hospital medical staff progress notes

l.EH!gHVAILEY HOSPITAL

In This Issue ...

Health Network Laboratories

Reduces Cluuges -Page 2

Needlestick Hotline -Page 4

P & T Highlights - Pages 15-18

Telecotiference Questionntdre

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Medical Staff Progress Notes Volume 5, Number 9

September. 1993

From the President The PHO and IPA

Bylaws with the Provider Agreement has been approved by the Managed Care Committee. At the General Medical Staff Meeting on the 13th, Dan Grauman of the Raleigh Group reviewed our progress to date and our future plans. We are working on the fee schedule and will begin work on the vitally important care aspects of our program ..

At an earlier General Medical Staff Meeting, we presented the Physicians' Assistance Program (PAP). Information explaining the program was distributed to our homes. This program is provided to promote personal and professional well-being of our Medical Staff. It is a confidential program, and no information about a participant is released to outside parties without the participant's knowledge and permission. Also, Medical Staff funds are available to permit free access for up to five sessions. If anyone is interested, please contact Oliver Neith, Program Manager, at 433-8550, John Turoczi, Ed.D., at 481-9161, or Michael W. Kaufmann, M.D., at 402-2810.

The Partnership for Community Health in the Lehigh Valley is presenting a

Town Hall meeting on a proposed Managed Care program for low income and the uninsured on September 20, at 7 p.m., in the Franklin Room of the Holiday Inn, Routes 22 and 512 ' Bethlehem. As you know, the Partnership for Community Health in the Lehigh Valley is a program involving all the area hospitals with Pool Trust funding to address the health care of the poor and uninsured in our area. I encourage as many physicians as possible to attend this informational session.

The Medical Record Committee asked that I notify the Medical Staff that e~ective- October 1, 1993, failure to stgn the Outpatient Discharge Instruction Sheet (MRD-03) used for ambulatory patients will become a deficiency per ICAHO and Department of Health Regulations. Unsigned verbal/telephone orders are marked with a yellow "sign here" sticker on the nursing units. Attendings can sign for another attending or resident. Sign all orders before discharging a patient. Effective October 1, Medical Records will place a deficiency on orders that have been flagged by nursing and still remain unsigned at the time of analysis. Failure to comply with these deficiencies could ultimately lead to suspension.

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In an effort to communicate with the medical community on behalf of their members, we have received a request from the Allentown Lehigh Valley Hospital Liaison Committee of Jehovah's Witnesses to meet with physicians who are willing to provide care to Jehovah's Witnesses. Additional information is available in Medical Staff Services at Cedar Crest &. 1-78.

Finally, we formally welcome Elliot J. Sussman, M.D., as our new President and CEO. We are confident that we

have a leader who demonstrates both I understanding of the many health care complexities and a vision to lead us into the future as a sound and thriving organization and community.

I hope everyone had a great summer!

Best regards

J~ Candio, M.D. President, Medical Staff

Health Network Laboratories.Announces Decrease in Charges

Lehigh Valley Hospital is pleased to announce the implementation of a new outpatient fee schedule for Health Network Laboratories. This new fee schedule represents a decrease in charges for most outpatient testing.

The new charges were developed in response to your concerns about high charges and are based on our costs and the market. We feel comfortable that the list of tests and the prices developed address most testing.

We appreciate your support of the Hospital and Clinical Lab and hope that we may continue to provide services to you to an even greater extent.

If you have any questions or concerns, please contact Sharon L. Boley, Peripheral and Ancillary Sites Manager, at 402-2552 ..

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Follow-up of Patients Receiving Tamoxifen on National Surgical Adjuvant Breast and Bowel Project (NSABP) Protocols

The following guidelines are recommended for women receiving tamoxifen on NSABP treatment protocols. These procedures are in keeping with the current follow-up guidelines for women entered into the Breast Cancer Prevention Trial.

