Minnesota Health care News July/Aug (Summer) 2011 by Minnesota Physician Publishing

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July/August 2011 â&#x20AC;˘ Volume 9 Number 7

Plastic surgery Sam Economou, MD

Cataracts Sherman Reeves, MD

Pain management John Mrachek, MD

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CONTENTS

4 7 8

JULY/AUGUST 2011 • Volume 9 Number 7

16 18

NEWS

PEOPLE

PERSPECTIVE Kristina Bloomquist, MEd, CPHQ, CHRC Medica Research Institute

10 QUESTIONS Sam Economou, MD Plastic Surgery Consultants

12 14

OBSTETRICS Prenatal screening and diagnosis

CALENDAR July: Boating and water safety August: Psoriasis

20 22 24

TAKE CARE East meets West

QUALITY CONTROL Health care-associated infections

T H I R T Y- S I X T H

SESSION

By John P. Mrachek, MD

FIRST PERSON A promise kept By James Murr

By Charles Bransford, MD

By Jane Pederson, MD, MS

MINNESOTA HEALTH CARE ROUNDTABLE

By Ann Settgast, MD, DTM&H

ANESTHESIOLOGY Pain control

OPHTHALMOLOGY Cataract surgery By Sherman W. Reeves, MD, MPH

TRAVEL MEDICINE The local goes global

ARCHITECTURE HONOR ROLL Health care facility design

By Taryn M. McEvoy, MD

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com

Accountable Care Organizations Accountable to Whom? Thursday, October 13, 2011 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: Created as part of national health care reform, accountable care organizations (ACOs) are now part of every health care policy discussion. As defined by the 111th Congress, ACOs are organizations that include physicians, hospitals, and other health care organizations with the legal structure to receive and distribute payments to participating physicians and hospitals to provide care coordination, invest in infrastructure and redesign care processes, and reward high-quality and efficient services.

Exactly what this means is unclear, and a confusing array of levels and qualifications for ACOs has been proposed. With 2012 as a start date for Medicare reimbursement through ACOs, Congress is developing firm definitions at this time. Some say ACOs turn physicians into insurance companies; others say they are a way for physicians to take a leadership role in fixing a broken system. As health care organizations race to join, create, or redefine themselves as ACOs, they all face more questions than answers. Objectives: We will review the history, goals, and rationale behind the ACO model. We will review the latest federal guidelines defining what an ACO can be. We will discuss how the ACO will affect health insurance companies, employers, and the pharmaceutical industry. We will illustrate what must not be allowed to happen if the model is expected to succeed. We will examine who decides if ACOs are successful and how those decisions will be made. We will explore why so many people, representing very different perspectives on health care, are opposed to the idea and what can be done for it to achieve its best potential.

ASSOCIATE EDITOR Martha Malan mmalan@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com

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Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans. Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; e-mail mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

NEWS

MDH Creates Public Health Data Website The Minnesota Department of Health (MDH) has created a website for sharing public health data with residents of Minnesota. The Minnesota Public Health Data Access (MNPH Data Access) is designed to be an electronic gateway to the state’s health and environment data, officials say. The new website provides both general information on public health topics and specific, detailed data from the public health tracking measurements that the agency maintains. Officials say it will be a “one-stop shop” for data about health, the environment, and other risk factors that affect public health in Minnesota. For consumers, the site answers basic questions about public health issues, then provides links to more detailed data. For example, on the topic of asthma, it outlines the health prob-

lems caused by the condition, gives prevention suggestions, and provides links to agencies and programs that address asthma in Minnesota. The site can also be used by local public health officials and providers to gather information about health and environment trends over time. The website currently includes data on air quality, asthma, heart attacks, childhood lead poisoning, carbon monoxide poisoning, and chronic obstructive pulmonary disease. Officials say more data and tools will be added this summer.

Walking Prescribed As a Tool for Fighting Depression HealthPartners Medical Group will prescribe walking as an additional tool for treating depression, along with medication and/or therapy. Officials with HealthPartners note that an estimated 19 million Americans are living with depression and most of them first seek

help in a primary care setting. With research showing that physical activity can improve mental health, HealthPartners providers will prescribe exercise as part of a comprehensive approach to treating depression. The health system has created a program that gives pedometers to patients to encourage them to exercise by walking. HealthPartners officials note that a more extensive exercise program may seem overwhelming to patients with depression, so walking is a first step in helping patients begin to exercise. “The pedometer program is not meant to replace medication or therapy that may be beneficial to the patient,” says Art Wineman, MD, regional assistant medical director. “But it can be an effective tool in our toolkit for patients. Exercise works because it increases the feel-good chemicals in your brain. It also improves energy, relieves anxiety, and helps sleep.”

Mayo Rolls Out New Brand for Health System A new branding effort is taking place in health facilities in Minnesota, Wisconsin, and Iowa, as Mayo Health System becomes Mayo Clinic Health System. The Rochester-based health system first announced plans for the change last October, and the new name became official on May 23. The change may seem subtle, but it will be more noticeable in communities whose hospitals and clinics have operated under locally familiar names that in many cases have had the words “Mayo Health System” added on. With the new branding, for example, Franciscan Skemp Healthcare in LaCrosse, Wis., becomes Mayo Clinic Health System La Crosse. St. Joseph’s Mayo Health System in Mankato will now be known as Mayo Clinic Health System in Mankato. Fairmont Medical Center becomes Mayo Clinic Health

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MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

System Fairmont. Officials say all 70 communities that are served by Mayo Clinic Health System facilities will now see a common, uniform name for health care delivery. “Mayo Clinic Health System has evolved over time, and today our sites work together more closely with each other and Mayo Clinic than ever before,” says Rob Nesse, MD, chief executive officer, Mayo Clinic Health System. “We operate as one system and work together to provide our patients with the care they need, where they need it—whether that’s in their hometown, a neighboring community, or in Rochester. Our new name reflects that.”

North Memorial Hospital Has Close Call with Tornado The tornado that caused major damage to northwestern Minneapolis on May 22 came within a half mile of North Memorial Hospital in Robbinsdale, but the facility was not damaged and was able to provide medical treatment to 43 people who sustained injuries due to the storm. The tornado did damage North Memorial Clinic–Camden Physicians, a primary care clinic on Webber Parkway in Minneapolis. That site was closed for a few days because of broken windows and interior damage from wind and rain. According to Andy Cochrane, president of operations at North Memorial, the hospital followed its usual protocol for severe weather, but the rapid development of the storm was a problem. “The challenge with this storm was just how quickly it happened,” he says. “By the time someone identified a funnel cloud … it was basically right in the neighborhood.” Just how close the tornado came to the hospital could be seen on video from a security camera located at the hospital’s helicopter landing pad. The video shows the large tornado, seemingly blocks away, moving quickly

across the ground, followed by blinding rain. At the hospital, staff had already taken precautions such as making sure windows were closed and blinds were down to guard against flying glass if windows were blown out. Patients were moved away from windows and public areas were cleared. After the storm passed, officials note, staff at the hospital were asked to stay on through the regular shift change to ensure that extra personnel were available if needed. Hospital officials say the 39 people who came in that Sunday did not represent a large enough number to create overcrowding at the emergency room and, since most of the injuries were minor, the storm victims were relatively easy to care for. Two storm victims were hospitalized, but both were released within days. The Minneapolis tornado and the much more damaging one in Joplin, Mo., underscored the importance of training and of working together with other facilities, Cochrane says. He notes that in cases like the Joplin tornado, where a large hospital was severely damaged, other community hospitals were quick to help out and take in patients. In Minneapolis, North Memorial had conducted a severe weather drill just weeks before the tornado, Cochrane says. “People would love to have more lead time than these things give you,” he says. “But that’s why we do these drills, to provide a safe environment for the patients we have, and then, postevent, so that people have a place to go.”

MDH Warns Public About Tick Season As tick season arrives in Minnesota, officials with the Minnesota Department of Health (MDH) are reminding people that 2010 saw a record number of cases of tick-borne diseases. Minnesotans, they say, should

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News to page 6 JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

News from page 5 increase their efforts this summer to protect themselves from ticks. The biggest increase in tickborne disease cases in 2010 was the 720 cases of human anaplasmosis, more than double the 300plus cases found in recent years. There were 56 cases of babesiosis, up from 31 in 2009, and 1,293 cases of Lyme disease, up 21 percent from 2009, officials say. MDH officials say tick-borne illnesses can range from mild to severe. Complications can include swelling of the brain, organ failure, and death. About 30 percent of the 2010 anaplasmosis patients were hospitalized, and one patient died. Nearly half of the babesiosis cases were hospitalized and one patient died. “With Minnesota’s more common tick-borne diseases reaching epidemic levels in some areas, it is crucial that Minnesotans protect themselves from tick bites to prevent serious tick-borne illness,” says Ruth Lynfield, MD, Minnesota state epidemiologist.

Dayton Vetoes Health Budget As expected, Gov. Mark Dayton vetoed the Health and Human Services (HHS) omnibus bill at the end of the 2011 session, along with all other major budget bills, setting the stage for a special session this summer. Health care, as always, was a major piece of the budget puzzle, and the Legislature’s $1.8 billion in cuts had raised cries of protest from a range of sources, including health organizations such as the Minnesota Medical Association and the Minnesota Hospital Association. Dayton and Department of Human Services Commissioner Lucinda Jesson had also raised a host of objections about the health omnibus bill as it moved toward completion in May. In a May 24 letter to Sen. Michelle Fischbach, president of the Minnesota Senate, Dayton outlined his reasons for vetoing the HHS bill. He sharply criticized

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

the bill’s cuts to services, its cancellation of the Medicaid expansion he signed into law, the limitations it puts on the state’s adoption of the federal Affordable Care Act, and its restrictions on stem cell research. “This Health and Human Services bill passed by the House and Senate would cause devastating harm to many thousands of Minnesotans, which I will strongly oppose,” Dayton wrote. “A reduction of this size jeopardizes the progress Minnesota has made in providing health coverage for the uninsured, supporting our seniors in their communities, offering treatment and community support for people with mental illness, and establishing a public health infrastructure that protects all Minnesotans. … We have made so much progress in health care over the last two decades in Minnesota. I will not allow that progress to be turned back in one year.”

Publisher’s Note As this edition goes to press, the threat of a state government shutdown is creating major concerns for the health care industry. Because so many institutions we serve would be affected by a government shutdown, combined with the Fourth of July holiday and staff retirements and replacements, we have decided to combine our July and August editions. The next edition of Minnesota Health Care News will be distributed after the Labor Day holiday. We regret any inconvenience this may cause our readers and business partners. Paid subscribers will still receive 12 editions.

