August 2019

In this issue:

The residency immersion experience

A message from Thomas Balcezak, MD, Chief Medical Officer

Summer is always an exciting time at our medical center as the first weeks of July bring in the newest members of our 150 clinical training programs who come here to further their medical training.

Our residents and fellows learn from our diverse and clinically complex patients and our talented, knowledgeable and dedicated medical staff. In turn, the organization’s educational mission infuses a spirit of curiosity, youth, and lifelong learning into our institutional culture. As a recognition of the importance of our training programs to patient care and the development of clinical expertise, we have expanded from 969 trainees and 88 programs in 2005 to 1,369 trainees and 150 programs in 2019.

We know that trainees here, and at other large academic medical centers, sometimes feel disconnected from the institution. Strengthening those connections benefits the hospital – trainees provide a substantial portion of front-line clinical care, and their perspective is invaluable in informing our efforts to enhance quality, safety and patient experience. Moreover, retaining our talented trainees once they graduate enriches our medical staff and our communities.

Under the leadership of Dr. Stephen Huot, our GME Office has accomplished much, and has exciting plans for the coming year. As a part of our ongoing efforts to incorporate the voice of trainees in decision-making, we substantially increased resident and fellow representation on committees and governance bodies across the institution. In recognition of the importance of leadership skills among physicians, we initiated a three-part development series for chief residents, and expanded the reach of our Young Physician Leadership Curriculum in conjunction with the Connecticut State Medical Society.

Trainees are immersed in front line clinical care, and are most acutely aware of the strengths and weakness of our systems of care. As such, they are uniquely oriented to take part in our critical quality and safety improvement activities. Under the leadership of Dr. Beth Emerson, we recently held our first GME quality and safety symposium, and have formalized resident representation on several key committees, including the Serious Event Review Committee and the System Quality Committee. Dr. Emerson has also worked to increase critical reporting of safety events by members of the house staff. We plan to build upon those successes in the coming year, and we will strengthen the relationship between the GME area and the office of the Chief Quality Officer by increasing the integration of quality improvement science into the curricula of our many training programs.

As a leading hospital, our training programs produce future leaders in research, clinical care, health policy, education and other aspects of health care. It is thus crucial that our trainees reflect the enormous diversity of our country and world. To that end, under the leadership of Dr. Ingenia Genao, we supported several events to increase recruitment of individuals who are members of groups historically underrepresented in medicine. These efforts led to a significant increase in our recruitment of underrepresented minorities this past year, and the trainee class who began in June is the most diverse ever in the history of our institution. We will continue to build on our success in the coming year.

Health care continues to change rapidly. It is critical that we equip our trainees with all the skills they will need to make them successful and have the maximal positive impact in whatever professional endeavors they may seek out. As care models evolve towards team-based configurations, it is critical that physicians have formal leadership skills, and are able to connect effectively with their team members and patients. As such, in the coming year, we will continue our accelerating efforts to increase our trainees’ exposure to all parts of the healthcare enterprise, and incorporate aspects of emotional intelligence into our educational curricula.

The priorities driving our ongoing work to advance our educational mission remain the wellness of our house staff, increasing leadership development, ensuring our programs reflect the diversity of those we serve, and that quality improvement science becomes part of the core skills all our trainees learn as a part of their clinical training. I thank you for your participation in our teaching mission and welcome your feedback on how to enhance our educational programs and better incorporate them into the fabric of our hospital’s community. As ever, I can be reached via email at thomas.balcezak@ynhh.org.

 

Patient Safety and Quality Metrics

12-Month Period

 7/17-6/18

 8/17-7/18

 9/17-8/18

10/17-9/18

 11/17-10/18

12/17-11/18

1/18-12/18

2/18-1/19

 3/18-2/19  4/18-3/19  5/18-4/19  6/18-5/19

C. diff

 171

 173

 176

 179

 177

179

178

176

 177  185  179  170

CAUTI

 59

 55

 56

 59

 54

56

59

60

 61  62  62  63

CLABSI

 79

 73

 72

 75

 74

69

71

72

 74  81  85  89

SSE

 16

 15

 12

 11

 13

17

21

23

 22  24  23  24






 

 

 

       

