450 Stanyan St. San Francisco, CA 94117
ISSUE 16 MAY 2012
450
MD
St. Mary’s Medical Center Physician Newsletter
stmarysmedicalcenter.org
LIBRARY ACCESS AND SERVICES The St. Mary’s Medical Center Graduate Medical Education
The full-text article will be returned to you via fax or PDF
department maintains a medical library for SMMC physicians,
within 72 hours unless an urgent request is submitted.
staff and trainees. Printed volumes of many medical journals
Although it is rarely necessary to obtain articles from obscure
dating back 10 to 15 years are available on site. We also current-
journals via inter library loan, the turn-around time for this
ly subscribe to a small number of print journals, including:
service is 7 to 10 business days – and possibly more if numerous
• Annals of Internal Medicine
articles are requested.
• CHEST
• Critical Care Medicine
SMMC physicians who wish to access on-line journals for
• JAMA
browsing should contact the GME office, located at 2235
• Journal of Graduate Medical Education
Hayes Street, 4th floor, at (415) 750-5781 between 9:00am and
• Journal of Hospital Medicine
4:00pm Monday through Friday.
• The American Journal of Medicine
• The New England Journal of Medicine
A small library of medical textbooks is available for on-site
An extensive collection of more than 200 other journals in
reference use. Duplicate copies may be checked out for up
all major specialties are also available online through our
to 10 days, and may be renewed if needed for a longer period.
medical school affiliations.
MKSAP and Med study Board preparation material are available upon request.
To request journal articles from our library: Fax or E-mail your contact information to (415) 750-8149 or
Library material may be printed or copied, but personal
Kimberly.banks@dignityhealth.org. Be sure to include:
photocopying services are not available.
1. Journal Name, 2. Author, 3. Title*, 4. Date, *Full citation if available
Chief of Staff Message Francis Charlton, MD
We all love to take care of patients, but few of us love “the paperwork” involved, which is increasingly being performed electronically. It seems paradoxical that the time and energy devoted to documentation has continually increased as we aim to make “meaningful use” of the electronic health record. Why didn’t I take my high school typing class in more seriously? Although we’re aided by the latest in voice-recognition software and instant-turnaround dictation services, we are expected to fully document every aspect of each patient encounter down to the finest detail. If we fail to do so, we won’t be fairly reimbursed for the services we provide. More importantly, the quality and safety of patient care will be deficient. This is especially true for our hospitalized patients, who are cared for by numerous providers from a
wide array of healthcare disciplines, most of whom don’t have a long-standing relationship with the patient that might assist them in understanding his or her particular needs, assets, goals, and circumstances. The delivery of optimal care is indeed a team effort that requires coordination among all who come in contact with the patient. Effective, prompt communication enables the teamwork that bears the fruit of successful patient outcomes. Assiduous attention to thorough documentation can nullify the inherent danger of taking care of strangers. We must redouble our efforts in this regard to maintain a safe environment for our patients. Timely, effective communication -- verbal, written, and electronic -- is a crucial component of good patient care. We will be rewarded with improved outcomes if we focus on improving the quality and timeliness of the required documentation that ensures our patients are safely cared for by our healthcare team. Thank you for your attention to the devil in these details.
Conditions that are Reportable to the Department of Public Health
the Department of Public Health (DPH) to carry out its tasks. Reportable conditions are mostly infectious, and reporting is required in order to facilitate containment of infection and investigation of potential outbreaks; for surveillance and public education purposes; and for contact tracing for some STDs and tuberculosis. DPH can also provide advice on specialized lab testing and post-exposure prophylaxis where appropriate.
by Dr. José Eguía
Two non-infectious conditions are also required to be
Under state law, health care providers involved in
reported: Alzheimer’s disease and disorders
the care of a known or suspected case of certain
characterized by lapses of consciousness.
