REP JULY 21 by BOC design Inc

vol.29 no.7 • July 2021

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Cardinal Health’s Robert Rajalingam Cardinal Health’s president of U.S. sales for medical solutions discusses the company’s commitment to customers, embracing diversity, and facing adversity as a team.

Virtualize Thyself. There was a time when maybe you wished you could conduct business meetings in your pajamas but we never really thought it would happen. Our experienced sales and service teams are still here for you and committed to continue as your trusted selling partner. We can help ensure your success by providing the diagnostic products still critical to you and your customers. Until we can work together in the field again, SEKISUI Diagnostics will be here for you in any other way possible. Because we understand, every result matters.

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JULY 2021 • VOLUME 29 • ISSUE 7

PUBLISHER’S LETTER The travel industry should give us all inspiration..... 2

PHYSICIAN OFFICE LAB Sepsis Update Sepsis is dangerous. But if treated early, the patient outcome is usually favorable..... 4

DISTRIBUTION A New Hybrid Experience at NDC Exhibition 2021 Another first for NDC in the books.......... 8

IDN OPPORTUNITIES Supply Chain Leader Profile Jennifer Chenard, director of strategic sourcing, Trinity Health, Livonia, Michigan...................................14

Jennifer Chenard

The Geriatric ED

INFECTION PREVENTION COVID Fatigue and the Infection Preventionist The need for infection preventionists has never been greater. What can hospitals and healthcare systems do to appropriately staff those positions?.........16

TRENDS

Specially outfitted EDs accommodate elderly patients, though expense is an issue...............................................38

Collaborative Diabetes Care The AMGA’s Together 2 Goal® campaign has concluded after five years. What were the results?.............................44

HIDA

Primary Care’s Challenge Tomorrow’s primary care practice should feature multiple team members, closer collaboration with other providers, and a greater awareness and usage of community resources. How will it get from here to there?........................34

HIDA Supports the Medical Supplies for Pandemics Act..... 45

NEWS Industry news....................................48

Rep Corner

Karl Scheetz is Loving it His territory? ‘Everywhere on earth.’

Subscribe/renew @ www.repertoiremag.com : click subscribe repertoire magazine (ISSN 1520-7587) is published monthly by Share Moving Media, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Copyright 2021 by Share Moving Media. All rights reserved. Subscriptions: $49.00 per year for individuals; issues are sent free of charge to dealer representatives. If you would like to subscribe or notify us of address changes, please contact us at the above numbers or address. POSTMASTER: Send address changes to Repertoire, 1735 N. Brown Rd. Ste. 140, Lawrenceville, GA 30043-8153. Please note: The acceptance of advertising or products mentioned by contributing authors does not constitute endorsement by the publisher. Publisher cannot accept responsibility for the correctness of an opinion expressed by contributing authors. Periodicals Postage Paid at Lawrenceville, GA and at additional mailing offices.

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July 2021

PUBLISHER’S LETTER

The travel industry should give us all inspiration As I’ve started traveling again, I find myself noticing new things. I’m so thankful for the

inspiration I’ve received from those working in the travel industry. We all have our stories over the last year, but this industry has been affected in a way that’s hard to comprehend. This past week I was blessed to meet and watch two Delta employees in the Sky Club. The first one was Derek, an older gentleman working with pride and passion as he made his way around the club. Derek’s work ethic and attitude were incredible. He never stopped unless it was to say hello to customers or ask if they needed anything. His demeanor was such an inspiration to see.

Scott Adams

The second was Armaud. He was working a packed bar and making everyone feel good, not only with cocktails, but also his personality. As I came back for a refill, I brought back my glass so he wouldn’t have to waste another one. His comment to me was priceless: “Thank you so much, obviously you’ve been here long enough to see we’re slammed.” To which I replied, “Yes sir, I’m so sorry.” He then said something that surprised me: “Don’t be sorry, we’re glad you are all here; it sure beats the alternative.” Here was a guy in the weeds with a line of customers and who could easily have been distraught or complaining. Instead, he was embracing the challenge – and more importantly, thankful for it.

testing and yet you embraced it. Through work ethic and a desire to take care of America’s care givers you were able to thrive. Like Armaud said, being busy and scrambling to keep your head above water sure beats the alternative! This month’s cover story with Cardinal Health’s President of U.S. sales for medical solutions, Robert Rajalingam, embraces both lessons mentioned above. The story comes from a Road Warriors podcast I recorded with Robert last month in which he discussed the lessons learned throughout his career as well as facing a global pandemic while taking over the helm at Cardinal. I hope you enjoy the read as well as the podcast found on Repertoiremag.com or in the QR code below.

Both men reminded me of some valuable lessons: 1. Always take pride in yourself and your work 2. Be thankful for the things you have today and take care of those that take care of you.

Dedicated to the industry, R. Scott Adams

As I watched those two, I couldn’t help but think about the Repertoire audience this past year and a half. You’ve all been in the weeds chasing down PPE or diagnostic COVID

 Road Warriors and Their Untold Stories Episode #18 - Robert Rajalingam

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PHYSICIAN OFFICE LAB

Sepsis Update Sepsis is dangerous. But if treated early, the patient outcome is usually favorable. Awareness of sepsis as a specific clinical condition has dramatically improved in the past 10

By Jim Poggi

years due to the diligent efforts of the Sepsis Alliance and a large number of other advocacy groups from both clinical and laboratory disciplines. What we know today is that sepsis is the leading cause of death related to hospitalization and costs the U.S. healthcare system more than $24 billion annually. It’s the costliest single clinical condition in hospitals. Additionally, sepsis can be caused by a range of infections, many of which we typically consider relatively benign and easily treated. These causes include respiratory infections such as pneumonia, group A strep and influenza (more on this later), urinary tract infections, enteric diseases including C. difficile and skin infections including MRSA.

As a final note of review, sepsis is NOT a disease, and it’s not contagious. It’s defined as “the body’s overwhelming response to infection, which can lead to tissue damage, organ failure, amputations and death.” From a metabolic standpoint, sepsis typically unleashes a powerful immune response, resulting in what is described as a “cytokine storm.” Cytokines are a part of the immune system that pass messages to the immune system to attack a foreign substance and rid the body of it. In healthy conditions, their 4

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signaling stays in control and results in removal of the infecting substance. But in sepsis, their signal goes out of control and unleashes a far greater immune response than is appropriate. As dangerous as sepsis can be, if diagnosed and treated early and aggressively, the patient outcome is usually favorable. More than 70% of those who suffer from sepsis will recover fully if treated promptly. The key is recognizing the symptoms of sepsis and rapidly taking action to overcome it.

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PHYSICIAN OFFICE LAB Clinicians frequently use the acronym TIME when they describe the symptoms of sepsis. It’s worth putting into your vocabulary. The classic symptoms of sepsis include: ʯ Temperature: elevated or below normal. ʯ Infection: sepsis typically presents as a result of an infection. ʯ Mental confusion/decline: the patient may be sleepy, easily confused, or difficult to rouse. ʯ Extremely ill: patients frequently state that they are concerned they may die.

Sepsis amid the pandemic So, how does sepsis fit into the world we live in today, with the COVID-19 pandemic an everyday concern? Unfortunately, with the widespread incidence of COVID-19, it’s amplifying the number of cases of sepsis worldwide. While any respiratory infection can lead to sepsis, the widespread incidence of COVID-19 has created far more opportunities for the development of sepsis. We are still learning to understand all the associated comorbidities related to the development of COVID-19 infections, but it’s becoming very clear that COVID-19 can unleash the classic “cytokine storm” typically associated with sepsis. In addition, its attack on the lungs and other organs complicates treatment and accelerates the urgency to treat it as well as to manage any associated comorbidities, including sepsis. How does all this impact us and the customers we serve? Many of us work in primary care, rather than the hospital market. As a result, our clinicians may see a patient in the early stages of COVID-19 and then pass along those most acutely ill to an appropriate tertiary care facility. Post recovery, our customers will also engage with the patient to assure their complete recovery. We have a role in the early diagnostic side of things and also in post recovery care of the patient. To be effective consultants, we need to be alert to the possibility of sepsis accompanying a COVID-19 infection. Those of us who call on urgent care and free-standing emergency centers are likely to have customers seeing more patients who present with sepsis. Over the past year, we have become well acquainted with the tests appropriate for diagnosis of COVID-19 including RT-PCR, antigen tests and COVID-19 antibody tests. Working with our key lab suppliers, we can now also present the facts about appropriate screening and diagnostic tests that can be performed in any setting, including the physician office to assist in diagnosis of sepsis related to COVID-19. These tests include lactate, procalcitonin, CBC, monocyte distribution width and interleukin-6 (IL-6). As we know early 6

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diagnosis is key to rapid, effective patient treatment and presents the best opportunity for full recovery. TIME is of the essence. In the post recovery world, our customers need to be alert to identify any residual organ damage that may have resulted from sepsis. Here again, we have a key role to play. Our diagnostic arsenal includes virtually every lab test available to assess organ health, including ALT, AST, creatinine, urea nitrogen and CBC. There’s growing evidence that COVID infections have wide ranging organ impact, including the heart, so there may be a broader range of assays post COVID-19 than those typical of patients with sepsis unrelated to COVID-19. Be sure to work closely with your key lab supplier to know the facts about appropriate diagnostic tests as well as those appropriate for patient follow up post sepsis.

