Focus April 22, 2010

FOCUS Christiana Care nationally recognized for innovation

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hristiana Care Health System has been named the 2010 Alliance Innovation Award winner from the Alliance of Independent Academic Medical Centers (AIAMC), a national organization made up of 69 major academic medical centers and health systems.

The award recognizes Christiana Care for innovative approaches to medical education and research that result in better patient outcomes.

Transformation Antimicrobial stewardship

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Physician communicators

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Clinical/Education News Grand Rounds

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ACT graduation

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General News Earth Day 2010

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VNA’s Evergreen II offers adult day program 15 Volunteers deserve thanks 18

Present in New Orleans to accept the 2010 AIAMC’s Innovation Award were (from left) Robert J. Laskowski, M.D., Theresa Fields, Loretta Consiglio-Ward, Christiana Care received the award for RN, MSN, Samantha DeCouto, D.O., Lee developing and implementing an inno- Ann Riesenberg, Ph.D., RN, Elizabeth vative graduate-level, 12-week course. Kunkel, D.O., Carol K. Moore, RN, MS, Matthew Stofferahn, M.D., Sarah The curriculum focuses on inter-profesSchenck, M.D., and Brian W. Little, M.D., sional learning through collaboration Ph.D.

on quality improvement projects. The aim of the course is to produce measur- National Initiative: Improving Patient able improvements in quality and Care through Graduate Medical patient safety.

Education since 2007,” says Kimberly “We are honored to receive the Pierce-Boggs, AIAMC executive direcInnovation Award,” says Robert J. tor. “Christiana Care serves as an Laskowski, M.D., MBA, president and excellent example of the successful CEO of Christiana Care. “It validates integration of graduate medical educathe dedication of so many of my coltion and quality. The AIAMC board of leagues at Christiana Care to provide directors is delighted to present quality education aimed at transform- Christiana Care with this award.” ing the way we deliver care.”

Dr. Laskowski accepted the award on “Christiana Care has been an active participant and leader in the AIAMC

behalf of Christiana Care at the AIAMC’s annual meeting on March 26 in New Orleans, La.

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New program improves patient safety toxicity and medication-related adverse events.

ASP co-chairs John Piper, M.D., and Elizabeth Marino, Pharm.D., BCPS.

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oughly 50 percent of antimicrobial agents are misused. One negative result of their misuse is that an antibiotic can lose effectiveness against the disease-causing microbes they were designed to combat, a phenomenon known as antimicrobial resistance. The result can be lost lives, rising costs and the weakening of our health care delivery system.

The World Health Organization (WHO) says this phenomenon could threaten global stability and national security. In response, Christiana Care Health System will be launching a new stewardship program to help direct antimicrobial use and do our part to curb the main cause of microbial resistance, the overuse and misuse of antibiotics.

Demonstrated success The implementation of antimicrobial stewardship programs (ASPs) have consistently demonstrated decreases in antimicrobial use, improved clinical outcomes and reduced costs without increasing harm from drug resistance,

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FOCUS April 22, 2010

During this era of multi-drug resistant (MDR) infections, the Infectious Disease Society of America has been promoting “Bad Bugs No Drugs” and the 10 new antibiotics by 2020 (“10 x 20”) campaign to emphasize the need for development and funding of new antibiotics with new mechanisms of action to target MDR pathogens. Over the past 25 years there have been significant decreases in the number of antimicrobials introduced to the market. That is why health care system ASPs play a crucial role in preserving our limited antibiotic selection, as well as improving patient care and holding the line on health care costs.

Goals/Mission Numerous professional organizations, including the IDSA, the Society for Healthcare Epidemiology of America and the Society of Infectious Diseases Pharmacists, support establishing ASPs. At Christiana Care, the ASP is a joint commitment between Pharmacy Services, the Infectious Diseases Section of Medicine, Infection Prevention/Epidemiology and Microbiology with the common mission to promote judicious and appropriate use of antimicrobials within the health system. Our main objectives are to optimize clinical outcomes, minimize the development of antimicrobial resistance, and reduce overall costs associated with misuse of antibiotics.

This involves not only assessing the actual prescribing patterns of antimicrobials, but also ensuring that treatment options consist of optimal selection, dose, route and administration of the most narrow and cost-effective treatments.

Successful ASPs require the talent and dedication of multiple disciplines. At Christiana Care, prescribers will be able to order antimicrobials as usual, but the ASP will review charts every weekday for patients receiving selected antimicrobials using ASP/P&Tapproved criteria. ThIs will enable regular assessment of whether continuation of therapy is justified or warrants ASP intervention.

Timely follow-up Timely follow-up will assess the status of all ASP recommendations. If one is warranted, the physician who wrote the order will be informed by telephone or a note on the official ASP intervention form (found in the progress note section of the chart). The form will allow practitioners to provide a rationale for continuing treatment if it differs from ASP recommendations and will not remain a permanent chart document but will be removed upon patient discharge.

ASP recommendations will promote appropriate, evidenced-based practice to ensure optimal outcomes and decreased costs for our patients. Data will be collected both pre- and postimplementation to assess trends in antimicrobial use and prescribing patterns that can be used to create specific Christiana Care antimicrobial treatment guidelines.

ASP committee members include:

Carol Briody, Infection Control; Marci Drees, M.D. - Infection Control/ Epidemiology; Michael Kalina, M.D., Intensivist/Surgery; James Ley, M.D., Infectious Diseases; Sarojini Misra, MS, SM, Microbiology; Anand Panwalker, M.D., Infectious Diseases; and Tuhina Raman, M.D., Intensivist/Pulmonary.

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Physician Communicators improve doctor-hospital relations

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t’s 10 o’clock on a Thursday night and a patient in the Emergency Department is admitted to the hospital with chest pains.

Soon after, the patient’s primary care provider receives a call or fax from the Physician Communicator Service, a program that keeps doctors informed about their patients’ care.

stay. To serve those doctors, the communicators also notify primary care providers who usually do admit their own patients and follow them in the hospital if and when one of their patients is admitted by another physician, such as a hospitalist.

“If someone calls and says, ‘my mom is in the hospital,’ it is reassuring to them that we are aware of the situation,” says John Fenice, M.D., of Heritage Medical Associates, a primary care, gerontology and podiatry practice in Wilmington.