Gynecologic

The use of tamoxifen is known to result in estrogen-like effects in both laboratory animals and humans. In the medical literature, there are now numerous reports, both retrospective and prospective, that appear to associate the use of tamoxifen with an increased risk of endometrial cancer. It is well documented that unopposed estrogen significantly increases a woman's risk of developing endometrial carcinoma. The association of endometrial cancer with tamoxifen use appears to be in keeping with the metabolic qualities of

· tamoxifen, which can act as a nonsteroidal estrogen. The following guidelines should be considered in the follow-up of women receiving tamoxifen on NSABP treatment trials to allow for the identification and effective treatment of any endometrial abnormalities:

• Yearly gynecologic examination - Endometrial sampling should be encouraged. - Endovaginal ultrasound may be a way to identify individuals in whom endometrial sampling would be required.

• During each follow-up visit, women should be questioned regarding the development of any gynecologic abnormalities that may have developed, particularly post-menopausal bleeding. Any abnormalities reported should be promptly evaluated. Significant gynecologic abnormalities should be reported to the NSABP Biostatistical Center.

Ophthalmic

Tamoxifen is structurally similar to other drugs with well known ocular side effects; these agents include chloroquine (Aralen HCI), chlorpromazine (Thorazine), and thioridazine (Mellaril). There have been reports of ophthalmic side effects associated with tamoxifen use. The initial reports were at doses higher than that used in NSABP treatment trials. A recent prospective study by Pavlidis, et al, of 63 women on long-term, low-dose tamoxifen identified a prevalence of 6.3% of retinal toxicity. Documentation of the retinopathy is lacking in this report, and no photographic or psychophysical results other than the visual acuities are presented. The reversal of findings and symptoms after the drug was discontinued provides a strong argument for causality, but it is difficult to believe that such a high frequency of retinopathy would not have been previously recognized, given the large number of women who are currently receiving tamoxifen therapy.

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A cross-sectional investigation (conducted at selected sites) of a large subset of women entered into NSABP protocol B-14 will evaluate ophthalmic abnormalities associated with long-term, low-dose tamoxifen administration. Until the results of this evaluation are available, detailed ophthalmic examinations are not required for women receiving tamoxifen on NSABP trials. The following guidelines should be considered in the follow-up evaluation of all women receiving tamoxifen in NSABP treatment trials:

Needlestick Hotline A telephone hotline has been · established for Lehigh Valley Hospital employees and physicians to access information concerning blood and body fluid exposures and follow-up actions. The telephone number is 402-STIK (402-7845) and can be reached from both within and outside the hospital.

A four-minute, pre-recorded message reviews the procedure for employees and physicians to follow when reporting a blood and body fluid exposure. It also outlines the follow-up testing procedures utilized by the Employee Health and Infection Control Departments. At the end of the pre-recording, individuals are able to leave a message, and the Employee Health Department will return their call on the next working day. Employees and physicians are also instructed to redial the hotline if they wish to hear the message again or to contact the

• During each follow-up visit, women should be questioned regarding the development of any ophthalmic changes that may have occurred. Any significant abnormalities reported should be referred for additional evaluation. Any interventions for ophthalmic abnormalities should be reported to the NSABP Biostatistical Center.

If you have any questions or concerns regarding this information, please contact David Prager, M.D., Medical Director, John and Dorothy Morgan Cancer Center, at 433-6691.

Employee Health Nurse on call through the paging operator (extension 8999).

It is hoped that this telephone hotline will provide timely advice to individuals and help to alleviate some of their concerns and fears regarding an exposure situation.

Laboratory Update

Reminder: Glucose Tolerance Tests Since February 1, 1993, aD glucose tolerance tests, with the exception of gestational screens, have been performed by and scheduled with the staff in the Endocrine Testing Station. The actual glucose tests will be performed and reported by the clinical

· laboratory. This improvement provides a more controlled setting for the test and is handled by specially trained registered nurses.

