To keep Lee Health leaders and our medical staff updated on the latest developments through the Clinical Collaboration Council, we are proud to launch the CCC Update newsletter. This monthly publication contains the latest news and information about the CCC and the work being done to apply health system-wide best practices and standards. The newsletter provides an overview of the active Clinical Consensus Groups and workgroups and details the next steps for each project as it moves toward implementation. The first issue was distributed via email on Feb. 22 to physician’s preferred email on file in the Medical Staff Office. If you would like to be added to the distribution list, please email ClinicalCollaborationCouncil@LeeHealth.org. To establish access to the CCC Sharepoint site, please contact Lisa Markgraf at Lisa.Markgraf@LeeHealth.org.

FEBRUARY, 2018

CCC UPDATE NEWSLETTER LAUNCHES NEW & REVISED ORDER SETS – JANUARY PHARMACY & THERAPEUTIC COMMITTEE UPDATE - FEBRUARY CDI DOCUMENTATION NEWS FROM THE MEDICAL LIBRARY CONTINUING MEDICAL EDUCATION EMERGENCY DIAL CODES PHYSICIAN OF THE MONTH PHYSICIAN NOMINATION FORM ARTICLES SUBMISSION

ISSUE 2

Medical Staff Matters

REVISED 3947 ATRIAL FIBRILLATION OBSERVATION ORDERS - CARDIAC DECISION UNIT 3936 SEPSIS ICU SUPPLEMENTAL ORDERS 3948 SEPSIS ICU ADMISSION ORDERS 3646 SEPSIS NON-ICU ADMISSION ORDERS 3849 MED SURG/PCU ELECTROLYTE REPLACEMENT PROTOCOL 3892 SEPSIS NON-ICU SUPPLEMENTAL ORDERS 3018 NICU ADMISSION ORDERS 3401 ACUTE HEMODIALYSIS ORDERS 3589 ACUTE HEMODIALYSIS SUPPLEMENTAL ORDERS 3778 PERITONEAL DIALYSIS ORDERS 3716 ABATACEPT (ORENCIA) INFUSION ORDERS 3841 ADMISSION PEDIATRIC PERFORATED APPENDICITIS INTERVAL TREATMENT

ORDERS 3642 PEDIATRIC HEMATOLOGY/ONCOLOGY SICKLE CELL ADMISSION ORDERS 3643 PEDIATRIC HEMATOLOGY/ONCOLOGY FEVER/NEUTROPENIA ADMISSION

ORDERS 3805 PEDS HEM/ONC WINRHO ADMISSION ORDERS 3475 SIMPLE DIAGNOSTIC TESTING PRE&INTRA-PROCEDURE ORDERS 3475-A BIOPSY DIAGNOSTIC TESTING PRE & INTRA-PROCEDURE ORDERS 3475-B COMPLEX DIAGNOSTIC TESTING PRE & INTRA-PROCEDURE ORDERS 3725 SKIN TEAR ORDERS EPIC ONLY CHANGES 641 POST-PARTUM/POST C-SECTION ORDERS 1111 POST-PARTUM/POST VAGINAL DELIVERY ORDERS 648 ORAL & MAXILLOFACIAL SURGERY POST PROCEDURE ORDERS OBSOLETED 3664 NURSING COMPLEX WOUND MANAGEMENT PROTOCOL 3806 GENERIC WEIGHT BASED DOSING ORDERS 3807 TOCILIZUMAB (ACTEMRA) WEIGHT BASED DOSING ORDERS 3808 IMMUNE GLOBULIN IVIG (GAMUNEX) WEIGHT BASED DOSING ORDERS 3809 INFLIXIMAB (REMICADE) WEIGHT BASED DOSING ORDERS 3895 BELIMUMAB (BENLYSTA) WEIGHT BASED DOSING ORDERS Paper copies for the remaining 49 post-procedure order sets are also being retired. Epic versions are still in effect.

