WAVES Fall 2013
Another key to success Bayhealth earns recognition from The Joint Commission
ER 1 year later
each and every reported accountability measure where there are at least 30 denominator cases; and 3) have at least one core measure set that has a composite rate of 95 percent or above, and within that measure set all applicable individual accountability measures have a performance rate of 95 percent or above.
Bayhealth Makes the Grade
A 95 percent score means a hospital provided an evidence-based practice 95 times out of 100 opportunities. Each accountability measure represents an evidence-based practice – examples include giving aspirin at arrival for heart attack patients, giving antibiotics one hour before surgery, or providing a home management plan of care for children with asthma.
The Joint Commission Top Performer on Key Quality Measures® 2012 • Heart Attack • Heart Failure • Pneumonia • Surgical Care
Bayhealth earns recognition from The Joint Commission Bayhealth was named Top Performer on Key Quality Measures® by The Joint Commission, the leading accreditor of health care organizations in America. Bayhealth was recognized for exemplary performance in using evidence-based clinical processes that are shown to improve care for certain conditions.
Bayhealth is one of 1,099 hospitals in the U.S. earning this distinction for attaining and sustaining excellence in accountability measure performance. Bayhealth was recognized for its achievement on heart attack, heart failure, pneumonia and surgical care.
The ratings are based on an aggregation of accountability measure data reported to The Joint Commission during the 2012 calendar year. The list of Top Performer organizations increased by 77 percent from last year and it represents 33 percent of all Joint Commissionaccredited hospitals
reporting accountability measure performance data for 2012. Bayhealth and each hospital named as a Top Performer on Key Quality Measures must: 1) achieve cumulative performance of 95 percent or above across all reported accountability measures; 2) achieve performance of 95 percent or above on
has made a commitment to accreditation and to positive patient outcomes through evidence-based care processes. Bayhealth is proud to receive the distinction of being a Joint Commission Top Performer on Key Quality Measures,” says Bayhealth’s President & Chief Executive Officer Terry Murphy, FACHE. In addition to being included in today’s release of The Joint Commission’s “Improving America’s Hospitals” annual report, Bayhealth will be recognized on The Joint Commission’s Quality Check website (www.qualitycheck.org). The Top Performer program will be featured in the December issues of The Joint Commission Perspectives and The Source.
Commitment to quality
“Bayhealth and all the Top Performer hospitals have demonstrated an exceptional commitment to quality improvement and they should be proud of their achievement,” says Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president and chief executive officer, The Joint Commission. “We have much to celebrate this year. Nearly half of our accredited hospitals have attained or nearly attained the Top Performer distinction. This truly shows that we are approaching a tipping point in hospital quality performance that will directly contribute to better health outcomes for patients.” “We understand that what matters most to patients at Bayhealth is safe, effective care. That’s why Bayhealth
Bayhealth Report to the Community 2013 Integrity
For more information about Bayhealth’s commitment to quality, download our 2013 Annual Report to the Community by visiting www.bayhealth.org/communityreport 1
Bayhealth’s STEPS Program Saves Lives
Bayhealth cardiologist Harjinder Grewal, MD, performed a specialized cardiac ultrasound to rule out the presence of any blood clots. According to Clinical Educator Tricia Bentley, if blood clots are not caught in time the patient is at risk for serious damage to the heart, brain or lungs. Luckily, no blood clot was present so Dr Grewal was able to perform a cardioversion to change Clark’s abnormally fast heart rate back to a normal rhythm. “He shocked me back into rhythm, so my wife couldn’t get rid of me that trip,” he joked. “Even though they put him back in rhythm, he still can’t dance,” Mrs. Clark shot right back.
August 21 was a fairly typical day for William Clark of Clayton, though he was feeling just a little under the weather. However, that wasn’t enough to keep him from his weekly visit to Bayhealth’s STEPS to Healthy Aging’s blood pressure clinic at Bayhealth Outpatient Center, Smyrna. And that’s a good thing.
