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ISSUE

14

450md St. Mary’s Medical Center Physician Newsletter

October 2 0 11

stmarysmedicalcenter.org

Chief of Staff Message Francis Charlton, MD We as a medical staff are a large and enormously gifted

Medical staff bulletin boards can now be found in all patient

group. Our responsibilities are far too great and daunting

care areas. Insulin dosage guidelines and other helpful clinical

to be managed by just a few of us. Although there are quite

information can be found on the boards.

a number of physicians active in medical staff affairs, the ever increasing array of duties and tasks required of us to insure patient safety while we provide the highest quality care demands that more of us engage in the vital but sometimes tedious and occasionally uncomfortable processes of credentialing, peer review, and systems analysis and improvement. That’s a long-winded way of crying “HELP”.

Optimal pain control is not only a hot topic, but also an elusive goal. Our anesthesiologists always have someone available on-call for pain management. Call the hospital operator to reach the on-call person to assist with any of your difficult in-patient pain management problems. This is a valuable and underutilized resource available to all of us. Your patients will appreciate you making it available to them. Additionally,

Departments and sections all need to have vice-chairs

a electronic order post-op power plan designating who is

willing and able to function in instances which preclude

responsible for pain control is in the works.

involvement of the Chair. Absence due to vacations, illness, or scheduling conflicts, as well as credentialing and peerreview matters involving the Chair, demand that we have a reliable back-up in every department/section. We as a medical staff will function much more effectively if we have active engagement of all of our diverse specialties across the board, especially regarding those matters that require your expertise, such as the afore mentioned credentialing and peer-review. Please contact your Chair if you are interested in working together with us to strengthen and improve our medical staff. It is important to broaden our base of both

Pain management is important for all patients. You can help achieve this goal by clearly identifying the physician in charge of pain orders so that both nurses and physicians know whom to contact. This can either be yourself or a consultant. Please identify the pain management physician by placing a pain sticker with the provider name and contact number on the front of the patient chart and/or entering an electronic “Consulting Physician” order. If you are designating someone other than yourself, you must first get consent to do so. By simply clarifying who to call about pain, everybody wins.

involvement and leadership – our future depends upon it.

FLU SHOTS ARE AVALIABLE FOR PHYSICIANS Free flu vaccines are available to physicians through St. Mary’s Employee Health Department. If you would like to get your shot, please call the Infection Control Coordinator, Jeanne BarryDimech, RN, CIC at 415-750-4824


BRE A S T C ANCER AWARENESS MONTH As October comes to a close, we invite you to honor yourself

and the American Cancer Society’s Look Good… Feel

and the women in your life who are over 40 (mother,

Better program.

daughter, sister, aunt, grandmother, and yourself) by asking

7. Multidisciplinary Breast Panel: multi-specialist, multi-

them – Have you had your mammogram? YOU CAN have the ability to positively impact their life and your life forever.

hospital review of a breast cancer patient’s diagnosis

and treatment for initial or second opinion

8. Second Opinion Breast Cancer Clinic introducing

St. Mary’s newest addition - breast cancer oncologist,

Alan Kramer, MD

St. Mary’s offers a comprehensive breast health and breast

If you would like more information on our services, call

cancer program including screening and early detection

the CHW Cancer Center at 1-855-CANCERØ (226-237Ø).

through diagnosis and treatment of breast cancer.

Services featured this month include: 1. Certified Breast Imaging and Breast Cancer

Center Navigator

2. Radiology’s new virtual imaging program including

mammography and bone densitometry

3. Female dedicated breast surgeon and

breast reconstructive surgeon

4. Female Radiation Oncologist and new state of the art

equipment featuring vision RT – one of four in California

5. Hi-tech Infusion Center for all IV infusions/injections

including osteoporosis, chemotherapy,/ immunotherapy

and support injections and transfusions

6. Support Services including: a female oncology certified

dietician, female lymphedema therapist, rehab therapies

Physicians and Staff Celebrated THINK PINK at the CHW Cancer Center on October 13, 2011. Pictured left to right. Sara Huang, MD (Radiation Oncology); Laura Fullem-Chavis (Director of Cancer Services), Leigh Allen, PT (Lead Physical Therapist)