medical conditions must report them to the local department of public health. Although any
The human conditions that must be reported are
provider can report these conditions, the ultimate
listed below; those that clinicians are more likely to
responsibility falls to the attending physician or
come across on a routine basis are in boldface.
their delegate. The Laboratory will report diagnoses for which they have a positive culture
For more information, refer to the San Francisco
or serologic result. However, some conditions are
DPH website (www.sfcdcp.com/diseasereporting.
treated empirically -- without laboratory
html), or contact Infection Control (750-4075) or
confirmation -- or have lab testing whose results
Dr. José Eguía (Bpr: 443-0367).
may be delayed (as in tuberculosis, for example); for these, clinician reporting is essential to allow
Communicable Disease Control Unit Phone: (415) 554-2830 Fax: (415) 554-2848 Monday - Friday 8AM to 5PM For urgent reports after hours, follow the prompts to page the on-call MD AIDS Office Phone: (415) 554-9050 Animal Bites (mammals only) Phone: (415) 554-9422 Fax: (415) 864-2866
STD Clinic:
Phone: (415) 487-5555 Fax: (415) 431-4628
Tuberculosis Clinic:
Phone: (415) 206-8524 Fax: (415) 206-4565
Human Conditions that must be Reported Immediately (within 1 hour) report by phone
Within one working day report by phone or fax
Within 7 calendar days report by phone, fax, or mail
• Anthrax*
• Amebiasis
• AIDS (1)
• Botulism*
• Babesiosis
• Alzheimer’s Disease
• Brucellosis*
• Campylobacteriosis
• Anaplasmosis/Ehrlichiosis
• Cholera
• Chickenpox (only hospitalization
• Ciguatera Fish Poisoning
and death)
• Dengue
• Cryptosporidiosis
• Chlamydia trachomatis infections (3)
• Diphtheria
• Encephalitis, infectious
• Coccidioidomycosis
• Domoic Acid/Amnesic
(specify etiology)
• Creutzfeldt-Jakob Disease (CJD)
Shellfish Poisoning
• Haemophilus influenzae invasive
• Cyclosporiasis
• Escherichia coli: shiga toxin
disease (less than 15 years of age)
• Cysticercosis
producing (STEC)
• Hepatitis A, acute infection
• Disorders Characterized
including E. coli O157
• Listeriosis
by Lapses of Consciousness
• Foodborne illness (2 or more cases
• Malaria
• Ehrlichiosis/Anaplasmosis
from different households)
• Meningitis (specify etiology)
• Giardiasis
• Hantavirus infections
• Pertussis (Whooping Cough)
• Gonococcal infections (3)
• Hemolytic Uremic Syndrome
• Poliovirus infection
• Hepatitis, Viral
• Measles (Rubeola)
• Psittacosis
• Hepatitis B (acute or chronic)
• Meningococcal infections
• Q Fever
• Hepatitis C (acute or chronic)
• Paralytic Shellfish Poisoning
• Relapsing Fever
• Hepatitis D (acute or chronic)
• Plague*
• Salmonellosis (non-typhoid)
• Rabies
• Shigellosis
• Hepatitis E, acute infection • HIV (1)
• Scombroid Fish Poisoning
• Staphylococcus aureus infections,
• Influenza Deaths (in laboratory-
• Severe Acute Respiratory
severe (ICU/death) in a previously
confirmed cases for age 0-64 years)
Syndrome (SARS)
healthy person
• Influenza, novel strains
• Shiga toxin (in feces)
• Streptococcal Infections,
• Legionellosis
• Smallpox*
outbreaks of any type and
• Leprosy
• Tularemia*
individual cases in food handlers
• Leptospirosis
• Viral Hemorrhagic Fevers*
and dairy workers only
• Lyme Disease
(e.g. Ebola, Lassa viruses)
• Syphilis (3)
• Lymphogranuloma venereum (3)
• Yellow Fever
• Trichinosis
• Mumps
• Any unusual diseases
• Tuberculosis (4)
• Pelvic Inflammatory Disease (3)
• New diseases or syndrome not
• Typhoid fever (cases and carriers)
• Rickettsial Diseases
previously recognized
• Vibrio infections
• Rocky Mountain Spotted Fever
• Outbreaks of any disease
• West Nile Virus infection
• Rubella
• Yersiniosis
• Rubella Congenital Syndrome
* Potential Bioterrorism Agents
• Animal Bites (mammals only) (2) • Chancroid (3)
• Taeniasis • Tetanus • Toxic Shock Syndrome • Transmissible Spongiform Encephalopathies (TSE)
Comprehensive Lung Center Opens at St. Mary’s • Mock Code Blues, which keep our staff’s skills sharp with virtual reality training St. Mary’s is putting the finishing touches on its new Com-
mouth and into the lung. In the past, such biopsies required in-
prehensive Lung Center, which opened mid-April, add-
volved surgeries in order to obtain the same degree of accuracy.