Sepsis is the leading cause of death related to hospitalization and costs the U.S. healthcare system more than $24 billion annually. It’s the costliest single clinical condition in hospitals. So, once again COVID-19 presents us with both challenges and learning opportunities. It has opened up our eyes to the need to test for IL-6 as an indicator of an impending cytokine storm, a learning we can use for every incidence of sepsis. It has also increased awareness in the clinical community and even with the general public that respiratory infections can and do have a range of systemic impacts and may affect many organs. The clinical community has benefitted from the experience gained in treating COVID-19 patients that will have far-reaching impact on diagnosis and treatment of sepsis and respiratory infections in general. While the COVID-19 pandemic has been a difficult and continuing challenge, it has presented all of us with opportunities for growth. The knowledge we have gained leads us to be better and more well-informed consultants.

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DISTRIBUTION

A New Hybrid Experience at NDC Exhibition 2021 Another first for NDC in the books Courtesy of NDC, Inc.

Another “first” for NDC is in the books with the successful completion of the first-ever hybrid NDC Exhibition

2021. NDC was proud to accommodate guests, both virtually and live, providing something for everyone to begin carefully easing back into “normalcy.”

The hybrid Exhibition opened its doors for a Welcome Reception to kick off this year’s show, held onsite at the Gaylord Opryland Hotel. While several in-person events were sprinkled in across the three-day Exhibition agenda, all keynotes and education sessions took place virtually, giving attendees the flexibility to experience the 2021 show from an office anywhere. During the Opening General Session on Tuesday morning, NDC President & CEO, Mark Seitz, delivered supply chain updates, followed by important NDC initiatives discussed by NDC Chief Strategy Officer, Todd Ross, and NDC Chief Commercial Officer, Mark Kline. Linda Rouse O’Neill (HIDA) provided a government update, and attendees were then inspired by former NFL player and ESPN analyst/host, Merril Hoge’s “Find A Way” keynote address. Later that day, attendees had the opportunity to engage in compelling presentations from two impactful speakers. In “#ChallengeAccepted” with Jen Widerstrom, the former undefeated NBC’s The Biggest Loser coach sat down with NDC’s Ian Fardy to talk everything from career and nutrition to mental well-being and 8

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Industry titans Mike Carver and Phil Kelsey enjoy a long-awaited live gathering at the Gaylord Opryland Hotel with their spouses.

Members and vendors felt right at home in Nashville under their cowboy hats.

You’ll never see patients the same way again.

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DISTRIBUTION how to have fun during this stressful time. Then, with 25 years’ expertise in the healthcare industry, Dr. Wessels shared his best practices, dos & don’ts, methodology and influencing techniques in “Foundations of Distance Selling with Influence.” NDC proudly honored the unprecedented performances of our distributor and manufacturer partners during 2020. Much like the “Cameos” featured in NDC’s virtual awards ceremony last October, this year’s annual Awards Presentation was hosted by a number of familiar faces off the big screen who NDC found to announce the winners! This star-studded event was followed by a Musical Performance by John Rich, American country music singer and songwriter. Apart from the numerous virtual business meetings and networking

This year’s “Better Together Celebration” proved to be a hit among NDC Exhibition attendees!

Attendees reconnect over drinks and hors d’oeuvres on the SimPow Patio.

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Attendees had fun competing in “Cornhole for a Cause” while raising over $15,000 for American Military Family.

Held outdoors at Gaylord Opryland, attendees raised over $15,000 for American Military Family’s essential cause through entering NDC’s Cornhole for a Cause competition and bidding virtually on unique and exciting silent auction items!

Old friends reunited: Brad Thompson and Midmark’s Chip Fellows and Mark Fisher enjoying a chance to catch up.

sessions available to all attendees, another on-site networking event that proved to be hugely successful was the Better Together Celebration / Military Appreciation Charity Event. Held outdoors at Gaylord Opryland, attendees raised over $15,000 for American Military Family’s essential cause through entering NDC’s Cornhole for a Cause competition and bidding virtually on unique and exciting silent auction items! During the event, on-site attendees enjoyed food and beverages while experiencing an electrifying live performance from AnD, Andrea and Dominique, better known as the musical duo from the 2020 awards presentation. This year’s Virtual Exhibition Tradeshow made it possible for distributors to circulate and connect with exhibiting manufacturers, many of whom had proactively scheduled Zoom business meetings to augment the exhibit experience. Following a full day of networking on the tradeshow floor, the event wrapped up on Wednesday afternoon with a warm and lively SimPow Send-Off at Broadway’s Redneck Riviera. Initial feedback from the firstever hybrid NDC Exhibition indicates the event benefitted all in attendance. The virtual platform allowed distant distributors and suppliers to reconnect while the in-person events brought a feeling of normalcy back to networking. Rather than bask in the success, word is, the NDC team is already hard at work planning to top this year’s Exhibition in 2022. Above all, NDC is grateful for the continued participation of their valued distributor and vendor partners and hopeful that this year’s hybrid experience offered attendees opportunities to create meaningful connections with fellow healthcare supply chain industry leaders. www.repertoiremag.com

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July 2021

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about testing during the past year, the image that comes to mind is cars lined up for a couple of miles for drivers and passengers to get a nasal swab to know whether or not they’re infected with COVID-19,” said Dr. Fred Tenover, vice president of scientific affairs for Cepheid, a molecular diagnostics company based in Sunnyvale, Calif.

Cepheid received FDA emergency use authorization (EUA) for its 4-plex SARS-CoV-2, Flu A, Flu B and RSV combination test. This assay is offered in Cepheid’s GeneXpert Xpress System. It offers actionable detection and on-demand results with one sample collection. It optimizes the GeneXpert System module capacity by combining two Xpress tests into one. It’s important for hospitals, urgent care and physician offices to detect and differentiate between flu, RSV and COVID-19, which all present with similar symptoms. Current flu and 12

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SARS-CoV-2 therapies need definitive diagnosis for each pathogen. This differentiation identifies potential cases of co-infection during respiratory season and provides risk assessment for patients and staff while resuming traditional healthcare procedures. “We didn’t have a flu season this year probably due to social distancing and mask wearing and not seeing as much transmission,” Dr. Tenover said. “But as people start to congregate again and take the masks off, and kids start going back to school, the CDC is predicting that this next flu season could be a bad one. So,

you really need to know that your test is going to pick up flu as well as COVID and the differentiation between the two.” “The Cepheid test produces a fast and highly accurate answer,” Dr. Tenover continued. “It is standardized across all venues, including the central lab and near patient testing sites. The point-of-care (POC) assay is the same assay found in academic medical centers, the national reference laboratory and in mid-sized hospitals.” This empowers patients with rapid results and assists hospitals, urgent care centers and physician offices to effectively manage limited resources. It provides labs with singletest confidence to accelerate workflows and support clinicians with ondemand, timely and accurate results. “The value of the GeneXpert Xpress System comes in ease of use and a high degree of accuracy,” Dr. Tenover said. “Anyone can use this. It’s no more difficult than using a Keurig coffee maker.” “SARS-CoV-2 is an RNA virus and RNA viruses always mutate. We expect them to. They have the ability to cause more infections, be more severe and in some cases, evade vaccines,” Dr. Tenover continued. “But all of these viruses are detected by the Cepheid assay. None of the emerging mutant strains are escaping detection.”

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IDN OPPORTUNITIES

Supply Chain Leader Profile Jennifer Chenard, director of strategic sourcing, Trinity Health, Livonia, Michigan 14

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Repertoire: What is the most interesting/challenging project you’ve worked on recently? Jennifer Chenard: The most interesting and challenging project I have worked on recently is most likely not much different than other healthcare organizations – to locally source PPE during the pandemic. I was tasked with finding local and U.S.-based sources for masks, disinfecting wipes, hand sanitizer and face shields; And we needed quick turn-around times.

Understanding the specifications for the products we needed from my manufacturing background, I was able to quickly reach out to local sewers to make cotton masks. I made a phone call to Detroit Sewn, and luckily, the owner called back the very next morning. We met at Detroit Sewn with a sample, reviewed specs online, and the owner was quickly able to manufacture prototypes. We were able to gain clinical use approval, and from there, they began manufacturing. We now not only have masks, but reusable gowns as well. For disinfecting wipes, we were able to call on PAK Technologies to supply Trinity Health when were in need. PAK technologies is a U.S.-based manufacturer for disinfectants. They came to our rescue by answering our call and supplying wipes on a monthly basis.