12-Month Period

 5/17-4/18

 6/17-5/18

 7/17-6/18

 8/17-7/18

9/17-8/18

10/17-9/18

11/17-10/18

12/17-11/18

 1/18-12/18  2/18-1/19  3/18-2/19  4/18-3/19

Colon SSI

 41

 43

 45

 44

 50

46

51

51

 50 49  50  53

Hysterectomy SSI

 12

 13

 14

 16

 17

17

18

17

 16  15  17  14

PE/DVT

 70

 66

 69

 67

 63

66

67

69

 72  69  72  70

Iatrogenic Pneumothorax

 5

 6

 7

 6

 6

6

7

7

 7  5  5  6

 

The Patient Safety and Quality metrics are reported on a 12-month rolling timeframe. The most recent timeframes differ based upon the various databases reporting the metrics. 12-month rolling total updated with AHRQ v6.0 definition starting January 2017.

Patient Safety and Quality Metric Definitions

Colon and Hysterectomy SSI: A surgical site infection within 30 days of the operative procedure, classified as superficial, deep, or organ/space infections based on CDC/NHSN surveillance definitions.

C. diff (Clostridium difficile): A patient who develops diarrhea greater than 48 hours after admission to an inpatient unit and for whom the C. diff testing (either rapid toxin, cytotoxin or PCR) is positive.

CAUTI (Catheter Associated Urinary Tract Infection): A patient who has an indwelling urinary catheter in place for over two days, with at least one of the following signs or symptoms: fever > 38? C, suprapubic tenderness (with no other recognized cause), costovertebral angle pain/tenderness (with no other recognized cause), urinary urgency (not while catheter in place), urinary frequency (not while catheter in place), or dysuria (not while catheter in place).

CLABSI (Central Line Associated Blood Stream Infection): A primary bloodstream infection (not related to an infection at another site) that develops in a patient with a central line in place over two days before onset of the infection. Culturing the catheter tip is not a criterion for a CLABSI.

Iatrogenic Pneumothorax: A pneumothorax caused by medical care, with certain exclusions for trauma, cardiac and thoracic surgery patients.

PE/DVT (Pulmonary Embolism/Deep Vein Thrombosis): Any PE/DVT that occurs postoperatively.

Serious Safety Event: A deviation from generally expected care that results in moderate to severe patient harm.

 

U.S. News & World Report places YNHH on national honor roll as one of the top 20 hospitals in the US

Yale New Haven Hospital (YNHH) continues to rank among the top U.S. hospitals with its placement on this year's U.S. News & World Report’s national Honor Roll – among the top 20 hospitals in the nation. Of the nearly 5,000 hospitals surveyed in their annual "America's Best Hospitals" list, YNHH ranks nationally in 12 of 16 specialties.

In each of the 12 specialties, YNHH gained greater national prominence over last year’s rankings. Psychiatry (#9) is now ranked in the nation’s Top 10 while Geriatrics and Pulmonology are both ranked at #16. Ear, Nose and Throat (#19), Kidney Disorders (#20), Diabetes and Endocrinology (#24), Urology (#30), Neurology and Neurosurgery (#38), Gynecology (#39), Gastroenterology and Cancer (#45 each) and Heart and Heart Surgery (#48).

According to U.S. News & World Report, hard numbers support the rankings in most specialties – death rates, patient safety, procedure volume and other objective data. The entire national listing is available online at www.usnews.com/best-hospitals.

 

Interventional Radiology consults now in Epic

Interventional Radiology (IR) consults for inpatients on the York Street and Saint Raphael campuses can now be requested via Epic consult, supported by the Command Center as of Aug. 5. This streamlines the process for inpatient providers for interventional care in the Heart and Vascular Center, since they no longer need to use the case request to attempt to select the correct interventional care.

 

Tuberculosis surveillance

Mark Russi, MD, medical director, YNHHS Wellness and Employee Population Health, recently notified employees that in response to recent changes in Center for Disease Control (CDC) guidance for tuberculosis surveillance among healthcare workers, YNHHS is eliminating the requirement that YNHHS employees complete annual PPD (tuberculin) or IGRA (interferon gamma release assay) testing.

New employees will still be required to complete PPD or IGRA testing at the time of initial employment. PPD or IGRA testing will also continue to be carried out whenever an unprotected exposure (as identified by YNHHS Infection Prevention) occurs with an immediate post-exposure test and follow-up testing eight to 10 weeks later.

