Focus: October 22, 2009

FOCUS One Voice project launches innovative medication tip cards This is another in a series of articles about projects that are transforming care delivery at Christiana Care.

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ilmington Hospital’s One Voice project has launched its newest strategy to include patients and their families in care plans: talking in detail with patients about their medications using handy new tip cards.

Clinical News New precision CO2 laser enhances surgery safety

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AHRQ survey results show improving culture of safety

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Secondhand smoke cancer screening program

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General News New voluntary benefit may bring insurance savings 12 Welcome new M-D Staff

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Social networking policies and guidelines

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In response to patient survey data showing that discussing medications with patients and families is a strong component of patient satisfaction, the One Voice team developed the medication tip cards to serve as a reminder and a quick reference for nurses.

Covering commonly prescribed drugs The small laminated cards hang from a metal ring on every medication cart on each unit. Covering the 30 most commonly prescribed drugs at Wilmington Hospital, the cards contain both the generic and brand names of each medication, what the medication is used for, its most common side effects and any precautions.

“Nurses like them because they don’t have to search the full medication literature to get the information,” says Inpatient Pharmacy, Wilmington, Director Rob Thornton.

Researching the drugs prescribed on each unit, Pharmacy developed a list

Makaba Bakayoko, RN, reviews medications with a patient on the ACE Unit at Wilmington campus. of 50 of the most common medications—15 to 20 of them standard on all units, and the others specific to individual units.

The department then designed the format for the cards and generated the data.

Introducing Medication Task Force Now, the Medication Task Force, a One Voice subgroup led by 3E’s Deborah Dennison comprising RNIIs from each unit, works to further improve and promote the process of communicating medications’ purpose and side effects to patients.

“Having Pharmacy involved in this project has been great,” says Paula Tomanovich, RN, BSN, ACE Unit, Wilmington. “Working together as a team improves the experience for

C O V E R , M E D I C AT I O N T I P C A R D S ,

everyone, especially the patients.”

One Voice is an interdisciplinary team of a patient/family advisor, health care providers and representatives from Pharmacy, pastoral care, case management, social work and patient relations.

Forging strong relationships It focuses on improving the patient care experience by forging better communication among patients, their families and health care providers.

CONTINUED

Using the Electronic Administration Record (EMAR) computer on the cart, nurses print out the formulary information on the medication, highlight the side effects, and put the printout in the patient’s folder.

Patients still receive full printed information about their medications.

Implementing medication tip cards follows putting white boards with information about the plan of care in each patient’s room on select units

and instituting bedside shift reports.

But according to Senior VicePresident, and Associate Chief Medical Officer Janice Nevin, M.D., MPH, the cards prompt nurses to discuss the medications with patients and families. “The cards are another example of the structures Christiana Care is creating to include patients and families.”

Junior Board volunteers greet, help patients and visitors find their way at Wilmington Hospital

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Junior Board volunteers Jeanne Checkel (left) and Joanne Gioffre are helping patients find their way during construction on the Wilmington campus.

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FOCUS Oct. 22, 2009

uring construction at our Wilmington campus, Christiana Care’s Junior Board is leading the way—literally.

Realizing that during construction and renovation people might have difficulty finding their way around the hospital, the board created the Greeters Committee to help patients and visitors through the potential confusion.

“People will need direction and guidance,” says Janice Nevin, M.D., MPH, senior vice-president and associate chief medical officer, “particularly at the new main entrance and at the bank of elevators that reach the OR and floors 1 – 8.”

During construction of the six-story office building and the nine-story tower, the 17 members of the committee, under the leadership of Dotty Flynn and Mary Julian, will help visitors with directions and will escort patients to appointments.

“The Greeters Committee couldn’t

have come at a better time,” says Dr. Nevin. “The committee is just the latest example of this fantastic group’s long history of support.”

During the summer, the committee ran a pilot program to determine the best placement for greeter stations and to clarify responsibilities. On Oct. 5, the committee began work in earnest, with Junior Board members Linda Depfer and Karen Kelly serving as pioneers.

“With the closing of the circle, the greeters will be particularly helpful,” says Barbara Burd, Junior Board president. “The Junior Board sees this new committee as an excellent way to support the hospital during this exciting transformation.”

After construction is completed, the committee intends to continue helping people find their way, says Flynn.

“Guiding lost people and offering a smile and kind word to someone in distress is what we’re all about.”

New precision CO2 laser system enhances safety

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hristiana Care surgeons are performing delicate otolaryngeal surgery and neurosurgery less invasively and more accurately with the new OmniGuide Carbon Dioxide (CO2) Beam Path fiber laser system.

What’s more, patients can be discharged usually within one or two days instead of the seven to 10 days required with external surgery.

More precise excisions “The new laser allows us to reach areas that were less accessible before and to make more precise excisions.

Because we sacrifice less normal tissue, there’s less morbidity to patients,” says Robert Witt, M.D., FACS, chief of Head and Neck Oncology at the Helen F. Graham Cancer Center.

With the new laser system—two at Christiana Hospital and two at Wilmington Hospital surgeons can remove tumors involving the larynx through endoscopic procedures rather than open surgery in selected cases.

Because the new procedures require no tracheotomy to open the windpipe, patients can talk immediately and often can eat the next day, Dr. Witt says.

Allowing surgeons to control penetration depth, CO2 lasers have always been the safest and most accurate of all lasers. Because water, 60-70 percent of cell composition, absorbs CO2 laser energy more quickly and fully than other types of laser energy, CO2 lasers produce less heat spread through tissue—and therefore cause less trauma.