Return to Index Return to Index

Medical Staff Matters

PHARMACY & THERAPEUTICS COMMITTEE FEBRUARY

Lee Health Inpatient Formulary Addition:

• Dialyvite 800/Ultra D dialysis vitamin was added to formulary as requested by Nephrology. Dialyvite 800/ Ultra HD is the vitamin prescribed for dialysis patients in the community. The P&T committee determined that dialysis vitamins are therapeutically equivalent.

Lee Health Inpatient Formulary Deletion:

• Nephrocap (due to the addition of Dialyvite 800/ Ultra D). Therapeutic Interchanges:

• The P&T committee determined that dialysis vitamins are therapeutically equivalent. The Pharmacy will Therapeutic Interchange prescriptions for all other renal vitamins to Dialyvite 800/Ultra HD or current renal vitamin of choice on formulary.

• Hydromorphone (Dilaudid) injection shortage:

If hospital stock is exhausted, Lee Health inpatient pharmacy will engage the following strategy:

• Approved the ability of the pharmacist to therapeutic interchange on a case-by-case basis injectable hydromorphone to injectable morphine using a 1 mg to 4 mg ratio (e.g.; if hydromorphone 0.5 mg is prescribed it would be changed to morphine 2 mg).

• The pharmacist would indicate in the Order Mode dialog box “P&T Committee approved interchange due to national shortage of hydromorphone injection”.

• D5Lactated Ringers & Lactated Ringers IV Fluid Shortage:

If hospital stock is exhausted, Lee Health inpatient pharmacy will engage the following strategy:

• Prescribers should consider alternatives such as D5NS, D5 1/2NS, NS, etc.: • The pharmacist will therapeutically interchange D5NS for D5LR and NS for LR if the patient’s

sodium level is normal or low. • If patient’s sodium is high substitute D5 1/2NS for D5LR and ½ NS for LR • When making the substitution have the pharmacist use the “Notify-Initiate Hospital

Policy/Protocol” order mode which sends the order to the prescriber for co-signature. • Make a note in comment field in the Order Mode dialogue box that lets the prescriber know why

we made the change; “P&T approved substitute due to national shortage of D5LR or LR”

Return to Index

Medical Staff Matters

PHARMACY & THERAPEUTICS COMMITTEE FEBRUARY

ADDITIONAL DRUG INFORMATION:

Metoclopramide (Reglan) Injectable products shortage.

Conservation strategies (switching to oral therapy) and alternate anti-emetic agent choices will be of value in managing through this metoclopramide shortage. Providers should consider alternatives for N&V such as oral metoclopramide, ondansetron, dexamethasone, droperidol or haloperidol, phenothiazine anti-emetics, less emetogenic anesthesia, or other non-pharmacological approaches. In situations where metoclopramide is being used for other indications alternatives should be discussed with a pharmacist.

https://www.ashp.org/Drug-Shortages/Current-Shortages/Drug-Shortage-Detail.aspx?id=611

Alvimopan (Entereg) is on backorder - Alvimopan is a MU receptor opioid antagonist indicated for prevention of post-operative ileus currently restricted for use by colorectal surgeons. It is currently on national backorder and may not be available in the near future. Please use alternatives such as limitation of opioid use, chewing gum, early enteral nutrition, bran, laxatives, early ambulation, etc. as there are No alternative similarly acting pharmacological options available. ADDITIONAL POLICY INFORMATION:

Antimicrobial stop dates: Pharmacist revision of EPIC entries to match the intention stated in prescriber clinical note The pharmacist may enter a criteria based modification for an existing order of an antimicrobial agent without contacting the provider if the current stop date or duration of therapy does not match the duration stated in the prescribers clinical note. For other issues regarding antimicrobial therapy, a dialogue with the prescriber/provider will be required. MRSA PCR Nares Screening Ordered by the Pharmacist as an Antimicrobial Stewardship Initiative

