Medical Staff Bulletin

April 2019

In this issue:

• Addressing the need for coordinated, integrated care in the ambulatory setting
• Patient Safety and Quality Metrics
• New protocol addresses unsigned orders
• YNHHS improves echocardiogram Epic order process
• Use of mobile devices to capture images
• National Healthcare Decisions Day targets awareness
• New system-wide policies and procedures
• Reminder: Do not use patient information in email subject lines
• Newsmaker
• In memoriam

Addressing the need for coordinated, integrated care in the ambulatory setting

A message from Thomas Balcezak, MD, Chief Medical Officer

The care of our patients has changed dramatically over the past two decades as innovations in technology, drugs and procedures have advanced, patients have aged and become more clinically complex, and care has increasingly transitioned to outpatient settings. While we must continue to enhance the value of hospital-based care, the rapid changes occurring in health care require that we also expand our care outside of the hospital setting. To do that in a way that meets our goal of enhancing value, we must improve our ability to coordinate and integrate that care.

In the 16 years that I had a part-time practice in the community, I witnessed firsthand the unique challenges to providing coordinated, timely, and appropriate longitudinal care in the ambulatory setting where information is fragmented, support resources for coordination and follow-up are scarce, and reimbursement for navigating patients is non-existent. If we are to succeed in our quest to consistently provide health care of superlative value, we must consciously develop, strengthen and invest in relationships and structures that eliminate barriers to the provision of coordinated, efficient and appropriate care in the ambulatory setting.

Toward that end, we have identified some gaps in the services we provide in the ambulatory setting, listened to our colleagues practicing in the community, and are working to fill those gaps and build programs that meet the needs to provide high value and coordinated care. That work has included being honest about where we have strengths and weaknesses, and then using this knowledge to build unique programs in the ambulatory setting.

Our McGivney Advanced Surgery Center is one such example. When surgery is required, our patients are cared for at the state-of-the-art McGivney Advanced Surgery Center, which is similarly driven by a multidisciplinary model. As a result of these innovations, patient satisfaction has been outstanding, with McGivney surgery center care scoring in the 99th percentile nationally. The surgeons working at McGivney have provided similar feedback about the program. The case volume at the center has steadily increased over the past year, and we anticipate that trend will continue.

In an effort to increase the availability of services within the many communities we serve, we have expanded the North Haven Medical Center to offer a wide range of cutting-edge services. The North Haven facility has an outpatient site of Smilow Cancer Hospital, provides Interventional Immunology services, has an evaluation site for the Center for Musculoskeletal Care, and will inaugurate a new four-suite endoscopy center in May. The facility will also eventually house the Advanced Lung Disease program and Women’s Imaging services. Also in progress is an expansion at the Shoreline Medical Center in Guilford, where we will shortly open six state of the art operating rooms and additional imaging services. The clinical services at our Old Saybrook Medical Center and at One Long Wharf in New Haven are also expanding.

While increasing access to specialty services is essential to our ability to serve our patients wherever they are, we must acknowledge and address the immense challenges to providing adequate access to primary care. As a health system, we will commit to enhancing our relationships with primary care providers - be they employed, members of the faculty or members in community practice - by enhancing our ability to provide timely communication regarding the clinical issues of our shared patients, improving timely and easy access to services in a patient and provider-centric fashion, and consciously dismantling barriers to high value care that have developed in our geography. To do so, we will invest in key infrastructure to facilitate communication, access and coordination, and partner with those who share our values - as in the case of the Federally Qualified Health Centers, who provide essential care for our most vulnerable patients.

These programs are substantial, and illustrate that we recognize the need to enhance patient-centered communication and access to care in venues more integrated into the many communities we serve. This work requires ongoing engagement with our medical staff, and I welcome your input and involvement in shaping our ongoing evolution in the ambulatory space. As ever, I can be reached via email at [email protected]. Happy Spring!