PEOPLE The Minnesota Hospital Association (MHA) has awarded its highest honor, the Stephen Rogness Distinguished Service Award, to Debra K. Boardman, president and CEO, Fairview University Medical Center– Mesabi, in Hibbing. The award recognizes a hospital executive who has demonstrated a history of significant leadership beyond his or

Stay in the Game.

her hospital or system. The award citation noted that Boardman has been a health care leader at the local, state, and national levels and is known as a voice for rural hospitals. She has been a health care executive in northern Minnesota for the past 21 years. At the state level, she has been a frequent spokesperson at the Minnesota Legislature, advocating for rural and mid-level hospitals on various issues. Boardman served as chair of the MHA board of trustees chair in 2007 and is a fellow in the American College of Healthcare Executives. Certified genetic counselor Anna Leininger, MS, has joined Minnesota Oncology. After many years of service at HealthEast and the University of Minnesota, Leininger will collaborate with Thomas Amatruda, MD, in building the genetic counseling program for the east metro area.

Active Care for Active People

She is available for consultation at the Woodbury Clinic and at Maplewood Cancer Center. Anna Leininger, MS

Leininger is certified by the American Board of

Genetic Counseling and holds a master’s of science degree in medical genetics from the University of Wisconsin, Madison. The Women’s Health Leadership Trust has given its annual Jean Harris award to two health care leaders. This year’s award went to

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Carol Kraft, vice president and chief operating officer of SelectAccount, an affiliate of Blue Cross and Blue Shield of Minnesota; and Mary Larweck, founder of Emerald Quality Services, a health care quality and epidemiology consulting company. The award honors the women as “accomplished leaders in their professional careers and community involvement” who also have “mentored emerging leaders in health care.”

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The Minnesota Dental Association (MDA) presented several awards at its recent annual convention in St. Paul. James Westman, DDS, received the MDA’s Outstanding Service Award on behalf of his many contributions of time and talent to organized dentistry. He has been in private practice in Duluth since 1973. Julie Clouse, DDS, received the New Dentist Leadership Award on behalf of her service to the dental community that demonstrates loyalty to the profession and the public. A 2004 graduate of the University of Minnesota School of Dentistry, Clouse is a general dentist in Minneapolis. Robert Gardetto, DDS, received the President’s Award, in recognition of his leadership and advocacy on behalf of Minnesota dentists. He is currently a general dentist in practice in St. Cloud. William P. Hoffmann, DDS, was selected as the 2011 MDA Guest of Honor. Hoffmann has been an active member of the Minnesota Dental Association for 25 years; currently he is chair of the MDA Political Action Committee board of directors and is on the MDA Legislative Committee. He specializes in oral and maxillofacial surgery in Plymouth, Edina, and Chaska. Joel Michelson, DDS, received the Humanitarian Service Award for his commitment to his local, regional, and global community. He specializes in oral and maxillofa-

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PERSPECTIVE

Getting the most from health services Researchers probe issues of effectiveness, access, cost

Kristina Bloomquist, MEd, CPHQ, CHRC Medica Research Institute

Kristina Bloomquist, MEd, CPHQ, CHRC, is director of the Medica Research Institute. She has 20 years of professional experience in patient care and administrator roles including long-term care, inpatient and outpatient hospital care, and managedcare settings. Bloomquist has used her training in the scientific method and quality improvement principles to develop patient therapy programs, a hospital business line, health management strategies, and, most recently, the Medica Research Institute.

ne of the most pressing issues in health care today centers on structuring health services in a way that improves the health of populations at a cost that is affordable and leaves no one behind. Recognizing that our vast medical knowledge and advanced technologies far outstrip our ability to employ those resources effectively, Medica has formed the Medica Research Institute to apply dedicated resources to address these issues. David Tilford, CEO of Medica and chair of the institute’s board of directors, has made it clear that the institute is not a research and development department for Medica but a separate organization to conduct investigator-driven research that will benefit all who interact with health care, not just those enrolled in Medica insurance plans. Research leads to improved lives

tic testing appropriately and avoid unnecessary hospitalizations. Consumer engagement A second theme seeks to improve the way consumers get involved in managing their own health.This track studies how information empowers people to make decisions about their health and how they use health services. For example, we are looking at how people want to participate in health coaching: What kinds of people prefer what kind of settings—online, group settings, individually with a health coach, or in some other environment? We also are exploring how coaching addresses health improvement needs that might otherwise be unmet. At the same time, this research delves into who uses health coaching and the outcomes they experience. Part of this research also looks at how aspects of health coaching could be applied to health care services. Another area the institute is exploring within this research theme is whether incentives encourage people to take action—for example, adhering to recommendations for wellchild visits.

The institute’s mission is to conduct research that generates valid, meaningful, evidence-based information. These results can be used to develop activities that help protect health and improve lives. By applying scientific rigor to unanswered questions within health care, we Building on existing intend to provide value to relationships within the unique populations across the health care spectrum. health care community,

Making healthy choices easier

A third research theme focuses on the importance of Because the best research creating environments that we are creating new outcomes are typically make it easier for people to achieved through collaboraresearch opportunities. make healthy choices. A curtion, projects are carried out rent project within this track largely by working with other involves examining factors research organizations in our region and across that influence access for children with asthma. the nation. Building on existing relationships with- Areas of future exploration include community in the health care community, we are creating new engagement models for health improvement. This research opportunities. Among the participant could include, for example, how communities organizations are the University of Minnesota, might partner with schools and municipalities to Mayo Clinic, Allina Health System, Fairview Health find effective ways to encourage health in a variety Systems, the Institute for Clinical Systems of ways, including everything from school lunches Improvement, and MN Community Measurement. to sidewalks for walking. We also envision studies under this theme resulting in information used to Efficiency and effectiveness Current research focuses on three main themes. inform public policy. The first includes projects that identify ways to improve the efficiency and effectiveness of the provider system.These “best practices” endeavors include looking into more effective emergency room care for children, screening for adolescent health issues, patterns of using technology such as CT scans, and identifying physicians and clinics that provide high-quality care at low cost. Among the goals is determining best-practice processes or rules for emergency room care to use diagnos-

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

As these research projects produce results, the Medica Research Institute is committed to translating the findings for people across the health care spectrum—from patients to providers, purchasers, and regulators. We believe that translating our findings to everyone with an interest in bringing about improvements will benefit the entire health care system and all those who interact with it.

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JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

10 QUESTIONS

& Sam Economou, MD Dr. Economou is a principal in Plastic Surgery Consultants in Edina. He is a diplomate of the American Board of Plastic Surgery and a member of the American Society of Plastic Surgeons. Why do they call it plastic surgery? Plastic surgery derives its name from the Greek word plastikos, which means an object that can be molded or changed. It is an appropriate root, as we change the form of the human body with so many of the procedures we perform. Many think it is called plastic surgery because we use plastic in our procedures, which is not true. What are the risks and complications of plastic surgery? The risks involved with cosmetic and reconstructive procedures are not much different from any other surgical procedure. There is a small risk of infection, bleeding, unfavorable scar formation, delayed healing, and fluid collections associated with many of our procedures. Various procedures carry specific individual risks that we discuss with the patient at the time of the consultation. What special considerations must be taken into account with regard to reconstructive surgery for breast cancer patients? It is important that the type and location of the cancer are known. In addition, the plan for surgery by the general surgeon treating the cancer must be determined so that options for reconstructive surgery can be discussed with the patient. The patient’s breast size, position, and body proportions must be factored into any reconstructive options we consider. Also, any other treatments such as potential chemotherapy and radiation therapy can affect the reconstructive plan. Finally, patient preference plays a major role in determining which form of reconstruction is performed. What criteria should a prospective patient use to select a plastic surgeon? Selecting a plastic surgeon should be done very carefully. I would suggest that patients research the surgeon’s training and background and confirm certification by the American Board of Plastic Surgery. Unfortunately, some physicians calling themselves “cosmetic surgeons” do not have the same training and board certification that plastic surgeons do. The caveat “buyer beware” applies here. Beyond that, I would suggest having consultations with multiple plastic surgeons to investigate their personal experience, approach, area of expertise, and personality. In the end, your goals should match the surgical plan. You should feel at ease with the proposed surgery and the surgeon doing it. Please tell us about the ways you work with other kinds of physicians. Many of our patients are referred to us by their primary physician, who is familiar with our work. We also work with many other specialists in coordinating care of our cancer patients, who often see physicians in multiple specialties. In addition, we work directly with general surgeons in performing breast reconstructions. We also often perform tummy tucks at the same time a gynecologist performs a hysterectomy.

Photo credit: Bruce Silcox

How are your services covered by health insurance? Any medically necessary procedure is covered by insurance but would be subject to copays and deductibles. That would include cancer care, breast reconstruction, breast reduction, and biopsy of any suspi-

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

“

”

You should be as comfortable having surgery as the surgeon is performing it.

cious lesion. Cosmetic procedures are not covered by insurance, but patients are provided with an all-inclusive estimate at the time of their consultation so they know up front the cost of their surgery. What is the most common misperception about plastic surgery? Cosmetic surgery is perceived to be the realm of the rich and famous. The reality is that most cosmetic surgery is performed for the average person. Sometimes, because of the portrayal of plastic surgeons on TV, we are viewed as doing cosmetic surgery only. Contrary to that, most plastic surgeons do a combination of reconstructive and cosmetic surgery. Our training is very broad-based and includes a wide range of procedures. Another misconception is that we perform “scarless” surgery. We try to place scars strategically and use techniques to minimize them, but all surgeries produce a scar of some sort. What are some common procedures you perform that most people don’t know about? In my practice we perform a large number of melanoma surgeries. Many patients are surprised that a plastic surgeon is performing the operation, but often reconstruction is needed as part of the operation. We are able to provide that. Another surprise is the large number of breast reductions done both here in Minnesota and nationally. It is usually an insurancecovered procedure and gives relief to back pain. Another procedure done frequently that many are unaware of is post-gastric bypass body contouring. Many of these patients have dramatic weight loss that

REGENC Y

results in significant laxity of the skin (loose skin) throughout the body. We offer multiple procedures to address this problem.

What are the latest advances in plastic surgery? Surgical procedures haven’t changed dramatically, but we are trying to alter them to allow for a more rapid return to work and activities. Some of the noninvasive means of body contouring, such as cryotherapy and ultrasound, show some promise, but are not at a point that they can reproduce the results of conventional liposuction. There is great promise in fat transfer in reconstruction and augmentation of the breast. Stem cells may someday play a role in both reconstruction and rejuvenation of the skin. Ongoing studies will reveal more information in time.

What would you tell someone who is considering plastic surgery? I would advise the patient to become an informed consumer. Knowledge is power. Educate yourself on the procedure being considered so that you can ask good questions. Use credible websites to gather information. Use the suggestions above to select a surgeon. Don’t be afraid to ask questions. You should be as comfortable having surgery as the surgeon is performing it. Define your area of interest so that the consultation can focus appropriately on your concerns. Write down concerns or questions so you don’t forget them. Above all, it is important to set realistic expectations of surgery with your surgeon so you can anticipate the outcome appropriately.

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Giving People Their Lives Back Regency Hospital of Minneapolis is an intensive critical care hospital serving the needs of medically complex patients that require acute level care for a longer period of time than traditional hospitals are set up to provide. We are a national network of hospitals with a different way of thinking, a different way of caring, and a different way of treating, and it shows in everything we do.

