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PHYSICIAN SPOTLIGHT PAGE 3
Sally Houston, MD ON ROUNDS
Sports Medicine Community Weighs In Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI ... 6
Mending Cherub Hearts Johns Hopkins Children’s Heart Surgery Program launched to provide comprehensive cardiology care with Florida Hospital for Children at new 10-bed PICU By LyNNE JETER
In early June, Florida Hospital for Children leaders Constantine Mavroudis, MD, and administrator Marla Silliman, along with All Children’s Jeffrey Jacobs, MD, executives and more than 300 well-wishers celebrated the opening of the new 10-bed Pediatric Cardiac Intensive Care Unit (PICU) at Florida Hospital for Children and the official launching of the new Johns Hopkins Children’s Heart Surgery program at Florida Hospital for Children. The red-letter event marked the end of a decade-long (CONTINUED ON PAGE 5)
All Children’s President Jonathan Ellen, MD; Florida Hospital CEO Lars Houmann; Dr. Jeffrey Jacobs, cardiothoracic surgeon at All Children’s Hospital; Dr. Constantine Mavroudis, medical director of the Pediatric and Congenital Heart Center at Florida Hospital for Children; and Martha Silliman, administrator of Florida Hospital for Children officially open the new Pediatric Cardiac Intensive Care Unit at Florida Hospital for Children and launch the new Johns Hopkins Children’s Heart Surgery program at Florida Hospital for Children.
Novaerus ‘Kryptonite’ New technology called ‘the most significant development in HAI prevention in decades’ By LyNNE JETER
When West Gables Health Care Center Administrator Marco Carrasco learned about a new technology to reduce healthcare-acquired infections (HAI) at the 120-bed skilled nursing facility in Miami, where the median age is 86 and the average short-term stay is 32 days, he immediately contacted the Tampa-based company that developed it.
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Soon after, Carrasco implemented Novaerus, the first scientifically-proven system for airborne infection control, HAI and disease prevention. Encased in small, inconspicuous units, Novaerus provides continuous airborne infection control by passing air through its patented disruptive plasma field. The process emits billions of harmless electrons that destroy the protein bio-films of viruses. It also breaks down the cell walls
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PhysicianSpotlight
Sally Houston, MD
Executive Vice President and Chief Medical Officer, Tampa General Hospital By JEFF WEBB
TAMPA - Sally Houston broke her arm when she was 7 years old. As a consequence, she missed a lot of school days that year in Silver Spring, Md. For many children, that might be viewed as a gift. But for Houston, it was a threat to her long-term plans. “I remember saying to my mother ‘If I miss too much school, I’m not going to be able to go to Vanderbilt,’” said Houston, who already had her sights set on the esteemed university in Nashville where both parents graduated. But not only had Houston already picked out where she would attend college, she knew what she would study. “Ever since I can remember I’ve wanted to be a doctor, said Houston, whose grandfather attended medical school at Vanderbilt. She also has three uncles who are physicians, which may help explain this anecdote: “My niece recently found a ‘prescription’ that I wrote when I was a little girl. I couldn’t write in cursive. Maybe I couldn’t even write, but I scribbled on the paper because I knew that no one could read a doctor’s handwriting anyway!” she said. Such single-mindedness paid off for Houston, who went on to earn her bachelor of science degree in psychology at Vanderbilt, where she also worked as a deejay playing classic rock at the school’s radio station. Fulfilling her lifelong ambition, Houston enrolled in medical school at Vanderbilt and it was during her third year that she became interested in infectious diseases. “I went to a conference and the ID physicians were excited about what they were doing. I hate to use the term ‘infectious,’ but their enthusiasm was certainly engaging,” said Houston. While an undergrad she also had met Jamie Scarola who, after graduation, returned to his native Tampa to work as a civil engineer while Houston finished medical school. The day after she was graduated the couple married in Nashville. That was 26 years ago. Houston moved to Tampa and completed her residency in internal medicine and then a fellowship in Infectious Diseases and Tropical Medicine at the University of South Florida College of Medicine. During that time she was mentored by Margarita Cancio, MD, who introduced her to John Sinnott, MD, who became the division director. (More recently he was appointed the Chair of Internal Medicine at USF Morsani College of Medicine.) Houston was a faculty member at USF and a key clinician at Tampa General Hospital, where she first reported for duty as intern on July 1, 1987. In 2007, while serving as the elected medicalnews
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chief of staff at Tampa General, she was asked to accept the position Senior Vice President and Chief Medical Officer, overseeing more than a dozen departments and programs. In March, Tampa General’s new CEO Jim Burkhart expanded Houston’s responsibilities and promoted her to Executive Vice President and Chief Medical Officer. One of Houston’s primary responsibilities is Tampa General’s physician group, where “I will be assuming a greater role,” she said. “We’re also adding a chief quality officer and patient experience officer, both of whom will report to me,” said Houston, 53. Houston’s role is entirely administrative now and she misses treating patients, she said, but she does make rounds sometimes and frequently speaks with patients to make sure things are going well. “I’m working every bit as a hard as I did (as a practicing physician), sometimes harder. I’m pretty much on call 24/7,” Houston said. She necessarily “spends a lot of time in meetings,” but every day is different, which is one of the reasons I really like the job. It’s certainly not boring,” she said. Houston works very closely with the physician leadership at Tampa General, “which is my favorite thing to do because I get to spend time with my colleagues,”
she said. “Just about anything that has to do with physicians crosses my path, whether it’s trying to recruit a new physician or dealing with a problem a physician encounters,” she said. “There is a very rigorous process for bringing new physicians on staff and that is handled through that Medical Staff Services Office, which reports to me.” Houston said she also still lectures occasionally to fellows at USF. Outside the hospital, Houston carves out time for she and husband Jamie (“He’s the only human being on earth who would put up with my crazy schedule!”) to go paddle-boarding. “I figured it was something we could do together. We have fun and get some exercise. It’s quiet and pretty and we usually go in the morning. When it’s calm you can see so much sea life; it’s very relaxing,” she said. Usually they launch right from their home on Apollo Beach. A stress-reliever for Houston is her daily trip to the gym. “Believe it or not, I actually like to go to the gym. A lot of people look at it as a chore, but it helps me manage stress and keep balanced, and it’s a place where I can think and have time to myself, which I do not get much of,” she said. Tampa General now has a “small fitness center that is really more like a fitness room,” Houston said, adding that CEO Burkhart has said he is going to build a real fitness center. “I can’t wait!” she said.