Before launching the service in 2008, there was no plan in place that notified doctors about their patients being admitted through the ED. To date, physicians have received more “The notification program is the stepping than 30,000 admission notifi- stone for greater communication within our cations. community, increasing the quality of care to “Doctors would all patients.” take care of a patient for 20 years but they had no way of knowing that someone was in the hospital,” says Michael Cinkala, manager of Physician Relations. “The doctors found that very frustrating and told us so—and we heard them loud and clear.”

Hours: weekdays 7 a.m.-11:30 p.m.

The Physician Communicator Service initiated immediate, transformational change. Two full-time staffers work at the call center from 7 a.m.-11:30 p.m., Monday through Friday, phoning primary care providers to let them know their patients have been admitted, the nature of their complaints and who is attending them in the hospital. After hours and on weekends, the information is faxed to doctors’ offices.

Cinkala notes that about two-thirds of community doctors do not follow their patients in the hospital. The Physician Communicator Service keeps those doctors informed during their hospital

David Curran, CEO Brandywine Medical Associates Now includes discharge notices The well-received program expanded in November 2009 to include discharge notifications. The primary care provider receives a discharge summary, including a list of medications, within 72 hours after a patient goes home. So far, more than 2,600 notifications have been sent.

Cinkala says the discharge summaries help doctors to prepare more effectively for patients’ follow-up visits. The summary also relieves some of the pressure on the patient to report new prescriptions or therapies.

Feedback on the system from doctors and practice administrators has been positive, improving follow-up and patient care.

“When we receive a discharge notification, our nurse practitioner calls the patient and makes an appointment for him to come into the office,” Dr. Fenice says.

Physician communicators Monique Medley (left) and Liz Steward keep primary care physicians informed whenever their patients are admitted to Christiana Care.

Effective communication also gives doctors an opportunity to provide care with a personal touch, says David Curran, CEO of Brandywine Medical Associates, a family practice with locations in Pike Creek, North Wilmington and Wilmington.

“The notification program is the stepping stone for greater communication within our community, increasing the quality of care to all patients,” say Curran. ✔ Doctors who would like to make certain

the Physician Communicator Program has their most up-to-date contact information and admission preferences, can call Physician Relations at 302-733-2899.

E D U C AT I O N

W E E K

Grand Rounds Medical Thomas Nasca, M.D. Residents who feel inadequately educated in their specialties are fueling a flight to subspecialties where they can receive additional training, says Thomas Nasca, M.D., MACP, CEO of the Accreditation Thomas Nasca, M.D. Council of Graduate Medical Education, the private, nonprofit group that evaluates and accredits residency programs in the United States.

“American graduate medical education is broken.”

The ACGME is working with review committees and specialty boards to develop specific benchmarks of skills and knowledge that residents in every specialty must achieve at certain stages in their residencies, such as the third month, first year and second year.

These milestones will document residents’ growth in mastering core competencies.

“People start at different points and progress at different rates,” Dr. Nasca says. “We want to be able to effectively remediate poor performers.”

He noted that the federal government will spend $90 billion over the next 10 years to measure physician effectiveness and expects a return on its investment.

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Surgical Julie G. Nyquist, Ph.D. Specific feedback from attending physicians is an essential component in educating residents, says Julie G. Nyquist, Ph.D., a professor in the Division of Education at the Keck School of Medicine at the University of Southern California.

Julie G. Nyquist, Ph.D. “Effective role modeling is really key.”

Nyquist encouraged doctors who are teaching residents to make brief notations about residents’ performance so they can provide more detailed observations on residents’ progress.

“If you’re not taking notes, they aren’t going to get the kind of feedback they deserve.”

Residents also should take advantage of technologies that enable them to review learning experiences.

“Your new [Virtual Education and Simulation Training Center] has a magnificent ability to videotape for you.”

Without feedback, mistakes go uncorrected and bad habits begin to form—and good habits can slip away because they are not reinforced, Nyquist says.

Residents and attending physicians gave examples of feedback they had received over the years.

A negative example: “I am going to do everything in my power to get you fired from this program.”

Dr. Nasca also says revised standards for duty hours established by the ACGME in 2003 are not effective.

New standards are being developed that will focus on the residents’ level of supervision, as well as the wide range in individual sensitivity to fatigue.

On the positive side, a text message: “Good job on that gallbladder today.”

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“They make us feel all glowy inside but they don’t take you to the next step,” she says.

FOCUS April 22, 2010

Nyquist noted that neither comment offered guidance the resident could learn from and that even compliments should offer substantive feedback.

ACHIEVING

COMPETENCY

TODAY

ACT graduates largest class yet

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hirty-five colleagues graduated from the Achieving Competency Today (ACT) course March 31—the largest graduating class since its inception in 2004.

The 12-week graduate level course teaches quality and team skills while teams develop projects that promote interdisciplinary interaction, with the outcome of five new performance improvement projects. A certificate of completion was also presented to Christine Chastain-Warheit for completing the ACT course facilitator training program.

Christiana Care is a recent recipient of the 2010 Alliance of Independent Academic Medical Centers (AIAMC) Innovation Award for demonstrating an organization-wide change in the development and/or implementation of innovative education programs for residents, physicians and other staff.

This prestigious award exemplifies creative approaches to medical education and research, such as ACT, that result in better patient outcomes.

percent of patients coming to the practice were in compliance with the American Academy of Pediatrics recommended well child visit schedule, while 25 percent were not up to date.

By standardizing a process for nurses to routinely evaluate the need for such a visit and to prompt scheduling while a child is in the office for a sick visit, 95 percent of eligible patients over a two-week rapid cycle test were appropriately scheduled. To help support this process, an information sheet was created to remind parents and caregivers of the importance of a well child check-up, which is more comprehensive than immunizations alone.

“The Amazing Race…”

Through research and surveys, this team identified a need within the organization for a more standardized approach to urgently responding to the declining pediatric patient not only on the pediatric unit, but in all areas where pediatric patients are served. The goal of the project was to develop a Pediatric Rapid Response Team (PRRT). The team was able to A recent Christiana Care resident develop a PRRT policy, design a flow graduate and ACT course participant chart, and identify an education and reported that the knowledge and skills evaluation plan to track results. The acquired in the course was a major project has been transitioned to a pretopic of discussion during job interidentified implementation team. At views. “It’s nice to know that I’ve had least three members of the ACT team such great learning experiences at remain involved as well. The PRRT Christiana Care and I wanted to share will be piloted at Christiana Hospital. this positive feedback with you,” she “I’m taking what?!” says.