They essentially vaporize cells by boiling away the water.

Until the OmniGuide, though, the long wavelength of CO2 lasers limited their use to line-of-sight procedures, and the equipment was large and unwieldy.

The OmniGuide BeamPath system directs CO2 energy through a flexible fiber optic tube that surgeons can manipulate into previously impossible-to-reach areas.

Adds flexibility during brain tumor resection “Delivering the laser through fiber optics provides more control of the energy at the tumor surface, allowing for more accurate and complete brain tumor resection,” says Magdy Boulos, M.D., director of the Surgical NeuroOncology Multidisciplinary Center (MDC). “The new laser is safer. We can go around corners, resecting as much as possible of the tumor without damaging surrounding eloquent neural tissue.” Damaging eloquent tissue could cause loss of

Robert Witt, M.D., FACS, chief of Head and Neck Oncology at the Helen F. Graham Cancer Center, with Surgical Technologist Michele Lloyd at Wilmington Hospital with the OmniGuide fiber optic laser system.

sensory processing and minor or even complete paralysis.

For patients with otosclerosis, Michael Teixido, M.D., uses the OmniGuide to remove bone growth from the stapes in the inner ear, afterward inserting a piston prosthesis. The stapes transmits sound to the inner ear through vibration, and the bone growth reduces the stapes’ ability to vibrate. Dr. Teixido is one of a handful of surgeons nationwide OmniGuide’s manufacturer has asked to help improve the technology by providing feedback on his experiences with it.

“With OmniGuide technology, we can use the CO2 laser wavelength safely in hard-to-reach areas—something surgeons have been waiting for for decades,” says Dr. Teixido.

Survey shows success in transforming culture of patient safety

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esults from the Agency for Healthcare Research and Quality (AHRQ) 2009 Hospital Survey on Patient Safety Culture attest to Christiana Care’s success in transforming its culture of patient safety.

From 2006, the first year health care providers at Christiana Care participated in the survey, to 2009, the percentage of respondents who gave Christiana Care an overall patient safety grade of either “A” or “B” rose six percent to 75 percent, above the benchmark for teaching hospitals nationwide.

The improvement in other scores is equally impressive: n Effectiveness of handoffs and transitions—15 percent improvement n Management support for patient safety—11 percent improvement n Teamwork across units—8 percent improvement n Organizational learning-continuous improvement—7 percent improvement ARHQ, the Federal agency established to improve the quality and safety of health care for all Americans, released the first Survey on Patient Safety Culture in 2004 to establish a benchmarking database to help hospitals evaluate themselves over time and against other hospitals. The 2009 database contains information on more than 600 U.S. hospitals.

“The survey is a valid, well established instrument that helps us track changes in our patient safety culture and evaluate the impact of our patient safety interventions,” says Senior Vice President of Quality and Patient Safety Sharon Anderson, RN, MS. Measuring patient safety culture at the unit/department level and the overall hospital level, the survey assesses four 4

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FOCUS Oct. 22, 2009

aspects of the patient safety culture: n Reporting culture—the frequency of reporting mistakes n Just culture—whether mistakes are handled as individual problems or system problems n Flexible culture—teamwork and respect in units n Learning culture—assessment and evaluation procedures and opportunities to learn from mistakes Improving teamwork and learning Christiana Care showed significant improvement in all areas, especially in teamwork and organizational learning. Many of Christiana Care’s transformation initiatives underlie this success: n Team Training—The team training curriculum is designed to improve patient outcomes by building communication and other teamwork skills. n Storytelling—Sharing stories about actual errors or good catches in a blameless environment enables staff not only to address systems-based failures but also to realize the important role each staff member plays in actively preventing errors. n No Harm Intended: Lessons Learned in Patient Safety—These sessions increase visibility of errors, show the human impact of errors, and involve staff actively in developing solutions to enhance patient safety.

The sessions allow for openly discussing and analyzing errors in order to learn from them. n Improved handoff communication—To ensure that complete information is communicated to the next provider of care, Christiana Care has developed and implemented a number of procedures for effective handoffs: Round Trip Ticket—to report pertinent information to other departments

when patients move from one department to another.

DATAS tool—to report patient condition during handoffs. An electronic DATAS template is in development.

SBAR—to report findings to a physician or other members of the health care team. A progress note template based on SBAR is being piloted on several nursing units Standardized hand-off communication—a process using digital dictation is in development.

Enhanced WebPaging—A system to improve RN/MD communications n Achieving Competency Today (ACT) course—In this 12-week course, interdisciplinary teams develop performance improvement projects—and enhance their team building skills.

Just as the survey illuminates successes, it also illuminates opportunities for improvement. One opportunity is in management response to error.

Because 45 percent of the staff reports feeling as if “their mistakes are held against them,” Christiana Care is focusing on how to balance a fair and open culture with system and individual accountability.

These are just a few examples of Christiana Care’s determination to become an error-free hospital.

Committing to the time and resources the survey requires is another example—because transforming a culture requires assessing it.

“Health care has become so complex, so highly technical, so multidisciplinary that we must constantly assess where we are, how far we’ve come, and where we need to focus,” says Chief Medical Officer and Patient Safety Officer James Newman, M.D. “The AHRQ survey helps us understand how our organization is committed to keeping our patients safe.”

Generous Copeland gift launches new Arrhythmia Center

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lectrophysiologists at Christiana Care now have the latest technology at their fingertips to treat complex heart rhythm disorders.