ing another dimension to the hospital’s ability to provide
With new procedure, patients can go home within hours.
• Staff members can learn and practice procedures on Sim Man and get immediate feedback from him
Cardiac Symposium
patients with the latest in medical technology.
At the March 20, 2012, Cardiac Symposium, topics included
Patients requiring surgery will have access to our team, includ-
EKG arrhythmia recognition; atrial fibrillation; sudden death
Lung cancer screening will be available to people at high
ing our new SMMC-UCSF thoracic surgeon, Dr. Pierre Theo-
risk for the disease. They can be self referred, or referred by
dore. Dr. Theodore provides a full range of thoracic surgeries,
their physician based on their smoking history, or pulmonary
including mediastinoscopy and video-assisted thoracic surgery,
symptoms. Screening allows patients to be diagnosed -- using
which allows surgeons to insert a camera and surgical tools
low-dose radiation CT of the lungs -- at an early, curable stage
through tiny incisions in the chest to diagnose and treat lung
Nursing Shared Governance at St. Mary’s
of disease.
cancer and other pulmonary disease.
Shared governance is a model that provides direction for the
ST. MARY’S NURSING NEWS
Pulmonary patients will also benefit from the center’s mini-
Dr. Theodore will head the center with Dr. Jamie Bigelow. Dr.
decision-making, allowing them to demonstrate accountability
mally invasive diagnostic and therapeutic techniques, includ-
Theodore’s areas of expertise include lung neoplasms and lung
and ownership for their practice. According to Tim
ing Endobronchial Ultrasound (EBUS), which allows a physi-
transplantation. Dr. Bigelow has practiced pulmonary and criti-
Porter-O’Grady, who developed the Shared Governance model,
cian to biopsy suspicious lymph nodes and nodules by passing
cal care medicine at Saint Francis Medical Center since 1999.
its goal is to achieve better patient outcomes. St. Mary’s has four Nursing Councils: the Quality Council, Nurse Professional Development Council, Nurse Practice Council and the Nurse Coordinating Council. Our nurses actively participate
DIABETES IN CALIFORNIA
in these councils, giving them a voice in determining practice standards, patient safety, quality and leadership. Shared
Diabetes is a complex disease that is sweeping the country. Its prevalence is strongly influenced by social circumstances. Three million Californians – including 1 out of 10 adults -- have diabetes. The state’s ethnically diverse population has a higher risk and prevalence of type 2 diabetes. Total health care and related costs for diabetes treatment in California alone is about $24.5 billion each year. The disease represents a significant and growing economic challenge for California families, employers and communities, especially during these difficult economic times. In California, there are: • Especially high rates of diabetes in the Central Valley • A high prevalence of uninsured diabetics, especially among the Hispanic/Latino population, and a tremendous county-by-county variation in coverage of uninsured diabetics • A growing prevalence of diabetes in young adults (ages 18-44) with behavioral and health-access risk
profiles that make them particularly vulnerable to developing complications in the prime of their lives. Source: The California Diabetes Program www.caldiabetes.org. St. Mary’s Medical Center is the only hospital in San Francisco that offers free weekly classes and an outpatient education program accredited by the American Diabetes Association. Ask your doctor for a referral to see one of our diabetes educators if you need support or want more information in the management of your diabetes care. Some additional resources for diabetes information:
➜ www.diabetes.org ➜ www.eatright.org ➜ www.spiral.Tufts.edu (a multilingual site) ➜ www.learningaboutdiabetes.org ➜ www.nutrition.gov
pharmaceutical reviews of anti-coagulants and anti-platelet drugs; and preoperative coronary artery stent management.