When she can find time, Houston likes to feed her appetite for U.S. Civil War history. Growing up in suburban Washington, D.C., “my parents took me to a lot of battlefields. We went to Gettsyburg annually,” she said. “I read all three volumes of Shelby Foote’s history of the Civil War, and I loved Ken Burns’ miniseries on PBS. I read biographies of the generals, and Doris Kearns Goodwin’s book about Lincoln’s cabinet. I’m always interested in learning more about leadership skills, so I like to read about people I perceive were good leaders,” she said. Houston also is pursuing a new exotic interest. “I just started as a tour guide in training with Elmira’s Wildlife Sanctuary in Wimauma. They provide a home for animals who have been given up by their owners, or from operations that have been shut down. They have exotic cats, wolves, lemurs, bears, and birds to name a few,” she said.
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Novaerus ‘Kryptonite’, continued from page 1 of bacteria, and denature mold, allergens and odors. Cost effective, each unit requires less energy than a 40-watt light bulb. Environmentally, Novaerus eradicates nearly 100 percent of all airborne pathogens and reduces microbial surface counts by up to 90 percent. “We’re on the cusp of the next significant advancement in medical technology, and once healthcare facilities across the country are able to follow our lead, I expect we’ll finally see a reversal in the ever-growing numbers of HAI cases,” said Carrasco. For a before-and-after comparison, West Gables Health Care Center had 485 admissions, of which eight patients were rehospitalized for pneumonia during the sec-
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ond half of last year. During the first two months of this year with Novaerus technology, Carrasco noticed enhanced quality outcomes and a significant reduction in readmissions. Of 115 total admissions during that time frame, only three patients were re-hospitalized for pneumonia. But the real eye-opener, Carrasco said, occurred in the room of a tracheotomy patient who was highly susceptible to infection as the opening in her neck healed. “Every case is unique, but these patients are at a high risk of infection because of the openings and tubes in their necks,” he said. “The fact … this patient recovered and went home sooner than what we consider to be the standard length is remarkable.” Odor control is a bonus, said Carrasco. “When you first enter our building, you notice the air feels fresh and is completely absent of any odor,” he explained. “The Novaerus units eliminated odors in the common room and hallways, allowing us to forgo the use of harsh chemicals that simply masked smells.”
U.S. Rollout
Launched just before Christmas in Florida, the response to Novaerus has been incredible, said company CEO Kevin Maughan, who met Carrasco during the Florida Health Care Association’s (FHCA) annual convention last year. By late spring, 15 percent of Florida’s skilled nursing facilities (SNF) had implemented Novaerus. “Ninety-five percent of those who’ve tried the Novaerus system are customers,” said Maughan, who stumbled across the technology being used in the aerospace industry in 2008. “I’d eyed it for the infection control industry, of which some $15 billion is spent on surface cleanliness and hand hygiene. Yet the negative outcomes based on HAIs cost about $40 billion. It seemed the market had a problem with that. As I did more research, I learned that almost no one was treating the air.” Maughan rolled out Novaerus in the U.K. and Ireland in 2009. After a clinical trial showed a 68 percent reduction in environmental MRSAs (Methicillin-resistant Staphylococcus aureus) at a London hospital with Novaerus, the U.K. National Health Service selected it as last year’s leading air Smart Solution for HAIs. “We see ourselves as a complementary and cost-effective component of good nursing care,” said Maughan, noting that HAIs kill more people annually than breast cancer, prostate cancer, and automobile accidents combined. Maughan expedited the introduction of Novaerus to the market at an affordable price after a family member of a scientist working on the technology required a leg amputation from an HAI. The company’s medical model involves leasing the equipment to healthcare facilities for three to five years. The typical cost to a SNF is roughly $2,500 a month, Maughan said. “There are no startup fees or hidden costs or expenses,” he added. “It’s Medicare cost reportable, and we also have a money back guarantee.”
TARGET: TAMPA When Novaerus CEO Kevin Maughan was seeking a corporate home in the United States, Tampa was an easy pick. “We knew Florida well,” he said. “We wanted it to be our launch market in the U.S. Logistically, Tampa was the right place from a cost perspective. We also found rich talent in the Tampa market, which will help us dramatically increase our operations over the next few years. We were eager to be in an area with four universities and wonderful resources.” Novaerus plans to add 175 employees to its existing workforce of 25 in Tampa by mid-2014, with 35 to 45 new hires by the end of this year. “It would be helpful for us to find people with infection control backgrounds that have also worked on the commercial side of healthcare,” said Maughn. “It’s a difficult mix to find, but they’re out there.”
Standard HAI Prevention Practices • Isolating infected patients; • Requiring staff to wash their hands after each patient examination and ensure hand hygiene stations are numerous and easily accessible; • Minimizing the use of invasive devices, such as catheters; • Wearing protective gowns, masks, gloves and other equipment; and • Cleaning surfaces with harsh chemicals. SOURCE: Novaerus.