What is happening at SFO? The SFO Medical Clinic – operated by St. Mary’s Medical Center You may not be aware, but The SFO Medical Clinic has been running as a department of St. Mary’s Medical Center since 2001. The Clinic provides occupational health, urgent care, medical surveillance, travel medicine, wellness and prevention services to a corporate client base within the airport and to offices in proximity to the airport as well as to the tens of thousands of travelers that pass thru the airport daily. The Clinic provides care for work related injuries, injuries that might occur in the airport as well as care to individuals who require drop-in medical urgent care. The SFO Clinic was newly renovated in 2009 and is a comprehensive clinic that includes: physical therapy, radiology services, a trauma suite, a minor surgical suite, numerous exam rooms and a negative pressure exam room for contagious illnesses like SARS or H1N1. For more information visit: http://www.flysfo.com/web/page/atsfo/passenger-serv/med-serv/

Please forward comments and ideas for future issues to: christina.hayeschandler@chw.edu


OBSERVATION STATUS

INPATIENT PAIN MANAGEMENT OPTIONS AND GUIDELINES

Observation care is a well-defined set of specific, clinically appropriate services, which

Do it yourself or consult/designate

include ongoing short term treatment, assessment, and reassessment before a decision

a specialist.

can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. (CMS definition) • Status ordered for patients who then require a significant period of treatment or

monitoring in order to make a decision concerning their admission or discharge.

• The reason for observation must be clearly documented in the medical record.

• Anesthesia provides 24/7 coverage

for formal pain consultation. Call the operator to contact the physician on call. • To minimize confusion and

Example: Unexpectedly prolonged recovery after surgery or present to the ED

enhance timely care, please clarify

and require a significant period of treatment or monitoring before a decision is made

who is responsible for pain orders.

concerning their next placement.

You may do this by affixing a pain

• Observation is an active treatment to determine if a patient’s condition is going

management sticker to the front

to require that he or she be admitted as an inpatient or if it resolves itself so that the

of the patient chart after contacting

patient may be discharged.

the designated provider, as well

• Orders and documentation must be clear, concise and convincing • Evaluate the patient’s condition to determine whether the patient requires

monitoring for a minimum of 8 hours.

as entering an electronic “Physician Consult” order.

• Patient must be re-evaluated at 23 hours to determine plan • Determine whether patient’s condition can reasonably be expected to improve

If we coordinate our pain management

efforts in this way, everybody wins.

within 24 to 48 hours

• Determine whether patient should be admitted within 48 hours

Case Management Week

Can Observation Status be changed to Inpatient Admission? YES! Patient status may be changed anytime within 48 hours if the following conditions are met: • The patient requires continuing services and monitoring beyond 48 hours,

and the condition is severe enough to require inpatient treatment.

• Discharge orders haven’t been written

Can I convert an Inpatient Admission to an Observation Status? YES! In cases where Case Management / UM Physician Advisor determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the

St. Mary’s acknowledged Case

status from inpatient admission to observation status as medically necessary, provided all

Management week

of the following conditions are met: • The change in status is made prior to discharge; the hospital has not submitted

a claim.

• A physician concurs with the decision. • The physician’s concurrence is documented in the patient’s medical record. Please see Case Management on unit or call 415-750-5714 or discuss with UM Physician Advisor prior to changes

October 10 – October 14

Meet the St. Mary’s Case Managers Top row L to R- Jeanette Panameno, Kelly Christopherson, Jo Tice, Mary el Corsiglia, Olga Molina, Kelly Morrison- Haynes, Jackie Keane Bottom row L to R- Libby Baxter, Marlene Castro, Barbara Brownell, Amy Whalen


Diabetes Subcommittee News Give no subcutaneous insulin without basal insulin on board. For initial dose: 1

Determine patient’s insulin sensitivity*

2

Multiply sensitivity and weight (actual dry weight, in kilograms) to determine total daily insulin

e.g.: 70 kg X sensitivity* Sensitive 0.3 X 70 = 21 units/day Moderate 0.5 X 70 = 35 units/day Resistant 0.7 X 70 = 49 units/day 3

Give half as Lantus daily

e.g.: (for 70 kg person) Sensitive =10 units/day Moderate = 17 units/day Resistant = 25 units/day 4

If patient eating, give 1/3 of the amount calculated for the basal with each meal

e.g.:(for 70 kg person) 3 units 5 units or 8 units of short acting insulin (Humalog) Sensitive 1/3 X 10 = 3 units/meal Moderate 1/3 X 17 = 5 units/meal Resistant 1/3 X 25 = 8 units/day 5

Add variable amounts of correctional (Humalog) insulin per power plan.