Repertoire: What projects are you looking forward to in the next six to 12 months? Chenard: I am looking forward to continuing to support local manufacturing and U.S.-based manufacturers as we find new and creative ways to serve our healthcare systems. Repertoire: What is the biggest challenge/change facing healthcare supply chain professionals in the next 5 years? Chenard: I believe the biggest challenge facing healthcare supply chain professionals in the next 5 years is business continuity. We need to build resilient relationships with our suppliers and push to have an understanding of the supplier’s business continuity and redundancy

Being a leader is not about “I” or “ME”, it is about what impact can be made to those on my team, those around me, and the community. Vaughn Hockey out of Oxford, Michigan began manufacturing reusable gowns based upon samples we were able to provide. And last, but not least, we partnered with Technique, Inc. from Jackson, Michigan, for reusable face shields.

plans. Manufacturers ask this of their raw material suppliers, therefore in healthcare supply chains, we need to ask the same of our supply partners. With this information, we can then make more informed decisions related to supplies, continuity

and in the long run, it will ensure that if a pandemic or a supply disruption occurs, we can still continue to take care of our patients and we can help other hospitals do the same instead of fighting over the same supply base. Repertoire: Who do you look up to for inspiration or mentorship? Chenard: I continue to look for inspiration from those that foster a collaborative approach; those that have a purpose-driven outlook for the greater good. I look to mentors that know taking a risk and supporting it is the best motivator. I look to those who have been in the healthcare industry long enough to know that change is needed to continue to lower the cost because we need to keep the doors open so that we can take care of all people. Repertoire: How do you continue to grow and develop as a leader? Chenard: I believe staying grounded in my purpose allows me to continue to grow as a leader. Being a leader is not about “I” or “ME”, it is about what impact can be made to those on my team, those around me, and the community. If I’m able to keep that purpose in the forefront, I believe that I will able to help others grow into leaders. As a leader, it’s about growing others and giving them the opportunity to do what they thrive on, not to fall into a mold that was preset. www.repertoiremag.com

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July 2021

INFECTION PREVENTION

COVID Fatigue and the Infection Preventionist The need for infection preventionists has never been greater. What can hospitals and healthcare systems do to appropriately staff those positions? Linda Dickey, RN, MPH, CIC, FAPIC,

Dickey Consulting LLC, has been an infection preventionist for more than 25 years. In that time, “we’ve never been in a situation where we have either reused or extended the use of personal protective equipment, certainly on the scale that we’ve had to do with COVID,” she said. Dickey is president-elect of the Association for Professionals in Infection Control and Prevention (APIC). In the past, that reuse or extended use was simply not done as a fundamental tenant of infection prevention. Single-use items were used once and thrown away. Yet reuse and extended use was a situation that nearly every healthcare provider found themselves in amid the early days of the pandemic. “We all realized when we ran into the supply chain issues that it made us think differently about how reserves are handled,” she said. “And it made us think more about the cost of that, because, obviously, there was warehouse space and holding a lot of supplies to consider, versus just-intime inventory. COVID taught us all that we can’t always expect to have something readily available.” Because there were so many interruptions in the supply chain, infection preventionists had to be nimble and work closely with supply chain partners. “We probably worked more closely with them than we ever did before,” Dickey said, whether it 16

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INFECTION PREVENTION was examining personal protective equipment options, cleaning and disinfection options, or even options related to some types of services. “Not that we didn’t work closely with our supply chain partners before, but it made it abundantly clear that we are joined at the hip to try to solve these problems because they are quite vexing. COVID has been extremely challenging to our supply chain partners. It put them front and center in terms of trying to manage the availability of various types of products, hand in hand with maintaining safety.”

Linda Dickey

The beginning of the pandemic was extremely difficult for infection preventionists, Dickey said, because the guidance coming out was so fast, and so evolving. “Not only were people involved in epidemiology and infection prevention trying to calm fears and maintain patient care and answer questions, but we were doing it in the context of not necessarily having all the information that we would have known had the pandemic been further down the road. So, I think everyone in the whole world literally was working somewhat in a vacuum, learning about COVID-19,

Robin Carver

“ The impact to infection preventionists as a profession has been pretty profound over the last year. We talk a lot about the front-line care providers, because they were the ones there day in and day out.” – Robin Carver, RN, MSN, CIC, vice president, member engagement at Premier Inc.

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its transmission, what the options were for safe and effective care, and what the options were for actual treatment for these patients.” Many infection preventionists worked around the clock, either extending workweek hours or fielding calls on the weekend. Dickey said for her, those extended hours started in late January and continued throughout the year. She didn’t have her first day off until Mother’s Day. “Our leadership was phenomenal, and our supply chain leader was over-the-top phenomenal and still is,” she said. “But we constantly had to find time to communicate with each other and develop communications that went out to the organization and make sure that we were all on the same page. That takes time, and thoughtfulness. And so, I think a lot of infection preventionists probably experienced that level of intensity for quite some time.” Even off the clock, infection preventionists were still fielding questions from family or friends about COVID-19. “They were reaching out and asking, ‘Can you give us any more information?’ ‘What does this mean?’ ‘What should we be able to do that’s safe?’ So, you not only experienced the stress on the professional side of your life, but your personal side as well,” Dickey said. “It’s been a marathon.

Extended fatigue Infection preventionists have been planning and preparing for pandemics for years, said Robin Carver, RN, MSN, CIC, vice president, member engagement at Premier Inc. “I don’t think anybody could have been fully prepared for what we experienced, because even as we wrote plans, and participated in drills, you never know truly what’s going to hit you.”

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INFECTION PREVENTION Now with COVID cases on the decline, many infection preventionists are admitting that they are exhausted. Fatigue has set in. “The impact to infection preventionists as a profession has been pretty profound over the last year,” said Carver. “We talk a lot about the front-line care providers, because they were the ones there day in and day out. But the IPs were also right there, day in and day out. And many of the IPs that I work with on a consistent basis have said, ‘I’m so exhausted. I have to be on call, or I have to be at the hospital 24 hours a day, seven days a week, because there are so many questions.’”

And the impact of the various organisms on different body systems.” Infection preventionists as a profession are very close to retirement age. “The last survey that I saw indicated 55% of infection preventionists were at retirement age, which will leave us a huge gap,” Carver said. In fact, Carver has worked with several health systems over the last few months who have said they need help finding an infection preventionist because they can’t adequately staff the position. “The reality is they’re just not out there. So, as we see people that have decided at the end of this pandemic that they can’t do this again,

More people entering the role of infection preventionist may have an epidemiology, public health or a laboratory background. Indeed, hospitals and health systems have relied on their infection preventionists to answer an onslaught of questions. How do we isolate patients? Can we reuse this medical equipment? Can we co-room patients together, and what’s the risk associated with that? How do we get the right air filtration in place? Infection preventionists have oversight into all those things in a hospital system, said Carver. “We think about them often as just the people that report hospital acquired infections or do hand hygiene policing. But they have to be experts across the board in things like ventilation, sterilization and disinfection of the environment and of medical devices. 20

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and don’t want to do this anymore, they’re either leaving the profession for other options or they’re retiring.”

Filling the gaps The role of infection preventionist, and who has filled that role, is evolving. In the past, most infection preventionists started as nurses. They may have transferred from some other role into the infection prevention role. “For a long time, I think that was a qualifier of industry hiring practices,” Carver said. Over the last decade, infection prevention has been moving into different disciplines. More people entering the role of infection preventionist may have an epidemiology,

public health or a laboratory background. “I know a few IPs that are respiratory therapists by training,” Carver said. “We’re really trying to broaden what is the definition of an infection preventionist.” A lot of health systems are also trying to tier their approach to infection prevention, Carver said. “If you think about it, just one part of what we do is surveillance – looking at lab results and determining in the clinical presentation, do they meet the definition of an infection? A lot of health systems are saying they can use a less experienced staff member for that.” As a result, some health systems have created a role called an epi tech, which might be someone that’s not a nurse or does not have a higher-level clinical background, to fill the role of surveillance. The epi tech may transition up to an infection preventionist. “They’ve created tiers in their departments,” Carver said. “It also helps anytime you have that ladder of progression for people in our profession, certainly helps capture their attention.” Salary is another lever for infection prevention. When hiring infection preventionists, infection prevention department leaders are competing against things like case management positions, where the employee can work 7 a.m. to 3 p.m., or they can work on the weekend and grab a weekend differential. But in today’s environment, infection preventionists have almost a 24/7 role. There are days they will have to be on call, late hours if an incident happens. They’re constantly having to figure out how to protect the staff or patients. “So, if you’re going to choose, you’re probably going to choose the role that pays a little bit more, and you’re there 7 a.m. to 3 p.m. and then turn around and go home. The other factor a lot of organizations

have been looking at is market salary. What do we need to do to really compete and get good talent in infection prevention roles?” Infection prevention is a very specialized discipline. There is a lot of education and preparation that goes into it, Carver said. “When you have a shortage of infection preventionists, that means if you have an IP or two that’s left in your department, they of course have to pick up more. It means that they have to be pretty dedicated to the regulatory reporting that has to happen.” CMS takes data from NHSN and calculates payments or penalties based on that in the value-based purchasing program. So, if a hospital is limited in the number of infection preventionists it has available, that means the reporting has to be their focus. “You have to make sure that the data gets in so you’re not penalized.” A shortage of infection preventionists means the hospital may lose the monitoring that needs to happen in the clinical area. “You lose the expertise of that person being able to guide practice changes at the bedside,” Carver said. “You lose that person monitoring the environment to make sure that you know things are being cleaned appropriately, that operating rooms are being turned over correctly. You lose that oversight when you’re very limited and the only thing they can do is pay attention to the regulatory reporting programs. And how long are they going to stay in that position, if all they do is sit in the office and go through data and report it to the government?”

