Medical Staff Bulletin

December 2018

In this issue:

On gratitude and optimistic collaboration

A message from Thomas Balcezak, MD, Chief Medical Officer

The holiday season and the end of another year always make me think about the many things for which I am immensely grateful. In addition to my family, who provide me with love and support and push me to improve myself as a person, I always return to how grateful I am to work with such amazingly talented and dedicated people in one of the most important fields in the world. Our medical staff’s commitment to patients and the pursuit of excellence gives me great hope that we will continue to make progress and advance our goal of excellence in patient care, and also improve the working lives of our caregivers.

As with many of our peer institutions, our frontline physicians, advanced practice providers and nurses work in a shifting and demanding environment and face daily stressors that result in levels of burnout that exceed 50 percent nationally. For a premier academic health system, such levels are burnout are incompatible with our goals of excellence for patients. If we are to be successful, any performance improvement work must consistently be sensitive to the needs and realities of those on whom we rely to provide care and caring to our patients and their loved ones.

We have had pockets of success. Clinical Redesign, our main process improvement engine, has demonstrated how physician-led, meticulously orchestrated efforts can reduce front line clinical pain points, enhance quality of care, and reduce unnecessary clinical variation and waste. Similarly, the journey towards high reliability has shown that we can transform our culture radically to enhance the safety of our patients.

That said, much remains to be done. Fragmented workflows, illogical divisions of labor and the need to tilt the balance of technology towards being an enabler of efficient care, and away from being an impediment, must be addressed if we are to develop a signature standard of patient-centered care. Here too, we have blueprints for a way forward. We have great opportunities to build on the foundational work pursued over the past five years by our Clinical Integration workgroups, whereby physicians working across the spectrum – in ambulatory and inpatient settings, independent community practices, the health system, or Yale Medicine faculty – have come together, formed relationships, and agreed on clinical guidelines and standards. These relationships will be key as we work together to design team-based models of care that allow our front-line clinicians to focus on what brings us fulfillment - improving our patients' health - without being overwhelmed by logistical and administrative burdens.

As we look forward, our solution for sustaining a vibrant and engaged physician and nursing population that can successfully power the work of enhancing value for our patients must include several components. We must do more to foster resilience, increase patient-centered alignment and coordinate among the many members of our diverse care network. This includes working across traditional lines of demarcation, and hardwiring a single-minded commitment to designing logical, patient centered, efficient, yet appropriately resourced, models of care into our institutional culture. These efforts are in process for 2019, and I believe that only by enhancing the fulfillment of our frontline clinical staff will we successfully maintain and build on our commitment to enhance substantially the health of the communities we serve.

I thank you for your engagement, and welcome your questions and feedback. As ever, I can be reached via email at [email protected]. I wish you a happy and safe holiday, and look forward to continuing to work with you in the New Year.

Patient Safety and Quality Metrics

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 voting to begin soon

All board-certified physicians within each of the applicable specialties evaluated by U.S. News (i.e., Cancer, Cardiology/CT Surgery, Diabetes/Endocrinology, ENT, Gastroenterology/GI Surgery, Geriatrics, Gynecology, Nephrology, Neurology/Neurosurgery, Ophthalmology, Orthopedics, Psychiatry, Pulmonary, Rehabilitation, Rheumatology and Urology) will soon receive a request to vote in the U.S. News reputation ranking. The request will come via email from Doximity, an online networking website for physicians used to calculate the reputational portion of the hospital rankings. Registered users may also receive a prompt when logging into the site.

As the U.S. News & World Report rankings are heavily weighted towards an institution’s reputation, the survey provides the opportunity for members of the medical staff to make their collective voice heard about the exceptional care provided across Yale New Haven Health. All System hospitals and ambulatory practices are home to outstanding physicians who continually advance medicine through the safe, high quality and compassionate care provided to our patients.

The reputation of the entire health system would be greatly enhanced if Yale New Haven Hospital is voted into the Honor Roll. One barrier to this in the past has been the reputational score, which is determined by physician vote. Members of the medical staff across Yale New Haven Health are urged to consider this when casting votes during the upcoming voting period.

Doximity reports that voting for the 2019 rankings will open in February. Additional information will be available once the voting period opens.

YNHHS launches System Medical Staff Bylaws Committee

The inaugural meeting of the Yale New Haven Health System Medical Staff Bylaws Committee convened November 13. Chaired by Michele Johnson, MD, the committee includes representatives from each hospital in the health system. The respective chief medical officers selected the members to serve in this important role. The number of practitioners across YNHHS who have more than one appointment at a health system-affiliated hospital is growing exponentially. Currently, approximately 1,200 of our 6,300 practitioners hold more than one appointment. The committee develops recommendations to standardize aspects of the medical staff bylaws that will eliminate confusion in terminology and make certain straightforward administrative practices and procedures consistent for all five hospitals. The System Bylaws Committee will communicate on a regular basis with each of the local Medical Staff Bylaws committees regarding its recommendations. Each of the health system’s five hospitals will continue to have individual medical staff bylaws. Members include: Michele Johnson, MD, chair, Yale New Haven Hospital; Gregory Buller, MD, Bridgeport Hospital; William Conlin, MD, Westerly Hospital; Kapil Desai, MD, Greenwich Hospital; Harris Jacobs, MD, Bridgeport Hospital; Thomas Pellechi, MD, Greenwich Hospital; Ross Sanfilippo, DMD, Lawrence + Memorial Hospital; Kevin Torres, DO, Lawrence + Memorial Hospital; Eugenia Vining, MD, Yale New Haven Hospital. If you have any questions regarding this new committee, please contact Theresa Zinck-Lederer, executive director, Medical Staff Administration, or Michele Johnson, MD, committee chair.

