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                      WEDNESDAY, JUNE 4, 2008


1.   New Inpatient Diabetes Protocol - This protocol is scheduled to be introduced on
     a hospital wide basis on 6/17. It has been in development over the last year and
     has involved physicians, nurses and diabetic educators from across the entire
     Hospital community. Jim Mersey, Chief of the Division of Endocrinology and
     Gail Sallitt, Diabetes Program Director of the Geckle Center, will lead the

2.   Meditech Update - What we hope will be a regular feature at this and the
     Department's Executive Committee meetings is a 5minute presentation of
     what Meditech can do for you. A different aspect of the system will be
     highlighted each month. Nursing Notes this month.

3. Dr. Fred Chan, Director of the Hospitalist Service -Direct Admission Protocol and
   To Observe or Not to Observe.

4. Dr. Neal Friedlander - 1:00 p.m. Discharge Time

5. Open Forum
                     DEPARTMENT OF MEDICINE
                    QUARTERLY STAFF MEETING


TO:           Members of the Department of Medicine

FROM:          Neal M. Friedlander, M.D., F.A.C.P.
               Chairman, Department of Medicine

DATE:         June 13, 2008

RE:         Minutes of the Department of Medicine Quarterly Staff Meeting

As usual there was not enough time in the hour, but a number of operational changes and
problems were discussed with the usual enthusiasm by those assembled. .

1.     New Inpatient Diabetes Protocol Scheduled to Go Live on June 17 - Jim Mersey
       and Gail Sallitt (the latter is head of the Geckle Diabetes center) again presented
       the new protocol. Jim gave a brief lecture as to the evidence that clearly shows
       that inpatients with hyperglycemia have a higher incidence of morbidity and
       mortality than patients who are normoglycemic. Helen Gordon pointed out that
       most of the studies were done in ICU patients but Jim and many other
       endocrinologists accept the fact that it applies to all inpatients. The traditional
       sliding scale doesn't keep patients normoglycemic (by the time you need it, by
       definition your patient's glucose is elevated) but the Basal/Bolus approach (long
       acting insulin such as Lantus and short acting insulin prior to each meal) achieves
       the desired result.

       As of July 14, only the new Diabetic Order Sets will be accepted by nursing, so if
       you write your traditional orders without using the new order sets, you will get a
       call saying your orders can't be accepted. The Nurse Practitioners will be
       available to help. The Order Sets and the Pocket Guide, copies of which are
       attached, are very straightforward and a few minutes with them are what you need
       to familiarize yourself.

       This new Inpatient Diabetes Order Set is part of a hospital wide 2-year effort
       involving all Departments. We know there will be some glitches, some gnashing
       of teeth when orders aren't accepted and revisions down the road. Nonetheless,
       this is the right thing to do for our patients and now is the time.

       Any questions, Jim, Gail and I are happy to try to help.
2.   Single Sign ON - Information Technology, with all the right intentions,
     formulated a new program that with one sign on, access to all Hospital
     computer systems would be achieved. It was done for HIPAA reasons among
     others. What has occurred is that a computer is "locked" if an individual signs on
     and forgets to log off when they leave. This happens all the time on the floor and
     computers which are on short supply on the units as it is are even less available.
     Information technology, under the leadership of Tressa Springmann and Patricia
     Duty, has resolved that problem and others. A special kudos to Pat who showed
     grace under pressure as she fielded the physician complaints/comments at the
     meeting. Attached is her memo discussing the problems and the solutions-all of
     which are now in effect. Also, thanks to Alan Kimmel who worked closely with
     IT on these issues. Remember IT is always a work in progress.

3.   Kate O'Connor-Devlin of Nursing who will act as our Meditech guru (and at each
     meeting will give a 2 minute demonstration of how to solve a particular problem
     with Meditech), discussed accessing nursing notes via Meditech.

     These notes may not be quite as comforting as the old hand written nursing notes
     but if you log onto Meditech, at the bottom of the screen is a box marked
     "Assessment and Notes. "Click onto that and all the notes by the nurses are
     available. Also don't forget the box "Care Trends" which can tell you system by
     system how your patients are doing. Even appropriate skeptics like John
     Covington and Alan Kimmel are relatively satisfied with the system but we will
     keep working on it. Any questions, Kate is happy to help.

4.   Fred Chan discussed the Direct Admissions Protocol which are straightforward.
     They are attached to this email and have been distributed last month with the DEC
     minutes. Kate O'Connor-Devlin will make sure the Admitting Office has the new
     Diabetic Order Sets that can be faxed to you if you need to admit a patient with
     issues of diabetes/hyperglycemia (e.g. steroid induced).

     Fred didn't have time to discuss the issue of whether to admit a patient as a
     "Regular Admission" or as an "Observation Status." Getting it right is very
     important to the Hospital. I am attaching a memo I sent to all the Department
     Chairs who requested a summary of this issue. I am happy to kick the tires with
     you on this issue if you have any questions.

5.   1 P.M. Discharge - As of June 2, there is a Hospital wide effort to achieve this
     goal. Failure to do so only means that our patients get backed up in the ED and
     patient care doesn't flow. Every Hospital in the community struggles with this

     I realize how important the discharge visit is. It's the moment when you make
     sure that medicines, discharge instructions and follow-up are clear. It takes time,
     but it has to be our goal that we meet the 1 P.M. discharge time. Prepare your
     patients and their families when they are admitted that this is the time. The Nurse
       Practitioners have been instructed to try and anticipate who is going home and to
       call you in the morning to see if there is anything that they can do for you. Paul
       Foster and the Faculty have adjusted their rounds to take this goal into account
       and Fred, Chris and Rekha and the Hospitalists are also changing their rounding
       patterns. The lab now has a shift that starts at 4 A.M. to have the morning labs
       done promptly and Meditech has a box that allows you to let Radiology and other
       testing centers know that you anticipate your patient going home that day and do
       those patients first. Care Managers have been alerted to help as well.

       So when you get calls about discharges, please accept these calls with grace. The
       people calling you are helping all the patients in the Hospital. This effort is crucial
       if we are going to make a dent in ED Back-Up and forestall yellow and red alerts.
       Once again, let me know of any concerns.

FINALLY, the year is coming to a close and I can visualize fall already. If you are
interested in being appointed to the Department Executive Committee or would like to be
or would like to nominate someone(s) to assume the role of Vice-Chairpersons for a one
year stint (it does carry a small stipend and two people are selected), please call me. No
false modesty. The Medical Staff leadership is focused on identifying those physicians
who might aspire to Medical Staff/Department leadership in the future. This is a way to
get a taste of it.

Have a great month. The next Department of Medicine Executive Committee Meeting is
on Wednesday, July 2, at 7:30 A.M. It is Wander's birthday so you will be asked to sing.


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