Upon the recommendation of the Executive Committee of the Infection Control Committee, Microbiology will no longer call positive Clostridium difficile results to the physicians or to the units. Results will, however, be available through PHAMIS and on chart copies.

In order to meet patients' needs, the Endocrine Testing Station is available Monday through Friday from 9 a.m. to 4p.m.

To schedule an appointment or for more information, please call the Endocrine Testing Station at 402-2690.

If you have any questions or concerns regarding this issue, please contact Georgia Colasante, Microbiology Supervisor, at 402-8190.

Tips for Improving Relationships from the Physician Well-Bei~g Group

The following are just some of the suggestions coming out of the Physician Well-Being Group:

• TALK. Do you try to protect your significant other and/or your children from some of the horrible and difficult things happening to your patients? Are you still trying to split what happens in your professional life from your personal life? Perhaps it's time tore-evaluate and stop protecting your significant other, family, and more important, yourself! Let the people

closest to you know .what your everyday experience feels like -positive and negative.

• USTEN. After maldng clinical decisions about patients' lives, taking genuine interest in your partner's day experiences may seem rather boring. Remember, they also have their life with all of its stressors and perhaps listening to their reality may prove helpful to them and to you. Isn't that one of the elements of a •personal partnership?•

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Legal .Briefings

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• DISAGREE AGREEABLY. At home, instead of "win-lose" resolutions can we work toward "win-win" resolutions? For some, the question is, "Do I want to control all the time?"; for others it is, "Do I want any control?" There are options between the two extremes, but it takes time and work -- it's worth it!

• DATE. If you're married, make a date with your spouse. Do you remember that a date can be watching the sunset, gazing at the stars, or sitting on a park bench observing people or the ducks? MAKE the time to say to your partner, "You are important to me."

• PLAY-FUN-HUMOR. When was the last time you had a pillow fight or a water battle? Indeed, when was the last time you and your partner shared a joke, laughed, tickled one another? If

A recently published article titled, Risk Manaaement: Easy as Pie, by Dr. Warren Wacker, highlighted his personal experience with 45 years of clinical practice, including 18 years as director of the Harvard University Health Service. He pointed out that proverbs, truisms, and the folk wisdom of many generations are applicable ~ nearly all human activities - includmg loss prevention and the improvement of patient care. Some examples include:

• An ounce of prevention is worth a pound of cure • Discovery favors the prepared mind • Live and learn •. Experience is the best teacher • Brrds of a feather flock together • There is

there never was a time, consider it NOW. If you've lost it in the ensuing years, you might want to reintroduce it. Relationships can be fun, playful, and humorous in spite of the work you do.

• SEEK SUPPORT - GIVE SUPPORT. Invest yourself in a support group such as the Physicians' Well-Being Group -- yes, this is a plug for the group! However, if you do not use this group, use another group for you and/or your partner.

The Physician Well-Being Group extends an invitation to new members. For more information regarding where and when the group meets, contact Janet M. Laudenslager, Physician Rdations, at 402-9853, ,or John C. Turoczi, Ed.D., facilitafA?r of the Physician Well-Being Gr~up, at 481-9161. ' ..

no such thing as a free lunch • The optimal size of a committee is one and a half people.

Dr. Wacker went on to provide his own list and observations as follows:

• Criticizing a colleague based on hearsay is "bad mouthing" • Serious. problems arise more often when care ts given by multiple providers • If you ordered a laboratory test, x-ray, etc., you must have wanted the results • Any woman of childbearing age who has abnormal vaginal bleeding may have an ectopic pregnancy •

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Inexperienced providers are more likely to misdiagnose or mismanage • Patient care algorithms are not etched in stone • Knowledge without judgment is useless • Acute appendicitis is still difficult to diagnose • Verbal referrals often result in disaster • Patients with possible fractures should have appropriate x-rays, STAT • Getting angry with a patient will lead to a bad outcome • It is the provider's responsibility to be certain the patient is informed, not the patient's • Appropriate immunization is the most successful example of preventive medicine • The provider should always find out why a patient missed an appointment • Never prescribe a drug, give an injection, or do a procedure unless you are certain that it is appropriate • "Crocks," "turkeys," or· over-complainers are not immortal • Never assume that an unexpected laboratory result is a "lab error" • A patient's history is still the most important part of a patient's evaluation • Don't be afraid to look it up or ask a question • If you make a mistake admit it • Poor handwriting