Physicians now treat patients with the newest generation Stereotaxis Niobe® Magnetic Navigation System in the Mr. and Mrs. Gerret and Tatiana Copeland Arrhythmia Center in the Interventional Suite at the Center for Heart & Vascular Health. The stereotaxis system was made possible thanks to a generous gift from the Copelands.

“Introduction of the stereotaxis system places us at the forefront of current technology and significantly advances our ability to provide highly specialized cardiac care for our patients in Delaware and surrounding communities,” says Medical Director Timothy J. Gardner, M.D. “Few centers surpass our capabilities in this area.”

Easily recognized, challenging to treat Atrial fibrillation is a common heart rhythm disorder easily recognized but challenging to treat, prevent or cure.

The complexity of previously available ablation techniques limited treatment options to few patients by only a small number of highly trained physicians.

According to Brian Sarter, M.D., medical director of the Electrophysiology (EP) Lab, the new system represents a major advance in catheter-based interventional cardiology.

“Stereotaxis technology allows us to manipulate catheters inside the heart more precisely and more consistently with a greater margin of safety and efficacy,” he says.

The added safety and expectation of easier and shorter procedures could make more patients eligible for catheter ablation of episodic and chronic atrial fibrillation, possibly even tripling the number of procedures performed in the next two to three years.

The new EP stereotaxis lab in the Interventional Suite at the Center for Heart & Vascular Health initially will treat arrhythmias and guide left ventricular lead placements for cardiac resynchronization therapy. Future applications may include the treatment of multi-vessel and other complex coronary artery diseases.

Revolutionary technology What makes stereotaxis technology so revolutionary are magnetic fields that allow physicians direct control of the tip of soft catheters. Unlike other catheters used for radiofrequency ablation, stereotaxis catheters are more flexible and easily manipulated through the labyrinth of cardiac blood

Timothy Gardner, M.D., medical director of the Center for Heart & Vascular Health (front, left) snips the ribbon opening the new Mr. and Mrs. Gerret and Tatiana Copeland Arrhythmia Center.

vessels.

The electrophysiologist automatically controls the motion and targeting of the fully integrated catheter and digital fluoroscopy mapping by using a joystick, computer mouse or touch screen.

Reduced exposure to X-ray What’s more, stereotaxis remote technology and less time required for digital fluoroscopy potentially can reduces X-ray exposure significantly for patients and the electrophysiology team, as well as lead protective clothing time for both physicians and staff during the procedure.

Using stereotaxis along with Dr. Sarter are Christiana Care electrophysiologists Raymond Miller, M.D., associate director, Electrophysiology Lab, Piamsook Angkeow, M.D., Stephen Blumberg, M.D., John Hynes, M.D., Roger Kerzner, M.D., Joseph Pennington, M.D., and Henry Weiner, M.D.

Sen. Carper attends orthopedic surgeons’ second annual regional educational symposium ore than 160 surgeons, primary care physicians, physician assistants and physical therapists turned out for the second annual Delaware Orthopaedic Symposium Oct. 9 hosted by Christiana Care and the Delaware Society of Orthopaedic Surgeons.

M.D., Christopher Casscells, M.D., and Alex B. Bodenstab, M.D., the seminars focused on operative and non-operative remedies for hip and knee pain.

Keynote speaker and Senate Finance Committee member Sen. Tom Carper opened the conference with an address about shared responsibility in health care reform.

Fifteen orthopedic surgeons (below) taught at the annual Delaware Orthopaedic Symposium Oct. 9 at the John H. Ammon Education Center.

U.S. Sen. Tom Carper (front row, red necktie), keynote speaker, talked about shared responsibility in health care reform.

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The symposium included three educational tracks (orthopedic surgery, pediatric orthopedics and allied health) and featured 15 speakers from Christiana Care, A.I. duPont Hospital for Children and nationally known orthopedic surgeons Todd Albert, M.D., and Thomas Graham, M.D. According to Brian Galinat, M.D., who organized the event along with Randeep Kahlon, M.D., "In just its second year, this conference has become a respected regional event that brings providers together to discuss issues related to one and joint health."

The symposium was preceded by two consumer education seminars titled “Moving Freely Without Pain.” Led by Delaware surgeons William A. Newcomb, M.D., Steven M. Dellose,

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The consumer seminars and annual symposium are repeated each October.

New education clinics are more convenient for chemotherapy patients

Doriel Ward, Ph.D., named director of Research

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ocial workers, dieticians, financial counselors and coaches are available at any time for a consultation at the Helen F. Graham Cancer Center.

But a new approach for patients receiving chemotherapy may make counseling more convenient and improve awareness and use of the many support programs available for patients and their caregivers.

Recently, the Cancer Care Management Group at the center established a schedule of miniclinics in the Chemotherapy Infusion Suite to provide daily patient support, including counseling on diet, wellness, finances, community resources and organizing medications.

Therapy time: A good time for learning “Patients and their families often have little to do while the patient is receiving treatment,” says Tricia Strusowski, the group’s director. “During testing and diagnosis, patients and their families may be shocked and unable to consume the amount of information we want to give them.

“Once they have started treatment, they are more settled and able to hear about support options, ask questions and choose what’s appropriate for their situation.”

“The idea to offer programs right in the infusion suite came as a result of feedback from the year-old Patient/ Caregiver Advisory Group,” Strusowski explains.

The group noticed poor attendance at similar programs in the evening, but since the time and place changed patient and caregiver awareness and use of support programs has grown.