The goal of this project was to THE PROJECTS improve a patient’s confidence in dis“Promoting Well Child Check-ups: It's cussing their discharge medications not just about the shots!” with their health care provider and to This team focused on increasing the improve their understanding of disnumber of well child check-ups sched- charge medications by providing a uled at Wilmington Hospital’s take-home medication card completed Pediatric Practice Program. Baseline by the resident physician involved in data revealed that approximately 75 their care. The team analyzed data

From left, front row, Renee Kottenhahn, M.D., FAAP, Elizabeth Mitchell, MS, RN, Ellen Mochache, MS, APN. Back row, Sajid Noor, D.O., Toby Thomas, Pharm.D., Seema Dattani, M.D., Elaine Turochy, RN.

From left, front row, Mary Ann Quinn, RN, Jessica Apel, D.O., Ariel Arandia, RN, Amy Little, D.O. Back row, Earl Lacy, MLS (ASCP), Dennis Harris Jr., RN, Thomas Sargent, D.O., Matthew Judd, D.O. (team facilitator).

It’s Magnetic!

“Forces of Magnetism” Force 14: Professional Development

ACHIEVING A C T,

CONTINUED

COMPETENCY

ACT graduates largest class yet from a survey of patients in the Emergency Department and found that only 25 percent could provide a complete list of medications that they were taking. The team also developed a survey to measure the patients' confidence in discussing their discharge medications with their health care provider. Although the goal of improving confidence by 25 was not met in this rapid cycle test, the team found that 100 percent of the patients surveyed thought the medication discharge card was helpful and plan on using it.

From left, front row, Matthew Stofferahn, M.D.; Patty Blair, RN; Ken Birkentall, ED Administration Coordinator. Back row, Andrea Read, D.O., Jennifer Grilli, M.D., “Only YOU can prevent unnecessary Suhani Shah, PharmD; Samantha DeCouto, 1:1 safety sitters” DO; and Loretta Consiglio-Ward, MSN, This team sought to ensure that the RN, team facilitator.

From left, front row, Evan Guthrie, M.D., Kim Proctor, RN II, Justin Morea, D.O. Back row Karla Testa, M.D., Elaine Morris, RN, Carmen Pal, RN (team facilitator), Wendy Gault, BS, CMD, Amy Whalen, RN. ✔ The next ACT course begins Sept. 8 and runs to Dec. 1, 2010. Applications are due by July 30. For more information, please e-mail Theresa Fields, tfields@christianacare.org. CME and CECH credits are available.

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TODAY

continuing need for a safety sitter is reviewed by a physician every 24 hours. They surveyed nurses on several floors and found that 40 percent of nurses agreed or strongly agreed that safety sitters remain in place longer than necessary. A form was placed on each patient’s chart to facilitate a conversation between physician and nurse about whether a sitter was still needed. They achieved their goal of having the need for a sitter reviewed every 24 hours in 100 percent of patients. The potential for savings is

tremendous and they hope to show that the duration of sitter cases will decrease as a result of their success.

“MIND THE GAP: Improving transitions from the ED to the primary care office” Patients and caregivers experience challenges with moving from one care setting to another. This team evaluated the current process of notification from the Emergency Department to outpatient practice setting following emergency care visits of Adult Medicine Office (AMO) patients.

Interventions implemented were designed to improve the patients’ ability to identify the AMO as their medical home and create a notification process for the primary care physician with the ultimate goal of effecting follow-up care and improved clinical outcomes.

From left, front row: Jessica White, M.D., Cynthia Griffin, MS. RN, CPHQ, Anita Symonds, MS, BSN, RN. Back row Ann Principe, MSM, CPAN; Raymond Carter, MD; Leena Kansagra, PharmD; O. George Billings, MDiv, BCC

That Christiana Care: n

Purchased 40% of its energy this year from a wind farm?

n Has more than 50 environmental champions who encourage sustainable activities throughout our health system? n Partnered with the Delaware Nurses Association this year to collect more than 508 lbs. of unwanted or expired medications for disposal?

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arth Day 2010 marks another year of demonstrating caring for our planet by reducing, reusing and recycling things that would have turned into waste.

At Christiana Care many statistics point to our “green” improvements.

Last year our health system reduced:

Medical waste by 34 percent.

Air emissions by 49 percent. n Use of standard plain white paper 7.5 percent—a whopping 64,000 pounds. n n

We also recycled 1.4 million pounds of paper, cardboard, plastic, cans and bottles in 2009. And, by reusing sharps containers, we reduced plastics waste.

Our efforts to reduce waste and reuse

Celebrating Earth Day 2010

activities and initiatives by educating and recycle materials have been recogemployees and reinforcing committee nized in the past year by key agencies, initiatives. Unit champions also are including: resourceful, providing new ideas and n Practice Greenhealth Awards. initiatives, and a direct link to commit- Making Medicine Mercury Free - tee members.

Wilmington Hospital. (Christiana Champions: Hospital earned the honor in 2007.) n Liaison between the environmental - Partners for Change - Christiana stewardship committee and units or Hospital. departments. n EPA Trailblazer Award. n Promote sustainable workplace pracHelping sustain our green efforts is tices. the Environmental Stewardship n Encourage recycling, reducing and Committee, led by Bob Mulrooney, reusing. vice president, Facilities Engineering, n Explore opportunities for waste with support from environmental reduction, energy conservation, and champions throughout the health syswiser use of resources. tem. Unit champions are staff memn Participate in systemwide projects. bers or volunteers dedicated to helping the committee on environmental

Environmental Stewardship Committee members and others who turned out to put finishing touches on the new Christiana Care Green Garden for its Earth Day dedication included, from left, standing, Nora Protokowicz, Ann Darwinski, Barbara Gayton, Michelle Lauer, Jason Funyak, Deb Dibert, Burt Wilson, Bob Mulrooney, Nadia Hellenga, Jeff Krebs, Jill Karpinski and Laura Schaeffer; kneeling, Willie Wright, Mary Kate Itzstein, Mike Frawley, Marcus Suhr, Sandy Reddy and Kim Frey.

Michele Lauer, who coordinates efforts of our environmental champions, singled out Patient Escort Supervisor, Lisa Abbott, OR Nurse Deb Dibert, RN, and Lab Tech Willie Wright for going above and beyond in their efforts to support the program.