· never won a malpractice suit • Self-

LIFESAVERS by Donna Petruccelli, R..N., B.S.N., CCRN

Patients who present with tachycardia may demonstrate sinus tachycardia, ventricular tachycardia, nonparoxysmal supraventricular tachycardia, or paroxysmal supraventricular tachycardia. Although the distinctions between them may be difficult, their treatments are very different. Because

justification is not accurate recorcikeeping • Young people have acute MI's and old people have acute appendicitis • The reason pencils have erasers is because we all make mistakes (Einstein) • Physicians who do not read nurses' notes or listen to what a nurse· tells them are fools • Unless a new drug is unique or is 100 times better than current drugs, don't prescribe it for at least a year after it has been released to the market • Pharmacology is learned better from text books, journals, or professional meetings than it is from advertisements or detail persons • A good memory is no substitute for accurate records • Critical situations are made worse by panic • Quiet contemplation is often better than doing "something" • The secret of patient care is caring for the patient (Peabody).

Readers are welcome to submit their own additions to the Department of Legal services/Risk Management. If you have any questions regarding any legal issues, please contact the Department of Legal Services/Risk Management at 402-8201.

failure to correctly identify and treat the various wide and narrow complex tachycardias can have lethal results, specific ACLS guidelines have been set forth.

If the tachycardic patient displays serious signs and symptoms, immediate cardioversion is recommended.

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Furthermore, if the patient has wide-complex tachycardia of an uncertain type, it should be treated as ventricular tachycardia. If a patient with ventricular tachycardia is mistakenly diagnosed with paroxysmal supraventricular tachycardia, and treated with verapamil, death can occur. This is because verapamil has been shown to increase heart rate and decrease blood pressure in patients with ventricular tachycardia, especially Wolff-Parkinson-White syndrome. In order to prevent delays or errors in treatment, lidocaine is the

Congratulations! YehiaY. MishrikiM.D., chief of the Division of Ambulatory Care, received the Dean's Special A ward for Excellence in Clinical Teaching at Lehigh Valley Hospital at the commencement exercises of the Hahnemann University School of Medicine.

Michael Rhodes, M.D., chief of the Division of Trauma, was awarded the Teacher of the Year Award in Surgery at "this year's Residents' Appreciation Dinner.

Also at the dinner, David Musser, M.D., chief surgical resident, was the recipient of the Paul Bosanac Research and Publication Award, for his paper, Death and Adverse Cardiac Events Followin& Carotid Endarterectomy. This award was established in 1983 by the Dorothy Rider Pool Health Care Trust for the intern, resident, or fellow

recommended first agent of choice in ventricular tachycardia and in all wide-complex tachyarrythmias of uncertain origin.

Adenosine is now recommended as the initial drug of choice for hemodynamically stable PSVT because it does not produce hypotension to the degree that verapamil does and because of its ultra-short half-life. In addition, patients with ventricular tachycardia who were given adenosine did not deteriorate clinically.

who "demonstrates excellence in research or investigation, or who publishes an original paper in a prestigiQus medical journal. • Dr. Musser's paper, co-authored by Gary G. Nicholas, M.D., vascular surgeon, and James F. Reed m, Ph.D., Director of Research, was recently accepted for publication in the Journalof Vascular Surgery.

Francis A. Salerno, M.D., chief of the Division of Geriatrics, was selected as the 1993 American Geriatrics Society/Marion Merrell Dow Clinician of the Year.

Douglas A. TozzoH, D.P.M., podiatrist, successfully passed both parts of the 1993 Foot Surgery certification examination and has become a Diplomate of the American Board of Podiatric Surgery with Certification in Foot Surgery.