Cancer patients and those who support them in their journey can now attend one-hour daytime miniclinics at the Helen F. Graham Cancer Center to gain valuable information about health, wellness and more.

Here’s a daily schedule: Mondays, 9:30-10:30 a.m.

Ask Your Dietitian Tuesdays, 10-11 a.m.

Know Your Community Resources Wednesdays, 10-11 a.m.

Wellness Wednesday Thursdays, 10-11 a.m.

Meet Your Social Worker Fridays, 10-11 a.m.

Meet Your Money Coach or Organizing Your Medicines

Strusowski expects patient satisfaction to so climb even higher as patients and their caregivers learn about the program.

For more information about this program, contact Strusowski at 302-6234710 or e-mail strusowski@christianacare.org.

Doriel Ward, Ph.D. oriel Ward, Ph.D., has been named Christiana Care director of Research, responsible for the overall direction of the Research Office, strategic planning of research activities, mentoring of young researchers and development of new programs.

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Dr. Ward comes to us from MD Anderson in Houston, Texas, where she was in charge of Cancer Therapeutics and Phase 1 trials for the Department of Cancer Medicine.

Her research experience is in public health issues, including racial and ethnic disparities in cancer care and AIDS. “She brings a wealth of experience in grants management, which should improve both the quality and extent of grants for which we are successful,” says Brian W. Little, M.D., Ph.D., vice president, Academic Affairs & Research.

Email dward@christianacare.org or call the research office, 623-3830.

Cancer screening program focuses on secondhand smoke

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oe Hullinger was a fitness enthusiast, an active guy who enjoyed running and boating.

Then Hullinger developed a cough he couldn’t shake. He lost weight and couldn’t figure out why.

His doctor ordered a chest X-ray that revealed a tumor. In September 2001, Hullinger was diagnosed with Stage 4 lung cancer, a small-cell type associated with smoking.

Was never a smoker But Hullinger never smoked. “He ate broccoli every day,” recalls his sister, Cathy Sullivan. “Chicken, no red meats.” His doctors believe his cancer was caused by secondhand smoke, first in his parents’ home and then on

From left, Daniel Sullivan, Cathrine Sullivan, Bernadette Yeager and Tom Bauer, M.D. (Inset) Yeager and Cathrine Sullivan’s brother, Joe Hullinger (inset), who died at 41 in 2002.

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FOCUS Oct. 22, 2009

the job, where Hullinger worked long hours in confined spaces as a computer programmer.

“The earlier the exposure and the greater the exposure to secondhand smoke the greater the prevalence of cancer,” says Thomas Bauer, M.D., chief of thoracic surgery at the Helen F. Graham Cancer Center. “We know that children who are exposed to secondhand smoke develop many kinds of respiratory problems, from asthma to lung cancer.”

Christiana Care is participating in a program to screen people who aren’t smokers but have been exposed to secondhand smoke. It is funded by the Flight Attendants Medical Research Institute (FAMRI) established as part of a settlement of a suit brought against the tobacco industry by flight attendants seeking damages for illnesses linked to secondhand smoke in planes.

Hullinger fought his cancer courageously and aggressively, undergoing a combination of chemotherapy treatments. But because the disease was already advanced, the cancer could not be contained. He died 15 months after his diagnosis. Since then, two of the most dedicated participants in the program are Hullinger’s sisters, Bernadette Yeager and Sullivan, as

well as Sullivan’s husband Danny.

“They are advocates,”“ says Barbara Marconi, RN, BSN, OCN, research nurse and study coordinator. “They are dedicated to getting the word out about secondhand smoke.”

As FAMRI participants, the two sisters received a free, noninvasive, low-dose CT scan that can detect lung cancer when it is at Stage 1, before it has spread and when it can be surgically removed. At that stage, the survival rate is about 90 percent, according to published I-ELCAP data.

“The test is easy and quick—and there’s an immediate sense of relief,” Yeager says.

Eligibility requirements Programs participants must be 40 or older, have smoked less than 100 cigarettes in their life times, and have a significant history of being exposed to secondhand smoke.

The siblings have encouraged others to participate in the program. And they have changed their behavior, avoiding secondhand smoke.

“I don’t stay around smoke any more,” Yeager says. “I feel it’s polluting our lungs.”

In addition to being a FAMRI participant, Christiana Care is one of only 52 institutions in the Early Lung Cancer Action Project. ELCAP screens smokers and former smokers for lung cancer in order to detect the disease at Stage 1.

That program is open to people who are 40 and older who have smoked for at least one year. To learn more about the FAMRI and ELCAP programs, call 302-623-5227.

Thomas Bauer, M.D., Jennifer Packard, M.D., receives leads New Mexico prestigious Howard Schubiner Award cancer trial

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homas Bauer, M.D., chief of Thoracic Surgery at the Helen F. Graham Cancer Center, is principal investigator (PI) overseeing a Phase II clinical trial in Albuquerque, N.M., of an early-stage diagnostic for lung and other cancers.

He is working with Biomoda Inc. to help determine the usefulness of the company’s trademarked diagnostic test CyPath® to detect lung cancer earlier in the sputum of patients with lung cancer. Dr. Bauer’s role is to lead the study, which utilizes CT scans and other data on study participants as part of the longitudinal component of the study.

“In addition to his thoracic surgery practice and his faculty positions, Dr. Bauer is widely recognized by his peers as one of the top lung cancer researchers in the field,” says Biomoda President John Cousins.