 

Patient Safety and Quality Metrics

 

The Patient Safety and Quality metrics are reported on a 12-month rolling timeframe. The most recent timeframes differ based upon the various databases reporting the metrics. 12-month rolling total updated with AHRQ v6.0 definition starting January 2017.

Patient Safety and Quality Metric Definitions

Colon and Hysterectomy SSI: A surgical site infection within 30 days of the operative procedure, classified as superficial, deep, or organ/space infections based on CDC/NHSN surveillance definitions.

C. diff (Clostridium difficile): A patient who develops diarrhea greater than 48 hours after admission to an inpatient unit and for whom the C. diff testing (either rapid toxin, cytotoxin or PCR) is positive.

CAUTI (Catheter Associated Urinary Tract Infection): A patient who has an indwelling urinary catheter in place for over two days, with at least one of the following signs or symptoms: fever > 38○ C, suprapubic tenderness (with no other recognized cause), costovertebral angle pain/tenderness (with no other recognized cause), urinary urgency (not while catheter in place), urinary frequency (not while catheter in place), or dysuria (not while catheter in place).

CLABSI (Central Line Associated Blood Stream Infection): A primary bloodstream infection (not related to an infection at another site) that develops in a patient with a central line in place over two days before onset of the infection. Culturing the catheter tip is not a criterion for a CLABSI.

Iatrogenic Pneumothorax: A pneumothorax caused by medical care, with certain exclusions for trauma, cardiac and thoracic surgery patients.

PE/DVT (Pulmonary Embolism/Deep Vein Thrombosis): Any PE/DVT that occurs postoperatively.

Serious Safety Event: A deviation from generally expected care that results in moderate to severe patient harm.

 

New protocol addresses unsigned orders

The Medical Records Committee for Yale New Haven Hospital is implementing a new protocol related to unsigned orders for all ED and inpatients at the York Street and Saint Raphael campuses. Beginning in May, providers' access to Epic will be "read only" until they address their unsigned orders older than seven days.

The committee found instances were providers did not sign orders for inpatients, which creates regulatory risk and leaves hospital charts incomplete. Unsigned orders exist in charts that providers may not enter again (i.e. patient was discharged or transferred to a different service).

Epic will present providers with their own unsigned orders greater than seven days upon entering any patient's chart so that they can be addressed (either signed or declined). Until they are addressed, Epic will be read-only. If an emergent order entry is needed, this screen can be temporarily bypassed. 

Direct questions, via email to: [email protected].         

 

YNHHS improves echocardiogram Epic order process

A clinical redesign team project that originated at Bridgeport Hospital's echocardiography laboratory identified several opportunities where decision support could improve workflow and create better long-term solutions across Yale New Haven Health.

Findings and recommendations from a multidisciplinary team with representatives from across the YNHHS (including cardiologists, sonographers and department leaders from the echo departments) resulted in the following changes to the echo orders within Epic as of March 26, 2019:

• The number of available choices for "echo" orders has been reduced.
• Order names no long indicate "contrast. " Wording has been changed to "Image Enhancement."
• "Reason for Exam" is now a drop-down list that considers appropriate use criteria for performing an echo, with the "Other" option and ability to input free text.
• The "Order Priority" quick button list will include "Discharge Dependent" for all echo exams except transesophageal echoes.
• A best practice alert will fire if the patient has had a finalized study within the prior six months.

 

Use of mobile devices to capture images

Mobile technology has been deployed and is widely used by clinicians to secure and share clinical images for patient care. It was recently discovered that mobile devices (Haiku, Mobile Heartbeat) are being used inappropriately to capture images of documents which is outside of their intended use.

Mobile devices should never be used to capture documents as they will appear incorrectly in the photo document type and will not be available to other clinicians for patient care. In an audit limited to the last two month only, 23,000 documents were uploaded inappropriately (e.g. informed consents, telemetry, EKGs, etc.) and not indexed correctly for access in Epic.