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OPHTHALMOLOGY

Cataract surgery

hile cataract is the leading cause of visual impairment in the United States and worldwide, modern cataract surgery with intraocular lens (IOL) implantation is one of the most effective surgical therapies in medicine today. In contrast to most of history, cataract patients today enjoy a quick, painless, outpatient procedure with extremely low complication rates and a rapid recovery of visual function. Further, an ongoing revolution in surgical techniques and IOL technology over the past decade now also allows for highly accurate correction of preexisting refractive error and relief from presbyopia (farsightedness), lessening or even eliminating the dependence on glasses for distance vision and reading postoperatively. Causes of cataract The word cataract comes from the Latin cataracta, for “waterfall,” which aptly describes the white and foamy appearance of an eye clouded by advanced cataract. We now know that damage from oxidation and changes in hydration of the lens itself are responsible for the clouding observed with cataracts. Such changes are most commonly brought about during the natural aging process of the eye, though trauma, certain drugs, and inherited conditions can also result in lens clouding. In its early stages, a cataract may cause only a minimal decline in visual clarity or quality, or only intermittent symptoms such as glare or starbursts in settings with bright light. As the cataract becomes more opaque and grows increasingly dense, the quality of vision may begin to suffer noticeably. At this point, glasses may no longer provide satisfactory vision, and surgical removal is the only option for restoring sight.

Advances restore vision quickly, effectively— and sometimes better than ever By Sherman W. Reeves, MD, MPH

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MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

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Cataract surgery From its first written description in India around 500 BC, until the mid-1700s, cataract surgery was performed by inserting a needle into the eye and pushing the cloudy lens out of the pupil and into the vitreous cavity in the back of the eye, clearing the visual axis of the opaqueness. The procedure, called couching, restored at least ambulatory vision to subjects who had previously been completely blind from

limited its popularity and acceptance by surgeons. In 2006 a significant advance in toric IOL technology gave it greatly improved rotational stability. This model is now a well-established option for correcting astigmatism at the time of cataract surgery. Presbyopia IOLs Presbyopia is the condition of losing near vision due to aging. While the majority of cataract patients have been presbyopic for years, the removal of the crystalline lens during cataract surgery and implantation of a distance-vision-targeted monofocal IOL results in complete dependence on reading glasses for clear near vision. The ophthalmic community has sought to develop IOLs that provide an increased range of clear vision and relieve the presbyopia symptoms that result from the use of an implanted artificial lens. Within the past decade, two strategies have been pursued: multifocal IOLs and accommodative IOLs. Multifocal IOLs

cataract. However, complication and infection rates were, not surprisingly, high. Through the 19th and early 20th centuries, anesthesia, sterile technique, and specialized instrumentation improved, allowing surgeons to completely remove the clouded lens from the eye, though large incisions in the front of the eye were still required. Further, while efforts to develop replacement IOLs had been made, none were successful and thick “Coke bottle” glasses or contact lenses were required for patients to achieve reasonably good vision postoperatively. Therefore, even through the latter part of the 20th century, cataract extraction was typically delayed until lens opacity had resulted in severe vision loss and life with cataract glasses was the lesser of two evils. In the late 1970s and 1980s, breakthroughs in IOL technology allowed safe and effective lens implants to become a routine part of cataract surgery. This advancement, combined with the development of small-incision surgical techniques, radically transformed the procedure. Today, with modern surgical technique and intraocular lenses, cataract surgeons not only can remove cataracts, but also can closely tailor the patient’s vision to a desired refractive target. Further, an explosion of specialty lenses has occurred over the past decade, allowing correction of astigmatism and presbyopia, greatly decreasing postoperative dependence on glasses for patients who desire it. Astigmatism correction Over the past several years, specialized IOLs have been developed not only to correct the overall myopia or hyperopia of the eye, but also to decrease astigmatism, a blurring of vision that results from the shape of the cornea. These astigmatism-correcting IOLs require precise alignment in order to be effective. Small amounts of misalignment or postoperative lens rotation can greatly reduce the astigmatic correcting effect of these lenses. The first IOL for astigmatism, called a “toric IOL,” was approved for use in the United States in 1998, but problems with postoperative rotational stability

The addition of multiple optical zones into an intraocular lens represents one approach to providing both distance and near visual capability with a single lens implant. While this technology has been effective, all multifocal lenses, by definition, present more than one image to the retina. Thus, while multifocal IOLs deliver an increased range of vision, they also are invariably associated with some degree of unwanted visual phenomena, such as glare and halos. The challenge for designers of these lenses, first introduced in the late 1990s, has been to increase optical quality across a range of focal lengths while decreasing unwanted optical Cataract surgery to page 34

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OBSTETRICS

Prenatal screening and diagnosis Chromosomal abnormalities can be identified early in pregnancy By Taryn M. McEvoy, MD

s an obstetrician/gynecologist (ob/gyn), I am privileged to be part of my patients’ pregnancies. A highlight of my job is the first OB visit. While it’s exhilarating for the parents-tobe, the experience can also be overwhelming. This article addresses one of the most anxiety-provoking and confusing parts of the first OB visit—screening and diagnostic tests for genetic disorders. The screening and diagnostic tests available today are vastly different from those of even 15 years ago. They include tests aimed at certain conditions that can be identified prenatally: Down syndrome (trisomy 21), trisomy 18, and trisomy 13. Down syndrome is the most commonly occurring chromosome abnormality, and the severity of the condition varies from person to person. Trisomy 18 and 13 both are severe chromosomal abnormalities associated with life-threatening complications in the first few days to years of life. The risk of chromosomal abnormalities increases with maternal age. For example, the risk of Down syndrome for a woman at age 20 is one in 1,480. At age 35, the risk is one in 353. At age 40, the risk is one in 85. In the past, maternal age of 35 or older was considered sufficient risk for having a child with Down syndrome that diagnostic tests should be offered. Now, with the advent of screening tests for chromosomal abnormalities, every woman—regardless of age—should be offered screening and diagnostic tests.

Screening tests

A screening test determines the chance or risk of having a baby with Down syndrome, trisomy 18, or trisomy 13. Such tests are never absolute and cannot tell if a fetus actually has the specific condition. A diagnostic test ascertains definitively whether the fetus actually has a specific condition. First-trimester screening is normally done between the start of the 11th week of pregnancy and the end of the 13th week. It consists of a blood test that measures the levels of two chemicals in the mother’s blood, and an ultrasound examination that measures the nuchal translucency, which is the amount of fluid behind the neck of the fetus. Those two values plus the maternal age are put into a mathematical formula; the result is the risk for having a baby with a chromosomal abnormality. It is important to note that, since this is a screening test, even if the risk is low there is still a small chance the baby may have a chromosomal abnormality. Between 82 percent and 87 percent of Down syndrome cases will be detected with first-trimester screening. Another 5 percent of the screening tests come back showing an increased risk, but that does not mean that a baby actually has Down syndrome. It means only that there is an increased risk and more tests are recommended. Another option for screening is the quad screen, a blood test done in the second trimester between 15 and 22 weeks. It measures chemicals in the blood similar to the first trimester screening. Eighty-one percent of Down syndrome cases will be detected and, as with first-trimester screening, it also has a false-positive screen rate of 5 percent. The routine ultrasound that all pregnant women receive around 20 weeks is another screening test. Ultrasounds are very good at picking up major birth defects but not as accurate for picking up Down syndrome. Combining the results of the ultrasound with either first-trimester Healthful, locally grown and raised organic screening or the quad screen makes the ultrasound more accurate. foods and wellness products since 1972.

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If any of the above screening tests suggest the possibility of an abnormality, a patient will be offered a diagnostic test. The diagnostic test

will provide a definitive diagnosis as to whether drome or a chromosomal abnormality would the fetus has a chromosomal abnormality or not. mean for them and also what they would want to The reason most people do not go directly to do with the information from the screening or Every woman— diagnostic tests is that these tests are invasive and diagnostic tests. have a small risk—0.5 percent to 1 percent—for There are many reasons couples choose to regardless of age— miscarriage. The diagnostic test that is offered proceed with screening or diagnostic testing. should be offered will depend on how far along the pregnancy is. It Some couples would choose to terminate an screening and diagnostic normally takes up to two weeks to get the result affected pregnancy. Others want to know in order from a diagnostic test. tests for chromosomal to learn as much as possible about the chromosoChorionic villus sampling (CVS) is a diagnosmal abnormality before the baby is born. There abnormalities in her are many people who decline screening or diagtic test that is done between the 10th and 13th developing fetus. nostic tests because they do not think they would weeks of pregnancy. A small part of the placenta use the information. Others state that if they did is removed through the maternal abdomen or have a screening test that was of concern they through the cervix. would not want to proceed with invasive diagAmniocentesis is a diagnostic test that is done nostic testing, so they do not want the added between weeks 15 and 20 of pregnancy. An stress. obstetrician, guided by ultrasound, inserts a fine It is important to know that when it comes needle through the mother’s abdomen to withdraw a small amount of fluid from the amniotic sac. Amniocentesis is to screening and diagnostic tests there are no “right or wrong” also used to check for neural tube defects such as spina bifida and answers. It is a very personal decision. The physician who is caring anencephaly (the absence of all or a major part of the brain) and for you in your pregnancy is a good place to start asking questions. genetic disorders such as sickle cell anemia or cystic fibrosis. In addiGenetic counselors are another excellent resource for patients who tion, it can be used to check the blood type of the fetus and, toward want additional information about genetic screening and diagnostic the end of the pregnancy, whether the fetus’s lungs are mature. tests. Do not be afraid to ask questions. It is also important to check with your health insurance company Making decisions to verify that the tests will be covered. The many options for genetic screening and diagnostic tests can be Taryn M. McEvoy, MD, is an obstetrician/gynecologist at Oakdale Obstetrics overwhelming for a pregnant couple. My advice is for a couple to & Gynecology in Maple Grove and Plymouth. first talk with each other about what having a child with Down syn-

JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

T R AV E L M E D I C I N E

global The local goes

Reduce risk before you travel By Ann Settgast, MD, DTM&H

Imagine two travelers, both of whom are traveling to Nigeria for one month. Patient A is a 51-yearold St. Paul native who will be supervising graduate students on a project in a remote rural region of Nigeria. Born in the U.S., he has never left the country. Patient B is a 51-year-old Nigerian office worker traveling home to Nigeria due to a death in his family. He has lived in the U.S. for 12 years. He will remain in Nigeria’s capital city, Abuja, for his entire stay. Which traveler is at higher risk? Do both need the same travel advice and preparation? These are concerns addressed by travel medicine. Practitioners of travel medicine offer expertise in global health risks, malaria prevention, proper vaccine use, and pre-travel counseling. In 2008, Americans made more than 60 million international trips. Furthermore, travel to developing countries has increased significantly in recent years, thereby escalating exposure to infectious tropical diseases and other travel risks.