A Brief History of Infection Control Advances In 1867, British surgeon Joseph Lister began using carbolic acid as an antiseptic in surgical procedures, significantly reducing mortality rates from infection by 30 percent within a decade. Before, a patient could undergo a procedure successfully only to die from a postoperative infection, ward fever. In the mid-to-late 19th century, various infection control protocols were developed and adopted, which remain vigorously enforced today: hand-washing, using heat to sterilize surgical instruments, and surgical masks. Medicine won significant battles against infectious diseases, including the eradication of tuberculosis. But in the mid-20th century, bacteria started fighting back. In 1947, only a few years after the advance of mass production penicillin, Staphylococcus aureus was discovered, one of the earlier bacteria indicating penicillin resistance. In 1961, Methicillin-resistant Staphylococcus aureus (MRSA) was first detected in Britain. Now, half of all MRSA infections in the U.S. are resistant to penicillin, methicillin, tetracycline and erythromycin. More recently, worldwide outbreaks of infectious diseases such as H5N1, severe acute respiratory syndrome (SARS), and H1N1 have emerged. Earlier this year, the Centers for Disease Control and Prevention (CDC) issued a warning around the growing threat of “nightmare superbugs” that are untreatable because they’re resistant to even the most powerful antibiotics. The CDC reports this class of superbug – Carbapenem-resistant Enterobacteriaceae (CRE) – has been found only in nursing homes and hospitals. About 4 percent of acute-care hospitals, and 18 percent of long-term acute care hospitals in America, reported at least one case of dangerous CRE bacteria – germs that are resistant to most ‘last-resort’ antibiotics. SOURCE: Novaerus.
Without thinking about it consciously during his formative years, Maughan’s foray into searching for a better way to fight HAIs began in childhood, after hearing tales of frustration about it from his medical family– his father, an MD; his grandfather, a pediatric surgeon; and his great grandfather, a general surgeon. “There hasn’t been one significant development in infection control since the late 19th century,” he said, knowing early on that “as bacteria become more resistant to traditional medicines and procedures, technology must play a role in their eradication.” Infection control companies have developed technologies that create hydrogen peroxide-based fogs or vapors to reduce the risk of cross-contamination of infec-
tious diseases associated with using a rag, wipe or sponge. Because they’re labor-intensive, Novaerus doesn’t consider those solutions competition. “Time is money, more than ever,” said Maughan. “Labor is so expensive, and time spent on HAI control by the nursing staff could be spent on other patient care needs. This technological solution requires no labor costs. By comparison, our solution is very inexpensive. It works 365/24/7.” To prevent aerial dissemination, technology can accomplish what medicine and standard HAI prevention practice cannot, such as eradicating airborne and surface pathogens and significantly reducing microbial surface counts, said Maughan.
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Mending Cherub Hearts, continued from page 1 journey for Florida Hospital for Children. “When I came to Orlando 10 years ago, one of the first projects I assessed was whether Florida Hospital was going to start the pediatric heart program the year I arrived,” said Silliman. “We had an approved CON (certificate of need) then, but I told them we probably weren’t ready as an organization to move forward just yet.” Ironically, the CON was approved three times. “One time, our surgeon on record died in an accident,” she recalled. “Another time, a surgeon (left) during our transition. So this was our third start. We had 250 mothers and babies leaving Central Florida. As CEO of the hospital, I wanted to be very careful as we were launching this program. It was highly important to get it right.” To assist Florida Hospital’s pediatric team, cardiovascular specialists from All Children’s Hospital in St. Petersburg had been commuting to Orlando every Friday for joint conferences and consults, including pediatric patients who were being transferred to the Tampa-area pediatric hospital. “The families of pediatric patients didn’t want to lose the relationships they’d built with the team in St. Pete because often families who have surgery when patients are young need to stay connected to these doctors for more surgery,” explained Silliman. “We wanted to keep the relationships strong with the teams that had
The new Johns Hopkins Children’s Heart Surgery program at Florida Hospital for Children is a joint collaboration with All Children’s in St. Petersburg, a 259-bed pediatric hospital that became a Johns Hopkins Medicine member in 2011, and Johns Hopkins Children’s Center in Baltimore, Md.
Florida Hospital for Children recently opened the Pediatric Cardiac Intensive Care Unit, adding 10 high-tech cardiovascular intensive care unit rooms to provide critical care for pediatric patients.
been developed between Florida Hospital and All Children’s and we agreed to work together. We jointly went forward with the CON this time, and agreed to create a partnership in a way that would outlive past partnerships.” In the middle of Florida Hospital’s plan to move forward, Johns Hopkins Medicine (JHM) acquired All Children’s, providing the St. Petersburg pediatric hospital the opportunity to expand its research and academic missions. “Johns Hopkins has an unbelievable brand,” said Silliman. “A new (executive) came to town (Jonathan Ellen, MD, initially vice dean/physician-in-chief and now president of All Children’s) and we instantly created a collegial relationship and sat down to see how we could best work together. As we were thinking through opening the site in Orlando, a proposal came out of the collaboration that we all accepted. Why not let this be the Johns (CONTINUED ON PAGE 8)
Orlando Pediatric Cardiology Standings When the new Johns Hopkins Children’s Heart Surgery program was officially launched at the Florida Hospital for Children in Orlando, many local patients and their families were able to stay closer to home. “Orlando didn’t need another pediatric open-heart program,” said Bill DeCampli, MD, co-director of Orlando Health’s Arnold Palmer Hospital for Children Arnold Palmer’s heart center, adding that another program would dilute expertise because of reduced volume at both places. Florida Hospital CEO Lars Houmann disagreed, pointing to a global view of the move. “Each time we add to the services we have available, we’re on mission,” he said. “Our goal is to be a destination.” In 2015, Nemours Children’s Hospital in Lake Nona Medical City plans to initiate a pediatric heart-surgery program, according to Nemours CEO Roger Oxendale.