The MRSA PCR nasal screening test is a method utilized by many institutions to assist in de-escalating antibiotic therapy in patients being treated for pneumonia. This test has been shown to have a specificity and negative predictive value of 92% and 98%, respectively in assessing a patient’s likelihood of having MRSA pneumonia, and is therefore a valuable tool in guiding anti-MRSA therapy de-escalation in this setting. With committee approval under the Medication Therapy Monitoring Pharmacist and Physician Collaboration Policy, pharmacists may now order a one-time MRSA PCR nasal screening test on all patients initiated on IV vancomycin, IV/PO linezolid or tedizolid for an indication of pneumonia. Results and therapy recommendations may then be discussed with the attending physician. Education will be provided to pharmacists to communicate the significance of the test and the appropriate ordering procedure.

Return to Index

Medical Staff Matters

PHARMACY & THERAPEUTICS COMMITTEE FEBRUARY

Current drug shortages:

• Alvimopan (Entereg) – critical shortage, variable supply • Amino Acid Injections & Clinimix (all presentations) - critical shortage, supply extremely limited • Bumetanide Injection - critical shortage, not being supplied • Bupivacaine 0.25% & 0.5% with epinephrine, all sizes - critical shortage, variable supply • Bupivacaine 0.5% SDVs - critical shortage, variable supply • Dextrose 5% in Ringer’s lactate 1000 mL – critical shortage, not being supplied • Diltiazem Inj (all presentations) – critical shortage, variable supply • Diazepam Injection 10 mg/5 mL – critical shortage, not being supplied • Fentanyl Injection, all sizes - critical shortage, variable supply • Heparin 1000 U in NS 500 mL - critical shortage, not being supplied • Hydromorphone 0.5 mg & 1 mg Injection - critical shortage, variable supply • Hydromorphone 10 mg/mL 5 mL - critical shortage, not being supplied • Labetalol Syringes 20 mg/4 mL – easing shortage, supplied limited • Lidocaine 0.5%, 1%, 2% with epinephrine, all sizes - critical shortage, not being supplied • Lidocaine 1% plain - critical shortage, variable supply • Lidocaine 2 g in D5W 250 mL - critical shortage, not being supplied • Metoclopramide 10 mg/2 mL - critical shortage, not being supplied • Meperidine 25 mg Inj - critical shortage, not being supplied • Morphine Injection – 2 mg & 4 mg – critical shortage, variable supply • Potassium Chloride 10 mEq and 20 mEq in 100 mL - critical shortage, variable supply • Ropivacaine 0.2% (all presentations) - critical shortage, not being supplied • Sodium Chloride 23.4% Injection - critical shortage, not being supplied • Sodium Phosphate Injection - critical shortage, variable supply • Sterile Talc Powder for Insufflation – no current stock, not being supplied, future supply questionable • Water for Injection - critical shortage, variable supply

Return to Index

Medical Staff Matters

Top 10 Queries sent in 2017

Total Queries Sent - 14,041

1. Malnutrition (CC or MCC) HCC: 2,657

Remember to refer to RD consult notes for weight loss and, lack of intake, fat/muscle deficits

2. BMI over 25: 1,023 Overweight, obesity, and morbid obesity with correlating BMI Morbid obesity= HCC

3. Pneumonia (MCC) HCC: 885 Try to specify type based on treatment given Unspecified pneumonia’s are NOT HCC

4. CHF (CC or MCC) HCC: 857 Acute or Chronic Diastolic or Systolic if echo is available for reference

5. CKD: 676 Note the Baseline GFR, Creat, BUN to determine stage AKI, CKD stage 4 and ESRD= HCC

6. CDI rule in rule out: 665 Try to be on the same page as consults

7. Acute Anemia (CC): 590 Acute blood loss anemia & iron deficiency anemia

8. Diabetes HCC: 582 linked to a Manifestation (i.e.: hyperglycemia, CKD, neuropathy etc.)

9. A-fib (CC) HCC : 570 Chronic, paroxysmal, persistent or stated as “new onset”

10. Respiratory Failure (CC or MCC) HCC: 407 - Acute, acute on chronic, or chronic and Hypoxia vs. hypercapnia - Use a diagnosis rather than symptom i.e.: SOB, tachypnea

- Acute Respiratory Distress is not a codeable diagnosis unless intent is to capture Acute Respiratory Distress Syndrome

- Respiratory Insufficiency = Other abnormalities of breathing in coding Terms

Return to Index

Medical Staff Matters

Majority of these queries are heavy weighted HCC (Hierarchical Condition Category)-> increases SOI/ROM, case mix index, & major impact on risk adjustment and pay for performance programs

All diagnoses when pertinent reflect a higher severity of illness and risk of mortality.