Which travelers are at greatest risk? If you guessed Patient B as the traveler at higher risk in the example above, you are correct. This is because he is a VFR traveler—one who is returning to his country of origin to visit friends and relatives. Researchers have found that VFRs make up nearly half of all travelers from the U.S. This group has special relevance for the state of Minnesota. While our foreign-born population (7 percent of total) is smaller than the national average, a high proportion (44 percent) arrive as refugees, and these patients are more likely to be from sub-Saharan Africa, which houses destinations with the highest travel risks. VFR travelers are remarkable in several ways. A greater proportion of immigrant VFRs contract serious (and preventable) travel-related illness than do tourist travelers. [For example, immigrant VFRs are more than four times likelier than other travelers to have malaria upon return. Typhoid fever, respiratory illness, tuberculosis, and sexually transmitted infections also affect VFR travelers disproportionately.] However, as a group they perceive less risk from travel-related disease and are less likely to seek pre-travel advice. Several other issues contribute to increased risks for VFRs:

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There is more to a pre-travel visit than just a few shots.

• They are more likely to have prolonged stays in areas where disease is commonly found, and to be in close contact with local populations. • They are more likely to travel at the last minute. • They are more likely to visit rural locations (which can pose higher risk) and to consume high-risk foods and beverages.

The pre-travel visit

Several key issues will arise in a pre-travel visit while answering two very important questions: Who is the patient? Where is she or he traveling? Because of the distinct risks for Patients A and B, travel advice for them will differ. However, the same broad categories will need to be addressed for both. Traditionally, traveler health advice has focused on preventing infectious tropical diseases. However, the vast majority of deaths during travel are due to pre-existing conditions, such as cardiovascular disease. Therefore, a medical history and optimization of treatment for pre-existing conditions are relevant to a pre-travel consultation. Injuries and accidents account for the next largest burden of travel-related mortality. These come mainly in the form of motor vehicle accidents, violence, and drowning. U.S. citizens traveling in most regions of the world have auto-accident death rates that are significantly higher than rates for native inhabitants. Also, international injury risk varies significantly by region visited. A pre-travel consultation should include discussion of personal safety measures such as seat belt and helmet use and personal flotation devices. For Patients A and B, the travel consultation will also include consideration of malaria, vaccines, and traveler’s diarrhea.

tion while they are in the U.S., this can be lost when one travels to a country with a high prevalence of disease. Measles and polio are examples of diseases that both travelers should be protected against prior to departure. As with malaria, VFRs are at greater risk for many vaccine-preventable illnesses while traveling. A study in 2000 showed that tourists accounted for 4 percent of travel-related typhoid fever, while VFR travelers accounted for 40 percent. Patients A and B both should be immunized against typhoid fever. Preventive vaccine is also recommended for travel anywhere within sub-Saharan Africa’s meningitis belt. However, Patient B’s anticipated prolonged contact with the local population puts him at higher risk. Yellow fever is a mosquitoborne virus with fatality rates approaching 50 percent. Both patients The local goes global to page 33

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Malaria

The Centers for Disease Control and Prevention estimates there are 1,500 cases of malaria in the U.S. each year, with about 35 in Minnesota. The vast majority occur in travelers and are related to failure to take preventive medications properly. Malaria is common in Nigeria and is potentially fatal. Since malaria is spread by the night-biting Anopheles mosquito, preventing bites between dusk and dawn is paramount. Patients A and B both should sleep under bed nets and use adequate insect repellent. Both also need to take preventive medications. There are multiple reasons why VFR travelers have a higher risk of malaria. Having been infected multiple times during childhood, our Nigerian patient might assume that this will not be a serious disease in him. While he is correct to a degree, immunity wanes over time. The longer he lives outside a malarious area, the less immunity he has. Furthermore, the Nigerian patient is likely to stay in a household where no one else is taking medication to prevent malaria or using bed nets or window screens. Unlike Patient B, his relatives do have significant immunity to malaria and may not understand his need for extra precautions.

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Vaccines

Vaccine needs will differ for Patients A and B. Patients not born in the U.S. are less likely to have received complete series of routine childhood vaccines. While herd immunity may confer some protec-

click JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

July Calendar Boating and Water Safety

Helping Others Through Lung Cancer We aim to bring comfort to our participants by providing tools to improve quality of life though education, support, and the knowledge that others are walking in similar shoes. The free meetings are held the first Thursday of each month. For more information, call 612-884-6300. Thursday, July 7, 5:30–7 p.m., Minnesota Oncology, 910 E. 26th St., Ste. 100, Conference Rm., Minneapolis

Perinatal Loss Bereavement Support This support program is for families who have experienced the loss of an infant through newborn death, stillbirth, ectopic pregnancy, or miscarriage. Meetings are held the second Monday of each month. For more information, call 320-251-2700, ext. 53528. Monday, July 11, 7–8 p.m., St. Cloud Hospital Conference Ctr., 1406 6th Ave. N., Maple Rm., St. Cloud

Considering the large number of participants in Minnesota, water-based recreation is still a relatively safe pastime. Still, in a recent 10-year period, an average of 38 persons died in non-boating drowning and 18 in boating accidents each year in the state. The Minnesota Department of Natural Resources (MNDNR) offers these tips for keeping boating safe for everyone in, on, or near the water: • Don’t drink and drive a boat. Besides being dangerous, operating a motorboat while intoxicated is illegal and carries heavy fines and penalties. The use of alcohol is involved in about a third of all boating fatalities. • Wear your personal flotation device (PFD, or life jacket). Every watercraft must be equipped with the proper number of Coast Guard-approved PFDs for each person on board. Children under 10 years are now required in Minnesota to wear a PFD on boats unless the craft is docked, moored, chartered, used as a swimming platform; or the child is under deck or in an enclosed cabin.

• Carbon monoxide can be fatal. Do not ski, drag, or tube closer than 20 feet from a motorboat or allow anyone to swim or sit near the stern of the boat when the engine or generator is running. • Capsizing (tipping over) and falls overboard are the two most common kinds of fatal boating accidents. If you do tip over, try to climb back onto your boat, even if it is still upside down. • Overloading or improperly distributing the weight of passengers and gear in the watercraft makes it unstable and hard to handle. • Be a courteous boater. Treat other boaters, shoreline residents, and other water recreation enthusiasts, as you would like to be treated yourself. For complete Minnesota boating regulations, visit www.dnr.state.mn.us. For questions, call MNDNR at 651-296-6157.

Lyme Disease Seminar Minnesota Lyme Association will host Sirid Kellermann, PhD, MBA, from NeuroScience, Inc. Dr. Kellermann will discuss the new Lyme test that measures inflammatory markers of Lyme disease as well as antibodies to the Lyme bacteria. For more information, visit www.mnlyme.com or email lyme@mnlyme.com. Tuesday, July 12, 6:30–9 p.m., First Lutheran Church of White Bear Lake, 4000 Linden St., White Bear Lake Stroke Affects Everyday Life: Cognition and Vision How you think, see, and perceive may be different following a stroke. Understand the changes and learn ways to function better. This seminar is for stroke survivors and their care partners to help them better understand recovery and living life after a stroke. Tuesday, July 19, 2–3:30 p.m., Abbott Northwestern Hospital, 800 E. 28th St., Rm. E1220, Minneapolis

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

Brain Injury Basics: Adjustment to Brain Injury Individuals, families, and friends are welcome to attend the seminar. We will discuss the process of adjustment, emotional aspects of changes, and adjustment challenges for individuals with brain injury and their loved ones. Registration is required. A $5 donation is appreciated. To register, call 612-378-2742. Thursday, July 21, 6–8 p.m., Brain Injury Association of Minnesota, 34 13th Ave. N.E., Education Ctr., Minneapolis

Spiritual Wellness This presentation will explore the meaning and dimensions of spiritual wellness and will offer ways of enhancing one's spiritual wellness through practical and simple steps. The speaker is Rev. Dr. Verlyn Hemmen. Verlyn is the chaplain manager and CPE Supervisor at United Hospital in St. Paul. No charge. Call 651-298-5493 with questions. Friday, July 22, 10:15–11:30 a.m., West 7th Community Center, 265 Oneida St., St. Paul

Prostate Cancer Education and Support Our group provides the latest information on prostate cancer and camaraderie for men and their families. Attendees include the newly diagnosed, those in treatment, and survivors. Most meetings include an expert speaker on clinical and life management topics, with time for questions and discussion. For a one-time registration, call 763-520-5285. Wednesday, July 27, 5:30–7 p.m., North Memorial Outpatient Ctr., 3435 W. Broadway, Robbinsdale

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to 612-728-8601 or e-mail them to jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

August Calendar 8

Pre-Diabetes Class This class is for those who have been diagnosed with pre-diabetes or are at a high risk for developing diabetes. A onetime group class outlines nutrition and exercise to reduce the risk. Cost covers written materials and a pedometer. Cost: $30. A support person is welcome to attend. Call 763-898-1000 to register. Monday, Aug. 8, 1–3 p.m., Fairview Maple Grove Clinic, 14500 99th Ave. N., Maple Grove

Staying Courageous Support Group It takes courage to deal with the daily challenges of a congenital or acquired disability. Here’s an opportunity to network with others who share similar experiences, do some creative problem-solving, and develop tools to cope with life’s obstacles. Contact Wendy Lonn at 763-520-0327 for more information. Wednesday, Aug. 10, 3–4:30 p.m., Courage Center, 3915 Golden Valley Rd., Education Ctr. 3, Golden Valley

Caregivers Support Group for Seniors Are you or is someone you know caring for a loved one? Because caring for another person touches us deeply with its many rewards and challenges, it is often helpful to share your experiences with other caregivers. Call Brenda Turner at 320-2520010, ext. 30354 with questions. Monday, Aug. 15, 7–8 p.m., Whitney Senior Center, 1527 Northway Dr., St. Cloud “My Arm and Leg Have a Mind of Their Own” Sister Kenny Rehabilitation Institute offers education for stroke survivors and their caregivers. Dr. Diane Chappuis, physiatrist and medical director at Sister Kenny, will discuss pain, spasticity, and clumsiness. For more information, contact Sue Newman at 612-863-4996. Tuesday, Aug. 16, 2–3 p.m., United Hospital, 333 N. Smith Ave., Bentson Family Conference Rm., St. Paul

Advance Care Planning Come and learn about the tools needed to assess goals, values, and beliefs about end of life care. Get tips on how to initiate a conversation with loved ones and pick a surrogate decision maker. Attendees may also schedule a free, private appointment to complete their advance directive. Free, but advance registration is required; call 651-430-4697. Wednesday, Aug. 17, 10–11 a.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Partners in Healing Are you someone that loves and cares for someone diagnosed with cancer? This program offers emotional support as well as other resources to take care of you and your loved one through this stressful time. You are encouraged to drop in. No registration is required. For questions, call Maria at 651-232-4759. Thursday, Aug. 18, 2–3 p.m., St. John’s Hospital, 1575 Beam Ave., Nygaard Boardroom, Maplewood

Bariatric Surgery Support Group This support group is designed for those considering surgery or who have undergone bariatric surgery. We encourage the well-being of the whole person—body, mind, and spirit. Our bariatric surgery support group is co-facilitated by nurse clinicians. Free and no registration is required. For more information, call 952-993-3180. Wednesday, Aug. 24, 5:30–6:30 p.m., Park Nicollet Frauenshuh Cancer Ctr., 3931 Louisiana Ave. S., Conference Rm. 1101, St. Louis Park

Nutrition and Fitness Learn easy ways to make healthy changes in your diet and exercise programs. Speaker Jodi Denker, is a master’s-prepared exercise physiologist at United’s Nasseff Heart Hospital. She works in cardiac services, employee health and wellness, and community health and education. Questions? Call 651-298-5516.