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Great Place to Work celebration

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hristiana Care’s 3rd annual Great Place to Work celebration takes place May 9-15, coinciding with National Hospital Week.

The celebration recognizes everyone’s daily efforts to make Christiana Care a Great Place to Work. With its competitive salaries, range of benefits and worklife balance programs, Christiana Care is committed to being one of the best

places to work in the Mid-Atlantic region.

During the week-long celebration, there are team contests, exciting prizes and random give-aways. And, there’s free soft pretzels and water ice for everyone.

Here are some highlights: HR Online Scavenger Hunt contest All employees have the opportunity to participate in completing a questionnaire consisting of questions related to

Gregory Masters, M.D., receives ASCO Statesman Award

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regory A. Masters, M.D., FACP, medical oncologist at the Helen F. Graham Cancer Center at Christiana Care, is a recipient of a 2010 Statesman Award from the American Society of Clinical Oncology (ASCO).

ASCO is the world’s leading professional organization representing physicians who care for people with cancer.

With more than 27,000 members, ASCO seeks to improve cancer care through scientific meetings, educational programs and peer-review journals.

Dr. Masters received the honor for his “extraordinary volunteer service, dedication and commitment to ASCO,” according to the organization.

Gregory A. Masters, M.D., FACP Recipients of the Statesman Award have volunteered at least 20 years of Dr. Masters receives his award at the service to ASCO. ASCO annual meeting June 4-8 in Dr. Masters is also director of the Chicago.

Medical Oncology Fellowship program Nicholas J. Petrelli, M.D., Bank of at Christiana Care. He is a member of America endowed medical director of Medical Oncology Hematology the Helen F. Graham Cancer Center, Consultants, PA. received the Statesman Award in 2008.

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what makes Christiana Care a Great Place to Work. Locate the answers by visiting and navigating the new HR Online Web site. Correctly completed questionnaires will be added to a pool by department for a drawing. There are three drawings—one each for Christiana Hospital, Wilmington and Satellite facilities.

The prize is a $250 gift card for the winning department.

Prize Patrol Team Be on the lookout for Christiana Care’s own Prize Patrol Team.

Employees are randomly selected and recognized for their contributions each day during the week with a token of appreciation.

You could be next!

Soft pretzels and water ice Employees can receive soft pretzels and water ice at a variety of locations during the week.

Look for a calendar on the Portals highlighting dates and times.

Upcoming events

Concepts in Respiratory Critical Care Presented by Christiana Care Health System Respiratory Care Department, Friday, May 14, 7:30 a.m. - 3:30 p.m. at the John H. Ammon Medical Education Center, Christiana Hospital.

View conference details or directions online at www.christianacare.org/rtconference.

American Nurses Association 2010 Nurse’s Week - May 5-12 “Nurses: Caring Today for a Healthier Tomorrow.”

Calendar Wednesday, May 5 n Gifts for Nurses will be distributed throughout the week on the units n Healthy Work Environment Webinar 11:30 a.m. - 12:30 p.m..

Thursday, May 6 n Liz Jazwiec, author of “Eat That Cookie.” 2-3 p.m., John H. Ammon Medical Education Center main auditorium. n Nursing Excellence Award Ceremony – Education Center Auditorium 4:30-8 p.m.

Keynote speaker : Liz Jazwiec *By invitation only for Award winners

and their guest n Christiana Care’s Annual Nursing Story Contest winners announced Friday, May 7 n Gift basket raffle winners will be announced by e-mail. Sponsored by the System Shared Decision Making Councils.

Saturday, May 8th n Unit-based celebrations.

Monday, May 10 (Ammon Center) and Tuesday, May 11 (Wilmington Hospital Conference Center) n Nursefest! 11:30 a.m. - 2:30 p.m.

Come and visit tables showcasing your neighboring units. Free food, Giveaways, and Raffles!

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A DV O C A C Y

At a Glance: Historic Health Reform Legislation

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he Patient Protection and Affordable Care Act signed into law on March 23 includes a large number of health-related provisions to take effect over the next four years.

The provisions include: n Expanding Medicaid eligibility. n Subsidizing insurance premiums. n Providing incentives for businesses to provide health care benefits. n Prohibiting denial of coverage/claims based on pre-existing conditions. n Establishing health insurance exchanges. n Supporting medical research.

Changes coming soon Some near-term changes to expect : n An end to coverage denial due to pre-existing conditions and ending of coverage once people get sick. n Children can stay on their parents insurance until age 26. n No policy can be more than three times the lowest policy cost in its age band rating. n Insurance companies are subject to a tax if they do not expend 85 percent of their premium revenue on medical and related services.

Future changes States will set up insurance exchanges so people can compare and shop for policies. In addition, people will be required to get health insurance or else face phased-in financial penalties.

Similar penalties will be phased in for large employers who do not offer insurance to their employees. People with low incomes will receive premium subsidies.

Cost control measures in the bill

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Community First Choice Option. n Changes state FMAP rates for newly eligible populations, and changes income counting rules for certain populations. n Increases the territories’ spending rate caps beginning with the second quarter of FY2011. n Provides additional program integrity funding through indexing of the Medicaid Integrity Program for fiscal years beginning with 2010. n Modifies Medicaid disproportionate-share hospital payment reductions.

Coping with more access and demand To help cope with the demand expected from this expansion of access, and to encourage more doctors to enter the field and physicians to participate in the programs, primary care physicians will get higher reimbursements. There will also be workforce incentives, including loan repayment, for primary care physicians in underserved areas or in the expanded public health service corps. The number of available residency slots expands.

Trauma and long-term care The Community Living Assistance Services and Supports, or CLASS Act, and the National Trauma Care Act Medicaid also were included in the new legislaIn terms of Medicaid and CHIP, the tion. The latter authorizes funding Act: support for trauma centers, while the CLASS Act provides the foundation n Increases primary care physician for more widespread purchase of payment rates for selected patient long-term care insurance to help peotreatments. ple care for the disabled. It has a voln Revises the definitionto make make the average manufacturer price more untary, long-term care program that closely reflect the manufacturers’ aver- pays cash to enrollees who suffer at least two limitations in daily activities, age prices. such as eating, bathing and dressing. n Delays the effective date of the

include both positive and negative sides, such as: n Programs that provide incentives and support to improve quality of care. n Penalties for hospitals with high readmission rates. n Reduced reimbursement for some specialties, such as imaging and radiology, to discourage over-use.