A pathway to more IPs In late March, APIC announced their intention to create an infection prevention and control curriculum for colleges and universities. APIC’s

IP Academic Pathway marks the first national effort to link undergraduate and graduate programs to the field of infection prevention and control, ultimately leading to certification in infection prevention and control.

into a higher education institution’s course of study through their undergraduate, graduate, and continuing education programs. “Creating the IP Academic Pathway is a national imperative,” said

Many infection preventionists worked around the clock, either extending workweek hours or fielding calls on the weekend. “The pandemic has brought to light the tremendous need for trained infection preventionists in our nation’s healthcare facilities,” said APIC CEO Devin Jopp, EdD, MS. “While APIC has a robust competency model and other resources to support professionals already practicing in the field, a clear pathway into infection prevention and control careers does not currently exist for college and university students. Through IP Academic Pathway, APIC plans to create an intentional track for infection prevention certification and degree programs. This will help not only the healthcare field, but also industries like entertainment, hospitality, and travel, which are increasingly hiring infection preventionists.” An APIC task force will develop the IP Academic Pathway core concepts, which will detail competencies needed to work successfully in infection prevention and control as outlined by the Certification Board of Infection Control and Epidemiology (CBIC). Once developed, the curriculum can be integrated

Jopp. “As the leading organization in infection prevention and control, APIC is uniquely positioned to lead this initiative. APIC will be soliciting input from both the infection prevention and higher education communities and seeking university partners that are willing to help design and pilot the new program.” Dickey said they are seeing the need for infection prevention expertise well beyond the acute healthcare setting. “COVID has shown very clearly that there’s a need for individuals who have this expertise in longterm care, home care and in other types of settings, even if it’s just to advise,” she said. “There are even industries outside of healthcare that have asked, ‘How do you operationalize some of these infection prevention measures, and what does that look like for my business?’” Dickey continued. APIC wants to help educate people on the role of infection preventionists. “So, I think that there’s actually quite a bright future and a strong future for people that are attracted to infection prevention.” www.repertoiremag.com

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For Robert Rajalingam, there was no ramp up. When

he was appointed president of U.S. sales for Cardinal Health’s medical products and distribution in October 2019, he and his team had to hit the ground running, dealing with the traditional challenges that come with serving a large customer base of both acute and non-acute facilities, as well as a significant recall. Then COVID hit. “On one hand it’s certainly been a challenge, given we’re all working at a frenetic pace,” Rajalingam said. “I think the last year plus, it’s been the hardest that I and many on my team have worked in our careers. It’s really about knowing your reason, your mission – know your why, as some people use that phrase – for what we’re doing.” In a recent interview, Repertoire Publisher Scott Adams spoke to Rajalingam about a wide range of topics, including Cardinal Health’s pandemic response, lessons learned, leadership insights and how the distributor plans to celebrate its 50-year anniversary. www.repertoiremag.com

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Cardinal Health’s Robert Rajalingam

Scott Adams: This past year has had its challenges for all of us. How have you been able to keep your team motivated despite the conflicts, obstacles, back orders – all the things that you had to deal with on a daily basis? Robert Rajalingam: While we’ve had a lot of challenges and obstacles this year, I think one of the positive aspects was just the heightened sense of mission. What we were doing has been critical. When else in our careers would the front page of whatever news outlet you visit talk about PPE distribution? There’s no doubt that was unheard of as dinner table conversation. I think for the folks on my team – the sales reps but also everyone in operations – there was a real sense of trying to help the customer. I think beyond that, just tactically, a lot of frequent communication came from me and the rest of our leadership team. Our reps operate pretty independently, and even more so in a virtual environment. Making sure the team heard from our leadership team, and me specifically, was important to let them know we’re on the front lines with them. I talk to customers multiple times a week if not every day. Our team knows that I’m experiencing what they are, and I think that’s been motivating for them. Adams: For all of your customers, especially on the health system side, you can go on any of their websites and the first thing you see is mission, vision, values. When everybody’s drinking from a fire hose, how do you keep your team focused on what you just described, your mission, vision as an organization and overall values? Rajalingam: It’s one thing to have it on a nice PowerPoint slide and mention it, and we certainly do that – but the way that I think our team really internalizes it is through the repetition and reinforcement of what we talk about every day in our staff meetings or all-team calls. For example, when we have a best practice to share, we recognize someone, or one of our reps shares a big customer win, I always try to tie it back to the five key values that we have as an organization. That’s where people start to really see, “OK, this is what Robert and the leadership team are focused on.” It’s a good reminder. Whether it’s best practices, wins, key messages, we’re always trying to incorporate our values consistently through our actions and messaging. Adams: Do you have a system in place that helps you come up with great ideas within your organization? 26

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Rajalingam: I wish I could say it was as organized as a system, but there are probably a few key principles we follow or ways we operate. One is having a diverse group of employees on our team. I think it starts there, so we avoid that consensus or groupthink. We’ve certainly made great strides toward that, in terms of a really diverse team. The second one is listening to customers and also observing customers, because there are things they don’t always articulate that you might notice, such as problems they’re encountering. They don’t even think to tell you that it’s a problem, but if you notice it and address it, it’s a way to make their life easier and make their experience working with us better. We’re trying to really put customer experience and customer engagement at the forefront of everything we do – and not just our sales reps, but everyone, whether it’s IT, folks in finance, people who are more peripheral to our customers. We haven’t solved this, but it’s a journey we’re on to put the customer experience at the center of everything we do.

Our reps operate pretty independently, and even more so in a virtual environment. Making sure the team heard from our leadership team, and me specifically, was important to let them know we’re on the front lines with them. Then the last thing I would say is we did have an internal business case competition that was successful. We had a number of great ideas. We teed up a few different problem areas for our employees, not just our sales reps but our employees across the organization, to engage, partner with people they normally wouldn’t partner with in our organization, and then look at a problem from a different lens. We came out with a good problem – we had more ideas than we could give one first place to. Certainly there was a winner, but we’re moving forward with a few of the ideas that otherwise we wouldn’t have arrived at.

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Cardinal Health’s Robert Rajalingam

Adam: What one or two things are you proud of within your organization over the last year? Rajalingam: There are a couple of things I’d mention. One is seeing the team really accomplish a goal that maybe at the outset was greater than something they thought they could achieve. Making progress toward the goal and doing what was needed on behalf of a customer, whether it was through the pandemic or some of the significant occurrences we had, the team showed up in a big way and I’m very proud of our organization. For instance, we had a significant gown and pack recall, one of the largest in FDA history by SKUs. We had reps spending nights and weekends for weeks at a time, shoulder to shoulder with customers, right in their inventory rooms and warehouses, working through sorting product and assembling kits. I got notes about reps who were driving for hours on Christmas Day to get product to cases where they were needed. Just seeing that dedication from our sales team, that’s better than any articulation of the mission. Their actions embody that, and it’s really energizing to me and I’m proud of that.