For subsequent dosing:

If the morning finger stick BG is above 140 mg/dL increase the Lantus by 10% every second day

If the change in finger stick BG from one meal (meal A) to the next (meal B) is over 50 mg/dL,

increase the first meal’s (meal A) insulin by 1 unit daily.

* Sensitive: Frail, thin, elderly, NPO or poor PO, renal or hepatic insufficiency (0.3units/kg) Moderate: Average weight, good PO, Type 1 DM (0.5 units/kg) Resistant: Overweight, on steroids, septic (0.7 units/kg)


MOBILITY IS MEDICINE – MESSAGE FROM REHABILITATION SERVICES – Maurine Coco, PT, MSPT, Director of Rehabilitation Services The human body was designed for movement. Though capable of adapting to the most extreme of physical pursuits, it is does have a strict “use it or lose it” policy. As such, our increasingly sedentary lives can have profound effects and limits the capacity of the human machine to perform even the most basic of tasks and activities. Joint pain, muscle imbalance, weight gain, metabolic changes, decreased activity tolerance, and increased risk of falls are just a few of the consequences of an underutilized human body. Add to this a new cancer diagnosis, heart attack; stroke - or even elective surgery - and the impact may further constrain mobility, potentially undermining the most effective medical treatments available. Fortunately, physical therapists are movement experts, trained specifically to alleviate barriers to activity and maximize function so that individuals can lead healthy, productive lives. Increasingly, their training and expertise are being called upon to serve patients in a variety of ways: • • • •

In critical care units, PTs work with intensivists, respiratory therapists, and nurses to engage patients with early, intense activity and mobility training to hasten vent weaning, decrease ICU length of stay, and increase likelihood of discharge home after hospitalization On the general ward, PTs work to promote patient activity and functional independence in order to prevent hospitalacquired deconditioning, reduce risk of falls, and identify early the patient’s need for post-acute care services In the outpatient setting, PTs increasingly work with those surviving cancer and cancer treatments to optimize their general physical recovery and promote active participation in life In community seminars, PTs educate aging adults and their family members about ways to diminish the risk of falls and improve balance in order to remain active and healthy living in the community

During National Physical Therapy Month, remember you have a partner at St. Mary’s Medical Center who is committed to maximizing patient outcomes and promoting a healthy community through movement. Mobility really is (the best) medicine!

For more information call Outpatient Physical Therapy at 415-750-5900 Acute Rehabilitation at 415-317-4652 or 415-680-0025

You’re Invited... St. Mary’s Annual Progressive Dinner ~ Presented by the Primary Care Council ~ Thursday, November 17, 2011 ~ 5 – 7:30 p.m. Begins in Main Lobby RSVP by November 9, 2011 to Lydia Lee: 415-750-5868 or lydia.lee@chw.edu


450 Stanyan St. San Francisco, CA 94117

ALAN KRAMER, MD JOINS ST. MARY’S MEDICAL STAFF Oncologist Board Certified: American Board of Internal Medicine; Medical Oncology Education: Dr. Kramer graduated from the University of Maryland. He received his medical degree from the University of Siena Medical School, Italy, with honors. He obtained his residency at the City Hospital at Elmhurst and completed a hematology fellowship at Mt. Sinai Hospital, both in New York City. Dr. Kramer then completed a medical oncology fellowship at the University of Texas, MD Anderson Cancer Center, where he stayed on their staff for three years in their Department of Head, Neck and Thoracic Oncology. Special Interests: His clinical interests are in cancers of head and neck, lung, breast and sarcoma. He recently has taken an interest in documentary film making and has initiated a Living with Cancer series with two award-winning documentaries to his credit: Living with Breast Cancer 2002; Living with Lung Cancer: The Wells Whitney Story 2004. For appointments with Alan Kramer, MD at St. Mary’s Second Opinion Breast Clinic, please call 415-750-5877.


450md October 2011