Medicare In terms of Medicare, the Act: n Starts to phase out the coverage gap under the Medicare prescription drug benefit, with a view to closing the gap by 2020. n Changes how Medicare Advantage payments are determined and creates an incentive system to reward high quality plans with higher payments. n Moves up reductions in payments to disproportionate-share hospitals to 2014 and reduces the cuts. n Changes the assumptions used to calculate Medicare reimbursement for advanced imaging services (assuming the machines are in use 75 percent of the time rather than 50 percent). n Increases funding for the Health Care Fraud Abuse Control program.

Triplets? We’re prepared OR offers moms and doctors more options

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hen Christiana Care planners began considering a fourth operating room in Labor & Delivery, they chose to invest in a larger, specially equipped facility.

doctors and their patients in scheduling Caesarean delivery,” he says. “We now have the ability to manage these patients in the safest, most appropriate manner.”

Possibly the first of its kind in the country, the state-of-the-art OR is specially equipped to handle Caesarean delivery for multiple births, particularly triplets. Christiana Hospital has been home to more than 500 multiple births in the past five years.

The OR is outfitted with a lift to safely place patients with special needs, such as mothers delivering multiple births, paraplegic mothers and others with conditions that may cause problems in the three existing ORs. The extra-wide operating table is equipped More options for C-section with boom-mounted fetal monitors and lights, and can support up to Before it was added in October 2009, the three existing ORs were scheduled 1,000 pounds. for Caesarean sections more than 80 The number of twin births increased percent of the time, says L&D medical 70 percent between 1980 and 2004. director Gregory DeMeo, D.O. Births of triplets, quadruplets and “Now, there is much greater choice for more multiples quadrupled during

that period. Since the OR opened, more than 50 sets of twins and four sets of triplets have been born there.

“It is large enough to accommodate all the extra pediatric staff that is present for multiple births so the parents aren’t separated from their children,” Dr. DeMeo says. “It is a beautiful place.”

U.S., Canadian agencies praise Christiana Care innovations

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hristiana Care was one of an elite group of about 30 hospitals and health systems to come together in a joint, by-invitation consensus meeting in March of the Agency for Healthcare Research and Quality and the Canadian Patient Safety Institute at AHRQ headquarters in Rockville, Md. The mission was to explore applying high-reliability concepts health care and to create systems that are safe, efficient and responsive. The model was developed by businesses that have high risks yet are reliable, such as the aviation and nuclear power industries.

“Immediately, we gravitated toward the common goal of how these concepts might be applied to improve patient safety,” says Michele

Campbell, RN, MSM, CPHQ, FABC, corporate director, Patient Safety and Accreditation Services. “The enthusiasm of sharing our experiences and perspectives across borders was contagious.”

Three Christiana Care innovations noted n The Patient Safety Mentor Program, designed to engage frontline staff in sharing and communicating important safety behaviors, practices and information.

The Sepsis Alert Campaign, in which sepsis is identified and treated earlier in the Emergency Department with pre-packaged antibiotic kits on rapidresponse carts.

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The eCare System, technology that enables remote teams to monitor patients in the intensive care unit, pro-

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viding an additional level of support and care.

“Christiana Care is right up there with the leaders in patient safety and now has international recognition of our innovations,” Campbell says.

Going forward, the participants will establish a learning network through which they can share expertise and information to improve quality and patient safety.

“This type of collaboration and cross fertilization is intensely enlightening,” says Kathleen McNicholas, M.D., medical director for Performance Improvement and Surgical Utilization Management. “There is much to be learned by taking this pool of knowledge and applying it to health care.”

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his annual update focuses on key areas where Christiana Care concentrates efforts to make and maintain our health system as a Great Place to Work.

Health & Wellness Christiana Care offers a variety of resources to help make getting and staying healthy a part of daily life for everyone. Christiana Care’s commitment to helping employees adopt healthy lifestyles is based on reasoning that better health enables our staff to lead happier more productive lives.

Employee Health Services (EHS). EHS provides services to our employees through: n Direct care and Education. There were more than 28,000 EHS visits in 2009 and EHS supported seasonal influenza inoculation during the recent campaign to prevent the spread of the H1N1 virus, providing more than 14,000 vaccinations. n Counseling. The Tobacco Cessation Program provides employees face-toface counseling and free nicotine replacement therapy to employees and their spouses.

Employee fitness centers. Christiana Care’s fitness centers at Christiana Hospital and Wilmington campus now have more than 1,300 members who take advantage of the top-quality equipment and convenient locations of these two facilities to get the regular exercise needed to improve and maintain good health. The fitness centers offer a myriad of classes, including 25 cardio- and strength-training weekly classes ranging from pilates to cardio weight lifting, to interval training, yoga, zumba and dance fitness programs.

Biometric Testing and Health Risk Assessment. This annual assessment n

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Assessment provides employees with basic information on their overall health status and recommendations for improvment. Feedback from biometric testing and risk assessment includes blood work results from measuring cholesterol and blood sugar, blood pressure and body mass index determined by height and weight. n

Weight loss assistance.

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Employee Assistance Program.

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Nutrition services.

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Diabetes education.

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Exercise services.

Other programs offered through Employee Health & Wellness include weight management programs such as Lose for Life, Walking for Fitness and the “Caught You Exercising” program and a new Wellness Champion Program that connects employees who want encouragement and support to stay commited to their fitness goals. In addition, wellness stations developed and adopted by some departments serve as a constant reminderthat fitness is important to happiness and productivity. ✔ For details on any of the above programs and much more, visit your portal, HR Online, Health & Wellness.

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Christiana Care also offers a variety of health and wellness programs, including:

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Better & Easier

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great place to work is a better and easier place to work. Many of the initiatives taken to advance patient care quality and safety also improve our work environment and help us maintain our focus on excellence. Changes in information, clinical and business technology all contribute to making our health system more attractive to the best employees and helps us transform our work place from good to great.