I like to learn from other leaders. I have mentors and others I talk to, but I also engage with a lot of podcasts and books. The other item that I’m proud of is our commitment to diversity, which spurs innovation and great thinking on our teams. We’ve been really intentional about that in our organization and my specific team. At an organizational level at Cardinal Health, we’ve closed the gender pay gap. We’re at 99%, essentially closing that gap, which typically is 15 to 20% at other companies. In my broader organization of over 1,000 people, we’re at about 50/50 male/female, which as you know, in most sales organizations isn’t very typical. Almost 40% of our hires in the last year have been ethnically diverse, and we’ve increased the number or the percent of female leaders and ethnically diverse leaders. For all of those things to happen, it takes our leadership really believing in the potential diversity can create in our organization for good ideas and great performance. It’s great to see that progress over the last year. 28

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Adams: How do you continue to grow and develop as a leader? Rajalingam: It starts with a mindset and an intentional commitment, so the notion of no matter what role you’re in or title you have, you’re always evolving to be a better leader than you were last week, last month, last year. I like to learn from other leaders. I have mentors and others I talk to, but I also engage with a lot of podcasts and books. There are some podcasts I listen to that are interviews with leaders in other spaces. One I listened to in the last month was Bob Iger, the former CEO and chairman of Disney. How does he develop creativity in his employees? There was another podcast interview with John Brennan, who was the former CIA director. How does he make tough decisions with incomplete information? Adams: What are some of the most important attributes you see in successful leaders today? Rajalingam: I think especially in this current environment, I notice a few things that make leaders successful. One, seeing disruption as an opportunity for improvement or transformation. I think everyone understands that we have more disruption now than at any time in our careers, whether it’s our specific industry, the healthcare supply chain, how we work, etc. We were just talking about virtual versus in-person and how we engage with employees across all different spectrums of diversity. There are so many disruptions happening. I think a leader today must be energized and opportunistic about that, versus scared of it and reluctant to embrace it. The other characteristic I think about is authenticity as a leader and the ability to inspire. I’ve found more and more that with my team and even leaders I work with, I’m energized when I know more about them as a person, versus just a title and someone you see in a business review-type meeting. Again, I try to be candid with my team as much as different virtual forums allow, so they understand who I am as a person, and that we have lives and families outside of work. I think that makes you more relatable. This all ties into the inspiration piece. Our CEO was talking to us last week about a letter he got from a board member. He mentioned managers light a fire underneath their people and leaders light a fire within their people. Adams: On the flip side, what are some dangerous traits you’re seeing in leadership today?

Cardinal Health’s Robert Rajalingam

Rajalingam: Overconfidence or arrogance, confidence without humility and being focused on yourself. One of the reasons I enjoy working at Cardinal Health is that I don’t see a lot of that in our leadership team. If you have a leader that is arrogant, then other folks start to model that behavior because they see that maybe it’s being rewarded. I’ve been in other organizations where that’s been the case in certain teams. It can lead to a sense that the rules don’t apply to you. You’re unaware of blind spots you may have, you make questionable decisions, and you have a lack of respect for your team. All of those things you learn by observation, and I’ve certainly seen that in the past. Adams: As a leader in a large organization, what are some of the qualities and traits you look for when you’re considering to promote somebody into a leadership role or somebody that’s starting the career path? Rajalingam: I have a list of a few things – they all start with C. One is just capacity – both intellectual and bandwidth. Are they smart? Can they work hard? That’s almost table stakes, but it’s important. I also think about curiosity. Are they a continuous learner? Are they always trying to seek out new information? Another quality is courage, which goes back to your earlier question in terms of are they willing to do the right thing under pressure and voice their opinions. Again, I think that’s really important. I also consider their competitive fire. Do they have a drive to win, especially in sales? I think you just can’t teach that. That’s something I try to look for in any type of interview or recruiting process. Then the last two qualities are communication and culture. Can you clearly convey your ideas and influence others? Certainly, most folks who are successful in sales are able to do that, but I think it’s a valued trait in any function. On culture, that’s an intangible one, but I think about whether I would want to sit next to them on a cross-country flight. That’s how I assess culture. If I don’t want to do that, then I probably don’t want to hire them and work with them. Adams: What was one of the most important risks you took, and why? Rajalingam: The risk that comes to mind is when I was working in business development at Medtronic and helping the CEO with some different opportunities. The preamble to it is that we had gone through a deal that didn’t 30

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work out so well, and through some diligence, we learned we couldn’t scale it up. The risk I took was in the second opportunity on the deal, there was a lot of consensus. You’ve probably been involved in things like that, where an entire organization from the CEO on down are bullish or gung-ho on a deal. People get deal fever and are ready to do it. The risk there was I was an associate of business development but was on point with due diligence. I knew that there were some risks to this deal, to this product, that would make it something that would be untenable for us to go forward. The risk was just speaking up on that, in a pretty broad setting with broad leadership present. For someone at that stage in my career, candidly, it was intimidating for me to do. However, I learned to really speak truth to power when maybe that wasn’t the proper thing to do. It went against the consensus in the room, and it certainly turned out to be a good decision in terms of what happened with that product in different hands. Thankfully we didn’t make that acquisition, but that really taught me to trust my intuition that was informed by facts and just build some confidence. It’s something I always counsel folks on my teams or folks I mentor about. “You’re hired into that role for a reason, and we want to hear what you have to say.” Adams: Can you tell us about your current goals? Rajalingam: From a team perspective, certainly our customers have gone through a lot over the last year. It’s been the most challenging on record, with all kinds of activity around PPE and COVID testing and things like that. I think the first one is making sure we acknowledge as a company that the experience for our customers has been difficult. We have self-awareness for that and are really improving and simplifying the customer experience. That is my number-one priority for me and my team – and really our entire business segment – as we’re going forward. We’re launching a messaging campaign, along with a lot of improvements and investments behind that to do exactly that. We’re excited about that. The other one is on a more qualitative level, and that’s to make sure for myself and my team that we have good balance, and the team is able to understand that what we’re in now is not a sprint, but a marathon. We’re essentially in a new normal. That phrase gets overused certainly, but I believe that’s the reality. I want to ensure that my team is creating that right work-life rhythm. Because when our reps are happy and fulfilled, that translates to what our customers experience.

Cardinal Health’s Robert Rajalingam

Cardinal Health at 50: Service at the Forefront Cardinal Health as a company is marking its 50th anniversary in 2021, and kicked off a year of giving back in January. Robert D. Walter was only 25 years old and fresh out of Harvard Business School when he decided to pave his own path. Walter founded the company in 1971 with the purchase of a small grocery wholesaler called Monarch Foods in Columbus, Ohio. He eventually changed the name to Cardinal Foods, in honor of Ohio’s state bird and the mascot of his high school. After more than 10 years of growth in food distribution, Walter pivoted to pharmaceutical distribution and purchased Bailey Drug in Zanesville, Ohio. That was the first in a series of acquisitions of pharmaceutical distributors that eventually led to an initial public offering on the NASDAQ stock exchange in 1983. In 1990, Mike Kaufmann, now the Chief Executive Officer of Cardinal Health, joined Walter’s growing team, and then in 1994, the business changed its name to Cardinal Health. “I have had the great fortune of knowing and working with Bob Walter for 30 years,” Kaufmann said. “He has helped make the company what it is today – a pharmaceutical distributor, a global manufacturer and distributor of medical and lab products and a provider of performance and data solutions for healthcare facilities. Bob also taught me a great deal as a leader – and continues to do so.” Since its inception, Cardinal Health has continually evolved to meet healthcare’s changing needs. But one thing that has remained constant is a deep

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commitment to its customers, partners, employees and communities. “It is a privilege to be with Cardinal Health today,” Kaufmann said. “We continue to adapt and innovate through a dynamic environment, building upon our scale and heritage in distribution with products and solutions to serve our customers and their patients – now and into the future.” Walter said, “We built the company on a sustainable foundation – doing business the right way. Not a day goes by that I don’t see evidence of the good work that Cardinal Health does for its customers, partners, employees and communities.”

Robert Rajalingam, president of U.S. sales for medical solutions, said Cardinal Health is commemorating its 50-year anniversary with a year of service. “We’re encouraging employees to actively engage in programs that are important to them in many different areas, including educational initiatives, food drives, improving the environment, ending prescription drug misuse, whatever it might be. Our goal is to record a minimum of 50,000 hours of volunteer service by the end of the year.” Throughout the year, employees will support causes that mean the most to them across four areas, one for each quarter of the year: equity,

our environment, health and hunger. “We’re purposefully beginning the year with equity-focused service,” Kaufmann said. “Diversity, inclusion and equity are core to who we are at Cardinal Health – we firmly believe that ‘as you are is just right for us.’” Looking ahead to the next 50 years, Cardinal Health is focused on improving outcomes – for customers, partners, employees and communities. “As we collectively navigate the pandemic, we are dedicated to continuing to fulfill our critical role in the healthcare supply chain, as we work to become healthcare’s most trusted partner,” Kaufmann said.

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TRENDS

Visits to primary care clinicians are declining, the workforce pipeline is shrinking as clinicians opt for more lucra-

tive fields, and many practices are struggling to remain open. Yet primary care is the only part of health care in which an increased supply is associated with better population health and more equitable outcomes.

“A strong foundation of primary care is critical to the health system,” conclude the authors of a new report from the National Academies of Sciences, Engineering and Medicine, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” It should be a common good, they say, made available to all individuals in the U.S., promoted by responsible public policy, and supported with the resources to achieve health equity. 34

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The recommendations in the report echo those of a 1996 publication by the Institute of Medicine. But those recommendations “remain fallow,” the authors of the new report admit. “[Twenty-five] years since the Institute of Medicine report, ‘Primary Care: America’s Health in a New Era,’ this foundation remains weak and underresourced, accounting for 35% of health care visits while receiving only about 5% of health care expenditures. [T]he foundation is crumbling.”