As soon as he walked into the clinic, Lindsay Dondarski, BSN, RN, and Trisha Bentley, BSN, RN, CBCN, knew he didn’t look well. For years, Bentley has evaluated Clark at the weekly clinic and knew something was not right. Dondarski checked his vital signs and his heart rate, which was too fast and irregular. She asked him to sit and rest a while so she could check it again. When Bentley rechecked his vital signs, she found no difference in the speed and irregularity of his heart rate.
Bentley called Clark’s family doctor, Marc Heller, DO, to report Clark’s irregular heart beat and request next steps. The physician told Dondarski and Bayhealth Clinical Educator Trisha Bentley, BSN, RN, CBCN, to take him to Bayhealth’s Emergency Department, which, thankfully, was right next door. “They walked me over there to make sure I didn’t just get in my car and drive home,” he smiled. “At the Emergency Department, they were very helpful and Lindsay called my wife so she could come meet me.”
Physicians at Bayhealth Emergency Center, Smyrna, evaluated Clark. They could administer medication to return his heart to its proper rhythm, but they needed to determine the cause for his irregular heartbeat. His cardiologist, Mark Johnson, MD, and his family physician, Marc Heller, DO, agreed he should be transported to Bayhealth Kent General by ambulance.
Cardioversion is the administration of low energy shocks to trigger a normal rhythm. Patients are temporarily put to sleep before the shocks are given. This type of cardioversion is done in a hospital as an outpatient procedure. Cardioversion is not the same as defibrillation (de-fib-rihLA-shun) which uses highenergy shocks to the heart to treat very irregular and severe abnormal rhythms due to life-threatening events like cardiac arrest.
“Trisha and Lindsay checked on me in the hospital the next day,” Clark said. “If it wasn’t for them, I might not be here today. I thank the Lord for them and this place. Everyone at the hospital took great care of me, and the food was very good too.”
Now, Clark follows up regularly with his cardiologist, who performs an EKG on him at every visit to ensure his heart is beating properly and in rhythm. And, he never misses his weekly visit to Bayhealth’s blood pressure clinic in Smyrna. “We’re very fortunate to have this weekly clinic, and my wife and I have even made friends here as well. And Trisha and Lindsay do a great job looking out for me. If I gain a pound, they’re after me,” he smiled. “I’m very thankful.”
Bayhealth’s STEPS to Healthy Aging Program, is a free program for anyone over age 50 living in Bayhealth’s service area. The goal of this program is to inform members of the latest health information for healthy aging, make new health skills a priority and improve lifestyle, diet and attitude for healthy longevity. For more information about the STEPS to Healthy Aging Program, call Bayhealth’s Education Department at (302) 744-7135 or (toll-free) 1-877-453-7107, or visit www.bayhealth.org/steps.
Bayhealth Emergency Center Nears One Year Anniversary When Bayhealth’s Emergency Center in Smyrna opened its doors on December 18, 2012, the staff expected to see close to 500 patients in the first several months. A few weeks in, that number was a distant memory. Since December, the story of the Bayhealth facility has been one of exceeding expectations, in all sorts of ways. Kim Ford, RN, BSN, CRN, Nurse Manager at the Smyrna Emergency Center, quickly revised the staffing plan to
meet growing volumes. She increased the nursing staff by 20% and added a physician’s assistant and nurse practitioner for busy days. An emergency scribe works seven days a week to assist with documentation so medical staff can devote more time to patients. The facility’s relatively small size allows for unique team dynamics. Many of the staff wear more than one hat. Amy Bradford, MT, ASCP, Medical Technologist, works in the lab processing samples, but also assists with registra-
tion, patient vital signs, phlebotomy, and general housekeeping. “Everyone takes an interest in what others are doing. We all step in to help when needed and teach each other about the different roles,” she said. “It’s a real team environment.” All employees experience a high level of patient contact at the Smyrna Emergency Center. Because nurses, physicians, medical technologists, and imaging technologists work side by side, collaboration is the order of the day. “Patient care is excellent because we all work so closely together. Laboratory profes-
sionals, physicians, and nurses can talk to each other in the moment about situations that might be causing certain outcomes,” explained Steven Talbot, DO, Medical Director of the Smyrna Emergency Center. For Brooke Zingone, RN, a nurse at the Emergency Center, one of its greatest strengths is the staff’s cumulative years of experience. Sharing best practices with colleagues, some of whom have been in their professions for over 20 years, is a tremendous asset in an environment where each new patient may present with a radically different set of issues.