Employees who carry out clinical rotations in areas of the world endemic for tuberculosis (sites other than United States, Canada, New Zealand, Australia and Western Europe) should have a pre-departure PPD or IGRA test done, as well as a follow-up test eight to 10 weeks after return. YNHHS Occupational Health Clinics will continue to be available to carry out such testing.

 

Program proves that when it comes to genes, one size doesn't fit all

Patients often wonder why certain medications work well for some but not others. Age, medical histories, health conditions and other medications can be factors. Yale New Haven’s Pharmacogenomics program is showing just how important genetic differences are. Pharmacogenomics is the study of how inherited differences in enzymes, transporters and other proteins can affect response to medications.

"Traditionally, medications are dosed based on what works for the average person," said Rebecca Pulk, PharmD, Yale New Haven Health’s Pharmacogenomics clinical coordinator. "Yet we know that individuals can have very unexpected responses to the same medication."

These differences can often be linked to variations encoded in the DNA unique to each patient. One patient who has inherited the ability to process a medication too quickly may never build up enough in the body to benefit from the drug. Another patient may not be able to clear the same drug at all, increasing the risk of side effects unless the dose is lowered.

Information gathered with a one-time pharmacogenomics test can be applied across a patient’s lifetime to make medications safer and more effective. There are evidence-based guidelines on applying pharmacogenetic information to the dosing for 80 medications.

Within Yale New Haven Health, pharmacogenomics is being introduced into routine clinical care through a collaboration among Pharmacy, Laboratory Medicine and Information Technology Services. Panel-based testing will be applied to patients who could benefit, and results fully integrated within the medical record.

"We can test all relevant pharmacogenomic markers with a single test – even markers that are experimental today, yet may affect patient care in the future," said Wade Schulz, MD, PhD, YNHHS’ medical director of Data Science. "Since we are integrating this genomic information into the electronic medical record, it can be used by all care team members. As our knowledge base grows, we will be able to use additional banked information without having to retest patients."

Multiple clinical pilots are under way in YNHHS to build evidence of pharmacogenomic testing’s clinical impact and assess the financial sustainability of adding testing to the standard of care. The first pilot focuses on patients 65 and older who experience an acute coronary event and present at hospitals throughout YNHHS. Pharmacogenomic testing of these patients helps ensure that clopidogrel, an antiplatelet agent, is reserved for patients for whom it is safe and effective.

Other clinical pilots involve patients being evaluated for bone marrow or kidney transplants. Pharmacogenomic information gathered before these procedures allows care teams to customize immunosuppressive therapies, infection prophylaxis and pain control. To date, over 90 percent of the nearly 200 patients tested have at least one change that could affect medication therapy across their lifetimes. Over 25 percent had a finding that directly affected the selection and dosing of the medications that triggered testing. The pilots have also identified medication issues beyond those related to the triggering indication.

"This testing has significant implications for patients, in terms of outcomes and safety," said Richard Lisitano, YNHH vice president, Administration. "Our hope is that pharmacogenomics will become one of the standard tools we use to determine the best medication and dose for each patient."

 

Technique can revolutionize treatment of pulmonary embolisms

Two interventional radiologists recently began performing the thrombectomy procedure in the Heart and Vascular Center at Yale New Haven Hospital that could save the lives of more patients with life-threatening pulmonary embolisms. Hamid Mojibian, MD, director, Cardiac CT/MR Imaging, and Jeffrey Pollak, MD, became the first in Connecticut to perform the, which does not require major surgery or clot-busting medications.

Previously, PE patients were admitted to the intensive care unit to receive thrombolytics. In life-threatening situations, patients might require surgery to remove clots.

With the new procedure, physicians insert a catheter fitted with a suction device into a small incision in the neck or groin. The physician guides the catheter to the lung clot and activates the suction device. As the physician removes the catheter, the suction device pulls the clot from the lungs, then out through the incision.

Mechanical devices have been used previously to break up PEs, but they’re less effective and required the use of thrombolytics, which can cause bleeding in other parts of the body.

"With this procedure, we can treat patients who have other conditions that make traditional PE treatments risky," Dr. Pollak said. "It is allowing us to save more lives."

The results of the procedure can be dramatic and fast.