“Repeat screenings under the longitudinal part of the study will probably save lives in our study cohort as well as provide additional data critical to FDA approval of the assay.”

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ennifer Packard, M.D., received the Howard Schubiner Award, a prestigious annual honor offered by the National Med-Peds Residency Association (NMPRA).

Dr. Packard, a fourth-year resident in Christiana Care’s Medicine-Pediatrics Residency Program, accepted the award Oct. 17 in Washington, D.C. The NMPRA presents the award to resident physicians who make extraordinary, lasting contributions to the organization’s success and/or Med-Peds at the local or state level.

“It is such an honor to receive this award," says Dr. Packard. “It truly speaks to the support I had from the Med-Peds Residency Program’s faculty, administration and fellow residents, Academic Affairs and Physician Relations. Christiana Care helped to make the Northeast Regional Med-Peds meeting a success through resources provided by Physician Relations. The John H. Ammon Medical Education Center was the perfect venue to host such an event.”

Allen Friedland, M.D., FACP, FAAP, director of Christiana Care’s Medicine-Pediatrics Residency Program, who nominated Dr. Packard, says, “She worked so hard on developing and organizing the best-attended regional med-peds meeting to date for medical students, residents and attending physicians.

Attendees came from all over the country and included people from as far away as California, Texas, Florida, New Hampshire and Wisconsin. I am

Jennifer Packard, M.D. so proud of Jen.” According to the award’s namesake, Howard Schubiner, M.D., the honor goes to a resident who “exemplifies the highest standards for excellence in MedPeds, including exemplary clinical care of patients, compassion and humanism in relationships with patients and with colleagues in medicine and hospital coworkers, involvement in community activities, and contributions to the field of Medicine-Pediatrics.”

“Jen’s successful template is being used as the model for other regional medpeds meetings. This year, there will be an unprecedented three regional meetings across the country, and all are using her template. She spent countless hours for about a year to organize the event in addition to her busy residency responsibilities.”

Dr. Packard is graduate of Jefferson Medical College.

Therapeutic Notes

Lisa Kletter Pharm.D The triazole antifungals (fluconazole, voriconazole, itraconazole and posaconazole) have numerous clinically significant drug interactions. The majority of these interactions involve oxidative metabolism via the cytochrome P450 enzyme system. To varying degrees, the triazoles are both metabolized by and affect the hepatic cytochrome P450 enzyme system. The enzymes mainly affected are CYP3A4, 2C9 and 2C19. The drug interaction profiles of each of these agents vary slightly due to the different affinities for these isoenzymes. For example, fluconazole is a much weaker CYP3A4 inhibitor and interactions with CYP3A4 substrates (i.e., cyclosporine, tacrolimus, some of the statins, calcium channel blockers) are generally only observed with doses > or = 200mg.

Some of the most significant and common drug interactions of the triazoles are elevated concentrations of cyclosporine, tacrolimus, sirolimus, warfarin, most calcium channel blockers, steroids, most benzodiazepines, protease inhibitors and many of the statins due to inhibition of the CYP enzymes. Phenytoin metabolism is also inhibited by the triazole antifungals, leading to increased phenytoin levels. Monitoring of serum phenytoin concentrations during concomitant therapy is suggested. Additionally, phenytoin, carbamazepine, phenobarbital, rifampin, and rifabutin induce the CYP enzymes that metabolize the triazoles, resulting in significantly decreased azole concentrations. Rifampin has the greatest effect and has been associated with undetectable levels of itraconazole, significantly reduced levels of fluconazole and voriconazole. Concomitant therapy with rifampin is contraindicated with voriconazole, not recommended with itraconazole and may require increased fluconazole dosing. These enzyme inductions can take up to two weeks to achieve maximum effect and persist for up to two weeks after discontinuing the interacting medication, leading to potential treatment failures or delayed response.

There are also P glycoprotein (P-GP) interactions. P-GP is a drug efflux transporter found in the gastrointestinal tract that limits exposure to drugs. P-GP substrates are structurally similar to CYP3A4 and so many 3A4 inhibitors will also inhibit P-GP. Fluconazole, itraconazole and posaconazole are known P-GP substrates, and itraconazole is a P-GP inhibitor. One of the best-understood interactions with P-GP and triazole antifungals is increased exposure to digoxin when given concomitantly with itraconazole.

Alterations in gastric PH can affect ketoconazole, posiconazole and itraconazole (capsules but not liquid formulation), which require gastric acidity for absorption. Drugs that increase gastric PH such as histamine-2 antagonists, proton pump inhibitors and antacids can decrease serum levels of ketoconazole, posiconazole and the capsule formulation of itraconazole.

The triazole antifungals have numerous drug-drug interactions. The major drug-drug interactions are associated with the P450 enzyme system. Particular attention needs to be paid to those interactions involving drugs with narrow therapeutic indexes since there is the potential for therapeutic failure or toxicity. Serum drug concentration monitoring may be useful for some of the drugs with narrow therapeutic indexes. A more extensive list of these drug interactions can be found in UpToDate, Micromedex and the hospital formulary.

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Publishing, Presentations, Appointments, Awards Publishing Darcy Burbage, RN, MSN, AOCN, CBCN, clinical nurse specialist at the Christiana Care Breast Center, Helen F. Graham Cancer Center, published a chapter about body image in the second edition of a new Oncology Nursing Society book titled "Psychosocial Dimensions of Oncology Nursing Care."

and Joseph J. Bennett, M.D., moderated a discussion on “Cancer Survivor Follow-up: Is Your Clinical Practice Evidence-based?”, at the American College of Surgeons’ 95th Annual Clinical Conference in Chicago.