FAST FACTS ABOUT JOHNS HOPKINS MEDICINE • It’s a $5 billion nonprofit global health system. • U.S. News & World Report has ranked it the nation’s leading hospital for 20 consecutive years. • It’s considered the birthplace of modern pediatrics. • The first “blue baby” operation to correct a congenital heart problem took place in 1944. • Leo Kanner, MD, conducted groundbreaking research with autistic children in 1943, becoming the first physician to apply the word “autism” to the childhood psychiatric disorder. • John Howland, MD, pioneered discoveries, such as fluid replacement for diarrhea. • Edwards Park, MD, defined Vitamin D’s role in bone loss. • George Dover, MD, serves as director of the Johns Hopkins Children’s Center and chairs the Department of Pediatrics for Johns Hopkins School of Medicine. • Johns Hopkins scientists typically receive the greatest single chunk of federal research money; $435 million in 2009. SOURCE: Johns Hopkins Medicine.
Heart Mender
The 4-1-1 on Constantine Mavroudis, MD, who leads the Johns Hopkins Children’s Heart Surgery program at Florida Hospital for Children When world-renowned cargenital heart repairs, arrhythmia diovascular surgeon Constantine surgery, coronary artery surgery Mavroudis, MD, was recruited in children, and adult congenital to be site director of the Johns heart interventions. Hopkins Children’s Heart Sur“In terms of operations gery Program at Florida Hospifor newborns to 18, we have a tal for Children (FHC), it was an comprehensive congenital heart especially appealing invitation program, with special expertise to practice medicine among colin arrhythmic surgery that’s relaleagues in a warmer climate than tively unique in this region,” said the Great Lakes region. Mavroudis, noting that one of Dr. Constantine Mavroudis “Several factors attracted 125 babies in the United States me to Central Florida,” said is born with a congenital heart Mavroudis, who was recruited to Florida defect. “We also perform operations that Hospital for Children, as director of the patients with adult congenital heart surCongenital Heart Institute in 2012. “One, I gery might need, of which the population had an opportunity to work with colleagues of Central Florida hasn’t been well served.” of 15 to 20 years who are based in St. Pete, Florida Hospital recently opened two and the organizational structure at Florida new operating rooms (OR) specifically deHospital and Florida Hospital for Children signed for pediatric heart surgeries. The wanted to partner with All Children’s to unique hybrid OR functions as a place for develop this program. After All Children’s surgical procedures and a catheterization became part of Johns Hopkins Medicine lab, or electrophysiology lab, and is deand I was recruited to Florida Hospital for signed with smaller equipment for pediatric Children, I liked the challenge of building a patients that’s also adult-friendly. Ten new new program.” high-tech cardiovascular intensive care unit Mavroudis is a vital part of the sixrooms feature a serene, nature-themed enmember team of heart surgeons among vironment for care of surgical patients. three Johns Hopkins sites, bringing interna“We’ve established a new program tional expertise in the fields of complex conthat’s working; all the kinks have been remedicalnews
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moved from the process,” said Mavroudis, who recently led an international symposium in Orlando on arrhythmic surgery and various related issues. “Our clinical results have been excellent, and we anticipate they’ll continue to be excellent. With adults, we had higher levels of complexity and still had a zero mortality rate. That’s noteworthy.” Mavroudis also sees “blue babies” who previously had surgery to repair their pulmonary valve and then return for a new pulmonary artery to be placed. “We’ll eventually develop a destination service for people outside the region to come and be treated,” he said. Born in Thasos, Greece, Mavroudis moved with his family to the United States as a toddler. For years, he visited Greece, where his first cousins reside, to perform complex pediatric cases pro bono for the Hellenic Heart Program he established. Unfortunately, the economic climate in Greece is so poor that he hasn’t visited his native country for several years. “I regret it,” said Mavroudis. “I speak the language and I’m simpatico with the culture. My first cousins and I keep in touch, speaking Greek to one another.” In the United States, Mavroudis thrived. Growing up in Jersey City, NJ, he
participated in Boy Scouts, student government, and varsity sports – football, fencing and baseball. At Rutgers University, he was captain of the fencing team and represented the United States in the Martini and Rossi World Invitational Tournament in 1968 before earning a biological sciences degree. After graduating from the University of Virginia School of Medicine in 1973, he completed general surgery training, thoracic-cardiovascular training, and a research fellowship at the University of California-San Francisco. Mavroudis’ appointments have varied from the University of Louisville School of Medicine, to Children’s Memorial Hospital-Northwestern University, The Feinberg School of Medicine. Most recently, he served as Chair of Congenital and Pediatric Cardiothoracic Surgery at Cleveland Clinic Children’s Hospital and Surgeon-in-Chief for the Department of Surgery and Division Head of Cardiovascular-Thoracic Surgery at Children’s Memorial Hospital in Chicago. A leading researcher, Mavroudis has published more than 400 peer-reviewed articles and book chapters, and recently published the 4th Edition of Pediatric Cardiac (CONTINUED ON PAGE 8)
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Sports Medicine Community Weighs In Zurich 2012 Concussion Consensus Statement clarifies issues, muddles others, exemplifies mystery of TBI By LYNNE JETER
No RTP (return to play) on the same day, regardless of circumstances. An earlier return to light exercise, recommended. And the differential between pediatric and adult patients, clarified. Those are among the highlights of the 2012 Concussion Consensus Statement derived from the 4th International Consensus Conference on Concussion in Sport, held last November in Zurich. Every four years, the International Ice Hockey Federation, International Olympic Committee, International Rugby Board, International Federation for Equestrian Sports, and FIFA (International Federation of Association Football) host the conference, which results in an updated concussion consensus statement. “The new statement shows that we basically still don’t understand concussions, and there are many opinions on how to diagnose and treat them,” said William Feldner, DO, a sports medi- Dr. William Feldner cine specialist at South County Family & Sports Medicine and St. Anthony’s Medical Center in St. Louis,
Mo., and team physician for Lindenwood University and USA Volleyball. He’s also a board member of the Joint Commission for Sports Medicine and Science, an editorial board member of the Clinical Journal of Sports Medicine, and past president of the American Osteopathic Academy of Sports Medicine. “And, while it’s not in the (consensus) statement, there’s some interesting genetic research going on. We may eventually be able to predetermine if someone is more susceptible to concussion based on their genetic makeup.” Marc Hilgers, MD, PhD, director for sports medicine fellowship, sports medicine research, and a sports medicine physician at Level One OrthopeDr. Marc dics with Orlando Health Hilgers in Central Florida, said he didn’t expect major changes in the 2012 consensus statement. “I’ve been keeping my finger on the pulse of knowledge and I knew what was coming down the pike,” said Hilgers, also the team physician for Orlando City Soccer and the Minor League Umpire Association, medical advisor for the Florida Orthopaedic Institute, and assistant professor of family medicine at the University of