Some of the report’s recommendations cover well-trodden ground, including: ʯ Shifting away from fee-for-service payment toward value-based models. ʯ Increasing physician payment for primary care services to more closely match that of specialty services. ʯ Creating new health centers, particularly in underserved areas. ʯ Developing digital health technology. But two recommendations, if implemented, could signal a new direction for the primary physician practices whom Repertoire readers call on: ʯ The development of interprofessional care teams. ʯ The creation of community-based training programs for primary care providers.

Interprofessional teams Primary care teams should fit the needs of communities, work to the top of their skills, and coordinate care across multiple settings, say the report’s authors. To do so, they need to “consider how to meaningfully engage the full range of primary care professions, including physician assistants, nurse practitioners, medical assistants, community health workers, behavioral health specialists, and others.” Furthermore, they should make efforts to integrate primary care and public health, behavioral health, oral health and pharmacy. Interprofessional teams typically include a core team, an extended health care team, and what the authors refer to as an “extended community care team.” ʯ The core team comprises the patient, their family, and various informal caregivers; primary care clinicians, who may be physicians, PAs, NPs, or RNs; and clinical support staff, such as medical assistants and office staff. ʯ The extended health care team can include community health workers, pharmacists, dentists, social workers, behavioral health specialists, lactation consultants, nutritionists, and physical and occupational therapists. ʯ The extended community care team includes organizations and groups, such as early childhood educators, social support services, healthy aging services, caregiving services, home health aides, places of worship and other ministries, and disability support services.

“Team-based care improves health care quality, use, and costs among chronically ill patients, and it also leads to lower burnout in primary care,” according to the report. But such teams demand skilled leadership, decision-making tools and real-time information. In addition, interprofessional teams: ʯ Are proactive and provide well-thought-out care, including pre-visit planning and laboratory testing. ʯ Distribute and share the delivery of care among team members. ʯ Share clerical tasks, such as documentation, non-physician order entry, and prescription management. ʯ Enhance communication through a variety of strategies. ʯ Optimize the function of the team through co-location, team meetings, huddles, and mapping workflow. “Family members and other informal caregivers are an important part of overall quality and care of patients,” says Rachel Buckholtz, a Medical Group Management Association consultant, commenting on the report. “Oftentimes they can provide reliable data that may otherwise get missed, which can help the provider make better decisions for the patient. They are better able to express the true medical condition, especially in the elderly population.

The dream team Teams in highly functioning primary care practices: ʯ See themselves as the linchpin between communities, and link people and families to specialists, acute care hospitals, and chronic care facilities. ʯ Have a deep grasp of physiology, therapeutics and technical medicine. ʯ Appreciate the assets and challenges of the communities they serve. ʯ Understand how the health system is constructed and works. ʯ Exercise exceptional skills in team-building, communication and collaboration. ʯ Demonstrate strong leadership and advocacy skills. Source: “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” National Academies of Sciences, Engineering and Medicine

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TRENDS “I see providers relying on resources in the community, but I do feel they need to become more aware and comfortable with all resources available to patients,” she adds. “That’s a hard ask, but one that is necessary, especially as functional medicine progresses. I have had many providers tell me they ‘don’t practice that kind of medicine,’ not understanding the resources available. “In some areas it’s as simple as telling [patients] where they can participate in co-ops for healthy fruits and vegetables. Many still only focus on treating a patient when they are sick enough for medications, instead of using the community resources to help them make wiser decisions on health before it becomes a chronic issue requiring traditional medications.”

Community-based training Training primary care clinicians individually in inpatient settings will not adequately prepare them to deliver highquality primary care, says the report. The federal government should support training opportunities in community settings and in rural and underserved areas, and provide economic incentives such as loan forgiveness and salary supplements. Trainees should be given the opportunity to work alongside non-physician care providers and extended care team members.

“Core to the delivery of primary care are competencies underlying team-based care; how to function in an integrated, interprofessional manner; and how to integrate and coordinate care with community-based care team members.… The challenge of achieving those competencies lies in incorporating interprofessional didactic and experiential learning into the already crowded medical and health professional education. Challenges also exist in educating and training students alongside the current workforce, especially in settings where the workforce itself is not functioning as an interprofessional team.

‘Family members and other informal caregivers are an important part of overall quality and care of patients.’ “The ability of a primary care team to address the broad range of population needs, including identifying community expectations, engaging individuals in preventive health care and counseling, and managing simple and moderately complex medical problems, is essential to creating a system in which the requirements of the populations and individuals are addressed efficiently and cost-effectively.” The study – undertaken by the Committee on Implementing High-Quality Primary Care – was sponsored by the Agency for Healthcare Research and Quality, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Academic Pediatric Association, Alliance for Academic Internal Medicine, Blue Shield of California, the Commonwealth Fund, U.S. Department of Veterans Affairs, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, and Society of General Internal Medicine.

July 2021

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TRENDS

The Geriatric ED Specially outfitted EDs accommodate elderly patients, though expense is an issue Picture this scenario. You have taken

your 90-year-old father to the emergency room at 4 p.m. following a fall. Considering his comorbidities, multiple prescriptions and mild cognitive impairment, his health is probably more complicated than that of others in the waiting area. But since his medical conditions do not require immediate medical intervention, he ends up in the middle of the queue. 38

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TRENDS You wait … and wait. The doctors and nurses are busy, and they’re doing the best they can. If the ED is at capacity and he needs to be seen right away, they can adapt and make room – even in a hallway – to address concerns quickly and safely. But if his evaluation is not completed by 8 p.m. and you determine he’s in no condition to wait any longer, you might take him home and make a note to call his primary care doc first thing in the morning. Had this occurred in a geriatric ED, things might have played out differently. Recognizing that a 90-year-old is more vulnerable than younger patients, the staff may have been able to rapidly usher your father into an area specifically designed for elderly patients. Instead of conducting standard triage, they would view his fall and ED visit as an “unfortunate opportunity.” They know that when a 48-year-old person falls, it’s most likely an event, whereas when a 90-year-old does, it’s a syndrome. So they would check his medications, cognitive abilities and balance. A social worker would assess his nutritional status, the quality of care and attention he is receiving at home, and whether or not he needs additional social resources.

‘This is about opportunities to redesign systems to better meet the needs of vulnerable older adults.’ “I am an emergency physician, and I’m proud of doctors and nurses who work in the emergency room,” says Kevin Biese, M.D., FACEP, associate professor of emergency medicine and geriatrics at University of North Carolina at Chapel Hill. “This isn’t about them not doing a good job. They do amazing work every day in very challenging settings. This is about opportunities to redesign systems to better meet the needs of vulnerable older adults.” A greater awareness of the geriatric patient’s needs and a structured program can help change that system.

Accreditation The first self-identified geriatric ED (GED) in the United States was established more than a decade ago. 40

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By 2014, the American College of Emergency Physicians (ACEP), the Emergency Nurses Association, American Geriatrics Society and Society for Academic Emergency Medicine had teamed up to create guidelines for a geriatric ED. Four years later, ACEP launched a voluntary accreditation program, classifying GEDs as level 1 (gold), level 2 (silver), or level 3 (bronze), based on staffing, care processes, education, physical environment, and specialized equipment. Requirements begin with demonstrating that the participating emergency department includes both a physician and nurse on staff with specialized geriatric training, meets environmental criteria such as easy patient access to water and mobility aids, and has a geriatric quality improvement initiative. Today approximately 250 emergency departments in the country have GED accreditation. As of February 2021, 13 of them had achieved Level 1 accreditation. “We’re thrilled with the progress,” says Dr. Biese, who chairs ACEP’s accreditation committee. “It speaks to the eagerness of our colleagues in emergency medicine to do a better job for vulnerable older adults, and to the need for a structured approach to accomplish that. “We’re just getting started. There are more than 5,000 emergency departments in the country. At the end of the day, our goal isn’t to get every one of them accredited, but certainly to create more awareness of the special needs of geriatric patients and to help our colleagues meet those needs.”

Demographics Between 2000 and 2010, the population 65 years and over increased at a faster rate than the total U.S. population, according to the 2010 Census. The population 85 and older is growing at a rate almost three times the general population. In the U.S., an estimated 10,000 baby boomers turn 65 every day, says ACEP. This demographic shift brings challenges to healthcare systems, as older adults visit EDs at higher rates than non-seniors, often present with multiple chronic conditions, are at increased risk from polypharmacy, and suffer from complex social and physical challenges, according to ACEP. Seniors make contact with the healthcare system at many points, though perhaps none as frequently and significantly as the emergency department. The expertise which an ED staff can bring to an encounter with a geriatric patient can meaningfully impact not only the patient’s condition, but also the decision to use relatively expensive inpatient modalities or less expensive outpatient treatments. More accurate diagnoses

and improved therapeutic measures can expedite and improve inpatient care and outcomes, help providers determine which older adults are likely to benefit from hospitalization versus outpatient care, and can guide the allocation of resources towards a patient population that, in general, uses significantly more resources per event than younger populations. The vast majority of geriatric EDs are not physically separate from traditional EDs, says Biese. “It’s hard to wrangle up [millions of dollars] to build a geriatric ED. We don’t want that to be a barrier. Of the 250 accredited EDs, only a handful have a separate space for older adults. But they are all making progress to improve care for vulnerable older adults.”