At the 25th National Association of Neonatal Nurses Annual Educational Conference, Sept. 23-26 in Austin, Texas: Nicholas J. Petrelli, M.D., et al., Bank n NICU’S Barbara Dean, BSN, RNC, of America endowed medical director and L&D’s Melanie Chichester, BSN, of the Helen F. Graham Cancer Center, RNC presented “Now and at the Hour published “Preoperative Multimodality of Our Death: Multicultural Therapy Improves Disease-Free Survival Dimensions in Palliative and End-of-Life in Patients With Carcinoma of the Care.”

Rectum: NSABP R-03,” online ahead of n NICU’s Barbara Dean, BSN, RNC, print in the Sep 21 2009 Journal of and Laure Maruszczak, BSN, RNC, Clinical Oncology, presented a poster titled 10.1200/JCO.2009.22.0467 “A Few Cents Can Make a Lot of Sense: Presentations How Two Staff Nurses Organized a Review Course with Minimal Expense Paula Stillman, M.D., Christiana Care senior vice president of Special Projects and Motivated Their Peers to Become Certified.” / president of Health Initiatives, Lisa Nellius, RN, Cardiac Rehab Manager, Vascular specialist Ralph P. Ierardi, Toni McMillen, RN, Cardiac Rehab, M.D., will appear Nov.12 at 7 p.m. on and John Shreve, senior systems anacable channel 21’s "Matters of the lyst, Cardiac Services, conducted a Heart Series," sponsored by Medtronics.

Web-based seminar, “Achieving Dr. Ierardi’s discussion will focus on Cardiac Rehab Excellence,” to tell their vascular disease audience how Christiana Care cliniAppointments, Awards cians and IT work together to deliver Nicholas J. Petrelli, M.D., Bank of evidence-based, patient-centric care.

America endowed medical director of Denise Lyons, MSN, GCNS, BC and the Helen F. Graham Cancer Center, Patricia M. Curtin, M.D., FACP, CMD was a featured speaker at the American presented a poster “Implementation of College of Surgeons 95th Annual a Constipation Protocol,” at the Clinical Conference. He shared inforGerontological Advanced Practice mation about the cancer center’s role in Nurses Association Annual Educational reducing Delaware’s cancer rate.

Conference in Savannah, Georgia. The Senior Social Worker Danielle Brown poster won first place in the poster received the Leukemia and Lymphoma project category.

Society Patient Service Award for the Delaware Chapter, recognizing her Diana Dickson-Witmer, M.D., associdedicated support for helping the ate director of the Christiana Care Society fill its mission.

Breast Center, and surgical oncologist

Thank you To our friends and coworkers for your prayers and expressions of sympathy when our daughter, Elizabeth Colmorgen, died in June. We can't adequately express how much comfort they gave us. God bless each of you. Martha Zazzarino and Garrett Colmorgen, M.D.

Congratulations To Jamie Bailey, BSN, RN, CCRN, on her recent promotion to RNII. To Carol Slijepcevic, BSN, RN, on her recent certification from the American Nurses Credentialing Center.

To Robert Cortez, Judy Pantalino and Elaine Sherman, for graduating from Wilmington University.

To Renee Collins and Porcia Jeffreys for receiving a Certificate of Completion for the ECHO Program.

To Tina Fisher, RN, bariatric case coordinator for successfully passing the Certified Bariatric Nurse (CBN) exam.

To Syreeta Davis for completing the School at Work (SAW) program, on Aug. 5, 2009.

To Leslie Harvell and Tameka Woods, winners of the employee essay contest on fitness. They shared inspirational stories that highlighted their summer physical activity experiences with their families. Look for their essays in an upcoming issue of Focus.

Upcoming events During National Medical Librarians Month, our libraries are planning these events: Monday, Oct. 26 and Thursday, Oct. 29, a librarian from the Gail Gill Consumer Health Library will demonstrate online consumer health databases in the Heart Center Lobby at Christiana Hospital.

Tuesday, Oct. 27 from 11 a.m.-3 p.m. “Pop Into the Library” at the Lewis B. Flinn Medical Library’s Reference Office in the John H. Ammon Education Center at Christiana Hospital for popcorn and brief demonstrations of library resources you can use to save time and maximize your productivity.

Wednesday, Oct. 28 and Friday, Oct. 30 from 11 a.m.-1 p.m. stop by the West End Café at Christiana Hospital to learn about the Medical Libraries’ resources.

Thursday, Oct. 29 a Scavenger Hunt starts at 9 a.m. at the Lewis B. Flinn Medical Library at Christiana Hospital and ends when the final answer is found. Prize for winner: $50 certificate toward a book purchase of your choice.

Buck-a-Book sale all week (Oct. 26-30) at the Lewis B. Flinn Medical Library at Christiana Hospital.

For more information e-mail Ellen Justice, Medical Librarian, at ejustice@christianacare.org or call 733-1179.

12

FOCUS Oct. 22, 2009

Medical Grand Rounds on Thursday, Oct. 29, from 8-9 a.m. features Peter Green, M.D., noted expert from Columbia speaking on celiac disease, which he describes as a silent epidemic.

2009 Wilmington Walk for Life & Breath is Saturday, Nov. 14 at 10 a.m. at the Chase Center on the Riverfront, Wilmington, with registration open at 8:30 a.m. For information, call 302655-7258.