"We have had patients come in critically ill, unable to breathe, and as soon as we suction out the clots, the patient revives immediately," Dr. Mojibian said.

"This procedure can fundamentally revolutionize patient care," added Kevin Kim, MD, YNHH section chief of Interventional Radiology.

 

YNHHS introduces MyChart Billing

With the launch of MyChart Billing, patients can now access clinical and financial information in one secure location via Yale New Haven Health’s MyChart online patient portal. In addition to using the portal’s many other features, patients can now manage healthcare balances within MyChart. From the MyChart login page, patients may choose to pay their bills as a guest, but are encouraged to sign up for an account to access features including most laboratory and test results, medical history, appointment information as well as to request and schedule appointments with their physicians.

 

Conference takes a 10-year look back at the Affordable Care Act

The Affordable Care Act at 10 looks at 10 years of the ACA by bringing together major players in its implementation along with an analysis of the law. Speakers include former White House Chief of Staff Rahm Emanuel, former HHS Secretary Kathleen Sebelius, former Solicitors General Don Verrilli and Paul Clement, former Majority Leader Eric Cantor, and additional academics, policymakers and lawyers. Presenters will reflect on the policy, legal and political advances and challenges that a decade of the ACA has brought.

The conference, hosted by Yale Law School, takes place at the Sterling Law Building, Yale Law School, 127 Wall St., New Haven. It begins at 4:30 pm on Thursday, Sept. 26 and continues from 8:45 am to 6 pm on Friday, Sept. 27.

The event is free and open to the public, but registration is required. CLE credit is available. Details and registration information is available on the Yale Law School's website.

 

Wound Science Symposium set for Sept. 13

A multidisciplinary panel of specialists and experts will present topics on the care, treatment, and management of chronic wounds during the 5th annual Wound Science Symposium Sept.13 at the Trumbull Marriott, 180 Hawley Lane, Trumbull.

The symposium, to run from 7:30 am to 4 pm, will include a special focus on geriatric wounds, skin failure and pressure injuries. The keynote speaker will be Jeffrey Levine, MD, a nationally recognized expert in wound care, pressure injuries and geriatrics. Those encouraged to enroll for the symposium include physicians, podiatrists, PAs, APRNs, nurses and anyone with an interest in assessing and treating wounds. The event is also an opportunity to earn contact hours and CME credits. For early registration, please call 888-375-2396.

 

Newsmakers

Lisa Lattanza, MD, has been appointed as chair of the Department of Orthopaedics and Rehabilitation at Yale School of Medicine and chief of Orthopedics at Yale New Haven Hospital, effective September 1, 2019. Dr. Lattanza is currently professor of orthopaedic surgery and vice chair for orthopaedic surgery at the University of California, San Francisco (UCSF). She also serves as chief of the Division of Hand, Elbow and Upper Extremity Surgery and program director for the Hand and Upper Extremity Fellowship at UCSF.

Dr. Lattanza obtained her medical degree at the Medical College of Ohio (now the University of Toledo College of Medicine and Life Sciences). She did her internship at the Harbor-UCLA Medical Center, completed her residency in orthopedic surgery at the University of Missouri Kansas City and did a fellowship in hand surgery at Columbia College of Physicians and Surgeons/Roosevelt Hospital. She did additional fellowship training in pediatric hand and upper extremity at Texas Scottish Rite Hospital for Children in Dallas, Texas. She joined the faculty of UCSF in 1999.

Elena Gutman, MD, has been appointed medical director of Accreditation and Regulatory Affairs for Yale New Haven Health. In this position Dr. Gutman will provide medical leadership and oversight primarily to ensure hospital licensure, accreditation, and CMS certification across the health system, in addition to other regulatory requirements. Dr. Gutman joins the Office of the Chief Quality Officer and will report to Steven Choi, MD, in this new role. Dr. Gutman joined the Yale School of Medicine Department of Anesthesiology as a faculty member in 2015 and is currently an assistant professor.

 

In memoriam

Robert J. Ardesia, MD, 56, of Cheshire, passed away on Monday July 1, 2019. He was an assistant professor of Clinical Medicine at the Yale School of Medicine and a practicing cardiologist at Yale New Haven Hospital and the former Hospital of Saint Raphael Hospital.