The facility’s relatively small size allows for unique team dynamics. Many of the staff wear more than one hat. “Most of our staff have between 10-17 years of experience,” she said. “We are a wonderful resource for each other.” High patient satisfaction scores attest to the impact of staff dynamics. In one recent month, 92% of patients reported that they received “very good” care, and the facility was nominated for two Bayhealth Service Excellence Awards by patients and employees. Local residents appreciate the Bayhealth Emergency Center’s proximity, as do area family physicians. “The Bayhealth Emergency Center has made life a lot easier for our patients and for us,” said Sally Fessler, medical assistant to Dr. Robert C. Donlick, of Clayton. “Our patients have been able to go there and be seen right away. With the Bayhealth online portal, I am able to easily access lab results and discharge instructions for follow-up care.”
Specialized Physical Therapy Services Now Available Just for Women Bayhealth is pleased to welcome a physical therapist with a special interest in women’s health and pre/post-natal physical therapy. Megan Anderson, DPT, of Dover received her Doctorate in Physical Therapy from Indiana University in 2009. After beginning her practice in Seattle, Wash., she was introduced to pelvic floor rehab and pre/post natal PT by a colleague. She has since completed focused coursework through the Herman and Wallace Institute including treatment of diagnoses such as dyspareunia (pelvic pain or pain during intercourse), stress and urge incontinence, pudendal neuralgia, and many others. She is also trained in biofeedback for neuromuscular re-education of the pelvic floor.
“A lot of women simply accept a certain amount of leakage as a normal part of aging, and it’s not,” she stressed. “Incontinence can be improved with strengthening exercises and muscle education. Additionally, many women have lived with pain during intercourse when they don’t have to. Any woman unable to tolerate a typical ob/gyn annual exam can learn strategies to overcome the pain.” Treatment for incontinence, for example, includes behavioral training to overcome urgency and to normalize bladder function. Since the therapy is so specialized, Anderson typically sees patients one to two times a week for several weeks, then at intervals the next few months to ensure patients are doing their exercises correctly and that their muscles are supporting them. Patients may see their family physician to request a prescription for this physical therapy, so Anderson may evaluate their condition and create a treatment plan. For more information on physical therapy services, please visit www.bayhealth.org.
HMBANA.org (Human Milk Banking Association of North America). For mothers who choose to formula feed, education includes safe preparation of formula, with guidelines on appropriate amounts to feed a newborn, as the American Academy of Pediatrics, as well as other agencies have made childhood obesity a top priority. Melissa Lim and son
Bayhealth Working Toward “Baby Friendly” Status Why is breastfeeding so important? Just ask Gail Smith, RN, IBCLC, Bayhealth Lactation Services Program Coordinator. “Breast milk is the single best food for your baby,” she said. “It has all the nutrients your baby needs to thrive, it protects your baby from illnesses and allergies, and it’s free!” Bayhealth’s commitment to breastfeeding is evident, as we are taking steps
toward being named a “Baby-Friendly”-certified hospital through the Baby-Friendly USA Corporation. The Baby-Friendly Hospital Initiative is a program and process for creating an optimal environment for maternal/ infant bonding and the initiation of breastfeeding. The initiative provides a nurturing environment not only for new mothers learning to breastfeed but also for breastfeeding mothers months after the birth of their children. “Bayhealth staff members receive ongoing education to ensure breastfeeding mothers who come into our hospitals for reasons long after the birth of their child – for example, they need x-rays
or even outpatient surgery – receive appropriate accommodations to continue breastfeeding during the course of their stay,” Smith added. These accommodations are also made for Bayhealth employees. Private lactation areas are available to nursing mothers to either breastfeed their baby or have a private area to pump during their break. Bayhealth Care Manager Emily Hanggi, BSN, RN-BC, and Bayhealth Physical Therapist Melissa Lim, PT, DPT, worked with their supervisors to ensure they were able to schedule sufficient time to pump. “As a physical therapist, you’re running around to see patients,” Lim said.