South Florida. “That’s why I wasn’t surprised, especially with the broad spectrum of specialists from all over the world who met to write the updated statement, that it was kept general and not too progressive.” Bill Hefley, MD, an orthopedic surgeon and partner at OrthoSurgeons based in Little Rock, Ark., said the latest consensus statement Dr. Bill Hefley showed “great development in the CRT (concussion recognition tool) for lay use.” The 2008 conference resulted in the development of the Sport Concussion Assessment Tool (SCAT2), a standardized method of evaluating athletes ages 10 years and older for concussions. “This tool takes out the ‘guesswork’ and interpretation for laymen,” said Hefley. “The SCAT3 has a background section, which is a great addition to the SCAT2. Also, the SCAT3 is much more streamlined with clinician instructions on its own page, rather than after each section. The Child-SCAT3 is a great new tool for younger athletes who may sustain concussions.” Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with Ortho-
Surgeons, highlighted the 2012 consensus statement’s importance “because it continues the worldwide awareness of concussions (and) shows the dedication the medical society has for learning more about concussions, how to recognize concussions, how to properly manage athletes with concussions, and how to properly and safely return an athlete to play after a concussion has subsided.” The only major blip noted repeatedly: the altered position on CTE (chronic traumatic encephalopathy). Hilgers called it “an interesting update … on an issue that had ‘percolated up’ since 2008.” • The 2008 section on chronic traumatic brain injury (TBI) notes: “Epidemiological studies have suggested an association between repeated sports concussions during a career and late life cognitive impairment. Similarly, case reports have noted anecdotal cases where neuropathological evidence of CTE was observed in retired football players. Panel discussion was held, and no consensus was reached on the significance of such observations at this stage. Clinicians need to be mindful of the potential for longterm problems in the management of all athletes.” (CONTINUED ON PAGE 9)
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Noncompetes are Once Again Relevant for Recruited Doctors By JEFFREY L. COHEN
When the Stark II (Phase III) regulations were released in August, 2007, they clarified that when a hospital recruits a physician to a medical practice, the employment agreement between the medical practice and the newly recruited physician may contain practice restrictions as long as they do not “unreasonably restrict the recruited physician’s ability to practice medicine within the recruiting hospital’s service area. This stymied many medical practices which were reluctant to hire a new physician without a noncompete and nonsolicitation provision. A 2011 CMS Advisory Opinion (No. CMSAO-2011-01) changed this. The Advisory Opinion involved a pediatric orthopedist who was recruited by a hospital to a medical practice. The medical practice wanted to hire the new doctor, but was not willing to do so without a noncompetition provision and other restrictive covenants. The practice asked CMS for guidance because the Stark regs suggested that perhaps a noncompete could not be contained in the employment agreement of a physician recruited by a hospital to join a local medical practice. In fact, a prior version of the Stark regs
was clear that noncompetes were not permitted in the employment agreements of physicians recruited by hospitals. Hospital recruitment transactions involve bringing a physician into a new area and funding the start up period (usually a year). The nice thing for a medical practice is that the dollars given by the hospital to the practice (the difference between salary and benefits and collections) can run into the hundreds of thousands of dollars! The down side was that the medical practice could not tie the recruited physician’s hands with a noncompete or other similar restriction. The Advisory Opinion is, however, a game changer because it allowed the medical practice to impose a noncompete on the recruited physician. As mentioned, the practice would not hire the recruited physician without the noncompete. The noncompete had a 25 mile radius, and the Opinion cited the following relevant facts: • The recruited doctor would remain on one of five hospitals within the 25 mile zone; • The recruiting hospital’s service area extended beyond the 25 mile zone, in which there were at least three other hospitals within a one hour driving range;
• The noncompete complied with applicable state law. Based on these facts, the OIG permitted a one year noncompete because it did not “unreasonably restrict the doctor’s ability to practice in the recruiting hospital’s service area. Certainly, many other medical practices can be sure to follow suit. Physicians interested in nocompetes must be familiar with state law. Getting to the bone of the issue, noncompetes are enforceable in Florida if: • The geographic zone in the noncompete is reasonable. This depends on where the practice draws its patients. If patients come to the practice from just down the street, a ten mile radius is probably overbroad; • The duration is two years or less (though it can be longer in some limited circumstances); • The employer has complied with all of the terms of the employment agreement. If the employer has breached the contract that contains the noncompete, most courts will reject a claim to enforce it; • The employer does the type of thing that the departing employee does. If the employee is the only person performing toe surgery for instance, and
the practice will not provide toe surgery services once the employee leaves, the practice probably does not have a legitimate business interest to protect by enforcing the noncompete; and • Stopping the ex employee from practicing in the geographic zone does not create a healthcare crisis or shortage. This is tough. Very few practice areas are in such dire straits that the departure of one doctor will adversely affect the provision of such services in the area. Physicians should also be familiar with the practical aspects involved in noncompetes. Mistake 1 - Racing to litigation Going to court is a crap shoot. Once litigation begins, it takes on a life of its own and costs can be nuts, sometimes in the hundreds of thousands of dollars. You may think it’s a simple noncompete case. There rarely is such a thing. And if you sue someone on a noncompete breach, they may turn around and sue you in the same lawsuit for something. And...insurance does not cover any such claims. That means you are paying out of pocket for a lawsuit, the certainty of which can (CONTINUED ON PAGE 8)
We’re here to help put your loved one on a path of help and hope. Town & Country Hospital Behavioral Health Attempting to help a loved one that is having a crisis can be difficult and confusing. Town & Country Hospital’s Behavioral Health Program, with our specially trained staff of physicians, nurses, social workers and therapists, makes sure our patients receive the care they need with the goal of a safe return to healthy living in the community. We work with the family to better understand mental illness and its treatment so they may work together in the care and future treatment of the disease. We are also a voluntary and involuntary Baker Act facility that accepts patients who may be a danger to themselves or others. Please call if you need our help.