The next topic in Respiratory Care’s COPD Lecture Series is “COPD and Alpha 1 Antitrypsin,” Tuesday, Nov. 17, 10 a.m.-noon. Albert Rizzo, M.D., will discuss treatment options. Testing for Alpha 1 will be done at this session in Room 1100, Christiana Hospital. Call Debbie Wood, 733-2562, to register.

Christiana Care Volunteers’ annual Reading is Fun Book Fairs are a great opportunity to buy books at a discounted price as holiday gifts for everyone from the newest grandchild to that special teacher. A portion of the proceeds from the book fairs will help such volunteer programs as the Video Doctor Program, NetLink and the adult day care centers. The book fairs will be open: In Room 1100, Christiana Hospital: n Nov. 8, 3-8 p.m. n Nov. 9. 7 a.m.-8 p.m. n Nov.10, 7 a.m.- 7 p.m.

On the 1st Floor at VNA, One Reads Way: n Friday, Dec. 4, 9 a.m.-2 p.m.

The Office of Quality and Patient Safety invites Christiana Care leadership, departmental chairs, staff and other colleagues and clinicians to join the Institute for Healthcare Improvement’s 21st Annual National Forum on Quality Improvement in Health Care Satellite Conference, from Orlando, Fla., via satellite at Christiana Hospital, Room 1100 and the Wilmington Conference Center. This conference is free to all employees. This real-time broadcast will include four keynote sessions, plus four mini keynote sessions.

For more information or registration, contact Jean Davis at (302) 733-2462 or jeadavis@christianacare.org.

For more information on the forum, visit http://www.ihi.org/IHI/.

Beginning Nov. 1 employees can take advantage of group discounts relating to auto, home and pet insurance.

The new voluntary benefit offering is administered by Marsh, a world's leading insurance broker and risk advisor.

The program provides employees with a Website and toll free number to request free quotes that could lead to lower premiums and better coverage In addition, if employees whose scheduled hours are 40 or more per pay period are eligible to pay the premiums via payroll deductions.

To get more information or to enroll on or after Nov. 1 call 1-866-7966291 or visit www.cchsvoluntarybenefits.com.

Welcome New Medical-Dental Staff Anesthesiology Manivanh Keobounnam, M.D. 2 Reads Way New Castle, DE 19720 Phone: 302-709-4709 Family & Community Medicine Hema Gouru, M.D. Westside Healthcare 404 Fox Hunt Drive Bear, DE 19701 Phone: 302-655-5822 Mary M. Hagee, D.O. Loughran Medical Group 3411 Silverside Rd. Wilmington, DE 19810 Phone: 302-479-8464 Gerry A. Rosales Jr., M.D. 1021 Gilpin Avenue, Ste. 104 Wilmington, DE 19806 Phone: 302-421-8282 Brooke E. Sheffler, M.D. Family Medicine Center 1401 Foulk Road, Ste. 100 Wilmington, DE 19803 Phone: 302-477-3300 Medicine/Cardiology Michael J. Kostal, M.D. 252 Chapman Road, Ste. 150 Newark, DE 19702 Phone: 302-366-1929 Medicine/Gastroenterology Jared Hossack, M.D., MBA 537 Stanton-Christiana Road, Suite 203 Newark, DE 19713 Phone: 302-225-2380 Medicine/Neurology Camilo A. Gutierrez, M.D. 774 Christiana Road Ste. 201 Newark, DE 19713 Phone: 302-731-3017

Medicine/Occupational Medicine Douglas B. Allen Jr., D.O. Smyrna Medical Aid Unit 100 S. Main Street, Ste. 101 Smyrna, DE 19977 Phone: 302-659-4545 Christina Bovelsky, M.D. Smyrna Health & Wellness Center 100 S. Main St., Ste. 101 Smyrna, DE 19977 Phone: 302-659-4545 Medicine/Physical Medicine & Rehabilitation Vaishali S. Vora, D.O. Center for Rehabilitation Wilmington Hospital Phone: 302-428-6744 Medicine/Pulmonary & Critical Care Medicine Michael T. McCurdy, M.D. eCare Telemedicine 200 Hygeia Drive Newark, DE 19713 Phone: 302-623-0600 Medicine/Internal Medicine Soon M. Chung, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868 Patricia A. Clancy, M.D. 131 Continental Drive, Ste 200 Newark, DE 19713 Phone: 302-366-1868 Kevin A. Copeland, D.O. Dept. of Medicine 6A39, Christiana Hospital Phone: 302-733-6342

Joseph M. Deutsch, M.D. Christiana Care Hospitalist Partners 200 Hygeia Drive, Ste. 2100 Newark, DE 19713 Phone: 302-623-0188 Ashwani K. Garg, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868 Tamar Y. Jackson, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868 Lisa M. Jones, M.D., MPH 111 Continental Dr., Ste. 406 Newark, DE 19713 Phone: 302-984-2577 Jonathan Kaufmann, D.O. 111 Continental Drive, Ste. 406 Newark, DE 19713 Phone: 302-984-2577 Janis Lawrence-Jackson, D.O. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868 Erin M. Meyer, D.O. Christiana Care Hospitalist Partners 200 Hygeia Drive, Ste. 2100 Newark, DE 19713 Phone: 302-623-0188 Priya R. Patel, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868

Morgan E. Leafe, M.D. duPont Hospital for Children Pediatric Department 1600 Rockland Road Wilmington, DE 19803 Phone: 302-651-5863