professional nursing practice. Nurses participate in unit-based
a camera-equipped bronchoscope with ultrasound through the
syndrome; implanted devices; anticoagulant therapies;
Governance elevates nurses from employees just doing a job to professionals sharing in health care decisions with other key stake holders. Sim Man has come to live at St. Mary’s Hospital
Who is Sim Man… • Sim Man 3G is a state-of-the-art patient-simulation training device
What does he do… • You will see Sim Man experience a cardiac arrest,
There were over 80 participants, with a standing-room-only crowd at the symposium, which was sponsored by SMMC, Cardiology Department, Education Department and the Nursing Professional Development Council.
Among participant comments: “Very interesting and helpful; had wonderful speakers that were all very knowledgeable.” “I could listen to Dr. Podolin all day. Good explanation of differentiation of rhythms.” “Our cardiologists are such excellent practitioners and speakers!” “Dr. Podolin’s presentation was awesome. I learned so much today that will help me as a heart nurse!” “Very interesting, informative, good MD engagement. Overall, great job and worth time commitment.” “Great hearing these people we watch and work with go on and on about what they know and love.”
stroke, heart attack right before your eyes. He can choke and respond to medications while he has an IV, chest tube or Foley catheter inserted • Sim Man can train staff without risk to the patient, and increase employee confidence.
The Real Benefit to St. Mary’s is… • Increased patient safety and quality of care through state-of-the-art simulations and practice
Upcoming Events • Nurses Week May 6th – 12th • May 9th Nurses’ Day
Advanced Wound By Megan Brunson, Program Director St. Mary’s Medical Center and Saint
treatment of wounds that resist healing --
while breathing pure oxygen at a
Francis Memorial Hospital are excited
often the result of diabetes, compromised
pressure greater than sea level.
to announce a new collaboration to heal
skin grafts, pressure ulcers, radiation
Hyperbaric therapy has been shown to
complex wounds and avoid unnecessary
tissue damage, trauma, and venous or
aid in the growth of blood vessels in areas
amputations: The Advanced Wound
arterial issues. Patients are treated by a
where they have been damaged, which
Healing – Amputation Prevention Center
multidisciplinary team of board-certified
results in expedited healing of the wound.
at St. Mary’s and the Hyperbaric
physicians – general surgeons, vascular
Hyperbaric therapy is also effective in
Medicine Center at Saint Francis.
surgeons, plastic surgeons, orthopedic
the treatment of many other conditions,
surgeons, internists, surgical podiatrists
including decompression sickness, bone
By bridging these services across two
and clinical wound specialists – with
infections and damage caused by
facilities, Dignity Health has combined
a common goal of successful healing
therapeutic radiation treatments.
nationally recognized surgeons and a
and reduction in the risk of amputation.
highly seasoned hyperbaric medicine
The physicians are aided by advanced
With their unique collaborative approach,
team to assure the best possible outcome
technologies in wound care, including
St. Mary’s Medical Center and Saint
for patients with a variety of chronic
bioengineered skin substitutes, negative
Francis Memorial Hospital have created
wounds and conditions.
pressure wound therapy, and hyperbaric
a highly respected, specialized
oxygen therapy.
interdisciplinary team, capable of
The outpatient wound center at St.