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Mending Cherub Hearts, continued from page 5
Noncompetes are Relevant, continued from page 7
Hopkins Children’s Heart Surgery program with one standard and multiple sites, so that care can be delivered in the communities where we partner, as if it had one oversight with the Hopkins name? We all agreed it would be an ideal program, that Florida Hospital could have all of its patients from within its network, and keep it local. The surgeons would all be one team, all appointed at Hopkins. Where it mattered, we’d do joint database submission, joint research and publications, and we’d have one quality of standard that could serve over 1,000 children a year, and jointly be a leading national pediatric hospital and a collaborative model to other programs.” The contractual agreement began a year ago, followed by many months of
never be guaranteed and which will seem endless once you run out of patience or money for the process. Often, the reality is that noncompete litigation involves the strategy or seeing which party can outspend the other one. If you are an employer, ask yourself the following two questions before commencing litigation: • Does it make good economic sense to enforce the noncompete? Is the former employee a business threat? • Is there a way to work out a deal with the employee, short of litigation? In some situations, it makes no business sense to pursue a noncompete. For instance, if the employee has been employed for several months and if the patients are all referred by the employer, then the employee may not be a competitive threat to the employer. The employer will find a replacement doctor at some point and refer the business to the new doctor. Case closed. It is also possible to work out settlements before going to court. For instance, you might avoid litigation by lowering the geographic zone or the duration. You might also negotiate a buy out of the noncompete. If you are an employee who wants out of the noncompete, sit down with the employer and see if you can agree on a way out, so that both of you can have peace and move on.
training to one standard. “Doctors and nurses were trained, and administrators were at the table,” said Silliman, noting the first surgery took place last September. “We’ve had close to 90 surgeries with zero mortality … and we’ve clearly had good, healthy volume in the program with great outcomes and strong oversight. Every week, partners from all sites teleconference to review potential surgeries. Working as a team, patients having surgery in Orlando are also getting input from Baltimore and St. Pete. We couldn’t be more pleased with the level of collaboration. The unit opening was a great milestone for us to have a physical space, and it was a visual moment for us of a progressive relationship.”
Heart Mender, continued from page 5 Surgery, which has been the gold-standard reference for pediatric and adult clinicians in the field. His professional leadership positions have involved presiding over the Southern Thoracic Surgical Association in 2002, and the Congenital Heart Surgeon’s Society from 2004 to 2006. Other reasons why Mavroudis, who turns 67 on July 19, was attracted to Central Florida? The warmer climate for his wife of nearly 30 years, Martha, an artist and gourmet cook, and a longer triathlon competition season for him. “When we lived in the north, I could
compete in three to four triathlons a year at the most,” said Mavroudis, who has completed 11 marathons and 34 triathlons in the United States. “Here, I can compete in eight to 10 triathlons, maybe 11 a year, with great pleasure and frequency.” Their firstborn, Paula Carrie Mavroudis, 28, a graduate of the University of Iowa, is a senior account executive for Edelman Public Relations Firm in Chicago. Their son, Constantine David Mavroudis, 26, is a fourth-year medical student at the Loyola University Chicago Stritch School of Medicine, planning a career in cardiothoracic surgery.