Simulation center draws international attention

Stephanie Sudikoff, MD, (left) director of simulation at the SYN:APSE (Simulation at Yale New Haven: Advancing Patient Safety and Education) Center for Learning, Transformation and Innovation, explained some of the center’s innovative features to Dr Richard Paget and Elizabeth Akers, a pediatric nurse, from Great Ormond Street Children’s Hospital in London. The British clinicians toured several simulation centers throughout the region during October to help them develop their own center.

Opioid Stewardship

By Jessie C. Riemer, MSN, RN

The current opioid epidemic in the United States has resulted in significant morbidity and mortality. According to the Centers for Disease Control (CDC), In 2016:

• More than 11.5 million Americans, age 12 or older, reported misusing prescription opioids
• More than 40 percent of all U.S. opioid overdose deaths involved a prescription opioid
• More than 46 people died every day from a prescription opioid-related overdose (a rate more than five times higher than in 1999)

Over the past year, groups across Yale New Haven Health System began efforts to reduce utilization of opioids and encourage use of alternative pain medications as well as non-pharmacologic pain management strategies.

Reducing Inpatient IV Opioid Administration

Administration of opioids via the intravenous route is associated with an increased risk of adverse effects such as nausea and vomiting, constipation, CNS effects and hypotension. Research has shown that subcutaneous administration provides equivalent bioavailability to intravenous administration with fewer side effects.

To promote the subcutaneous and oral routes of administration for opioids: 1) the Adult General Medicine Admission Order Set was updated in March 2018; 2) the default route of intravenous was removed for both parenteral morphine and hydromorphone; and 3) a multimodal analgesia medication panel (which included non-opioid and opioid analgesics) was added. Providers are encouraged to order the subcutaneous or oral route of administration whenever appropriate.

As part of our analgesia initiative, we are now tracking overall utilization of opioids (expressed as morphine milligram equivalents) including rates of IV administration as well as use of anti-emetics, naloxone and other agents to manage side effects of opioids. This data will identify opportunities for improvement.

Since March 2018, Greenwich Hospital already experienced a decrease in the percentage of IV Opioids administered.

FY 2019 Corporate Objective

In alignment with these initiatives, we have identified the following corporate objective for FY2019:

• Reduce utilization and prescription of narcotics through an opioid stewardship program to ensure our patients’ pain is managed effectively through appropriate use of narcotic and non-narcotic modalities. This objective will measure the average amount of morphine milligram equivalents used during inpatient hospitalizations and written for in discharge prescriptions.

Strategies to Minimize Opioid Utilization:

Classes of Multimodal Agents

• Acetaminophen
• NSAIDs
• Gabapentin & Pregabalin
• Muscle Relaxants
• Local Anesthetics
• Complimentary Modalities Opioids

Avoid ordering opioids whenever possible

• Order standing non-opioids (such as acetaminophen) for baseline pain control.
• Order multimodal analgesics and encourage use of non-pharmacological methods for pain control.
• If opioids are required, it is recommended that opioids are ordered to be given via the oral and subcutaneous routes first.
• IV opioids should only be ordered if other routes of administration are not effective.

Communications workshop available for clinical staff

Physicians, advanced practice providers (APPs) and nurses across Yale New Haven Health and Yale Medicine are urged to sign up for “Enhancing Relationship-Centered Communication,” a course offered through YNHHS Patient Experience.

This one-day, peer-led workshop will show how communication can improve health outcomes, patient satisfaction and professional engagement. The session includes didactic presentations, live demonstrations and practice activities with guided feedback to enhance relationship-centered communication skills. The goal of this course is to improve interactions between healthcare professionals and patients as well as conversations with colleagues and staff. The workshop also teaches clinicians to be more mindful in their approach with patients and families.

Sessions are available through April 2019. Upon completion, participants will receive 7 AMA PRA Category 1 credits.

Register at www.ynhh.org/events. Search for “communication” for a listing of upcoming dates. Sessions are 8 am - 4 pm at the YNHHS SYN:APSE Center for Learning, Transformation and Innovation, 730 Howard Ave., New Haven.

Need outstanding patient care? There's an APP for that

More than 200 people attended the Advanced Practice Provider (APP) awards dinner in October, where 10 awards were presented in nine categories: clinical leadership, mentorship, clinical excellence, distinguished APP leadership and APP of the year. Humanitarian, publishing, education and “Outstanding Newcomer” awards were also presented. The annual event honors certified nurse midwives, certified registered nurse anesthetists, nurse practitioners and physician assistants. Award presenters and recipients included Evans Simmons, PA-C; George Hayner, PA-C (accepting award for Therese Collett-Gardere, APRN); Ashley Phillips, CRNA; Brennan Bowker, PA-C; Cindy Guandalini, APRN; Barbara Stahl, APRN; Kristin Sykes, APRN; Tracy Gambardella, PA-C; Rory Condon, APRN; and Audrey Senior, APRN.

Request for patient stories

Yale New Haven Health often features patient stories to highlight the work and dedication of our physicians, nurses and staff in its print publications, websites and advertising campaigns. If you have a patient that you think would make a great story -- and who is willing to share his or her experience -- please contact Cynthia Whitcomb at 203-688-9440, [email protected].