formulating a treatment program
Mary’s is led by Dr. David M. Young and
The outpatient hyperbaric center at Saint
specifically tailored for each patient’s
Dr. Charles K Lee. It specializes in the
Francis Memorial Hospital is led by Dr.
medical situation. For individuals
Jamie Bigelow. It provides advanced
suffering from diabetic wounds, this
hyperbaric oxygen therapy for wounds
center will be especially beneficial. It’s
that are resistant to healing by traditional
estimated that 24 million people in the
approaches. In this advanced therapy, the
U.S suffer from diabetes, which makes
patient rests in a chamber for two hours
them susceptible to diabetic ulcers. Their amputation rate is 10 times higher than that of people without diabetes, but many of those amputations can be avoided with preventative care, adjunctive hyperbaric
“ It’s estimated that 24 million people in the U.S suffer from diabetes, which makes them susceptible to diabetic ulcers. ”
therapy, and a team-based collaboration between podiatric, vascular, and plastic surgeons.
After Hours Clinic
Americans work longer hours than workers in most other developed countries. The typical American middle-income family put in an average of 11 more hours a week in 2006 than it did in 1979. Although more than 805,000 people reside in San Francisco, there were no after-hours clinics to accommodate busy families – until this month, with the opening of the new After Hours Medical Clinic. Staffed by the Pacific Family Practice Medical Group, the clinic provides after-hours medical care at reduced cost for both patients and insurers. The clinic operates from 5:00 p.m. to 9:00 p.m. on weekdays and from 10:00 a.m. to 4:00 p.m. on Saturdays. The clinic provides walk-in care that focuses on acute conditions and exacerbations of chronic conditions. In a study by the California HealthCare Foundation, the most common diagnoses seen in non-emergency and non-primary care settings are upper respiratory infections (60.6 percent); other minor conditions such as allergies, insect bites, rashes, and conjunctivitis (9.5 percent); and urinary tract infections (3.7 percent). Preventive care, such as vaccinations and preventive exams, account for 21.6 percent of visits. These four categories combined accounted for more than 95 percent of all visits to acute care clinic sites. According to “Health Matters in San Francisco” and the California Office of Statewide Health Planning and Development, 18,000 emergency department visits were preventable. A combination of increased working hours for patients and diminished primary care access account for the
unnecessary use of emergency departments. Dr. Robin Weinick of RAND Health, one of the largest private health research groups in the world, estimates that 13.7 to 27.1 percent of all emergency room (ER) visits could take place in less intensive, walk-in-based care facilities. Delays in care and additional costs incurred in ER visits are a drain on health care resources. Several studies have estimated that costs of care in non-emergency, non-primary care clinics are $279 to $460 less per visit than ER costs for similar cases. “Extended hours have become a big concept in how to bring our practice to the people,” said Sophia Mirviss, MD. “It’s for existing patients, and also for people who come home and find themselves sick and really want to be seen but had to work all day. And for people who do not have insurance but want to get their strep throat checked but cannot go to the ER because it’s prohibitively expensive.” The clinic does not provide ongoing primary care. It transmits all medical encounters via an electronic medical records system to patients’ primary care physicians so that they can retain control of referrals and follow-up. The community has embraced this concept; many physicians have been strongly positive; and it has garnered support from Brown & Toland and other insurers, since it has the potential to reduce inappropriate ER and hospital use rates. Phone: (415) 750 -5500 Address: 2235 Hayes Street 5th Floor (Hayes & Shrader)
San Francisco Medical Society Perspective Pete Curran, M.D.
When I started practice in San Francisco five years ago I did not know anyone. One of the first things I did was to join the San Francisco Medical Society (SFMS). I was immediately introduced to a large group of local physicians that enabled me to expand my professional network and referral list. SFMS connects San Francisco physicians across specialties and practice sites and creates a collective voice in advocacy for health policy and health care delivery in our community.