Mistake 2 - Doing it Yourself Noncompetes are governed by state law. There are both statutes and cases that inform lawyers about what types of noncompetes are enforceable and which are not. Do not work off of an old contract to create a new noncompete, since the laws (and the cases that construe them) change often. Do not use a friend’s noncompete, since you will not be able to tell if it will be enforceable at this time or under the circumstances that apply to you. The enforceability of noncompetes is extremely fact specific. Since noncompetes are strictly construed by courts, drafting them requires a trained eye. The Advisory Opinion marks a significant development in the area of noncompetes for physicians recruited to medical practices by hospitals. Though some states do not allow noncompetes to be applied to physicians, many states do, including Florida. Finding a way to satisfy both the federal and state authorities will be essential for ensuring an effective and enforceable noncompete. With over 24 years of healthcare law experience following his experience as legal counsel for the Florida Medical Association, Mr. Cohen is board certified by The Florida Bar as a specialist in healthcare law. With a strong background and expertise in transactional healthcare and corporate matters, particularly as they relate to physicians. Mr. Cohen can be reached at www.floridahealthcarelawfirm.com
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Sports Medicine, continued from page 6
• The 2012 TBI section notes that “clinicians need to be mindful of the potential for long-term problems in the management of all athletes. However, it was agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. It was further agreed that a cause and effect relationship has not as yet been demonstrated between CTE and concussions or exposure to contact sports. At present, the interpretation of causation in the modern CTE case studies should proceed cautiously. It was also recognized that it’s important to address the fears of parents and athletes from media pressure related to the possibility of CTE.” “It seems unclear what their true position is between the two consensus statements and needs to be better explained,” said Ross, particularly given the unfortunate trend of former and current professional athletes taking their own lives for their families “to donate their brain … to prove CTE is in fact an issue.” Among high-profile, self-inflicted deaths in recent years are professional athletes Junior Seau, Derek Boogard, Dave Duerson, who may have been the only one to commit suicide and leave instructions donating his brain for the study of CTE. Former NFL Chicago Bears quarterback Jim McMahon has agreed to donate his brain to science after his death. Another point of controversy: concussion determination. A neuropsychologist in the field of treating concussions pointed out the 2004 consensus statement was driven largely on a grading scale (1-3) for concussion with loss of consciousness serving as a means of grading the severity of concussion, from which the 2008 consensus statement began to deviate. “My take is that a concussion is more black and white,” he said. “Either you have a concussion or you don’t. When you get into grading scales and severity ratings, you oftentimes relay misinformation to patients and the other providers involved in the case. Calling it a yes-or-no decision takes that away. Oftentimes, athletes get caught up in whether their concussion was mild or severe, which leads to poorly-based expectations about recovery. A concussion is a concussion and everybody recovers differently.” In the clinical treatment and management of concussion, the clinician is the key, said the neuropsychologist. “The consensus statements, the most recent one included, spend a lot of effort discussing sideline assessment tools, baseline testing, cognitive assessment tests, balance testing, RTP decisions, and preferred means of assessment or treatment,” he said. “All these components are tools that, when used correctly by a well-trained clinician, can be extremely valuable. But the clinician remains the most important piece in terms of concussion treatment and management. The consensus statements do very little in terms of providing practical guidelines for the clinical care of concussion with respect to the individual clinician.”
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GrandRounds
Notable Highlights Todd Ross, MS, ATC, an athletic trainer for Pulaski Academy with OrthoSurgeons in Little Rock, Ark., emphasized other notable 2012 Concussion Consensus Statement Todd Ross highlights: • In the preamble, “ … therapists, certified athletic trainers … coaches and other people” were replaced with “primarily for use by physicians and healthcare professionals,” which better addresses who should be diagnosing concussions and handling RTP decisions concerning concussions. • “Brain injury” was added to the first sentence to read: “Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain induced by biomechanical forces.” “One could argue the point of, by definition, a concussion isn’t an injury but a process,” he said. “Adding the language of brain injury nullifies this objection.” • A timeline for concussion status was identified as “in some cases, symptoms and signs may evolve over a number of minutes to hours,” which could broaden the clinician’s interpretation of signs and symptoms. • The “Classification of Concussion” subtitle was changed to “Recovery of Concussion.” • In the neuropsychological assessment subtitle, the second and third paragraphs were rewritten and show less of an emphasis on the patient seeing a neuropsychologist. However, the emphasis changes to neuropsychological (NP) testing and a multidisciplinary approach to concussion management.
Edward White Hospital Receives Blue Distinction Center Designation for Quality
First Robotic Single-Site Hysterectomy in Tampa Bay Performed at St. Petersburg General Hospital
Florida Blue has named Edward White Hospital as a Blue Distinction Center for spine surgery. The Blue Distinction Centers for Specialty Care® program is a national designation awarded by Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality specialty care. “Edward White Hospital is committed to the continuing process of providing high quality care to our patients. We owe our success to our exemplary spine surgeons, and our entire team that strives day in and out to provide the highest level of care possible to meet the needs of our community,” stated CEO Sharon Hayes. “We are proud to receive this exciting designation from a nationally recognized industry expert.” Since 2006, the Blue Distinction program has assisted consumers, providers and employers in identifying hospitals that deliver quality care in bariatric surgery, cardiac care, complex and rare cancers, knee and hip replacements, spine surgery and transplants. The selection criteria used to evaluate facilities is developed with input from the medical community and includes general quality and safety metrics as well as program specific metrics. Research indicates that the newly designated Blue Distinction Centers demonstrate better quality and improved outcomes for patients, with lower rates of complications and readmissions than their peers.
St Petersburg General Hospital continues to break new ground in minimally invasive surgery by performing the first successful robotic single-site hysterectomy in the Tampa Bay area in May. Meena Jain, MD, completed a robotic benign hysterectomy, making only one tiny incision through the belly button. Dr. Jain has performed hundreds of minimally invasive robotic surgery hysterectomies and is the first physician in Tampa Bay to perform the single-site procedure. She is a designated Epicenter mentor/proctor at the hospital, training surgeons from around the country. St Petersburg General Hospital is designated as one of only 28 GYN Surgery Epicenters in the US and one of only two in the state of Florida. Epicenter sites are chosen for their excellence in patient outcomes, passion for teaching, and ability to convey to others the value and specific technique of robotic surgery for their patients. St Petersburg General Hospital enjoys several “firsts” in minimally invasive robotic technology in the Tampa Bay area: 2011- purchase of the newest daVinci Si robot 2011- incorporated state-of-the-art surgical simulator with the robot 2011- designated as a GYN Robotic Surgery Training Epicenter by Intuitive Surgical, Inc. 2012- removed a gallbladder through
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one tiny belly button incision 2013- performed a single-site hysterectomy St Petersburg General Hospital uses robotic technologies for not only singlesite surgeries, but also additional procedures in Gynecology, Gynecologic Oncology and Urology.