Prescribed workflows are in place on each clinical unit to support timely upload/access to documents in Epic within either a one-hour STAT or 24-hour turnaround time. For more information on how to use established workflows for timely upload of documents in the hospital setting, please see a business associate on a clinical unit, contact Health Information Management at [email protected] or contact the Help Desk at 203-688-4357.

Key Points:

• Do not use mobile devices to capture documents.
• Follow established workflows on clinical units to ensure timely document capture which is accessible to others.
• When uploading patient photos, enter a brief description of the photo so that other users can easily identify the content.
• Periodic audits will be performed to ensure appropriate use of mobile devices to capture patient photos and prescribed workflows are followed for document capture.

 

Project ASSERT expands and celebrates 20 years of providing lifesaving substance use services

This year marks the 20th anniversary of Project ASSERT (Alcohol & Substance use Services, Education, & Referral to Treatment), an innovative program that provides lifesaving services to Yale New Haven Hospital Emergency Department patients with substance-use disorders.

A partnership between YNHH and Yale School of Medicine's Department of Emergency Medicine, Project ASSERT will soon be expanded to other emergency departments and clinics throughout Yale New Haven Health System.

The joint university-hospital effort recently received a $4.8 million grant from the federal Substance Abuse and Mental Health Services Administration to provide services in Greater New Haven, Bridgeport and New London. With some of the highest numbers of opioid overdose deaths in Connecticut, these cities have the greatest need for increased access to substance-use disorder (SUD) services.

Established by the YNHH Emergency Department (ED) in 1999, Project ASSERT has connected more than 52,200 ED patients with community-based alcohol and drug treatment services. The program now employs six health promotion advocates who work with ED patients seven days a week. Recently, the program collaborated with the Yale Program in Addiction Medicine to launch the Yale Addiction Medicine Consult Service (YAMCS). Led by medical director Melissa Weimer, DO, YAMCS is a multidisciplinary service designed to meet the needs of hospitalized patients with SUDs.

Gail D'Onofrio, MD, YNHH chief of Emergency Medicine and Yale School of Medicine chair of Emergency Medicine, is principal investigator for the project. "I am excited about the collaboration with hospital and community leaders throughout Yale New Haven Health," she said. "By greatly expanding the geographic region we serve, this grant will allow us to enhance partnerships and serve a broad range of patients with substance-use disorders."

YNHHS Project ASSERT will expand SUD screening, intervention and referral services to patients at risk for or having moderate or severe SUD, focusing on patients who are uninsured or covered by Medicaid. Project ASSERT aims to train 1,125 providers and staff over five years at each participating site on Screening, Brief Intervention, and Referral to Treatment, an evidence-based approach to identifying and treating individuals with SUD. In addition, the program will prepare 20 or more primary care providers to prescribe buprenorphine at their practices. It will also integrate evidence-based SUD screens within Epic to facilitate patient screening in participating primary- and emergency-care settings.

Connecticut is among the 10 states with the highest rates of opioid-related overdose deaths —with 27.4 deaths per every 100,000 people. Opioid overdoses kill more people in the state than car accidents or gun violence.

"We are extremely proud that for 20 years, Project ASSERT staff have been at the forefront of battling this epidemic. We hope that expanding the project will be a huge step toward reducing morbidity and mortality associated with substance use disorders," Dr. D'Onofrio said.

Members of the Project ASSERT team (l-r): David Pagano, inpatient health program advocate; Gregory Johnson, MS; Amanda Lewis, HPA;  Sue Bogart, Shevonne Mack, DARC.MSW; Caitlin Malicki, MPH, project director.

 

National Healthcare Decisions Day targets awareness

Yale New Haven Health observed National Healthcare Decisions Day Tuesday, April 16, to raise awareness, educate and empower healthcare providers and the public about advance care planning.