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Publications, Papers and Presentations Peter A. Keblisb, M.D., chief of the Division of Orthopedic Surgery, testified at a FDA hearing related to joint implant packaging. Lehigh Valley Hospital has been part of a key multi-center study group on cementless implant devices for total joint replacements since 1980. The new Director of the FDA is attempting to standardize implant packaging information as in the same fashion as drugs. IDtimately this may lead to a •PDR • for joint implants that would be part of a larger implant device categorization for physician reference. They have selected the LCS New Jersey Knee as the photo type knee system to initiate this process, since the knee system has been the first to go through a full investigational device exemption (1.-D.E.) in both the cemented and cementless fixation modes.

Dr. Keblish has testified at the FDA for medical input on three previous occasions on the safety and effectiveness of total joint devices. Cementless implant fixation has become one of the standard accepted procedures in orthopedic joint technology. Lehigh Valley Hospital operating room staff, research (IRB), biomedical photography, and other areas have all contributed to the multi-center studies that have culminated in their acceptance for safe and effective patient application.

Nelson P. Kopyt, D.O., nephrologist, co-authored a chapter in the textbook, ClinictJl Disorders of Fluid and Electrolyte Metabolism, Fifth Edition, edited by Narins. The chapter is on diabetic acidosis and coma.

StevenJ. Lawrence, M.D., orthopedic surgeon, recently bad his article, Jones Fractures and Related Fractures of the Proximal Ji1fth Metatarsal, published in Foot 111111 .Anlck Joumal, July/ August 1993 edition, Volume 14, Number 6.

Thomas D. Meade, M.D., orthopedic surgeon, was an invited lecturer at Ohio State University where he presented Grand Rounds on an Update on Knee Bracing in the Athlete.

Gary G. Nicholas, M.D., Program Director for the General Surgery Residency, and Mark Zelkovic, M.D., former chief surgical resident, co-authored a review paper titled, Carotid Endarterectomy in Symptomatic Patients. The paper was published by the American Heart Association's journal, HetUt Disease and Strolce, July/August 1993.

Upcoming Seminars, Conferences, and Meetings

Medical Grand Rounds Depression in the FJderly will be presented by Luciana A. Picchio, M.D., Associate Professor of Adult Psychiatry, Hershey Medical Center, on Tuesday, September 21.

Inflammatory Bowel Disease will be presented by Theodore Bayless, M.D., Professor of Medicine, Johns Hopkins Hospital, on Tuesday, September 28.

Medical Grand Rounds are held Tuesday of each week at noon in the Auditorium of Lehigh Valley Hospital, Cedar Crest & 1-78. For further information, contact the Department of Medicine at 402-8200.

Pediatric Conferences Representatives from the Safe Kids Coalition will make a presentation at Grand Rounds on Tuesday, September 21, at 8 a.m., in the Auditorium of Lehigh Valley Hospital, 17th & Chew. Representatives will discuss poison control, lead poisoning, bike safety, seat belt safety, TIPP and child abuse programs. A resource directory and numerous handouts will be available. Please attend and help get these important messages to families in our community.

Neonatal Intestinal Infections will be presented by Chris Chang, M.D., pediatric surgeon, on Friday, September 24, at noon in the O.R. Conference Room at 17th & Chew.

Update of Immunizations in ChDdren will be presented by Sarah Long,

M.D., chief, Section of Infectious Diseases, St. Christopher's Hospital for Children, on Friday, October 8, at noon.

Pediatric: SoHd Tumors will be presented by Edwin Douglass, M.D., Director, Outpatient Oncology Clinic, St. Christopher's Hospital for Children, on Friday, October 22, at noon.

The above conferences are held in the Auditorium of Lehigh Valley Hospital, 17th & Chew, unless otherwise noted. For more information, contact Beverly Humphrey in the Department of Pediatrics at 402-2410.

