450MDSt. Mary’S Medical center

PhySician newSletter

450 Stanyan St.San Francisco, CA 94117

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.

The St. Mary’s Medical Center Graduate Medical Education department maintains a medical library for SMMC physicians, staff and trainees. Printed volumes of many medical journals dating back 10 to 15 years are available on site. We also current-ly subscribe to a small number of print journals, including: • AnnalsofInternalMedicine • CHEST • CriticalCareMedicine • JAMA • JournalofGraduateMedicalEducation • JournalofHospitalMedicine • TheAmericanJournalofMedicine • TheNewEnglandJournalofMedicineAn extensive collection of more than 200 other journals in all major specialties are also available online through our medical school affiliations.

To request journal articles from our library:Fax or E-mail your contact information to (415) 750-8149 or Kimberly.banks@dignityhealth.org. Be sure to include:1.JournalName,2.Author,3.Title*,4.Date, *Fullcitationifavailable

The full-text article will be returned to you via fax or PDF within 72 hours unless an urgent request is submitted. Although it is rarely necessary to obtain articles from obscure journals via inter library loan, the turn-around time for this service is 7 to 10 business days – and possibly more if numerous articles are requested.

SMMC physicians who wish to access on-line journals for browsingshouldcontacttheGMEoffice,locatedat2235HayesStreet,4thfloor,at(415)750-5781between9:00amand4:00pm Monday through Friday.

A small library of medical textbooks is available for on-site reference use. Duplicate copies may be checked out for up to 10 days, and may be renewed if needed for a longer period. MKSAP and Med study Board preparation material are available upon request.

Library material may be printed or copied, but personal photocopying services are not available.

liBrary acceSS and SerViceS

ISSUE 16

May 2012

stmarysmedicalcenter.org

Immediately (within 1 hour) report by phone

• Anthrax*• Botulism*• Brucellosis*• Cholera• CiguateraFishPoisoning• Dengue• Diphtheria• DomoicAcid/Amnesic Shellfish Poisoning • Escherichiacoli:shigatoxin producing(STEC) includingE.coliO157• Foodborneillness(2ormorecases from different households) • Hantavirusinfections• HemolyticUremicSyndrome• Measles(Rubeola)• Meningococcalinfections• ParalyticShellfishPoisoning• Plague*• Rabies• ScombroidFishPoisoning• SevereAcuteRespiratory Syndrome(SARS)• Shigatoxin(infeces)• Smallpox*• Tularemia*• ViralHemorrhagicFevers* (e.g. Ebola, Lassa viruses) • YellowFever• Anyunusualdiseases• Newdiseasesorsyndromenot previously recognized • Outbreaksofanydisease

*PotentialBioterrorismAgents

Within one working day report by phoneorfax

• Amebiasis• Babesiosis• Campylobacteriosis• Chickenpox(onlyhospitalization and death) • Cryptosporidiosis• Encephalitis,infectious (specify etiology) • Haemophilusinfluenzaeinvasive disease (less than 15 years of age)• HepatitisA,acuteinfection• Listeriosis• Malaria• Meningitis(specifyetiology)• Pertussis(WhoopingCough)• Poliovirusinfection• Psittacosis• QFever• RelapsingFever• Salmonellosis(non-typhoid)• Shigellosis• Staphylococcusaureusinfections, severe (ICU/death) in a previously healthy person• StreptococcalInfections, outbreaks of any type and individual cases in food handlers and dairy workers only • Syphilis(3)• Trichinosis• Tuberculosis(4)• Typhoidfever(casesandcarriers)• Vibrioinfections• WestNileVirusinfection• Yersiniosis

Within7calendardaysreportby phone,fax,ormail

• AIDS(1)

• Alzheimer’sDisease• Anaplasmosis/Ehrlichiosis• AnimalBites(mammalsonly)(2) • Chancroid(3)

• Chlamydiatrachomatisinfections(3)

• Coccidioidomycosis• Creutzfeldt-JakobDisease(CJD)• Cyclosporiasis• Cysticercosis• DisordersCharacterized by Lapses of Consciousness • Ehrlichiosis/Anaplasmosis• Giardiasis• Gonococcalinfections(3)

• Hepatitis,Viral• HepatitisB (acute or chronic) • HepatitisC(acute or chronic) • HepatitisD(acuteorchronic)• HepatitisE,acuteinfection• HIV (1)

• InfluenzaDeaths (in laboratory- confirmed cases for age 0-64 years)• Influenza,novelstrains• Legionellosis• Leprosy• Leptospirosis• LymeDisease• Lymphogranulomavenereum(3)

• Mumps• PelvicInflammatoryDisease(3)

• RickettsialDiseases• RockyMountainSpottedFever• Rubella• RubellaCongenitalSyndrome• Taeniasis• Tetanus• ToxicShockSyndrome• TransmissibleSpongiform Encephalopathies (TSE)

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

byDr.JoséEguía

Understatelaw,healthcareprovidersinvolvedinthe care of a known or suspected case of certain medical conditions must report them to the local department of public health. Although any provider can report these conditions, the ultimate responsibility falls to the attending physician or their delegate. The Laboratory will report diagnoses for which they have a positive culture orserologicresult.However,someconditionsaretreated empirically -- without laboratory confirmation -- or have lab testing whose results may be delayed (as in tuberculosis, for example); for these, clinician reporting is essential to allow

Conditions that are Reportable to theDepartmentofPublicHealth

theDepartmentofPublicHealth(DPH)tocarryoutitstasks.Reportableconditionsaremostlyinfectious,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 STDsandtuberculosis.DPHcanalsoprovideadviceon specialized lab testing and post-exposure prophylaxis where appropriate.