CDI’s goal: to reduce the amount of query’s sent by having these diagnoses captured at the time the note is created.

Don’t Forget!

Please try to answer all of your queries on the same patient at the same time.

Breen Nabors RN

Clinical Documentation Improvement Educator Breen.nabors@LeeHealth.org

Return to Index

Medical Staff Matters

Earning CME credits through DynaMed Plus, the point-of-care evidence-based database, became easier.

User searches are submitted via DynaMed Plus to Tufts Healthcare Institute. Users are no longer required to set up separate accounts in Tufts. Tufts automatically sets up the accounts using information users provided when creating their DynaMed Plus Personal Accounts.

• If you don’t have it yet, create your DynaMed Plus Personal Account:

o Access DynaMed Plus from a hospital workstation – Databases page on the Medical Library website on IntraLee

o Select "Sign in/Create Account" in the upper right-hand corner of the screen o Provide your name, email address and specialty o You will receive a time sensitive e-mail from DynaMed Plus to set up your password o Once the password is created, you can log in to DynaMed Plus at www.dynamed.com/login

with your e-mail address and password from any browser, on any device from anywhere.

• How to redeem CME credits in DynaMed Plus:

o Sign into DynaMed Plus with your personal user ID and password o Conduct a search on your topic of interest. o As you read DynaMed Plus topics, CME credits are automatically added to the CME tab. o When you are ready to submit your CME credits, click CME in the toolbar o Click the Prepare for Submission link for the credits you would like to submit o Fill out the Required sections and add Optional comments if you wish o Click the Submit button to submit the credits you have prepared o Look for an email with a copy of your certificate o Access a PDF of your CME certificate from the Claimed Credits tab.

This new, simplified procedure will come into effect on March 15, 2018. You may still use your old user IDs and passwords, just remember to log-in before you start searching to take advantage of automatic CME tracking.

Return to Index

Medical Staff Matters

Pediatric Grand Rounds: “Calming the Storm:

Management of Delirious, Agitated and Combative Pediatric Patients from the ED to the ICU”

Brian Shultz, M.D. Christina Martin, PharmD

Thursday, March 15, 2018 6:30 – 7:30 PM Healthpark Medical Center • Captiva Room

Target Audience: Pediatricians, Family Practice Physicians, Advanced Providers, Nursing staff Learning objectives: Audience will be able to reference diagnostic considerations regarding pediatric delirium. Understand the pCAM-ICU scoring tool and monitoring parameters. Compare and contrast adult and pediatric methods for the treatment of

delirium and agitation. Discuss emerging trends for the use of ketamine in the pediatric population RSVP for CME and dinner – 239-424-2680 or CME@leehealth.org

LPG Hospital Medicine: CLABSI and CAUTI UPDATE Tuesday, March 20, 2018 12:00-1:00 PM

Healthpark Medical Center • Captiva/Sanibel Rooms Target Audience: Physicians, Physician Assistants

Learning Objectives: Define CMS CAUTI/CLABSI current state, review new guidelines on CLABSI/CAUTI, and discuss local and national data.