“However, I talked with my supervisor and told him I wanted to breastfeed for at least a year. He was totally on board with this and made sure to accommodate my needs. It was a very good experience.” Hanggi began working at Bayhealth several months after the birth of her son. As a new employee, she knew she wanted to continue to breastfeed. Her supervisors offered her several locations to pump her breast milk, but she was pleased when Milford Memorial’s lactation room opened during the last two weeks of her orientation period. She has been so successful in pumping and storing her breast milk that she has been able to donate some of her supply
to women who may have breast milk supply issues or want only breast milk for their babies. Several milk banks around the country take donations of human milk. For more information on them, contact
Bayhealth Offers New 3T MRI testing Shorter Scan Time, Better Image Quality
“There’s such an emphasis on breastfeeding that women who can’t may feel inadequate and need to be supported as well,” Lim stated.
Bayhealth now welcomes patients to our new 3T MRI scanner at Bayhealth Kent General—the only 3T MRI facility in Kent County.
“Yes, there is a push because people assume breastfeeding is easy,” Hanggi added. “I had no issues but it was still hard. Other women face difficulty pumping at work because of the nature of their jobs; we were lucky.”
3T MRI (Magnetic Resonance Imaging) offers a major leap forward in performance when compared to most currently-used MRI machines. Shorter scan times offer patients greater comfort, and the image clarity is of much higher quality than that produced by traditional 1.5T scanners. Images from the 3T MRI scanner provide better visualization of fine anatomic structures, meaning that physicians are better able to detect subtle abnormalities earlier and more accurately.
Gail Smith, RN, IBCLC, Bayhealth Lactation Services Program Coordinator Bayhealth Lactation Services offers support and guidance for new and experienced breastfeeding mothers. Please call (302) 744-7233 for questions or counseling, or visit www. bayhealth.org/breastfeeding for information on counseling, available classes and support groups.
could potentially change patient outcomes,” said Amit Newatia, MD, Bayhealth Director of MRI. Patients needing MRIs for a variety of reasons will benefit from the 3T MRI’s ability to reveal tumors, infection, and inflammation. Breast, orthopedic, neuro, and cardiac imaging will all be sharper, providing greater diagnostic clarity. At Bayhealth, 16 on-site, fellowship-trained radiologists read patient images and report the results to referring physicians within 24 hours, 7 days a week. To learn more about our imaging services, visit bayhealth. org or call 302-744-7060.
“The excellent image quality, combined with interpretation by highly-trained radiologists, provides the opportunity for much earlier detection of disease and other conditions that
Welcome New Physicians “I look forward to continuing the close partnership between Penn and Bayhealth cardiac surgery programs under the leadership of Dr. Szydlowski,” he added. Dr. Szydlowski joins Drs. John Mannion, Daniel Marelli, and Paul Fedalen in providing cardiovascular and thoracic surgery to the Dover community. He also serves as Bayhealth’s chief of cardiovascular and thoracic surgery.
Trinity Pilkington, MD
Pranitha Naini, MD
Gary Szydlowski, MD
Orthopaedic surgeon Trinity Pilkington, MD, has joined Bayhealth Orthopaedics of Dover, part of Bayhealth Medical Group. Before joining Bayhealth, Dr. Pilkington was an orthopaedic surgeon at Riverside Memorial Hospital in Newport News, Va.
Pranitha Naini, MD, has joined Bayhealth Hematology/Oncology Associates. Dr. Naini recently completed a fellowship in hematology/oncology at the University of Tennessee Health Sciences Center, in Memphis, TN.
Cardiovascular and thoracic surgeon Gary Szydlowski, MD, has joined Bayhealth Cardiovascular Surgical Associates.