Psychiatric Grand Rounds Malpractice Update for Psychiatry will be presented by Jll)ine Fiesta, Vice President, Legal Services/Risk Management, on Thursday, September 23, from noon to 1 p.m., in Room 916 of the School of Nursing.

Geriatric: Psychiatry will be presented by Garry Gottlieb, M.D., chief of Geriatric Psychiatry, Hospital of the University of Pennsylvania, on Thursday, October 21, from noon to 1 p.m., in the Auditorium of Lehigh Valley Hospital, 17th & Chew.

As lunch will be provided for both programs, pre-registration is requested. For more information or to register, call the Department of Psychiatry at 402-2810.

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Regional Symposium Series V Fifth Annual Neuroscience Symposium: Neurolopcal Complleadom of Medical Disease will be held on Friday, October 15, from 8:15a.m. to 4 p.m., in the Auditorium of Lehigh Valley Hospital, Cedar Crest & 1-78.

Physicians, nurses, and other health professionals concerned about neurological complications of medical disease will benefit from this program.

At the completion of the program, participants should be able to: • describe current research findings with clinical application for neurological complications of sepsis, diabetes, and cancer • discuss current diagnosis and tteannentofh~he • discuss neurological complications in the cardiac patient

Current Trends in Cancer Care will be held on Saturday, October 23, from 8 a.m. to noon, in the Auditorium of Lehigh Valley Hospital, Cedar Crest & 1-78.

Physicians, nurses, and other health professionals interested in the current trends of cancer care will benefit from this program.

At the completion of the program, participants should be able to describe: • the conservative surgical approach and adjuvant therapies for treatment of primary breast cancer • the combination therapy used in treannent of lung cancer • the new developments in imaging related to cancer • the nuclear medicine techniques utilized in diagnosing cancer

For more information regarding the above seminars, please contact Human Resource Development at 402-4609.

News from the Health Promotion and Disease Prevention Department

Several free public lectures, sponsored by the Chronic Disease Education Committee of Lehigh Valley Hospital, have been scheduled for the fall. Two of these upcoming programs include:

Mip'aines Today will be presented by Christopher I. Wahlberg, M.D., neurologist, on Tuesday, October 26, from 7 to 8:30 p.m., in the Auditorium of Lehigh Valley Hospital, Cedar Crest & 1-78.

At some point, SO" of the population will suffer from headaches so severe that ability to perform routine tasks becomes impaired. Dr. Wohlberg will provide information about the signs and symptoms of migraines, what may trigger them, and what happens in your body when they occur. Both non-pharmacologic and new drug treatments will be discussed.

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The Time Factor: Stroke Awareness and Treatment will be presented by Peter I. Barbour, M.D., neurologist, and Nancy Eckert, R.N., on Thursday, November 4, from 7 to 8:30p.m., in the Auditorium of Lehigh Valley Hospital, Cedar Crest & 1-78.

As you know, stroke is the number one disabling disease and the third most common leading cause of death in the adult population. The signs and symptoms of stroke and why time is of the essence when treating victims of stroke will be discussed.

• For Sale or L881e - Springhouse Profuslonal Cent•, 1676 Pond Road. Ideal for physician's office. Approximately 2,500 sq. ft. Wll finish space to specifications.

• For Sale or L881e - Medlcal-profuslonel office building on South Cedar Crest Boulevard, just minutes from c-. Crest It 1-78 8nd 17th It Chew. 3,560 total sq. ft. Ample pa'klng, security/fire alarms Installed. Ideal for physician group.

• For Sllle - Office building at Northeast conw of 19th 8nd Tum. Streets In Allentown. u.,.,_ level - 2,400 + sq. ft., *ue w.-dng room, two •ue consultation rooms, five uam rooms, etc. Low• level - 2,300 + sq. ft. Parking lot for 16 ~-

• For L ... e - Medical-professional office spiiCe located on Route 222 In Wescosvlle. Two 1 ,000 sq. ft. offices available or combine to form •a- suite.