Available via WebEx

LPG Hospital Medicine: “Pneumonia” Kenneth Tolep, M.D., FCCP

Tuesday, March 27, 2018 12:00-1:00 PM Healthpark Medical Center • Cayo Costa Room

Target Audience: Physicians, Physician Assistants Learning Objectives: Discuss microbiology of community and hospital acquired PNA, Identify appropriate diagnostic strategies

for patients with PNA, Discuss selection of appropriate PNA therapies Available via WebEx

Lee Health is accredited by the Florida Medical Association to provide continuing medical education for physicians. Lee Health designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Lee Health is an approved provider of continuing Nursing Education (FBN2151). Lee Health has applied for 1 contact hour for this lecture. Faculty and Lee Health will disclose any real or apparent conflict of interest related to the content of the presentation. Faculty will also identify any off label or investigational uses discussed as such.

Return to Index

Medical Staff Matters

Continuing medical Education

MOVEMENT DISORDERS FOR THE

“NON NEUROLOGIST” Saturday, March 24th, 2018

7:30AM-2:45PM

Charlotte Harbor Event & Conference Center 75 Taylor Street Punta Gorda, Florida 33950 AGENDA: 7:30 to 8:00 am: Continental breakfast/registration 8:15 to 9:15 am: “Drug Induced Parkinsonism, Essential & Parkinsonian Tremor” Daniel D. Dees, M.D. 9:15 to 10:15 am: “Psychogenic Movement Disorders “ - John Morgan, M.D. Break 10:30 to 11:30 am: “Parkinson’s disease Psychosis” - Ramon Gil, M.D. 11:30 to 12:30 pm: “Tardive Dyskinesia” - Daniel D. Dees & John Morgan Lunch 1:15 to 2:15 pm: “Neurogenic Orthostatic Hypotension” - Ramon Gil, M.D. 2:15 to 2:45 pm: Q’s and A’s Learning objectives:

• Understand the pathophysiology of Tardive Dyskinesia (TD), Parkinson’s Disease Psychosis (PDP) and Neurogenic Orthostatic Hypotension (NOH)

• Properly diagnose patients with TD, PDP or NOH and effectively treat them

• Understand the mechanism of action of the agents used for the treatment of these three common disorders

• Use non-pharmacologic interventions as part of the treatment NOH and PDP and common pitfalls to avoid when managing the population of patients at risk for these three disorders

• Enhance the quality of a multidisciplinary approach in the evaluation and treatment of these disorders, with the ultimate goal being to optimize patient’s management and quality of life

• Recognize the differences between Essential Tremor and PD tremor

• To recognize clinical features often indicative of a psychogenic movement disorder

Lee Health is accredited by the Florida Medical Association to provide continuing medical education for physicians. Lee Health designates this live activity for a maximum of 5 AMA PRA Category 1 Credit(s)TM. Lee Health is an approved provider of continuing Nursing Education (FBN2151). Lee Health has applied for 5 contact hour for this lecture. Faculty and Lee Health will disclose any real or apparent conflict of interest related to the content of the presentation. Faculty will also identify any off label or investigational uses discussed as such.

Target Audience: Physicians Advanced Practitioners Nursing staff FACULTY: Daniel D. Dees, M.D. Assistant Professor of Neurology University of South Alabama Mobile, AL John Morgan, M.D. Assistant Professor of Neurology Movement Disorders Division Augusta University, Medical College of Georgia Ramon A. Gil, M.D. (Course Director) Medical Director Parkinson’s Disease Treatment Center of SW FL Port Charlotte, FL

REGISTRATION FEES: Physicians $150.00 Physician Assistants and Nurse Practitioners $100.00 Rehabilitation therapists, nursing and other health care allied members $50.00. Residents and Fellows (free with a letter from the School) For online registration please visit: https://bookeo.com/leememorial EARN 5 CME/CNE CREDITS

Return to Index

Medical Staff Matters

Return to Index

Medical Staff Matters

Emergency Dial Codes changed to 444

Lee Health is dedicated to safe, quality health care. When an emergency occurs, clear communication is important for quick response to protect patients and staff. One way to ensure the quickest response in an emergency is to standardize emergency dial codes. Effective May 1, 2016, the emergency dial code in all Lee Health hospitals has changed to: 444. The emergency code system notifies staff about an event that requires immediate action. The intent is to relay urgent information in a timely, understandable manner and elicit a prompt and proper response. Standardizing the dial code across the system provides clarity since employees often work in more than one facility, sometimes within the same day. All gold card emergency information listings have been updated to reflect the new 444 dial code, and you may notice reminders posted near employee time clocks and volunteer check-in stations. Team meetings and huddles are great opportunities to remind staff of this important change, and to review all emergency codes. For more information, or if you have any questions, please see your immediate supervisor.