“We are very happy that Dr. Pilkington has joined our practice,” said Michael Mattern, MD, of Bayhealth Orthopaedics of Dover. “With the addition of Dr. Pilkington and orthopaedic surgeon Gabriel Lewullis, MD, we are responding to the growing need for advanced orthopaedic care in our area.” Jonathan Kates, MD, is also a member of Bayhealth Orthopaedics. Dr. Pilkington graduated with honors from the University of South Carolina School of Medicine and completed an orthopaedic surgical residency at Allegheny General Hospital in Pittsburgh, Pa. He continued his orthopaedic training, specializing in orthopaedic trauma and reconstructive surgery, at Harvard Medical School and Massachusetts General Hospital. Board certified by the American Board of Orthopaedic Surgeons, Dr. Pilkington is Bayhealth’s medical director for orthopaedic trauma. He specializes in minimally invasive joint replacement surgery. He is the first orthopaedic surgeon at Bayhealth to offer the muscle sparing anterior approach to the hip, with smaller incision and less muscle dissection, and eliminating post-operative positional restrictions. He also specializes in hand and upper extremity conditions, sports medicine knee and shoulder syndromes, and foot and ankle disorders.
She joins Drs. Iftekhar Khan, Kathrina Chua, Rishi Sawhney, and Adity Sharma in providing hematology and medical oncology care to central and southern Delaware communities. “Hematology and oncology is a fascinating field and I am proud to be a part of it. As an oncologist, I have an opportunity to make a difference in the lives of the cancer patients and their families during their tough times,” said Dr.Naini. Dr. Naini completed a residency in internal medicine at Sinai Hospital of Baltimore, affiliated with Johns Hopkins University, where she served as an attending physician for three years. Dr. Naini also sees patients in the Neuro Oncology Multidisciplinary Clinic at the Bayhealth Cancer Center with neurosurgeon James Mills, MD, and radiation oncologist Khanh Nguyen, MD.
For the past nine years, Dr. Szydlowski has served as associate chief, Division of Cardiothoracic Surgery; chief of section cardiac surgery; and physician practice leader with the Lehigh Valley Health Network, in Allentown, Pa. He also directed several cardiac surgery programs. “I have known Dr.s Gary Szydlowski for over a decade as one of the go-to surgeons at Lehigh Valley Medical Center. Gary is one of the best heart surgeons in the region. His arrival at Bayhealth and his appointment as the new Chief of Cardiothoracic Surgery will continue to provide the Dover community with wonderful cardiothoracic care and leadership that they have come to expect under a program started by Dr. John Mannion. Dr. Mannion, who has stepped down as Chief of Cardiothoracic Surgery, will continue to provide leadership at Bayhealth in his new role of Administrative Chief Cardiovascular and Thoracic Surgery,” said Michael A. Acker, MD, Chief, Division of Cardiovascular Surgery Director, Penn Medicine Heart and Vascular Center William Maul Measey Professor of Surgery, University of Pennsylvania Health Systems.
“It is a compliment to Bayhealth that we have been able to attract an individual with such an extensive experience in cardiothoracic surgery as our new chief surgeon,” said Dr. Mannion. After completing his medical education at Hahnemann University School of Medicine in Philadelphia, Dr. Szydlowski’s post-graduate training included residencies in general and cardiothoracic surgery at Thomas Jefferson University Hospital.
For more information on these and any of our Bayhealth physicians, please visit www.bayhealth.org.
Black White and
Gala CELEBRATING BAYHEALTH’S PARTNERSHIPS Saturday, February 1, 2014
Saturday, February 1, 2013 Dover Downs Hotel & Conference Center The Auxiliary of Milford Memorial Hospital and the Junior Board of Kent General Hospital together will host the 8th Annual Black & White Gala at Dover Downs Hotel & Casino on Saturday, February 1, 2014. The 2014 Black & White Gala promises to be a fun evening with entertainment by The Glass Onion Band, hors d’oeuvres, cocktail hour, a sit-down dinner and a cash bar. Visit http://www.bayhealthfoundation.org/ for details and to purchase tickets.