Here are some of the ways we’ve improved:

Computerized Provider Order Entry (CPOE) and EMAR (Electronic n

W O R K Medication Administration Record) implementation at both Wilmington and Christiana hospitals position Christiana Care at the forefront of hospitals focused on improved patient care and quality of services. n Vergence (Tap and Go) Badge Readers and the new Lock Feature installed throughout both hospitals provide access to clinical applications with a swipe of the employee/physician badge. n Symbiq Smart Infusion Pumps, jointly implemented by Pharmacy, Nursing, Clinical Engineering, Materials Management and Information Services called for designing a better distribution method to improve pumps’ availability and facilitate maintaining drug libraries on each pump. n The GetWell Medication Integration Project enables patients to view and click on their personalized medication list to receive additional information about their drugs and watch available videos. n Five maternity units at Christiana Hospital began using the Bed Management System to better enable nursing and organizational leaders to make patient discharge and occupancy decisions. n The Mother’s Own Milkbank System (MOMS) implemented in 2009 addresses patient safety issues coming from the Patient Safety Committee. MOMS handles the barcoding, inventory and enhanced administration of milk to our NICU babies and alerts if the right milk is not scanned to the correct infant. n A Refrigerator/Freezer Temperature Monitoring System now in use at both hospitals in Pharmacy and Food & Nutrition refrigerators and freezers automatically alerts if temperatures deviate from defined ranges and logs refrigerator/freezer temperatures at defined intervals, saving the extensive manual effort required in the past. n A new Food & Nutrition point-of-sale system makes cash registers at Christiana’s West End Café and eCafe,

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the Cancer Center’s Lakeview Café, and the Wilmington campus cafeteria able to accept M/C, Visa, Discover cards.

Chart Completion enables providers to look at the paper chart via accessANYware within 48 hours of discharge.

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n Acute Care Redesign ensures safe and timely delivery of care to patients presenting to the Emergency Department by redesigning processes, removing waste and improving coordination of care by the treatment team to reduce the overall length of stay. n Labor Management Reporting makes it easier for cost center managers to complete reports on budgeted and actual work hours per unit.

Learning and Development

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s a learning organization, Christiana Care continually transforms itself to stay in alignment with its identity, mission and strategic goals.

Learning accelerates transformation through experiential, continuous, interactive, innovative and informal experiences to promote thinking and growth at all levels of the organization.

To facilitate transformation efforts, our systemwide Learning Council has developed a common agenda for learning and measurement and a two-year strategic plan to enhance communications, accountability and cultural competency.

To further the professional growth and career goals of employees at all levels we have:

n Researched and identified a premier career development website solution to provide greater employee self-service options. The new functionality includes skill assessments that match skills and

Diversity, inclusion and health care equity A key theme at Christiana Care is the Transformation of Patient Care—bringing our mission and core values to life n Continued to offer many learning and so we can provide the best patient expedevelopment programs, including rience and outcomes. This includes School at Work (SAW), Expanding Your meeting the health care needs of the Career and Healthcare Opportunities increasingly diverse communities of (ECHO), Working, and Frontline Delaware. A Diversity and Inclusion Leadership.

Council comprising employees from difn We continue to enhance our on-boardferent levels and backgrounds is working process with the creation of a ing to develop an inclusive culture that journey of excellence template that prorespects and leverages the diversity of vides a checklist for employees and our colleagues to enhance innovation, managers of first-year events. quality of care, teamwork and value so Talent management we can deliver the best care for our patients as individuals.

Christiana Care’s talent management strategy focuses on the programs and ✔ To learn more about the programs menprocesses needed to build strong leadtioned above and new programs for the comers, address the anticipated shortages of ing year, please visit the System Learning top talent in health care, prepare internal site and the online Education Center, both candidates to fill upcoming leadership accessible through the employee portal vacancies, and implement programs to Education drop-down menu. increase education and development opportunities for employees at all levels. career interests with health care jobs and opportunities, and more robust career exploration opportunities.

This year, we have focused on quarterly transforming leadership forums fostering a learning community within our leaders, 360-degree assessments, the new Leadership Behaviors in Action program, and the continuation of our Whole Brain Thinking program.

A new Leader as Coach program launched in March helps leaders to enhance their leadership coaching capabilities. In addition, specialized programs are continuing for nurse managers and are being launched for physician leaders.

Development planning was extended to all employees, and succession planning expanded to all levels of leadership with the identification of high-potential leaders.

The Leadership Knowledge Center provides many valuable resources for leaders, including online simulations, elearning, and e-Books.

GET HELP WITH TOBACCO CESSATION

Dr. Rosenthal named chairman of Family & Community Medicine Appointed a full professor at Jefferson Medical College in 2006, he was awarded the Dean’s Citation for Excellence in Faculty Mentoring in 2008 and the Dean’s Citation for Excellence in Medical Education in 2004.

Dr. Rosenthal first arrived at Thomas Jefferson University Hospital as a Family Medicine resident in 1980. He received a Faculty Development Fellowship in Family Medicine at Jefferson Medical College and began his medical teaching career as an instructor in 1983.

He received his medical degree from the University of Medicine & Dentistry of New Jersey, Rutgers Medical School, and graduated summa cum laude in Biology from the University of Pennsylvania.

Michael P. Rosenthal, M.D.

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ichael P. Rosenthal, M.D., will be the new chair of the Department of Family and Community Medicine for Christiana Care Health System.

Dr. Rosenthal joins us after leaving his post as the vice chair of Academic Programs and Research for the Department of Family and Community Medicine at Jefferson Medical College, Philadelphia.

“On behalf of Christiana Care and the Department of Family and Community Medicine and Residency Program, I wish to thank David Bercaw, M.D., for his leadership while serving as interim chair while we conducted our search for a permanent Department chair,” says James Newman, M.D., Christiana Care chief medical officer.

Dr. Rosenthal brings more than 25 years of experience in medicine and medical education to Christiana Care.

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FOCUS April 22, 2010

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he Delaware Academy of Family Physicians Annual Scientific Assembly will be Saturday, May 8 at Arsht Hall, Wilmington Campus, University of Delaware, 2600 Pennsylvania Ave. Registration begins at 7:45 a.m. Cost is $50 per person, which includes continental breakfast and lunch. There is no charge for Family Medicine residents.

The assembly will be followed by the Academy’s Annual Dinner and Installation of Officers, May 8 at 6 p.m. at Wilmington Country Club, 4825 Kennett Pike, Wilmington, Del. ✔ Mail a check made payable to the

Delaware Academy of Family Physicians, P.O. Box 8158, Wilmington, DE 198038158. For more information call 302-4795515.

Gift stores offer convenient shopping

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eed a gift but don’t have time to go shopping?