The Alliance for Patient Access

Psoriasis Awareness Month According to the National Psoriasis Foundation (NPF), 7.5 million Americans live with psoriasis and psoriatic arthritis. Psoriasis is a chronic, autoimmune disease that appears on the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells. The cells pile up on the surface of the skin, forming psoriasis lesions. Generally, one type of psoriasis will clear and another form of psoriasis will appear in response to a trigger such as reaction to medication, injury to skin, or stress. Psoriasis is not contagious. There are five types of psoriasis: plaque, guttate, inverse, pustular, and erythrodermic. The most common form, plaque psoriasis, appears as raised, red patches or lesions covered with a silvery white buildup of dead skin cells, called scale. Psoriasis can occur on any part of the body and is associated with other serious health conditions, such as diabetes, heart disease, and depression. Treating your psoriasis is critical to good disease management and overall health. Work with your doctor to find a treatment, or treatments, that reduce or eliminate your symptoms. For more information and support, visit NPF at www.psoriasis.org or call 800-723-9166. Friday, Aug. 26, 10:15-11:30 a.m., West 7th Community Ctr., 265 Oneida St., St. Paul

National Alliance on Mental Illness (NAMI) Connection NAMI Connection is a weekly recovery support group for people living with mental illness. Attendees learn from each other’s experiences, share coping strategies, and offer each other encouragement and understanding. The group meets the first, second, fourth, and fifth Mondays of the month. For more information, call NAMI at 651-645-2948 or Christina at 651-283-4821. Monday, Aug. 29, 7–8 p.m., Advent United Methodist Church, 3945 Lexington Ave. S., Eagan

Bringing health care policy and good medicine together

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ANESTHESIOLOGY

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gery. It is clear that what we do on Monday makes a difference on Friday. As perioperative physicians, we have a unique view of health care in the period before, during, and after surgery. We are perfectly positioned to coordinate all aspects of surgical care. We can offer so much to patients, our physician colleagues, to our hospitals, and to health care as a whole. Our involvement may include making sure that a patient’s hypertension is addressed postoperatively, or that patients who appear to have sleep apnea receive proper follow-up diagnosis and care. One of our primary responsibilities is to assure appropriate pain control beyond the immediate postoperative period. Most patients who are having surgery are primarily concerned about anesthesia or pain. Many studies have demonstrated that poor postoperative pain control leads to poor outcomes. We feel that excellent surgical care cannot be had without excellent postoperative pain control. As a result of the paradigm shift in anesthesia care, Northwest Anesthesia PA, which provides all anesthesia services at Abbott Northwestern Hospital and its Orthopedic Institute Surgery Center, has developed a sophisticated acute pain service (APS) to address postoperative pain. The philosophy of the APS is simple: Provide superior postoperative pain control while minimizing the side effects. The APS uses a variety of mechanisms, skills, and techniques to control pain, including peripheral nerve blocks, multimodal preemptive analgesia, neuraxial (spinal nerves) blocks, and ketamine infusions. These nonnarcotic mechanisms for controlling pain avoid many of the unwanted side effects of narcotic medication, which include nausea, vomiting, constipation, itching, sedation, respiratory depression, and potential addiction.

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Orthopedic patients

ames was surprised when his anesthesiologist wanted to talk about developing a plan for controlling the pain he may have on Thursday—the third day after his upcoming surgery. “I thought he just took care of me in surgery, kept me asleep, and woke me at the end,” James said. In fact, there is much more to this specialty and much more to what anesthesiologists do for patients. The role of the anesthesiologist has expanded over the last decade. Before that, it was common practice for the anesthesiologist to be responsible for the patient just in the operating room (OR). Typically, he or she met the patient just prior to inducing anesthesia and then transferred postoperative care to a nurse in the postanesthesia care unit (PACU). It was up to the surgeon or other physicians to deal with pain control beyond the immediate postoperative period. Now, though, there is a new paradigm within the specialty of anesthesiology. Today’s anesthesiologists are involved with all aspects of care and they are central figures in the continuum of surgical care. By John P. No longer are we Mrachek, MD responsible for the care of patients only during sur-

Pain control Good news for patients

www.mppub.com 20

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

Many orthopedic surgical procedures are associated with intense postoperative pain. We have developed multiple techniques for controlling postoperative pain. We tailor these techniques to the surgical procedure as well as the patient’s needs. We use specific nerve blocks for every orthopedic surgical procedure performed. For example, we use a continuous interscalene nerve block (placed in the nerves in the neck) for complex shoulder procedures including rotator cuff repair and joint replacement. This nearly painless procedure involves placing a catheter to deliver local anesthetic to the nerves that provide feeling to the shoulder. We use ultrasound guidance to place the nerve block for patient comfort and to confirm catheter placement. The catheter is then connected to a disposable infusion pump that allows a continuous infusion of local anesthetic for excellent pain control. We do these procedures preoperatively as part of our preemptive analgesia. This technique essentially eliminates the need for IV narcotics. As a result, we can conduct our non-joint replacement shoulder surgery on an outpatient basis. Patients are able to recover at home, avoiding unnecessary hospitalization or the need for convales-

Patients should consider postoperative pain control when choosing a facility for surgery. cence in a hotel recovery unit. Superior postoperative pain control improves the patient’s outcome and satisfaction, increases safety, reduces use of health care resources, and increases inpatient capacity. This is a rare win-win-win-win situation. It is better for the patient, the physician, the hospital, and the payer—exactly the result that everyone is hoping to achieve with health care reform. Preventing chronic pain Chronic pain is a devastating condition suffered by thousands of people throughout the United States. Conservative studies show one in four adults in the U.S. report chronic pain and 50 percent of cancer patients have chronic pain, causing patients and family members significant suffering. A 2003 study estimated the cost of chronic pain in the United States at $61.2 billion annually. Chronic pain often arises from acute pain episodes such as a fracture or a surgical procedure. Pain from a surgical procedure, though often intense, should be transient, and with time should resolve. Unfortunately, in some patients that acute episode is prolonged, leading to chronic pain lasting months or even years. Could early comprehensive pain control diminish or even eliminate some chronic pain syndromes? Significant scientific and clinical evidence demonstrates that excellent postoperative pain control leads to a decrease in the incidence of chronic pain. This should be important to patients, physicians, and payers when considering options for surgery. It is an important element that is often overlooked, but one that may have as big an impact as any other component of perioperative care. Patients and their physicians should consider postoperative pain control when choosing a facility for surgery.

site of disease. We know that volatile anesthetics, interaction between the nervous and endocrine systems in response to the stress of surgery, and opioids adversely affect these factors. One study looked at the recurrence of breast cancer after surgical resection over a 36-month period. Fifty patients had surgery with paravertebral nerve anesthesia and analgesia combined with general anesthesia and 79 patients had general anesthesia with morphine for postoperative pain relief. Recurrence and metastasis-free survival was 94 percent versus 82 percent at 24 months and 94 percent versus 77 percent at 36 months in the patients receiving paravertebral and general anesthesia, respectively. These results are compelling and have prompted a larger study to confirm these findings. Another study looked at the recurrence of prostate cancer following prostatectomy. It, too, showed a decreased incidence of recurrent disease following the use of regional analgesia instead of narcotics. Again, this warrants a larger trial. But, the initial results are compelling and exciting. It is clear that high-quality, comprehensive, postoperative pain control is a critical component of high-quality health care. The availability of such care should be an expectation of every patient requiring surgery. As James attests, “This pain control was great, I felt great, and I got back to living my life quicker.” John P. Mrachek, MD, a physician with Northwest Anesthesia PA, is director of Acute Pain Service at Abbott Northwestern Hospital.

Are we preventing cancer from recurring? Abbott Northwestern’s APS offers comprehensive, coordinated, multimodal postoperative pain control. This includes the use of nerve blocks located beside or adjacent to the spinal column for breast cancer surgery. In this procedure we inject local anesthetic near the nerve roots of the nerves that give feeling to the chest. We also place a small catheter to continue to infuse local anesthetic so that we can provide extended pain relief. This is very similar to an epidural that is placed for labor pain relief. These paravertebral nerve blocks allow us to create a band of numbness covering the surgical site, minimizing the need for deep general anesthesia and narcotic pain medicine. It provides a better experience for the patient while avoiding side effects such as nausea, vomiting, sedation, and sleep disruption. Could these techniques also prevent certain cancers from recurring? Two recent studies have suggested this provocative theory. Surgical resection—i.e., lumpectomy and mastectomy—remains the best treatment for breast cancer. However, residual disease is a real possibility. Metastatic spread of these residual cells is affected by many factors, especially the body’s natural ability to kill tumor cells via the immune system and development of new blood vessels at the

Mike Mesick, MD Mike is Board certified in family medicine, holistic medicine and medical acupuncture. His patients appreciate his willingness to form a partnership with them to not only diagnose and treat their current condition but also assist with their goals for optimum health.

JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

FIRST PERSON

A promise kept

“In sickness and in health, until death do us part” By James Murr

ean and I had been enjoying retirement for several years when our daughter became concerned that her mother seemed anxious for no apparent reason. A trip to the Mayo Clinic in February 2001 to check things out changed our world: Doctors diagnosed Jean with Alzheimer’s disease. I knew very little about Alzheimer’s and information was hard to find, so I went about educating myself on the basics of the disease. Today, the amount of information in cyberspace can be overwhelming. Missing from the information, both then and now, was how a person can successfully take care of a loved one, until the end, at home following a diagnosis of Alzheimer’s. Jean’s symptoms were minor in the beginning, but as the disease progressed so did the severity of her symptoms. The thought of placing her in a nursing home did not cross my mind. I would take care of Jean in our home, not because there were no other options but because we had made a promise to each other years ago: “When one of us is no longer able, the other will be there to do the caretaking.” This turned out to be a rewarding decision and one I would follow again. Many new experiences loomed on the horizon. There came a time when I knew I could not do this alone. It is so important to do what you can, but also to know when to seek help. Jean was a social lady and I had to find a way to keep her from going into loneliness and depression. It was important that any helper connect with Jean on a personal level. With that in mind, I decided to hire companions first and caregivers second. Companions came in the form of family, friends, or hired help who enjoyed being around Jean. I am grateful that Jean never did experience loneliness or depression. Find a path or make one Many years ago, my high school yearbook challenged graduates to “Find a Path or Make One” in life. I believe that God gave me good physical and mental health to see this through. I didn’t ask for a cure; that will happen, but not in my lifetime. Looking back on the nine years I cared for Jean in our home, I feel guilt-free. I did all I could to win every battle, even though I knew all along that we would lose the war. Modifications to the home had to be made to accommodate Jean’s changing needs and to ensure her safety. The earlier you do this, the better prepared you are when the time comes to use them. Spending a lot of money on modifications is not necessary, but being creative is. There is no need to remodel your home, but do find an area that can work, even an unconventional one. I picked the living room to be Jean’s main living area rather than a small, back bedroom that was not in the sight of visitors. It was important to keep Jean front and center where no one could ignore her. Simple changes made for an easy transition as her disease progressed. I knew the areas Jean walked around in our home, so I installed grab bars along those areas. To choose between large or small ones, I brought one of each to Jean to see which she could grasp better. The smaller ones worked better for her with her arthritis. Those were a big help and a small expense, enabling her to help herself for as long as she could. Looking through the newspaper’s for-sale section, I found a used combination standup and walking hoist. This proved to be very useful when the time came that Jean needed assistance moving around and being lifted to bathe or for toileting. Rather than pull up our carpet, I decided to stain plywood and screw it in over the existing carpeting

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

along the paths Jean used. This made it easier for caregivers to move Jean around and also proved to be easy to clean. The basics

For more information Almost two years after Jean’s passing, I continue to educate myself on available resources and new information that may be of service to others. Everyone needs support when going through this challenge. Among many excellent resources available online is the Minnesota Department of Human Services, www.dhs.state.mn.us/cdcs. The National Institutes on Aging caregiver guide, www.nia.nih. gov/Alzheimers/Publications/caregiverguide.htm, is also an excellent source of information, as is the Alzheimer’s Association website, www.alz.org.