ROI The cost-effectiveness of geriatric EDs appears to be widely accepted. A study in JAMA Network involved Medicare beneficiaries who visited one of two EDs – Mount Sinai Medical Center in New York City and Northwestern Memorial Hospital in Chicago – that implemented the Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancements (GEDI WISE) program, sponsored by the CMS Innovation Center.

The researchers determined that the program was associated with lower Medicare expenditures, with total Medicare savings per beneficiary of $2,436 in the Mount Sinai cohort and $2,905 in the Northwestern Memorial cohort at 30 days after the initial ED encounter. This association remained statistically significant up to 60 days, with a mean savings per beneficiary of $1,200 in the Mount Sinai cohort and $3,202 in the Northwestern Memorial cohort. But a few things still need to be ironed out before geriatric EDs are widely adopted, wrote Maura Kennedy, M.D., MPH, Department of Emergency Medicine at Massachusetts General Hospital and Harvard Medical School, in an accompanying editorial. “Evidence that higher-quality models of care, such as GEDs, can reduce health care costs should catalyze the adoption of these models,” she said. This is more likely to happen when the savings generated benefit the entity shouldering the costs. However, in the GEDI WISE program, the savings went to the payer, in this case Medicare, while the costs of sustaining this intervention beyond the grant-funded period were borne by the hospitals. “Asking hospitals to spend their own money to save Medicare money is unlikely to be sustainable. Growth of this care model requires that health care systems also benefit financially from the cost savings.” www.repertoiremag.com

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July 2021

TRENDS

What makes an ED a geriatric ED? The list below is a suggested starting point for the design and equipping of a geriatric ED, per the American College of Emergency Physicians.

Furniture

ʯ Exam chairs/reclining chairs may be more

comfortable for geriatric patients, and they facilitate transfer processes. ʯ Furniture should be selected with sturdy armrests, and ED beds should be at levels that allow patients to rise more easily for safe transferring. (Some studies show that bedrails do not reduce the number of falls and may increase the severity of falls.) ʯ Extra thick/soft gurney mattresses decrease development of skin breakdown and decubitus ulcer formation. ʯ Upholstery should be soft and moisture-proof to protect the fragile skin of older patients. It should be selected to reduce surface contamination linked to healthcare-associated infections. ʯ Economic evidence supports early prevention of pressure ulcers in ED patients by the use of pressure-redistributing foam mattresses. ʯ Reclining chairs in the ED (instead of gurney beds) have been shown to reduce pain and improve patient satisfaction.

Special equipment

ʯ Body warming devices/warm blankets. ʯ Fluid warmers. ʯ Non-slip-fall mats. ʯ Bedside commodes. ʯ Walking aids/devices. ʯ Hearing aids. ʯ Monitoring equipment. ʯ Respiratory equipment, to include a fiberoptic intubation device.

ʯ Restraint devices. ʯ Urinary catheters, to include condom catheters. (Minimize risk of CAUTI.)

Visual considerations

ʯ Soft lighting is recommended, but exposure to

natural light has also been shown to be beneficial for recovery times and in decreasing delirium. ʯ Patients should have control of the lighting in their space so they can sleep when other lights are on. ʯ Light colored walls with a matte sheen and light

flooring with a low-glare finish should be used to optimize lighting and reduce glare. Fixtures that bounce light off the ceiling or walls increase overall room lighting while glare can be reduced with the use of matte surfaces. ʯ Patterns that have dominant contrasts may create a sense of vertigo or even seem to vibrate for older adults. Some older patients may misperceive patterns as obstacles or objects (e.g., leaf patterns on flooring, which may be seen as real leaves). ʯ Monochromatic color schemes should be avoided. Similar colors look the same for those with poor vision. Instead, allow colors to contrast between horizontal and vertical surfaces. ʯ Older adults experience a decreased ability to differentiate cool colors (greens, blues) as opposed to warm colors (yellows, oranges). In poorly lit areas, yellow is the most visible. Orange and reds are attention-grabbing. Blues appear hazy and indistinct and may appear gray due to yellowing of the elderly patient’s lens.

Acoustics

ʯ Private rooms or acoustically enhanced drapes

facilitate better communication and decrease anxiety and delirium. ʯ Older adults have increased sensitivity to loud sounds. The use of sound-absorbing materials (e.g., carpet, curtains, ceiling tiles) may reduce background noise and can also increase patient privacy. ʯ Loud noise sources in the hospital (e.g., overhead paging, machines) should be reduced. ʯ Music can decrease anxiety, heart rate and blood pressure. Patients should be provided with a way to listen to music and choose their programming without disturbing others. ʯ An enhanced acoustical environment can also increase patient privacy and safety. One study performed in an ED found that patients in curtained spaces reported they withheld portions of their medical history and refused parts of their physical examination because of lack of privacy. None of the patients in rooms with walls reported withholding information.

Source: American College of Emergency Physicians, www.acep.org/globalassets/sites/geda/documnets/geda-guidelines.pdf

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TRENDS

Collaborative Diabetes Care The AMGA’s Together 2 Goal® campaign has concluded after five years. What were the results?

The American Medical Group Association announced this spring that its Together 2 Goal® campaign has con-

cluded after a five-year run. Started in 2016, this initiative challenged participating medical groups and health systems to improve care for 1 million people with Type 2 diabetes. Over 150 medical groups and health systems across 36 states participated, utilizing evidence-based care processes to drive improvement. These groups represent 61,000 FTE physicians treating 2 million patients with Type 2 diabetes. All participants sent quarterly reports to measure progress, while using Together 2 Goal® resources and tools to further efforts.

Improving quality of care and patient outcomes One of the most significant opportunities this campaign provided was to improve the quality of care and patient outcomes for chronic conditions that have the greatest impact on quality of life, productivity, and costs for Americans, the AMGA said. Together 2 Goal® allowed health systems to track and report the data they collected to benchmark progress and performance against their peers. The highest performers were encouraged to collaborate, share their experiences, and adapt new best practices. Initially, the Together 2 Goal® campaign was only supposed to last three years, but it is important to establish long-term practices for diabetes management, the AMGA noted. One of the difficulties with diabetes management is the chronic symptoms can become challenging to maintain long-term. Because it is so easy for patients to go in and out of states of ideal diabetes management, the AMGA extended the Together 2 Goal® campaign two years to help groups hardwire their improvements and sustain improved diabetes care.

Four best practices for health systems 1. Engage the care team A coordinated care response is essential for optimal diabetes care. Engaging the care team is a crucial step for coordinated patient care. To effectively engage the care team, you need to establish roles and responsibilities, define your goals for success, support ongoing communication and training, enforce accountability, and empowering staff to function at the top of their license. Because diabetes care often involves many types of health providers, health systems should also consider engaging relevant specialists as a part of their care teams. 44

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2. Empower patients With the complexity of diabetes, it is important to empower patients with the tools and resources they need to manage their condition. A tailored approach that generates individualized goals and utilizes shared decisionmaking is the most effective step providers can take with patient care. It is also important to consider the patient’s perspective in their care process. What is their patient experience like? What can you do to improve it? Are there external social factors you have not considered, like transportation or housing? Additionally, patients should be referred to diabetes education classes or other resources to find better ways to support themselves daily. Knowledge is power! 3. Harness technology Part of improving diabetes management is leveraging the available technologies to better understand any gaps in care. Health systems can utilize technology like remote patient monitoring, e-coaching, while telehealth opportunities can help patients manage their diabetes while at home. Additionally, point-of-care tools in electronic health records, patient registries, and population management software can assist health systems identify patients that need diabetes care. 4. Develop external partnerships When you develop an external partnership, you might have an opportunity to offer services that meet patients where they are. Health systems can reach out to community-based organizations, faith-based organizations, insurance companies, public health organizations, and outside providers.

HIDA

HIDA Supports the Medical Supplies for Pandemics Act The Health Industry Distributors Association (HIDA) supports the Medical Supplies for Pandemics Act,

a bipartisan and bicameral effort bringing the best of the public and private sectors together to establish long-term preparedness solutions.

The Medical Supplies for Pandemics Act strengthens the public-private partnership between the Strategic National Stockpile and the commercial medical supply chain. The bill would significantly enhance the nation’s ability to successfully manage future pandemics. “Medical products distributors have the experience and expertise to help manage and distribute PPE and other essential products, and this bill ensures that critical knowhow can be put to even better use for the American people,” said HIDA President & CEO Matthew J. Rowan. “A well-managed and maintained strategic reserve of PPE and other medical supplies is a critical component of pandemic preparedness.” The bill would make improvements to the Strategic National Stockpile (SNS) by: ʯ Diversifying Production by directing the SNS to incentivize suppliers to geographically diversify medical products manufacturing.