• For Leae - Large, newly remodeled, completely furnished medical office space available for subleasing/time sh•e at Ced• Crest Professional Park. Top of the line telephone system. Transcription 8nd comput• system with electronic blllng available.

• For L ... e - Medical office spece located In Peachtree Office Plaza In Whitehall. One suite with 1 ,500 sq. ft. !unfinished - allowance avallablet, 8nd one 1 ,000 sq. ft. finished suite.

In addition to these programs, the Health Promotion and Disease Prevention Department offers numerous programs which may benefit your patients. Some of these programs include Nutrition, Weight Control, Exercise, Stress Management, and Smoking Cessation.

For more information about these and other programs, contact the Health Promotion and Disease Prevention Department at 821-2150.

• For L881e --Medical office space to sublet In MOB 1 at Lehigh Valley Hospital, Cedar Crest ltl-78.

e For L881e- Medical office spece located In Southeast Allentown ne. Mountalnvlle Shopping cent ••

• For L8Me - Slots •e currently available for the Brown Beg suite at Kutztown Professional Cent•.

• For Leae - SMre *P medlc8l office ~ Cedar Crest It 1-78. Fully furnished 8nd staffed. Multiple line phone system. Computerized blUing available.

• For Leae - Specialty practice time-share space available In • comprehensive health c.e facility. Riverside Professional Cent•. 4019. WynnewCHMi Drive. Leurys Station. Half- or U-dey slots Immediately available.

• For Leae - Professional office space available In en established psychology end psy~y practice at 46 North 13th Street. Allentown. Large. werm VIctorian building In a relued etmosph••· Secr-.y 8nd blUing available 8nd Included In some leeses. Furnished or unfurnished ful offices end sublets avellable. UtiUtles Included.

For more Information or for Mslstanee In finding IPPfOPIIete office space to meet your needs. contact Joe Pille, Physician Reletlorw Rep, at 402-9856.

WHO'S NEW The Who's New section of Medlt:tll SkqJ Progre11 Note1 contains an update of new appointments, address changes, newly approved privileges, etc. Please remember that each department or unit is responsible for updating its directory, rolodexes, and approved privilege rosters.

Medical Staff

Appointments

Gall E. BurgeyMD 175 S. 21st Street Easton, PA 18042 (215) 559-7474 Department of Obstetrics and Gynecology Division of Obstetrics/Gynecology Section of Beilign Gynecology Provisional Courtesy

SungiCbal, MD Concepcion Tan Yen, MD, PC 1728 Jonathan Street Suite 101 Allentown, PA 18104 (215) 432-2706 Department of Obstetrics and Gynecology Division of Obstetrics/Gynecology Section of Benign Gynecology Provisional Active

Clnis C.N. Chang, MD Lehigh Valley Hospital 17th & Chew P.O. Box 7017 Allentown, PA 18105-7017 (215) 402-7999 Department of Surgery Division of General Surgery Section of Pediatric Surgery Provisional Active

Zev EliasMD Allen Neurosurgical Association (Morrow) 1210 S. Cedar Crest Blvd. Suite1000 Allentown, PA 18103 (215) 433-3143 Department of Surgery Division of Neurosciences Section of Neurotrauma Provisional Active

Marian PeseckisMD Paul K. Gross, MD Allentown Medical Center 401 N. 17th Street, #312 Allentown, PA 18104-5104 (215) 820-3900 Department of Psychiatry Provisional Active

Stacie J. Well, MD Chief, Reproductive Endocrinology Lehigh Valley Hospital 17th & Chew P.O. Box 7017 Allentown, PA 18105-7017 (215) 402-mo · Department of Obstetrics and Gynecology Division of Gynecology Section of Reproductive Endocrinology Provisional Active

Change of Address

John M. Kauffman, Jr., DO Director of Medical Education Allentown Osteopathic Medical Center 1736 Hamilton Street Allentown, PA 18104 (215) 770-8307