Palm Beach Cancer Institute Joins Florida’s Largest Community-Based Oncology Network Florida Cancer Specialists & Research Institute (FCS), announced that Palm Beach Cancer Institute (PBCI) joined the practice, effective June 1, 2013. According to William Harwin, M.D, President of Florida Cancer Specialists, the new merger will increase the number of locations of the state’s largest independent oncology/hematology practice and provide expanded services to cancer patients on the east coast. The merger with PBCI will add four clinical sites to the Florida Cancer Specialists’ network, extending service areas to the communities of West Palm Beach, Palm Beach Gardens, Wellington and Atlantis in Palm Beach County. Patients will now benefit from additional financial assistance programs, fully-integrated electronic medical records with a user-friendly patient portal, and increased access to the latest cuttingedge treatments. Florida Cancer Specialists & Research Institute offers a full range of oncology and hematology services, including clinical research and the use of evidencebased medicine and proactive patient support services.
Largo Medical Center Receives Quality Achievement Award for Heart Attack Care Largo Medical Center earns another quality achievement award! It is one of two hospitals in Pinellas County to receive the American Heart Association’s 2013 Mission: Lifeline®Silver Receiving Quality Achievement Award. The award recognizes the hospital’s commitment and success in implementing an exceptional standard of care for heart attack patients in our community. Hospitals involved in Mission: Lifeline are part of a system that makes sure STEMI patients get the right care they need, as quickly as possible. Mission: Lifeline focuses on improving the system of care for these patients and at the same time improving care for all heart attack patients. As a “STEMI Receiving Hospital,” Largo Medical Center meets high standards of performance in quick and appropriate treatment of STEMI patients to open the blocked artery. Before they are discharged, patients are started on aggressive risk reduction therapies such as cholesterol-lowering drugs, aspirin, ACE inhibitors and beta-blockers and they receive smoking cessation counseling if
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PUBLISHER Jackson Vahaly jvahaly@southcomm.com FLORIDA MARKET PUBLISHER John Kelly johnkelly@orlandomedicalnews.com
Largo Medical Center Graduates One of the Largest Class of Doctors in Pinellas County This Year Largo Medical Center is graduating 40 interns, residents and fellows from its Graduate Medical Education (GME) teaching program making this sixth class of Largo Medical Center’s graduates, the hospital’s largest one yet. Each Resident has successfully completed his or her course of study and clinical training. Some will go on to advanced studies. Others will start medical practice. It is dedicated to providing the highest quality education for those who come to Largo Medical Center from our nation’s 23 osteopathic medical schools. The program is the West Coast Academic Center for Nova Southeastern University and is also affiliated with the University of South Florida Morsani College of Medicine. Largo Medical Center’s GME program is accredited by the American Osteopathic Association to provide clinical training in 13 residency and fellowship programs and currently has 128 residents in training,” according to Anthony Ottaviani, DO, MPH, Director Of Graduate Medical Education (DME) and Chief Academic Officer. This year’s graduation took place at the Safety Harbor Resort & Spa in June. There were more than 300 attendees, diplomas awarded to the graduates and many awards presented. needed. Hospitals must adhere to these guidelines-based measures at a set level for a designated period of time to be eligible for the achievement awards.
New Surgical Care Unit Opens at Florida Hospital Carrollwood Patient Safety Top Priority
AMA Tampa Bay Healthcare SIG Breakfast with Champions
The new Surgical Care Unit at Florida Hospital Carrollwood offers patients innovative safety features and technologies of tomorrow. The 25 private rooms are designed to provide patients with greater safety, more personalized care and better outcomes helping to ensure an overall enhanced patient experience. Each room is specially equipped with the latest safety features including smart pumps delivering fluids, nutrients and medications at precisely controlled rates, real-time vital signs monitoring, and bedside computers all of which have been identified as key to ensuring a safe, healing environment for patients. In addition, Florida Hospital Carrollwood was the third hospital in the state to reach HIMSS Level 7, the national standard for patient safety through the use of electronic medical records and recently, the hospital received “top safety honors” from the Adventist Health System, of which it is a member. And, our Bariatric Surgical Weight Loss program is a Surgical Review Corporation Center of Excellence for excellence in safety, efficacy and efficiency. During their hospital stay, patients can have access to special amenities including the GetWell Network, providing personalized patient education and entertainment, and Patient Care Channel- offering relaxing and healing programming, room service and guest meal service.
The social media revolution is the defining communications trend of the third millennium. From blogs to facebook to Twitter to YouTube, the power of worldwide broadcasting and publishing is now available to anyone. Have you considered how these technologies are likely to affect your organization? Are you proactively exploring how you can use these tools creatively to accomplish organizational objectives? See the presentation of The Mayo Clinic Story-Bringing the Social Media Revolution to Healthcare on Friday, September 27. Come to the Centre Club at 123 South Westshore Blvd. on the eighth floor and listen to Lee A. Aase, hospital social media pioneer and director of the Mayo Clinic Center for Social Media as he shares how Mayo progressed naturally from traditional media relations to direct-to-consumer news delivery to giving patients a platform for their stories. He will describe the steps taken, safeguards developed and concrete results achieved. Finally, Aase will share Mayo Clinic’s vision to move social media use beyond marketing, applying these revolutionary tools to improve health and healthcare for people everywhere. Networking and a hot breakfast are available at 7:30 am with the presentation beginning at 8 am. There is limited seating so to register or learn more, visitAMATampaBay.org. Price for admission is $30 for members, $40 for nonmembers and students $25.
Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.
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For quality, safe and compassionate care... Florida Hospital Carrollwood Bariatric Weight Loss Surgery Program Designated as a Center of Excellence in Metabolicand Bariatric Surgery™ by the Surgical Review Corporation. SRC sets a global standard for excellence for surgical specialties.
PHYSICIANS: SEND YOUR PATIENTS TO OUR FREE BARIATRIC WEIGHT LOSS SURGERY SEMINAR
Tuesday, June 25, 2013 | 6:30 p.m. Florida Hospital Carrollwood Auditorium
7171 N. Dale Mabry Highway Tampa, Florida 33614 FHCarrollwood.org | 813.932.2222
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