ʯ Investing in Capacity by directing the SNS to institute joint ventures with manufacturers. This ensures the ability to quickly ramp up to meet unanticipated increases in demand.

ʯ Encouraging Public-Private Collaboration by directing the SNS to work with commercial distributors to manage a cushion of critical pandemic supplies to meet the immediate needs of healthcare providers when a large-scale public health emergency occurs. This cushion could include PPE and testing supplies, as well as ancillary and infection prevention products. Distributors would keep inventory current by monitoring expiration dates, rotating and replenishing these buffer reserves as necessary.

This bill builds on important bipartisan legislative initiatives, specifically the supply chain provisions in the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 (PAHPAI). PAHPAI directs the public and private sectors to improve market capacity and identify key product substitutions. Every day, distributors utilize their existing infrastructure and expertise. Throughout the COVID-19 pandemic, medical products distributors collaborated with the federal government as trusted partners. In 2020, they reliably delivered 51 billion units of PPE the last mile to providers. This included a 1,200% increase in N95 respirators, 150% increase in face masks, 36% more gowns and 11% more gloves. HIDA resources on issues related to the pandemic, the healthcare supply chain, and the role of distributors can be found at HIDA.org. www.repertoiremag.com

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REP CORNER

Karl Scheetz is Loving it His territory? ‘Everywhere on earth.’ Karl Scheetz doesn’t hold back when describing his professional role. He identifies himself as “national sales di-

rector” for Source Products Ltd. in Youngstown, Ohio. His territory? “Everywhere on earth.” And markets? “Before, it was any market. Now that has shifted to more strategic and focused opportunities.”

His father, Richard, was a civil engineer, and his mother, Rita, a registered nurse. Karl graduated from The Ohio State University with an interest in politics. “As time went on, I just enjoyed sales and the constant contact with people,” he says. “I love working with people!” In 1990, he started working for Lyons Medical, a regional medical distributor in Youngstown, where his brother, Peter, worked as a sales representative. Karl focused on the physician and other non-acute markets in

Karl and Alba Scheetz with their three children, Luke, Marisa and Crescenzo.

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the Trumbull County area of Ohio. “It was an awesome place to work,” he says. “The owners were great gentlemen, and the sales and support staff were the best. I even met my wife there.” His wife, Alba, was a receptionist at Lyons. Born in Pacentro, a mountain village in central Italy, she immigrated with her parents – Crescenzo and Emma Battaglini – to the United States in 1974. (“I asked her out on her third day at Lyons,” he says.)

Small-town local provider In 1993, Lyons Medical was acquired by Owens & Minor, for whom Scheetz continued to work until 1995. Then he, his brother Chuck, and some investors formed Source Products. “Source was created so that end users could use a small-town local provider and not just be considered a ‘number’ when working with their distributor. We wanted people to be comfortable. We wanted them to be able to call us, place orders, get their questions answered and their hands held, if necessary. We wanted people to call us and not need a product code.” In its earliest days, the company’s business centered on one residential nursing facility and one dialysis group. Looking to expand its offerings, Scheetz met with the late John Sasen, vice president of PSS (now McKesson Medical-Surgical), with whom his brother, Peter, had worked in the past. “I reached out to John with my vision of creating Source Products, where I wanted to take it, and what I needed to get there,” he recalls. The two worked out an arrangement whereby Scheetz became a 1099 representative and converted Source Products’ physician book of business to PSS, while PSS supported Source Products with access to its product lines. “It was a synergistic and profitable venture for all,” he says. And it allowed Source Products to focus on the long-term-care and dialysis-center markets. In September 2018, Scheetz, his brother and general partners decided to sell the business to HemaSource, Inc. But he wasn’t ready to retire from sales. “I have three children to put through college,” he jokes. “Honestly, I love what I do. I can’t imagine doing anything else at this point in my life.”

Karl and Alba Scheetz have three children – Luke, Marisa and Crescenzo. “All have been brought up with a great work ethic, as they watched their parents and grandparents work hard to achieve the American Dream,” he says. (Karl’s father, Crescenzo, worked in the steel mills, while Emma was a restaurant cook for 35 years.) Luke is a junior at Youngstown State University and a former collegiate-level athlete specializing in long snapping. Marisa, who spent many years playing soccer, will attend Youngstown State University in the fall. And Crescenzo is an aspiring businessman. “He already has a war chest saved up, supports himself for his daily financial needs, and most likely will become a very successful entrepreneur someday.”

On a personal note, the acquisition has allowed Scheetz to focus on what he truly loves about the industry – sales, new markets and new medical technologies. And family.

New opportunities The acquisition by HemaSource created new opportunities for Source Products, including access to multiple large warehouses, a true logistics platform to ship nationally, and the finances to ultimately give Source Products the ability to compete nationally while maintaining that “small-town distributor feel that we cherish so highly,” he says. “There were many changes to deal with during the acquisition,” including changes in products and prices. “Things have really come together. We are maximizing our synergies to grow as one company.” On a personal note, the acquisition has allowed Scheetz to focus on what he truly loves about the industry – sales, new markets and new medical technologies. And family.

Karl was involved in Youth Sports as the children grew up, and has managed local flag football, soccer and lacrosse leagues. Today he is the president of the Canfield Lacrosse Club, Inc., a non-profit support arm for the sport. Scheetz is optimistic about the future of independent distributors. “Together, Source Products and HemaSource will grow technologically and financially to compete against the larger medical and pharmaceutical distributors in our respective specialty markets,” he says. “We will do everything we can to set ourselves apart and make sure our customers never become just a number.” www.repertoiremag.com

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NEWS

Industry News Longtime industry rep announces retirement John Winkeler, owner of St. Louis-based John Winkeler Associates, Inc., along with his wife Pat, are excited to announce their retirement effective June 2021.

continued for the next 18-plus years. Pat was part of the initial growth at ADC as she worked with the dealers, the sales reps, planned meetings, and eventually helped develop international sales. Pat married John and moved to St. Louis in 2002. The past 10+ years, Pat and John have worked side-by-side in the repping business Both Pat and John are grateful to have had the opportunity to work with so many amazing people who have unselfishly invested their time and knowledge which allowed everyone to grow together. Though they are sad to leave the industry they love, they both look forward in spending time with their families, traveling, and enjoying life to its fullest.

FDA requests funding to bolster supply chain

John and Pat Winkeler

John’s career began June 1970 working in the warehouse for a local medical supply dealer. He advanced his medical distribution career through customer service, sales, and then to assistant vice president of sales. That humble beginning set the groundwork for him to learn from the bottom up on what it takes to grow in this industry. It was 1991 when John Winkeler Associates, Inc., was founded as an independent rep organization covering multiple midwestern states proactively promoting with distribution to the end users in medical, dental, and veterinary markets. Throughout his career, John has achieved several national, regional, and local awards which he strongly feels recognize his partnerships with his dealer organizations and their reps. Pat’s medical career began with American Diagnostic Corporation (ADC) as their very first employee and 48

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The Food and Drug Administration (FDA) has asked Congress for a $6.5 billion budget, an 8% increase over the previous year. Congress will ultimately decide how much money the various health agencies get, but the requests indicate the federal government hopes to make supply chain resiliency a priority going forward. The new budget request proposes initiatives to regulate the healthcare supply chain and mitigate shortages of drugs and medical devices. After last year, it’s easy to see that the focus on the supply chain has increased dramatically. According to FreightWaves, the 2022 budget request mentions supply chain nearly 120 times, compared to just over 50 the previous year. Among other things, the FDA wants $21 million to create a Resilient Supply Chain and Shortages Program focused on medical devices. The program would be similar to the FDA’s Drug Shortages Program, created in 1999. Prior to the pandemic, the agency didn’t have a formal program to monitor the supply chain for medical devices. In the budget request, the FDA highlights how it began monitoring the supply chain for devices without a formal program. The proposed 18-person office would identify shortages before they happen and intervene to prevent them.

Patient positioning can make all the difference for consistent BP measurements. We know you realize the importance of blood pressure capture, the effects it can have on diagnosis and the impact to patients. However, following AHA/AMA recommendations for patient positioning during BP capture will help ensure more consistent, accurate and repeatable BP measurements. Something as simple as the patient’s feet not resting flat on the floor can increase the measurement by 5 to 15 points.1

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REP JULY 21

Articles inside

Industry news

The need for infection preventionists has never been greater. What can hospitals and healthcare systems do to appropriately staff those positions?

What were the results?

Another first for NDC in the books

Livonia, Michigan

HIDA Supports the Medical Supplies for Pandemics Act

Tomorrow’s primary care practice should feature multiple team members, closer collaboration with other providers, and a greater awareness and usage of community resources. How will it get from here to there?