masthead of the page. In addition to the new HCAHPS section, mortality data has been added to the existing sections on CMS measures for AMI, heart failure and pneumonia.

YNHH emergency number changes to 911
On Nov. 1, 2008, the hospital’s emergency number will become 911 — it will no longer be 119. When you call 911, please tell the operator what type of emergency has occurred: fire, cardiac arrest, medical emergency, police, etc. For routine security calls, YNHH Protective Services number is 688-2500. YNHH’s page operator codes are:

• CODE 5 — Adult cardiac arrest or medical emergency
• CODE 7 — Pediatric cardiac arrest or medical emergency
• ORDER #1 — Fire or smoke

Veriphy — notification of Diagnostic Radiology critical results — goes live
Veriphy, the new communication system which notifies the ordering physician that a critical or urgent diagnostic radiology test result is available, goes live on Monday, Oct. 20. Veriphy is integrated with the Diagnostic Radiology dictation system. This allows the radiologist to easily report and track a critical finding during the reporting process. Veriphy has been designed to follow a path of escalation based on each clinician’s preferences until the alert has been retrieved by a responsible provider.

Over the past six months, the Veriphy team has contacted more than 4,000 ordering clinicians to obtain the specific notification preferences of individual physicians — whether they would like to be contacted by pager, cell phone, text message, fax, email or answering service. This new system not only ensures that the physician receives the message, but also provides the required documentation for The Joint Commission.

For more information about Veriphy, please email veriphy@ynhh.org or call 688-5482

Adler Geriatric Center moves to 874 Howard Avenue
In an effort to create more inpatient beds, the Dorothy Adler Geriatric Assessment Center moved to 874 Howard Avenue in mid-September. Maternal fetal medicine will move into the space vacated by the Adler Center and 14 new inpatient beds will be added on SP 4-5 & 4-6. All Adler Center patients were notified of the move by telephone before their appointment. A major benefit of the new location is on-site parking for patients.

Hunger and Homeless Auction at Yale on Nov. 13
The Yale School of Medicine is hosting its 16th Annual Hunger and Homelessness Live Auction in Marigolds at 6:45 p.m., November 13, to aid homeless people in Greater New Haven. Get involved — visit www.yale.edu/hhauctionand make a donation.

YNHH to install defibrillators throughout hospital
As part of the Hospital’s patient safety efforts, automatic external defibrillators (AEDs) will be installed in all inpatient, outpatient and public areas in late November. The portable units, which will be hung on the walls like fire extinguishers, should provide quicker defibrillation for patients, employees or visitors who undergo sudden cardiac arrest and should improve survival rates. Training on the use of the AEDs will start in November; training schedules will be publicized.

Cardiac labs implement new scheduling system
In September, the Heart and Vascular Center implemented a new centralized scheduling system for the adult and pediatric interventional and electrophysiology services which will provide 24-hour availability to meet the scheduling needs of all members of the Medical Staff. All appointments may be called to the new scheduling coordinator Shelly Bruneau at 688-5017, weekdays between 8 a.m. and 4 p.m. After hours, a voice mail system will record messages for non-urgent procedures. Any emergency procedures that need to be booked that same day (8 a.m.-8 p.m.) may be booked through beeper 412-9144. This new process does not change our emergency on-call activation.

ED opens lab draw station to screen bilirubin
In response to an intensive focus on screening and early intervention of neonatal hyperbilirubinemia, the Pediatric Emergency Department (PED) at Yale-New Haven Children’s Hospital is opening a lab draw station for newborns who require bilirubin studies. The station is open 24 hours a day, including weekends and holidays. Pediatricians concerned about a newborn may send the family to the pediatric lab draw station in the PED, and families will be able to bypass the triage system, get registered into the lab draw station, have blood drawn and go home within a half hour. Specimens are analyzed by Yale-New Haven Hospital laboratory medicine services, and results are typically sent to the family’s pediatrician within an hour. For more information, contact Denine Baxter, RN, patient service manager for the PED, at 688-3333.

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

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Last revised: Dec. 5, 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.