There are many important things one needs to know about caring for an Alzheimer’s patient. Here are my top five. First, take care of yourself. Being a caregiver does not mean you must do everything by yourself. If you don’t accept help, this will be your breaking point, both physically and mentally. When family and friends hear about an Alzheimer’s diagnosis they always ask, “What can I do to help?” I say, give them something to do. Ask each person who offers if they will commit one or two hours a week or monthly. This will allow you to run errands, take a break, or attend an event. Expect that relatives and friends will withdraw from the situation as time goes on, so stay open to new offers and hire help from time to time to accommodate all involved. Your mental and physical health will thank you many times over. For Jean, the stimulus of having different visitors provided an additional benefit. Second, anticipate making modifications to your home before they become a necessity. By spending a little here and there, you won’t find yourself in a bind physically or financially when it is time to make use of them. If you are in the market for a new vehicle or to trade in, think ahead to a vehicle that can accommodate a wheelchair or one that can be modified with a lift or a ramp. A van or minivan will make better sense than a car. Third, remember to stimulate those parts of the brain that are still active. Engage the person with conversation, read to them, and enjoy a show on television. If they enjoyed music, then make that a part of the entertainment. When possible, set out on a short adventure. Consider a walk or a visit to a local area attraction or a community event. Fourth, educate yourself. You will better understand what you are in for if you know what to expect. Information can be found in books, on the Internet, or simply by connecting with others who have had similar experiences. Finally, know that all you have gone through may leave you feeling exhausted at times, but also exhilarated that you succeeded in keeping a loved one comfortable to the end. When death comes Jean spent the last 22 months of her life in hospice care under our roof. On the morning of Sept. 9, 2009, a hospice nurse gave Jean a physical and found no signs of a problem. With everything under control at home, I went to visit a homebound friend that evening. While visiting my friend, I received a call from Jean’s caregiver asking me to come quickly. Though I was only a short distance away, I arrived three minutes after Jean died peacefully in her sleep. I cherished one last moment together and a belated last goodbye. The timing of death can be extremely important to everyone’s well-being. At the time of Jean’s passing she was facing two major life-threatening issues that needed to be addressed in the next 60

days. Either or both could have caused her terrible suffering. Did God once again do us a favor? You don’t have to be young to be a caregiver. At age 86, I am happy to have honored Jean by taking care of her. This was my way of returning part of the love she showered upon me and many others throughout all the years. James Murr of South St. Paul is a retired businessman and the author of “Remembering Jean’s Greatest Gift: Living Happily at Home with Alzheimer’s.” He can be contacted at www.LivingHappilywithAlzheimers.com.

Living with gout? Keep enjoying life’s simple pleasures.

Gout is the most common form of inflammatory arthritis in men and affects millions of Americans. In people with gout, uric acid levels build up in the blood and can lead to an attack, which some have described as feeling like a severe burn. Once you have had one attack, you may be at risk for another. Learn more about managing this chronic illness at www.goutliving.org

JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

TA K E C A R E

East meets West Dharamsala, India, Dalai Lama’s compound, January 2006

The intersection of two approaches to medicine By Charles Bransford, MD

I am a 55-year-old internist from Stillwater, Minn., sitting on the edge of a new life. Actually, I am sitting on a boulder on the edge of a cliff not too far from my apartment at the Dalai Lama’s compound. It is early morning. Behind and to my left are the massive gray-white peaks of the Himalayas, backlit by the sun. To my right is a grove of beautiful scrub pines giving off the piney smell that is the same the world over. Behind and above the pines stands one of numerous stupas (mound-like structures containing Buddhist relics) that dot the Tibetans-inexile landscape. The thousands of prayer flags attached to each stupa give off a gentle fluttering sound as they send off endless prayers of compassion. Accompanying this quiet fluttering and the gentle squeaking of prayer wheels is an intense sense of peace and quiet. I look off to the steppes of northern India and see an infinite layer of clouds. The color is a muted purple with ever-changing shades of indigo and blue. Soaring on the clouds are eagles and hawks seemingly oblivious to any need for hunting, but rather simply enjoying the pleasure of flight and being lifted up by ever-changing currents of air. I have found my Shangri-La, the place I have looked for since reading James Hilton’s “Lost Horizon” as a child. This scene remains as real and intense an experience for me today as it was five years ago. Glimpsing another medical culture

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MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

Practicing traditional Western medicine in Stillwater since 1981, I have experienced the wonders of our health care system—from the discovery of the cause of Lyme disease, which turned out to be an ongoing epidemic in our area, to the miracle of giving clot-dissolving medication to a young man having a massive heart attack before my eyes, and watching it stop in its tracks. These medical advances required years of research by thousands of individuals and show the strength of our health care system. Yet I have also seen the thousands of people we simply have not been able to help—because of cancer, chronic fatigue, fibromyalgia, headaches, irritable bowel syndrome, depression, anxiety, and chronic pain, among many other illnesses. Over time I came to think that looking at another culture’s health care system could give us insights into our own. When I traveled to the Dalai Lama’s compound in 2006, it was as a student in a graduate-level course on Tibetan medicine that was offered by the University of Minnesota’s Center for Spirituality and Healing. We brought needed medical supplies (antibiotics, oxygen saturation monitors, an EKG machine, bandages, etc.) to the Tibetans. In return, we were given the gift of education from the Dalai Lama’s leading physicians at the Men-Tsee-Khang, often called “the Harvard of Tibetan medicine.” The Tibetan doctors had preserved as much as they could of their rich heritage of 2,000-plus years by transporting their ancient texts from Tibet, across the Himalayas, to Dharamsala, where they proudly house them in a museum. They freely shared their ancient knowledge with us.

Over time I came to think that looking at another culture’s health care system could give us insights into our own. Tibetan medicine shares elements of Chinese, Hindu, and yogic systems of care but has evolved in its own unique way, in part because of its isolating geography. Tibetan medicine is a holistic philosophy of care combining psychological, spiritual, and physical components. It holds that for each person, good health is achieved by understanding those components and how to keep them in balance. Physicians prescribe diets, meditations, types of yoga and exercise, and specialized herbs. A fundamental principle of Tibetan medicine is that in order to treat their patients, doctors must live the balanced life they preach. The Buddhist philosophy is deeply embedded in the daily life of the doctors and other medical staff, with prayers at the temple as well as prayers for individual patients. This deeply spiritual approach to medical practice aids Tibetan doctors in forging an emotional and spiritual bond with their patients. They are experts in physical diagnosis, intuition, empathy, and making a “heart connection.” In Minnesota: applying new experience In ways both small and large, my experience with Tibetan medicine has changed the way I practice medicine. For example, I stopped wearing my white coat. Beyond the widely recognized phenomenon of “white coat syndrome,” there is a vast array of positive and negative cultural mythologies attached to the white coat, let alone the power differential it implies. Communication is tough enough without it. Somehow, the Tibetan doctors gave me the courage to pursue a second subspecialty that I had been deeply drawn to—hospice and palliative care medicine. Tibetan doctors and the Tibetan culture do a wonderful job with death and dying. In the U.S. after World War II, my parents’ generation wanted to protect their children from death, and they were quite successful. Unfortunately, this has left us with a society that doesn’t understand the dying process. This leads to a multitude of unnecessary treatments at the end of life that increase both individual suffering and medical expense. When I ask patients if they know they are dying, they will typically say no, and I believe them. Tibetans have a better internal understanding of death. I began to study and practice mind/body medicine. My passion is yoga. At Stillwater Medical Group, we offer mind/body groups every season to our patients and staff. In these groups we develop our own personal healing stories through practices such as life maps, guided imagery, yoga, and meditation. We incorporate lots of music and poetry. Being with the Tibetan doctors, studying their healing system, and practicing meditation and yoga have changed the way I relate to and experience my patients. Tibetan medicine/culture has helped to change my consciousness by opening me up to an awareness of the collective unconscious of humanity. The most superficial layers of the collective unconscious hold all the rules of our culture: Stop at red lights, shake hands when you meet someone, keep a certain physical distance, form a line when more then one

person is waiting for something. It is all the cultural traditions we follow without thinking on a physical, psychological, and spiritual level. Below that is this wonderfully complex collective unconscious that we all share. At its deepest level, the collective unconscious is the reservoir of our human experiences as a species, a kind of knowledge we are all born with (think of the universal myths and symbols that psychiatrist Carl Jung so elegantly described in his writings). At the center of our consciousness resides the calmness we were born into, called “nonjudgmental awareness” (or, in Western psychology, “mindfulness”). It is in the collective unconscious that so much medical healing occurs—and it is in this very place that putting two healing systems together can be so valuable. For myself, the practice of meditation and yoga has made it easier for me to slip in and out of my collective unconscious and share it with my patients. We go to a common place together that gives healing a better chance to germinate. Charles Bransford, MD, is an internal medicine and hospice/palliative care physician at Lakeview Health System in Stillwater, Minn.