The Glass Box gift shop at Christiana Hospital and the Window Box gift shop at Wilmington Hospital may have just what you are looking for, whether it’s flowers, balloons, refreshments, reading materials or a special gift for a loved one, co-worker or baby.

The gifts shops are run by the Junior Board of Christiana Care and feature a great selection of reasonably priced merchandise. The gift shops also have convenient hours for Christiana Care employees on the go. Profits from both gifts shops benefit Christiana Care programs.

Glass Box Christiana Hospital 302-733-1100 Monday – Friday, 9 a.m. to 7 p.m.

Saturday and Sunday, 11 a.m. to 4 p.m.

Window Box Wilmington Hospital 302-428-2246 Monday – Friday, 9 a.m. to 4 p.m.

Saturday and Sunday, 11 a.m. to 2 p.m.

Coupon

VNA launches Milford Adult Day Care and Memory Center

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aregivers searching for adult day programs in the Milford area no longer have to look far. Christiana Care Visiting Nurse Association (VNA) has expanded services to include an adult day care at its Evergreen II Center to allow caregivers to enjoy some needed time off with the assurance that their loved one is in good hands.

“Delaware is a popular retirement destination, with a large portion of retirees residing in Kent and Sussex counties,” says Mary Fox, RN, BSN, program director for VNA’s Adult Day Care and Evergreen Memory Center.

Nearly one in four residents within a 20 mile radius of Milford is retired, she says. “This aging population needs regular, medical adult day programming.”

Quality care close to home Adult day care offers a friendly respite for caregivers and a good alternative to placing loved ones in long-term care. Finding a facility close to home also is a plus for families with loved ones that need additional support.

VNA offers full- and part-time adult day care options, as well as periodic respite care. The program is open to individuals 18 and older who do not require 24-hour nursing care, but have mental, emotional or physical needs due to age or illness. Daily programming focuses on recreational activities such as games, exercise, music and crafts. Clients socialize, discuss current events, share meals and enjoy fellowship.

Alzheimer’s services still available The Evergreen II Memory Center continues to provide structured, therapeutic care for individuals with

Alzheimer’s disease and related dementias. The Memory Center is a cooperative effort between VNA and the Delaware Health and Social Services, Division of Services for Aging and Adults with Physical Disabilities.

VNA Adult Day Care and Evergreen Memory Center is open MondayFriday from 8 a.m. - 4:30 p.m.

Transportation is available through the DART system.

VNA accepts Medicaid waiver, state caregiver dollars, long-term care insurance and private pay. ✔ For more information, call Mary Fox at 302-422-1575 and visit the VNA web pages on www.christianacare.org.

VNA’s Evergreen Centers’ daily adult day programming focuses on recreational activities such as games, exercise, music and crafts. Above, a patient enjoys a dance with an Evergreen staffer at the New Castle County facility.

Therapeutic Notes Clinical Considerations Associated with Protease Inhibitors in Regards to Acid Suppressive Agents

By Jaclyn M. McGinness, Pharm.D.

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harmacologically, proton pump inhibitors (PPIs) are acid suppressive agents that cause gastric alkalinization through inhibition of the gastric H+/K+-ATPase. Histamine-2 receptor antagonists (H2RAs) similarly decrease the production of gastric acid by inhibiting the action of histamine on parietal cells in the stomach. PPIs are the most potent acid suppressive agents and generally have a longer duration of action than H2RAs. Acid suppressive agents also demonstrate a dose-related effect. The type of acid suppressive medication, the dose and the timing of administration of each drug should be considered when placing patients on antiretroviral therapy, in particular with protease inhibitors (PIs).

There have been several studies performed among patients infected with HIV, and acid suppressive medications have been used extensively in this patient population. Of all the PIs, atazanavir (Reyataz®) has been studied the most extensively regarding drug-drug interactions with acid suppressive therapy. Atazanavir requires an acidic environment for absorption and dissolution. Concomitant use of acid suppressive agents and atazanavir could result in subtherapeutic plasma concentrations of atazanavir which, in turn, can eventually lead to treatment failure. It is important to separate the administration time of atazanavir-based therapy from calcium- or magnesium-containing antacids by 1-2 hours.

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Recommendations for administration of atazanavir with PPIs and H2RAs are listed below: Atazanavir has been evaluated the most extensively and the recommendations specified above should be followed only when placing a treatment-naïve patient on a PPI. It is crucial to note the more conservative recommendations in treatmentexperienced patients (i.e., prior antiretroviral therapy with protease inhibitors) as these patients generally require higher concentrations to inhibit viral replication and thus are more susceptible to the impact of these interactions.

There is a clear lack of clinically significant data regarding potential drug-drug interactions with PPIs and other PIs, including lopinavir/ritonavir, darunavir/ritonavir, indinavir, indinavir/ritonavir, and saquinavir/ritonavir, and thus can safely be coadministrated. Early data suggested that fosamprenavir might be susceptible to drug-drug interactions with acid suppressive agents, but this research has been disproven. Another PI that has been studied with PPIs which has clinical significance is nelfinavir (Viracept®). Co-administration of nelfinavir with PPIs can potentially significantly reduce nelfinavir concentrations by approximately 40 percent. Nelfinavir does not require an acidic environment for adequate absorption, so the mechanism of this interaction is unclear. However, co-administration of PPIs with nelfinavir could result in a decrease in virologic response as well as development of resistance and is therefore contraindicated. Nelfinavir however, can be safely administered with H2RAs as there are no documented clinical significant interactions. In addition, all protease inhibitors can be safely administered with H2RAs as long as they are staggered as per manufacturer recommendations.

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FOCUS April 22, 2010

Focus on Excellence – Best Practice Review – April 2010 Consistent with our strategies for engaging staff in continuous improvement and best practices, we regularly review important topics in Focus to help reinforce safe-practice behaviors. These tips reinforce information and enable staff to better articulate our safety practices during an unannounced survey.

Computer Workstation Use & Security Q. Why is it important to keep computer workstations secure?

A. It is important in order to keep patient information confidential and accessible only to those who are involved directly in the patient’s care. It is also essential to protect yourself from other staff, patients and visitors who can use your login to search for unauthorized information (e.g., patient information, e-mail, Internet).

Q. Is it important to keep passwords confidential?

A. Yes. Do NOT share them or allow someone else to use the computer under your password. Passwords establish individual accountability. Staff will have a unique identifier (or login ID) and password for use in logging into information systems where confidential information will be accessed. You are responsible for the use of your individual account and should keep your passwords confidential.