Return to Index

Medical Staff Matters

PHYSICIAN OF THE MONTH - JANUARY ANTHONY PIETRONIRO, M.D. - PEDIATRICS

THE STAFF AND ADMINISTRATION OF LEE HEALTH ARE PLEASED TO ANNOUNCE ANTHONY PIETRONIRO, M.D. AS JANUARY PHYSICIAN OF THE MONTH.

WE SALUTED DR. PIETRONIRO FOR EXEMPLIFYING THE QUALITIES OF AN EXCELLENT PHYSICIAN AND WE ARE PLEASED TO HAVE HAD DR. PIETRONIRO AS A RESPECTED MEMBER OF OUR MEDICAL STAFF SINCE JANUARY, 1996.

• DR. PIETRONIRO HAS AN IMPECCABLE REPUTATION OF DEDICATION, LOYALTY AND COMMITMENT TO HIS PATIENTS.

• DR. PIETRONIRO IS OFTEN IN THE HOSPITAL WEEKENDS AND EVENINGS VISITING HIS PATIENTS AND ASSURING THAT THEY ARE RECEIVING THE FINEST CARE FROM OUR SUBSPECIALTIES.

• DR. PIETRONIRO HAS A LONG STANDING HISTORY OF DEDICATION AND EXCELLENCE CARING FOR CHILDREN IN OUR COMMUNITY.

• DR. PIETRONIRO’S WORK IS AIMED TO ENSURE THE SAFETY AND WELL-BEING OF EVERY CHILD IN NEED.

• DR. PIETRONIRO CARES ABOUT THE PERSON, THE PATIENT AND THE SYSTEM. HE IS A GREAT MENTOR AND GREAT PEDIATRICIAN. IF I CAN BE AS THOROUGH AND CARING AS HE IS A DOCTOR, THEN I WILL HAVE SUCCEEDED IN THIS PROFESSION.

• DR. PIETRONIRO LONG STANDING CAREER MARKED BY HIGH LEVEL OF PROFESSIONALISM: CARING AND COMPASSIONATE ATTITUDE TOWARDS PATIENTS, COLLEGIAL AND COLLABORATIVE INTERACTIONS WITH PEERS AND STAFF.

CONGRATULATIONS DR. PIETRONIRO!

THANK YOU FOR ALL YOU DO.

Return to Index

Medical Staff Matters

PHYSICIAN OF THE MONTH NOMINATION FORM

Please take a moment to nominate the physician that Wows you! Nominations should be based on criteria such as consistent quality, attitude, professionalism, compassion, and going “above and beyond” what is reasonably expected. Lee Health wants to recognize physicians who exemplify these qualities of excellence.

Physician’s Name: ______________________________________________________________

Specialty: _____________________________________________________________________

Reason for Nomination: __________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Name (optional):________________________________________________________________

*Dept/Area:____________________________________________________________________

*Your Facility/Location:__________________________________________________________

*Award presentations are customarily scheduled in the unit where the most nominations are received.

Please click here and fax nomination to 239-343-0487, e-mail to POM@leehealth.org or interoffice mail to

PHYSICIAN OF THE MONTH FORM

Return to Index

Medical Staff Matters

Has your email address changed for your home or office?

Please email Kim Coombs at Kim.Coombs@leehealth.org or call her at 239-343-2142 with your new email address

Please submit any future

Medical Staff Matters Newsletter Articles to:

Yolene Derissaint, CPCS, CPMSM via e-mail at

Yolene.Derissaint@LeeHealth.org

Return to Index