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JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

QUALITY CONTROL

ore patients are picking up infections in health care settings in Minnesota and across the nation. These health care-associated infections (HAIs) are a growing problem—a complication that goes hand-inhand with the many new lifesaving medical technologies and procedures. HAIs are infections that can be acquired anywhere patients receive treatment for medical or surgical conditions, including hospitals, same-day surgery centers, clinics, nursing homes, rehabilitation centers, and kidney dialysis centers. They may be caused by bacteria, fungi, viruses, and other infectious agents. HAIs are among the top 10 causes of preventable deaths in the United States, according to the Centers for Disease Control and Prevention (CDC). CDC estimates that more than 2 million people— between 5 percent and 10 percent of hospital patients—develop hospital-acquired infections each year, at a cost of $28 billion to $45 billion. Nearly 90,000 patients die each year as a result of their infections. According to the U.S. Department of Health and Human Services, pneumonia and infections of the urinary tract, surgical site, and bloodstream make up over 75 percent of all infections acquired in the hospital. According to Hospital Compare, a Medicare website, in Minnesota, for patients discharged between Oct. 1, 2008, and June 30, 2010, 65 percent of reporting hospitals said they had no cases of vascular catheter-associated infections. Minnesota’s actual incidence rate for this infection is slightly better than the national rate. Data also show 40 percent of Minnesota’s reporting hospitals have had no cases

Health careassociated infections As numbers rise, Minnesota emphasizes prevention By Jane Pederson, MD, MS

WHO’S A BIGGER BASEBALL FAN, YOU OR ME? You’ll find that people with Down syndrome have a passion for knowledge and learning that can rival anyone you’ve met before. To learn more about the rewards of knowing or raising someone with Down syndrome, contact your local Down syndrome organization. Or visit www.dsamn.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696 26

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

Before surgery • Hospital prep. Ask your hospital team or doctor what you can do before surgery to prevent infection. Ask about the hospital’s infection control practices and hand hygiene policy. Follow any instructions given to you for preparation before entering the hospital for surgery or other invasive procedures. • Antibiotics/infections. Ask if the antibiotics you are prescribed are necessary, take them as directed, and don’t insist on antibiotics if your doctor doesn’t advise them. • Be careful with catheters. One in four Americans in the hospital right now has a urinary catheter. The risk of a urinary tract infection increases significantly if the catheter is in place longer than two to three days. If your catheter is still in place 48 hours after surgery, ask if it can be removed. • Know the people on your care team. All facilities should have a professional whose job is to prevent and control infections. If you have questions about your risk of infection, ask that person. • Hand hygiene. Germs hide on any surface in the hospital, including bed rails, stethoscopes, faucets, and the TV remote control. You can pick up these germs on your hands, so keep hands away from your wound and your face, and wash your hands frequently. Your room should be cleaned with disinfectant regularly. Be bold—it’s not impolite to insist that anyone who may touch you, including doctors, nurses, and visitors, wash his or her hands with soap or a 60 percent alcohol hand sanitizer. Source: Association for Professionals in Infection Control

of catheter-associated urinary tract infections during this time period. Minnesota’s actual incidence rate for this infection is slightly worse than the national rate. How HAIs happen

A wound can become infected following surgery or any type of invasive procedure. Wounds from trauma and burns, as well as pressure ulcers and sites where there was prolonged use of a catheter, also can become infected. An infection can start in any part of the body and can be acquired from contaminated equipment or from health care workers and visitors. Although all hospitalized patients are susceptible to contracting an HAI, young children, the elderly, and people with compromised immune systems are more likely to get an infection. Patients with underlying lung disease are more susceptible to pneumonia.

Health care-associated infections are among the top 10 causes of preventable deaths in the United States.

• Not enough nurses for the number of patients • Open beds close together Symptoms

Fever is often the first sign of infection. However, some patients, especially the elderly, may not develop a fever. Instead, they may experience rapid breathing or mental confusion. Other symptoms are low blood pressure, reduced urination, and a high white blood cell count. Patients with a urinary tract infection may have pain when urinating and blood in the urine. Symptoms of pneumonia may include difficulty breathing and coughing. Localized infections cause swelling, redness, and tenderness at the infection site. Prevention

Research shows that many HAIs are preventable. Educating and training health care workers and implementing evidence-based best practices to prevent infections can lead to a 70 percent reduction in certain HAIs. Health care facilities have developed infection control programs to identify high-risk procedures, such as urinary catheterization. In the operating room, medical instruments, equipment, masks, gowns, and gloves must be sterile. Frequent hand-washing by health care workers and visitors is critical to avoiding the spread of infection. In addition to hospitals, prevention activities also are focused on non-hospital settings, such as sameday surgery centers, nursing homes, and kidney dialysis centers. Health care-associated infections to page 32

In the next issue..

Risk factors

Increasingly, some types of bacteria are becoming resistant to standard antibiotic treatments. This is a result of overuse of antibiotics, which increases the likelihood of dangerous antibiotic-resistant bacteria like methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff). Additional factors cited by the Agency for Healthcare Research and Quality that increase the risk of HAIs include: • Use of catheters and ventilators • Receiving injections • Transmission of infections between patients and health care workers • Contaminated air-conditioning systems

• Sleep disorders • Ankle injuries • Wellness Roundtable JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

health care architecture honor roll

Minnesota Physicianâ&#x20AC;&#x2122;s 2011 Health Care Architecture Honor Roll recognizes nine outstanding projects completed in the past year. This yearâ&#x20AC;&#x2122;s Honor Roll includes a variety of types of construction, services offered, and locations. The projects include clinic and hospital construction, remodeled spaces, and facility expansions in urban, suburban, and rural Minnesota. Their medical services range from routine clinic visits to long-term care, behavioral health care, and emergency care, for patients spanning the age spectrum from newborn to elderly. Though the facilities differ in intended uses and populations served, they share a focus on efficiency, safety, and patient-centered care, often through the use of advanced technology. This yearâ&#x20AC;&#x2122;s nominations also demonstrate a trend toward facilities that allow tenants to hire their own interior designers (see p. 30). Minnesota Physician Publishing thanks all those who participated in the 2011 honor roll.

University of Minnesota Amplatz Children’s Hospital Type of facility: Children’s hospital Location: Minneapolis Client: University of Minnesota Amplatz Children’s Hospital

Architect/Interior design: Tsoi/Kobus & Associates Contractor: Kraus-Anderson Construction Company Completion date: March 2011 Total cost: $119 million Square feet: 231,500 (pediatric bed tower); 95,000 (parking garage) The University of Minnesota Amplatz Children’s Hospital is designed to create the ideal environment in which to provide and receive children’s health care, emphasizing safety, comfort, and efficiency. It consolidates existing pediatric and inpatient units and includes a pediatric intensive-care unit. All 96 patient rooms are private and same-handed; at 390 square feet, they are approximately twice the industry average for size, allowing ample space for distinct provider, patient, and family zones.All rooms include sleeping accommodations for two adults, a microwave and refrigerator, a work area with an Internet connection, and an all-purpose “kitchen table.” Each of the facility’s four 24-bed units is designed as a modified racetrack broken into neighborhoods of six beds each.A decentralized floor plan locates diagnostic and testing services near their corresponding clinics and bed floors, cutting down on staff travel time. A corridor on each patient floor separates support services from patient and family spaces, contributing to quieter patient rooms. With its anodized stainless-steel exterior that changes color depending on the light, the building creates a distinctive identity for the hospital.Wall-to-wall expanses of glass provide daylight and views for patients, staff, and family.An interior theme,“Passport to Discovery,” features imagery from various ecosystems and recalls the hospital’s research mission.The theme, expressed on each floor, aids in wayfinding and offers opportunities for diversion. Left: The anodized stainless-steel exterior changes color depending on the light. Inset: The colorful lobby carries out the facility’s cheerful, energizing color scheme.

Edina Crosstown Medical Office Building Type of facility: Medical office building/ orthopedic specialty center Location: Edina, Minn. Client: Edina Crosstown Medical, LLC Architect: Mohagen Hansen Architectural Group Engineer: Dunham Associates, Inc. Contractor: RJM Construction Completion date: June 2010 Total cost: $17.25 million (building shell); $5.2 million (interior build-out); $12.25 million (parking garage) Square feet: 75,000 (building); 145,000 (371-stall parking garage) The demolition of an existing office building on the site made way for this dynamic new building and parking garage.The challenge was to develop a solution that met tenant Twin Cities Orthopedic’s needs for space on a site that inherently had many challenges, including an odd shape that limited building and parking setbacks, groundwater issues, a cell tower, numerous critical utilities crossing the site, and a zoning classification that would not allow for effective redevelopment of the property.The project demanded creative solutions to numerous challenges,

requiring input, compromise, and flexibility on the part of all involved. The design of the exterior curved canopy and landscaping features offers a pleasing street presence and softens the scale of the building.The interior space feels innovative while remaining comfortable and inviting. The contemporary design incorporates gentle curves that guide visitors through, along with creative materials used consistently throughout the entire space. Distinctly different yet complementary color schemes differentiate each clinic.The building shell and core received LEED gold certification from the U.S. Green Building Council. The final product is a functional, aesthetically pleasing health care environment that meets the needs of both the client and the community it serves. Top: The interior design concept carries through the curve of the facility’s exterior canopy. Below: The rooftop gardens contribute to sustainability and helped the facility earn LEED gold certification status.

HONOR ROLL

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Fridley Medical Center Type of facility: Multi-tenant medical center

Location: Fridley, Minn. Client: Premier FMC, LLC Architect: Amcon Construction Interior design: Amcon Construction (common areas, Multicare Associates clinic and corporate offices, MultiCenter Physical Therapy, Goodrich Pharmacy); BDH&Young (Minnesota Oncology and VPCI tenant spaces); WCL Associates (MAPS Medical Pain Clinics) Engineers: Carlson Professional Services Inc., civil;Anderson-Urlacher, structural Contractor: Amcon Construction Completion date: October 2010 Total cost: $14 million Square feet: 60,000 Located on Allina’s Unity Hospital campus, Fridley Medical Center is a new, two-story medical office building that provides expanded facilities for Multicare Associates’ primary care and specialty clinic. Other tenants in the center include the Virginia Piper Cancer Institute–Unity Hospital and Minnesota Oncology, Goodrich Pharmacy, Top: Exterior of the multi-tenant facility Top inset left: In the facility’s main lobby, stone and wood are complemented by organic patterns that add texture not typically seen in medical offices. Top inset right: A climate-controlled skyway connects to the Unity Professional Building and Unity Hospital, allowing patients, staff, and visitors a convenient route to and from Unity Hospital, Unity Professional Building, and Fridley Medical Center without going outside. Left: In the Minnesota Oncology reception area, a combination of warm wood tones, decorative lighting, and unique materials provides a comfortable and cozy atmosphere for patients and staff. Below: Glass dividers embedded with real grass help create a natural, organic environment in the lobby of Multicare Associates.

MAPS Medical Pain Clinics, and MultiCenter Physical Therapy. As noted above, several tenants hired their own interior designers, to fashion spaces that meet the unique needs of their patients. The facility was designed with the understanding that health care environments can greatly affect clinical outcomes and patient, family, and caregiver experience and mood. Special attention was given to using daylighting, earth tones, textures, and natural materials, including wood and stone, to create a soothing, therapeutic environment that reduces stress and provides comfort to patients and staff alike.Additional notable features include a wellness walk and skyway connecting Fridley Medical Center to the Unity Professional Building and Unity Hospital. “It is our mission and vision to deliver high quality, multispecialty care that is convenient and accessible to our patients. In addition to expanding Multicare, this new building was designed to offer a variety of comprehensive medical services to meet the needs of the communities we serve,” says Jeanine Schlottman, chief executive officer of Multicare Associates.