Two non-infectious conditions are also required to be reported: Alzheimer’s disease and disorders characterized by lapses of consciousness.

The human conditions that must be reported are listed below; those that clinicians are more likely to come across on a routine basis are in boldface.

Formoreinformation,refertotheSanFranciscoDPHwebsite(www.sfcdcp.com/diseasereporting.html),orcontactInfectionControl(750-4075)orDr.JoséEguía(Bpr:443-0367).

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

comprehensive lung center opens at St. Mary’s

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

St.Mary’sisputtingthefinishingtouchesonitsnewCom-prehensiveLungCenter,whichopenedmid-April,add-inganotherdimensiontothehospital’sabilitytoprovidepatients with the latest in medical technology.

Lung cancer screening will be available to people at high risk for the disease. They can be self referred, or referred by their physician based on their smoking history, or pulmonary symptoms. Screening allows patients to be diagnosed -- using low-dose radiation CT of the lungs -- at an early, curable stage of disease.

Pulmonary patients will also benefit from the center’s mini-mally invasive diagnostic and therapeutic techniques, includ-ingEndobronchialUltrasound(EBUS),whichallowsaphysi-cian to biopsy suspicious lymph nodes and nodules by passing a camera-equipped bronchoscope with ultrasound through the

mouth and into the lung. In the past, such biopsies required in-volved surgeries in order to obtain the same degree of accuracy. With new procedure, patients can go home within hours. Patients requiring surgery will have access to our team, includ-ingournewSMMC-UCSFthoracicsurgeon,Dr.PierreTheo-dore. Dr. Theodore provides a full range of thoracic surgeries, including mediastinoscopy and video-assisted thoracic surgery, which allows surgeons to insert a camera and surgical tools through tiny incisions in the chest to diagnose and treat lung cancer and other pulmonary disease.

Dr.TheodorewillheadthecenterwithDr.JamieBigelow.Dr.Theodore’s areas of expertise include lung neoplasms and lung transplantation. Dr. Bigelow has practiced pulmonary and criti-cal care medicine at Saint Francis Medical Center since 1999.

nurSing Shared goVernance at St. Mary’SShared governance is a model that provides direction for the

professional nursing practice. Nurses participate in unit-based

decision-making, allowing them to demonstrate accountability

and ownership for their practice. According to Tim

Porter-O’Grady, who developed the Shared Governance model,

its goal is to achieve better patient outcomes. St. Mary’s

has four Nursing Councils: the Quality Council, Nurse Profes-

sional Development Council, Nurse Practice Council and the

Nurse Coordinating Council. Our nurses actively participate

in these councils, giving them a voice in determining prac-

tice standards, patient safety, quality and leadership. Shared

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,

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

• Mock Code Blues, which keep our staff’s skills sharp

with virtual reality training

• Staff members can learn and practice procedures

on Sim Man and get immediate feedback from him

cardiac SyMPoSiuM At the March 20, 2012, Cardiac Symposium, topics included

EKG arrhythmia recognition; atrial fibrillation; sudden death

syndrome; implanted devices; anticoagulant therapies;

pharmaceutical reviews of anti-coagulants and anti-platelet

drugs; and preoperative coronary artery stent management.

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: “Veryinterestingandhelpful;hadwonderfulspeakersthat 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!”

“Veryinteresting,informative,goodMDengagement. 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.”

diaBeteS in caliFornia

uPcoMing eVentS • Nurses Week May 6th – 12th

• May 9th Nurses’ Day

St. Mary’S nurSing newS

Advanced Wound aFter hourS clinicAmericans 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 accommo-date busy families – until this month, with the opening of the newAfterHoursMedicalClinic.

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 bytheCaliforniaHealthCareFoundation,themostcommondiagnoses 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(9.5percent);andurinarytractinfections(3.7percent). 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.

Accordingto“HealthMattersinSanFrancisco”andthe CaliforniaOfficeofStatewideHealthPlanningandDevelopment, 18,000 emergency department visits were preventable. A combination of increased working hours for patients and diminished primary care access account for the

unnecessaryuseofemergencydepartments.Dr.Robin WeinickofRANDHealth,oneofthelargestprivatehealthresearchgroupsintheworld,estimatesthat13.7to27.1percentofallemergencyroom(ER)visitscouldtakeplaceinlessinten-sive, walk-in-based care facilities.

DelaysincareandadditionalcostsincurredinERvisitsareadrain on health care resources. Several studies have estimated that costs of care in non-emergency, non-primary care clinics are$279to$460lesspervisitthanERcostsforsimilarcases.