Networking is an important advantage of being a member of the medical society, and the ability to reach a larger audience continues to evolve in the digital age. SFMS’ goal is to appeal to “all things physician” in San Francisco, and with our state organization, the California Medical Association, this is happening now with an updated interactive website, exclusive complimentary access to the HIPAA-compliant smartphone peer-to-peer communication app
DocBookMD, and frequently scheduled social mixers in town. The success of St. Mary’s Medical Center depends on appealing to new physicians to want to practice here, and retaining them by having their practices thrive. Joining forces with over one thousand fellow physicians in the San Francisco Medical Society is an excellent way to grow our own membership at St. Mary’s. www.sfms.org
Physician Satisfaction Survey Easy. Confidential. Online. We Want to Know We want to know what you like most about working at St. Mary’s and what aspects of our organization need improvement. Your input is crucial in making a better place to work, reducing physician turnover, and improving quality and service. The survey should only take 10 to 15 minutes.
Steps:
NEW INSULIN POWER PLAN
Website Link: http://improvingquality.com/?url=chw
Since the short acting insulin Humalog replaced
nursing and pharmacy communications, consistent
1.
Enter [Access Code] and click the Login button. This login code is to insure that only one survey is
regular insulin on formulary, between meals and
carbohydrate diet as well as lab orders. Its great-
completed per physician. This code is randomly assigned and will not be used to identify any
overnight, patients have almost no insulin on board.
est asset is guidance through ordering basal insulin,
physician’s survey responses. (Your access code was mailed to you with an introduction letter from CHW.
The uncontrolled gluconeogenesis causes high
so the patient is never without insulin on board plus
If you have misplaced your access code indicated below before completing the survey, please contact
glucose levels before the next meal and overnight.
insulin for meals and to correct high glucose levels
St. Mary’s Medical Staff Office during business hours, or, the hospital operator nights and weekends.
Used alone it causes a see-saw rise and drop of
before meals. CERNER reminds us to order all three
glucose putting our patients at risk for both high and
and directs us to the best multiplier for the patient’s
very low glucose levels. To provide the coverage at
sensitivity to insulin and will do the arithmetic. All
very low insulin levels that we used to achieve with
nurses will have received training in the reasons for
regular insulin, the patients need Lantus (glargine)
this “new” way of providing patient insulin needs,
insulin to provide that baseline (basal) insulin and
and why insulin is needed with meals, even if the
glucose rise. In response to our need for compre-
before meal glucose is below 160 mg%. There are
hensive, easily input orders, the CERNER diabetes
super users among house staff, hospitalist and nurs-
Summit and soft ware writers developed the Insulin
ing staff to help with the mechanics, or the reason-
power plan.
ing behind the orders.
Beginning mid May, CERNER goes live with the
This will allow us to deliver state of the art insulin
power plan that can insure we manage diabetes at
care for patients with diabetes and decrease the
state of the art, best practices, and expert recom-
roller coaster effects of short acting insulin given
mendation excellence. The power plan, covers
alone and only in response to glucose levels.
2.
Describe your position using the options in Step 1 - Demographics. The demographics are required fields and you will not be allowed to proceed until they have been completed.
3.
Click on the Continue button at the bottom of the screen.
4. Click on each bubble that represents the response option you would like to assign to each question. The survey response scale is given throughout the survey. Use the scroll bar at the side of the screen to navigate through the items. 5.
Once you’ve answered all survey questions, scroll down to find the open-ended questions. Record your comments by clicking in the comment box and begin typing.
6. When you are confident that you have completed the survey, click on the Complete Survey button located at the bottom of the screen. Computers are available in the medical staff office, and we will have a laptop available at all medical staff meetings.
The survey administration period is only through May 11, 2012. Don’t wait until the last minute. Your input matters!
$10
GIFT CARD
FREE $10 Starbucks or Drip Coffee gift card for completing the survey. Contact the Medical Staff Office to redeem your card.
stmarysmedicalcenter.org 800.444.2303