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

ship, will provide additional mixeduse development.

Whittier Clinic Type of facility: Medical clinic Location: Minneapolis Client: Hennepin County Medical Center (HCMC) Architect: HGA Architects and Engineers Engineer: HGA Contractor: McGough Construction Completion date: November 2010 Total cost: $16.5 million Square feet: 60,000 Whittier Clinic is a pedestrian-friendly family medical center that celebrates the cultural diversity of its neighborhood.The project has reinvigorated a neglected urban site just outside downtown Minneapolis, replacing an abandoned warehouse with a light-filled clinic designed to achieve LEED silver certification. The project is the first of two phases planned for the 3-acre site.The clinic provides urgent care, imaging, lab, and OT/PT services, and a physician residency program. Phase two, to be completed with city partner-

A diagnosis of

Cancer is overwhelming news.

It raises many questions few of us are prepared to answer, such as: • How can I take time off from work? • Can I get help paying bills? • What is the difference between a health care directive and a power of attorney? • Can I keep my health insurance even if I lose my job? • And many others.

The design team worked with the community and representatives of HCMC’s patient base to develop the exterior and interior character. Nearly half of the facility’s parking is located below grade, freeing surface space for community park and rain gardens.The primary entry features a public plaza and overhead trellis to welcome patients and community members. A playful mix of brick and metal panels minimizes the building’s scale along Nicollet Avenue. Inside, colored accents, based on HCMC’s branding logo, translate into wayfinding tools—especially important given the diversity of languages spoken by the patients. Each department entry is designated by one of the four logo colors, paired with over-scaled graphic images to facilitate wayfinding.These images and colors are combined in a two-story “feature wall” that greets patients as they enter the building and shields waiting areas from public circulation paths. Above: Windows flood the clinic building with light. Inset: Second-floor waiting space

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For additional information

Health-care associated infections from page 27

The Minnesota Hospital Quality Report website, www.mnhospitalquality.org, provides information on how consistently Minnesota hospitals use recommended best practices to prevent infections, pneumonia, heart attack, and heart failure. For example, information is available on the number and kinds of efforts taken to prevent bloodstream and surgical site infections and ventilator-associated pneumonia. Data on the site also show whether patients received all recommended treatments they should have received, based on their clinical condition, as well as results of a national patient survey that rates patients’ hospital experience according to certain aspects of care, such as pain management and communication with nurses and doctors. The Medicare website Hospital Compare, www.HealthCare.gov/compare, contains data on hospital-acquired infections at more than 4,700 hospitals across the nation.

Local and national efforts

Many national and local health care agencies and organizations are working to prevent, reduce, and ultimately eliminate HAIs. In Minnesota, these include the Minnesota Department of Health, Minnesota Hospital Association, and Stratis Health, Minnesota’s Medicare Quality Improvement Organization (QIO). Stratis Health has been assisting hospitals with strategies to improve surgical care by reducing the most common surgical complications, including infections. To improve patient safety for Medicare consumers, the Centers for Medicare & Medicaid Services is directing the Medicare QIOs to work with hospitals to reduce HAIs. Over the next three years, Stratis Health will work with public and private organizations to reduce the following types of infections in hospitals: • Central line-associated bloodstream infections. A central line is a tube that is inserted into a large vein in the neck or groin to allow injection of medication or fluids, or blood tests. • Surgical site infections. These infections may occur after surgery in the part of the body where the surgery took place. • Catheter-associated urinary tract infections. Having a catheter in the bladder may increase the chances of a urinary tract infection and may make it harder to clear the infection. • Clostridium difficile or “C. diff” infections. C. diff can cause severe diarrhea and other intestinal disease, including infection of

the colon, when normal bacteria are wiped out by antibiotics. Do your part to prevent HAIs

Before surgery or other medical procedures, do your homework. Access some of the many resources that can help you evaluate a hospital’s quality of care, ask your nurses and doctors the right questions, and make informed health care decisions. Jane Pederson, MD, MS, is director of medical affairs for Stratis Health, Minnesota’s Medicare Quality Improvement Organization.

Minnesota

Health Care Consumer June survey results... Association

100 80

Percentage of total responses

53.2%

60 40 20

50 40 30 23.4% 20

15 10

6.4%

29.8%

30 17.0%

6.4%

5 0

Does Unsatisfied Very not apply unsatisfied

44.7%

Satisfied

50 Percentage of total responses

21.3%

17.0%

Percentage of total responses

21.3% 20

Very satisfied

5. How satisfied were you with the costs associated with this visit?

44.7% 25

6.4% 2.1%

14.9%

4.3% Yes

4. How satisfied were you with the coordination of care provided during this visit (prescription access, imaging services, referrals to specialists, etc.)?

34.0%

95.7%

3. How satisfied were you with the follow-up care received after this visit?

2. How satisfied were you with the level of care you received?

1. Have you, or a member of your family, ever been to the emergency room of a hospital?

Each month members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health care delivery system. There is no charge to join the association, and everyone is invited. For more information please visit www.mnhcca.org. We are pleased to present the results of the June survey.

40 30 23.4% 20 14.9% 10

8.5%

2.1% Very satisfied

Satisfied

Does Unsatisfied Very not apply unsatisfied

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

Very satisfied

Satisfied

Does Unsatisfied Very not apply unsatisfied

Very satisfied

Satisfied

Does Unsatisfied Very not apply unsatisfied

Travelerâ&#x20AC;&#x2122;s diarrhea

The local goes global from page 17

should be protected with vaccine, which is 100 percent effective. Tetanus is another special case. Patient B may not have had a complete primary tetanus series during childhood. So even if both patients received a tetanus shot within the last two years, an additional dose may be reasonable in the Nigerian patient to continue (or complete) his primary series. Assessment regarding hepatitis A and B vaccine definitely differs for the two patients. All travelers to the developing world should be immune to the easily transmissible hepatitis A virus. Because our Nigerian patient comes from a country with adult prevalence of hepatitis A above 90 percent, it is very likely he is immune through natural infection and does not need the vaccine series. A simple blood test can confirm this. Risk of hepatitis B for travelers comes not only from high-risk behavior (e.g., unprotected sex with an infected person), but also from potential contact with the local medical system where the risk of infection via tainted blood supply or unhygienic needles would be higher than in developed countries. Our Nigerian patient has a higher chance of being a chronic carrier of hepatitis B. Even if he is not a chronic carrier, he is much more likely than our St. Paul native to be immune via natural infection that he has cleared. Therefore, a blood test for hepatitis B may preclude the need for the three-part vaccine series in him. Finally, both patients should consider a pre-exposure rabies series, as they will be far from a source of human rabies immune globulin should a bite occur.

Travelerâ&#x20AC;&#x2122;s diarrhea (TD) occurs in over half of travelers, despite personal efforts at prevention. Risk comes from travel to an environment where poor sanitation allows stool bacteria to circulate freely. While the travel consultation should include advice for preventing TD, treatment should also be addressed. The traveler should be taught to replace lost fluids through oral rehydration and, depending on travel destination and access to reliable medical care, may need to take along a course of stand-by antibiotic.

From pre-travel to post-travel

In summary, there is more to a pre-travel visit than a few shots. Pretravel consultation by a travel medicine professional will provide patients with useful (and potentially life-saving) advice. Even travelers leaving the next day can benefit dramatically from a travel visit. The VFR traveler is a special case, with unique and heightened risks in comparison to a tourist traveler. Pre-travel consultation is especially important for this patient. For patients who return with post-travel illness, a travel clinic is the ideal place to seek care. Minnesota is fortunate to be home to two of 49 worldwide sites that compose the Geosentinel Surveillance Network. These clinics collect and communicate data to promptly and effectively detect trends in travel-related illness. Their work enhances care for patients worldwide, making the local truly global. Ann Settgast, MD, DTM&H, is a global health faculty member at the University of Minnesota Medical School. She practices travel medicine at the HealthPartners Travel Medicine Clinic and primary care at the HealthPartners Center for International Health in St. Paul.

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet. Your privacy is completely assured; we wonâ&#x20AC;&#x2122;t even ask your name. Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now. We want to hear from you! JULY/AUGUST 2011 MINNESOTA HEALTH CARE NEWS

Cataract surgery from page 13

side effects. Advances in multifocal optics have greatly decreased unwanted visual side effects, with most patients achieving independence from glasses for both reading and distance vision and high satisfaction levels. While distance and near vision perform well with current multifocal IOLs, intermediate vision may be somewhat less clear. Thus, glasses may still be needed for extended work at mid-range visual targets, such as computer screens.

IOLs. Thus, reading glasses are often still required with this IOL choice. A new era of cataract surgery

While cataract surgery is one of the oldest surgeries recorded in human history, revolutionary changes in the past half century have transformed it to a highly successfully procedure with a remarkably low rate of complications. Present-day cataract patients enjoy a fast outpatient procedure with a rapid recovery and high postoperative levels of visual function. Recent advances in IOL and surgical technology offer cataract Cataract surgeons can not Accommodating intraocular lenses patients the opportunity to greatly decrease A second approach to presbyopia-correctonly remove cataracts, or even eliminate the need for correction ing intraocular lenses is accommodating with glasses postoperatively. While the pribut also tailor the IOLs. Similar to the natural crystalline lens mary goal of cataract extraction is to clear of the eye, these lenses attempt to provide patientâ&#x20AC;&#x2122;s vision to a desired the visual axis of opacity and restore visual enhanced near-focus capabilities by changrefractive target. function, these changes have ushered in a ing shape or position in the eye when a new era of refractive cataract surgery, near object is viewed. Currently, only one where enhanced postoperative visual function and decreased need accommodating IOL is FDA-approved for use in the U.S. The lens, for correction with glasses can also be obtained. initially approved in 2004, employs a unique design that allows the Sherman W. Reeves, MD, MPH, is an ophthalmologist and partner at lens to slightly change shape in the eye when a near object is Minnesota Eye Consultants. He specializes in cornea, cataract, and refracviewed. While the lens performs well at distant and intermediate tive surgery. ranges, fewer patients achieve near vision sufficient to read a newspaper than patients implanted with current-generation multifocal

MINNESOTA HEALTH CARE NEWS JULY/AUGUST 2011

A philosophy of caring is good. A history of it is better. Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity. That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

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To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016

break a vial habit

Model is for illustrative purposes only.

With FlexPen®, your patients aren’t limited by a vial and syringe. FlexPen® is a simple, patient-friendly insulin dosing option. And it’s available for the same copay as vial and syringe on most managed care plans.1* So, just add “FlexPen®” to your patients’ prescriptions and free both of you from the vial and syringe. For formulary access specific to your area, visit www.novomedlink.com. * Intended as a guide. Lower acquisition costs alone do not necessarily reflect a cost advantage in the outcome of the condition treated because there are other variables that affect relative costs. Formulary status is subject to change. Reference: 1. Data on file. Novo Nordisk Inc, Princeton, NJ.

October 2009