“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 theirstrepthroatcheckedbutcannotgototheERbecauseit’sprohibitively 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 reduceinappropriateERandhospitaluserates.

Phone: (415) 750 -5500Address: 2235HayesStreet 5th Floor (Hayes&Shrader)

St. Mary’s Medical Center and Saint FrancisMemorialHospitalareexcitedto announce a new collaboration to heal complex wounds and avoid unnecessary amputations: The Advanced Wound Healing–AmputationPreventionCenteratSt.Mary’sandtheHyperbaricMedicine Center at Saint Francis.

By bridging these services across two facilities,DignityHealthhascombinednationally recognized surgeons and a highly seasoned hyperbaric medicine team to assure the best possible outcome for patients with a variety of chronic wounds and conditions.

The outpatient wound center at St. Mary’sisledbyDr.DavidM.YoungandDr. Charles K Lee. It specializes in the

By Megan Brunson, Program Director

treatment of wounds that resist healing -- often the result of diabetes, compromised skin grafts, pressure ulcers, radiation tissue damage, trauma, and venous or arterial issues. Patients are treated by a multidisciplinary team of board-certified physicians – general surgeons, vascular surgeons, plastic surgeons, orthopedic surgeons, internists, surgical podiatrists and clinical wound specialists – with a common goal of successful healing and reduction in the risk of amputation. The physicians are aided by advanced technologies in wound care, including bioengineered skin substitutes, negative pressure wound therapy, and hyperbaric oxygen therapy.

The outpatient hyperbaric center at Saint FrancisMemorialHospitalisledbyDr.JamieBigelow.Itprovidesadvancedhyperbaric oxygen therapy for wounds that are resistant to healing by traditional approaches. In this advanced therapy, the patient rests in a chamber for two hours

while breathing pure oxygen at a pressure greater than sea level. Hyperbarictherapyhasbeenshowntoaid in the growth of blood vessels in areas where they have been damaged, which results in expedited healing of the wound. Hyperbarictherapyisalsoeffectiveinthe treatment of many other conditions, including decompression sickness, bone infections and damage caused by therapeutic radiation treatments.

With their unique collaborative approach, St. Mary’s Medical Center and Saint FrancisMemorialHospitalhavecreated a highly respected, specialized interdisciplinary team, capable of formulating a treatment program specifically tailored for each patient’s medical situation. For individuals suffering from diabetic wounds, this center will be especially beneficial. It’s estimated that 24 million people in the U.Ssufferfromdiabetes,whichmakesthem 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 therapy, and a team-based collaboration between podiatric, vascular, and plastic surgeons.

“ It’s estimated that 24 million people intheU.Ssufferfromdiabetes,which makes them susceptible to diabetic ulcers. ”

SanFranciscoMedicalSocietyPerspectivePeteCurran,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 interac-

tive website, exclusive complimentary

access to the HIPAA-compliant smart-

phone 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

stmarysmedicalcenter.org 800.444.2303

Physician Satisfaction SurveyEasy. 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:

Website Link: http://improvingquality.com/?url=chw

1. Enter [Access Code] and click the Login button. This login code is to insure that only one survey is

completed per physician. This code is randomly assigned and will not be used to identify any

physician’s survey responses. (Your access code was mailed to you with an introduction letter from CHW.

If you have misplaced your access code indicated below before completing the survey, please contact

St. Mary’s Medical Staff Office during business hours, or, the hospital operator nights and weekends.

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! FREE $10 Starbucks or Drip Coffee

gift card for completing the survey.Contact the Medical Staff Office to redeem your card.

$10GIFT CARD

NEW INSULIN POWER PLANSince the short acting insulin Humalog replaced

regular insulin on formulary, between meals and

overnight, patients have almost no insulin on board.

The uncontrolled gluconeogenesis causes high

glucose levels before the next meal and overnight.

Used alone it causes a see-saw rise and drop of

glucose putting our patients at risk for both high and

very low glucose levels. To provide the coverage at

very low insulin levels that we used to achieve with

regular insulin, the patients need Lantus (glargine)

insulin to provide that baseline (basal) insulin and

glucose rise. In response to our need for compre-

hensive, easily input orders, the CERNER diabetes

Summit and soft ware writers developed the Insulin

power plan.

Beginning mid May, CERNER goes live with the

power plan that can insure we manage diabetes at

state of the art, best practices, and expert recom-

mendation excellence. The power plan, covers

nursing and pharmacy communications, consistent

carbohydrate diet as well as lab orders. Its great-

est asset is guidance through ordering basal insulin,

so the patient is never without insulin on board plus

insulin for meals and to correct high glucose levels

before meals. CERNER reminds us to order all three

and directs us to the best multiplier for the patient’s

sensitivity to insulin and will do the arithmetic. All

nurses will have received training in the reasons for

this “new” way of providing patient insulin needs,

and why insulin is needed with meals, even if the

before meal glucose is below 160 mg%. There are

super users among house staff, hospitalist and nurs-

ing staff to help with the mechanics, or the reason-

ing behind the orders.

This will allow us to deliver state of the art insulin

care for patients with diabetes and decrease the

roller coaster effects of short acting insulin given

alone and only in response to glucose levels.