Q. When should computer screens be minimized?

A. Whenever staff is no longer using that computer screen or it is in the view of the public. Confidential information must be protected from anyone other than those specifically authorized to have access based upon need-to-know to perform one’s job. Computer screens should ALWAYS be minimized or workstations locked when not being used.

Special attention should be made to the easy access of the Computers On Wheels (COWS). They must be kept from public view and shut down when not in use.

Q. Is there a way to minimize the screens on Medication and Patient Care Technician Carts?

A. Yes. There is a button (a lightbulb—"privacy") on the med cart computer. It must be used when the cart is unattended and/or if information is in view of the public. Due to the "portability" of the carts, this needs to be reinforced.

To ask questions, contact the content expert: Dawn Romano, 623-7106. To reach the Safety Hotline, call SAFE (7233) from within Christiana or Wilmington hospitals. From outside the hospitals, call 302-623-SAFE. Further information is available on the portals in the Archives of Best Practices. From your portal, choose Focus on Excellence, Joint Commission Readiness, Ongoing Strategies, Educational Strategies, Monthly Q&A.

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hristiana Care Security Department’s first K-9 trooper, Hassan, died recently after a prolonged illness. Placed in service about 10 years ago, Hassan was a very social German shepherd and enjoyed interacting with staff and patients. “Hassan will be missed,” says Bruce Blackburn, chief of Public Safety.

His handler and partner, Cpl. Marine has a new K-9 named of Ingo.

Christiana Care has four K-9 units, and each is certified in bomb detection and patrol.

Hassan

B L E S S

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V O L U N T E E R S

Dear Christiana Care Volunteers: Especially during National Volunteer Week, we want to thank you for your unique and valuable service.

Your creativity and commitment make a difference every day in the lives of our patients and our staff.

We could not accomplish what we do without you.

Robert J. Laskowski, M.D.

Thank you for all you do at Christiana Care!

Best regards, Robert J. Laskowski, M.D., MBA President and Chief Executive Officer

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FOCUS April 22, 2010

Partnering with March of Dimes

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hree days a week, March of Dimes Family Support Specialist Kelly Cover offers helping hands and sympathy to the families of Christiana Care’s tiniest patients in our neonatal intensive care unit.

Cover distributes tote bags filled with educational materials and a baby journal to as many parents as she can reach. Siblings receive goodie bags with toys, snacks and coloring books.

‘A very gentle soul’ “She is a very gentle soul and a good listener, so families of all kinds gravitate toward her,” says Fern Butler, MS, RNC, NICU nurse manager. “We cannot imagine the nursery without Kelly.”

The program is an important and much-appreciated service, says Dot Fowler, MSN, RNC, director, Patient Care Services, Women and Children.

“We are grateful to the Delaware March of Dimes for the NICU Family Support Specialist Program and makCover works with parents, siblings and grandparents who are waiting for ing it possible for Kelly to work with the day when they can bring home the parents in our NICU,” she says. latest addition to the family.

Graduates come back to help She understands their worries and Cover stays in touch with some of the fears. Nine years ago, her daughter parents she has helped during the Marina was born prematurely and was three years she has worked in NICU. a patient in Christiana Care’s NICU for She calls them “graduates.” three weeks.

Like the mom who demonstrates “Going home without your baby is a very hard thing,” she says. “Having been there as a mom, I know what it is like to sit in those rocking chairs, hour after hour.”

Positive impact “Kelly has made a very positive impact,” says Butler. “She supports both the family and the staff who are working with the family.”

Cover, who has a master’s degree in counseling psychology, helps families fill those hours in positive ways, from organizing potluck suppers, to helping parents network, to scheduing holiday celebrations for couples on Valentine’s Day and Easter egg hunts for siblings.

She encourages grandparents to create scrapbooks of the babies’ progress and reaches out to the youngest mothers, with makeup demonstrations, given by another mother whose own baby has been a NICU patient.

March of Dimes Family support specialist Kelly Cover serves a hot potluck meal and some TLC for parents Paul Waterman and Monique Cannon in the NICUconference room at Christiana Hospital.

with programs for other parents. “It’s good for parents who are going through it to know there is life e after NICU,” Cover says.

✔ The March of Dimes will hold its annual March for Babies to raise money for programs to prevent prematurity on April 25 in New Castle County. To learn more, visit www.marmakeup, graduates come back to help chofdimes.com/delaware.

Neonatal crew takes Polar Bear Plunge The Neo Bears, a brave group of Christiana Care neonatal nurse practitioners, along with several RNs, physicians and clerks from Christiana Care and other hospitals, raised $1,550 for the Special Olympics of Delaware by plunging into the 42-degree waters of the Delaware Bay March 14 in Lewes.

2,323 people jumped in and helped raise more than $500,000 for June 11-12 event at the University of Delaware.

(From left) Laura Holloway NNP, Linda Marsiglia, NNP, Patty Boesenberg, Wendy Felts, NNP, Wendy Sturtz, M.D., Linsay Fanelli, NNP, and Kathy Leef, NNP, along with (not shown) Ana Arias NNP, Neonatal Fellow Raquel Gomez, M.D., Teresa Klingler, RN, Lisa Marra, RN, and Amanda Koronik, jumped in the Delaware Bay on March 14 to support the Special Olympics of Delaware.

Annual golf tourney fills special needs

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hristiana Care’s Breast Center Special Needs Fund received a $53,000 donation from Swingin’ With A Star (SWAS), Delaware’s most prestigious and profitable amateur women’s golf tournament.

The SWAS contribution represents a portion of proceeds from the organization’s 2009 golf tournament, held last June at the DuPont Country Club.

Christiana Care’s Breast Center Special Needs Fund offers much-needed financial support to eligible patients for medical expenses while delivering the breast care they need.

Net proceeds from the tournament established in 1992 have totaled more than $1.2 million.

(From left) Janet Davis, Tom Trezise, Emily Penman, M.D., Christiana Care Breast Center surgeon, Jane Vincent, Betsy Rawls, Sylvia Banks, Diana Dickson-Witmer, M.D., Christiana Care Breast Center surgeon, Carolyn Burger, Barbara Uberti Manerchia, and Irene Shadoan Lott, celebrate a $53,000 donation from Swingin’ With a Star.