Pediatrics/General Pediatrics Mary Bove, M.D. duPont Hospital for Children Pediatric Department 1600 Rockland Road Wilmington, DE 19803 Phone: 302-651-5863 Ember L. Crevar, M.D. MAP I, Suite 136 Christiana Hospital Phone: 302-733-4206

Surgery/Podiatric Surgical Service Rachel H. Tuer, D.P.M. Suite 303, Metroform 620 Stanton-Christiana Rd. Newark, DE 19713 Phone: 302-999-8511

Pediatrics/Neurology Sanjai C. Rao, D.O. 3521 Silverside Road Wilmington, DE 19810 Phone: 302-477-0121 Psychiatry/Psychology Scott D. Siegel, Ph.D. Helen F. Graham Cancer Center 4701 Ogletown-Stanton Road S-1209 Newark, DE 19713 Phone: 302-623-4890 Radiology Vinay Kandula, M.D. Department of Radiology 1600 Rockland Road Wilmington, DE 19803 Phone: 302-651-4646 Cyril Milunsky, M.D. 5936 Limestone Road, Ste 301 Hockessin, DE 19707 Phone: 302-234-5800 Boris Reznikov, M.D. 5936 Limestone Road, Ste 301 Hockessin, DE 19707 Phone: 302-234-5800

Employee Handbook, systemwide policies help guide social networking activities

W

hile Christiana Care employees may freely to participate in social networking on the Internet, employees should adhere to all company policies outlined within the Employee Handbook and systemwide policies located on all internal portals if they choose to be identified online as a Christiana Care employee.

The guidelines are as follows:

Limit participation in public communications to not unduly interfere with the timely completion of your job responsibilities. n Avoid communicating any material that violates the privacy or confidentiality of any employee, patient, or of Christiana Care. n Avoid disclosing any sensitive, proprietary, confidential, private and protected health information or financial information about Christiana Care. n Refrain from posting any material that is obscene, defamatory, profane, libelous, threatening, harassing, abusive, hateful or embarrassing to another person or any other person or entity. This includes, but is not limited to, comments regarding Christiana Care, its employees or affiliates. n Do not offer to buy or sell goods, operate a business or use Christiana Care communication tools for personal financial gain. n Do not endorse or appear to endorse a product or service without express written permission. n Do not use profanity or make n

14

FOCUS Oct. 22, 2009

John Emberger, RRT receives prestigious professional honor

derogatory comments toward the Christiana Care. n Be aware that you may be held responsible for any personal legal liability imposed for any content publish.

Use this disclaimer Employees must include the following disclaimer on published public communications identifying themselves as a Christiana Care employee (disclaimer may appear in your personal profile on each site): “The opinions expressed here are the personal opinions of [your name].

Content published here is not read or approved by Christiana Care before it is posted and does not necessarily represent the views and opinions of Christiana Care.”

Personal Internet conversations, blogging and posting updates should not be done during work hours or while using Christiana Care property.

Violations of Christiana Care communications standards may result in disciplinary action up to and including termination of employment.

Additional information on public communication, including tips and guidelines for your own protection, are in the Employee Handbook on the employee portal, under Standards of Conduct.

Questions regarding or further clarification of this policy may be referred to Christiana Care Employee Relations at 302-733-1121.

John Emberger, BS, RRT, FAARC

J

ohn Emberger, BS, RRT, critical care coordinator, has been appointed a fellow in the American Association for Respiratory Care (AARC).

Of the approximately 150,000 respiratory therapists nationally, only 200 are AARC fellows. Emberger is the only Delawarean ever to be awarded this honor.

Emberger was elected president of the Delaware Society for Respiratory Care in January.

“The FAARC credential, earned through actions and not a result of an exam, is a high honor recognizing leadership in respiratory care that has made profound and lasting contributions to the profession,” according to Christiana Care Respiratory Care Director Lori Killian MBA, RRT-NPS, RPFT, AE-C. He joined Christiana Care in 1997.

Skanska construction experts visit First State School

E

mployees from Skanska construction company paid a visit recently to students at the First State School to speak about the transformation underway on the Wilmington Campus and the extraordinary safety measures the company uses.

Students asked many questions about the project taking shape outside the windows of their school. They learned how the hospital—and the school—will remain fully operational during construction and about such things as wearing a hard hat on the construction site and harness safety belts the workers use.

Skanska employees stressed the importance of only using designated walkways on the campus.

When completed in 2012, the project will include a new Emergency Department, operating rooms, a nine-story patient tower and a medical office building.

Stefan Zablocki, safety manager (top photo) and Lyle Frederick, project executive (above, right), presented a variety of safety products to students at First State School on Wilmington Campus.

Summer VolunTEENS contribute 11,000 hours of service

T

his summer, more than 200 students from more than 40 area high schools participated in the Summer VolunTEEN Program sponsored by Volunteer and Student Administration staff.

The VolunTEENS contributed more than 11,000 hours of service at Christiana Hospital, Wilmington Hospital and the Preventive Medicine & Rehabilitation Institute, as well as various Physical Therapy PLUS locations and Imaging Services locations.

Many teens performed clerical tasks using their computer skills and

enthusiasm to tackle special office projects. Others volunteered more directly with patients, assisting on patient care floors, delivering flowers and serving meal trays.

The 2010 Summer VolunTEEN

Program runs from June 14 through Aug.13. Interested high school students should check online at www.christianacare.org/volunteer by early January or contact the Volunteer Offices at 302-428-2206.