 

To help highlight the importance of advanced care planning to patients, YNHHS sent an e-mail communication to patients encouraging them to:

• View an educational video, Who Speaks for You: Choosing Someone to Make Healthcare Decisions if You Can't: https://www.my-emmi.com/SelfReg/YNHHSPROXY
• Review information and forms related to Advanced Directives, Appointment of a Healthcare Representative, and Treatment Preferences and Living Will
• Discuss these forms with their loved ones and physician

The e-mail was sent to patients over 35 years of age who have had an encounter in our health system and provided an e-mail address that is captured in the medical record. The forms can also be found in Epic under "Tools" and clicking "Advanced Care Planning."

On April 16, department representatives discussed the benefits of making wishes known in advance, and advance directives brochures and legal forms were available. Visit http://inside.ynhh.org/Pages/National-Healthcare-Decisions-Day.aspx for documents and links to additional resources.

New system-wide policies and procedures

Yale New Haven Health recently approved the following policies and procedures. Follow the link to learn more about each one:

 

• Grant Submission and Award Management
• Evaluation and Management of Healthcare Worker Occupational Exposure to Blood and Body Fluids
• Reusable Instrument Handling
• High Level Disinfection Using the Trophon
• Patient Identification
• Temporary Cardiac Pacemakers (Transvenous, Epicardial)
• Informed Consent
• CT Simulation
• Delegation of Services for Outpatient Pharmacy Services at Yale New Haven Health
• Infection and Safety Control at Outpatient Pharmacy Services at Yale New Haven Health

 

Email reminder: do not use patient information in the subject lines

Policy and procedure related to the YNHHS Electronic Communication of Sensitive Information Standard stipulates that staff are not to include any protected health information (PHI) in the subject line of hospital/health system emails. This includes account numbers, medical record numbers and patient names, even if the email is sent internally. If you receive an email with PHI in the subject line, be sure to remove the PHI from the subject line when replying.

Here are a few additional reminders:

• Do not include PHI in the subject line of emails.
• Ensure the email address(es) to which messages that contain PHI or other sensitive information are being sent have been verified and are appropriate (e.g., same/similar names).
• Email communications containing sensitive information do not need to be encrypted when sending emails locally within the network. For example, emails sent to: ynhh.org; yale.edu; greenwichhospital.org; bpthosp.org; lmhosp.org; westerlyhospital.org.
• External electronic communication with PHI or other sensitive information must be sent encrypted. Type Encrypt in the subject field. There must be a space between the word encrypt and any other characters in the subject field. Encryption and the approval of the sender's vice president are required for any electronic communications containing PHI or other sensitive information sent to external email addresses.

For more information, contact the OPCC main office 203-688-8416, [email protected].

Newsmaker

Ken Yanagisawa, MD, FACS, managing partner of Southern New England Ear, Nose, Throat & Facial Plastic Surgery Group, LLP, has been elected to serve as chair of the Board of Governors (BOG), American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). The BOG is the grassroots member network comprised of local, state, regional and national Otolaryngology-Head and Neck Surgery Societies and works with the AAO-HNS Board of Directors to improve policies and program offerings. Dr. Yanagisawa oversees the Governance and Society Engagement, Legislative Affairs, and Socioeconomic and Grassroots committees. His goals for the year include advancing communications, networking, practice management and engagement opportunities for all otolaryngologists, especially those in private practice. The 2019 BOG Spring Meeting, set for Alexandria, Virginia, in April, will focus on academy strategic plan initiatives including advanced practice providers incorporation, provider wellness, advocacy and quality measure development. Dr. Yanagisawa continues to serve as chief of Yale New Haven Hospital's Saint Raphael Campus and is active in legislative efforts with the Connecticut Ear Nose and Throat Society.

In memoriam

The Medical Staff Administration Office is saddened to report the passing of Jacob Loke, MD, and David Dreyfus, MD, PhD. Dr. Loke, 78, internal medicine/pulmonary and critical care, died Jan 9, 2019. Dr. Dreyfus, 59, pediatrics/immunology, died Jan. 14, 2019.