Gary M. Panik, DO Northwestern Medical Center 7096 Decatur Street New Tripoli, PA 18066 (215) 298-8521

Practice Name Change

Lehip Valley RadioiO&Y Associates, PC has changed its name to Medical ImaaJna of uhtp Valley, PC which includes: Stanley Benzel, MD, Christopher L. Brown, MD, John F. Cox, MD, Walter J. Dex, MD, Thomas Fitzsimons, MD, Michael H. Geller, MD, James W. Jaffe, MD, Robert Kricun, MD, Harold G. Kunz, MD, Thomas E. Leet, MD, Zwu S. Lin, MD, James A. Newcomb, MD, Mark A. Osborne, MD, Howard Rosenberg, MD, Elliot S. Shoemaker, MD, Allen J. Weinstein, DO, Alan H. Wolson, MD, and Bradford A. Yeager, MD

Change of Status

John Lapp, MD Department of Medicine Division of Family Practice From Emeritus Courtesy to Honorary

Resignations

Douglas C. CUne, MD Department of Emergency Medicine Division of Emergency Medicine

David M. Perry, MD DepartmentofMedicine Division of Family Practice

Allied Health Professionals

Appointment

Uncia C. Fenstermaker, LPN Physician Extender Professional - LPN (1. Culel)

Change of Address

Thomas W. Lane, PbD Program Director The Guidance Program 1255 S. Cedar Crest Blvd. Suite3800 Allentown, PA 18103

P & T Highlights The following action were taken at the August 9, 1993 Pharmacy and Therapeutics Committee Meeting James A. Giardina, Director of Pharmacy

FORMULARY ADDITION REQUESTS

THE EYES HAVE IT

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Glycerin Ophthalmic Solution (Opthalgan, Wyeth-Ayerst) is a hyperosmotic ophthalmic solution used to facilitate ophthalmoscopic and gonioscopic examinations principally in edematous eyes. The principal adverse reactions are pain and irritation and consequently it is recommended

Hydroxypropylmethylcellulose Ophthalmic Solution (Occucoat, Ston) - is an ophthalmic surgical aid used in anterior segment surgical procedures including cataract removal and intraocular lens implantation. Hydroxypropyl-methylcellulose (HPMC) acts to protect corneal epithelium and other ocular tissues.

AND THE OLD PATENT PROTECTION GAME CONTINUES Nitrofurantoin Macrocrystals!Monohydrate (Macrobid, Proctor & Gamble) is a newly marketed and slightly different formulation of Nitrofurantoin which allows for twice daily dosing. Given that it is a more expensive product (than generic formulations), with no fewer side

that use be preceded by a local anesthetic. The usual dose of Glycerin Ophthalmic is 1 to 2 drops prior to examination. Glycerin Ophthalmic Solution was added to full formulary status.

Given that there are several products on formulary (Sodium Hyaluronate (Healon, Pharmacia) and Chondroitin and Sodium Hyaluronate (Viscoat, Cilco) which are used for similar procedures, HPMC was added for a 6 month therapeutic evaluation. HPMC is the least expensive of the three agents. .

effects (one study showed > incidence of common side effects vs Macrodantin), it was rejected. Additionally, the manufacturer only makes and recommends the 1 OOmg capsule BID (equivalent to Nitrofurantoin 50mg QID). Ever wonder why they make Macrodantin 1 OOmg?

DRUG USE EVALUATION (DUE) CORNER

Target Antibiotics - June/93

Ceftazjdime - Empiric use continues to be the indication for use in the majority of patients treated. Length of Therapy (LOT) av~rages 2.6 days: Ceftazidime usage was down with a corresponding increase in Piperacillin usage. Piperacillin is the preferred agent for aerobic gram negative bacilli resistant to Cefazolin, in non-penicillin allergic patients. For Suspected Pseudomonal infections, Piperacillin 5Gm Q8H is recommended.

IV Ciprofloxacin - high empiric use continues for the majority of patients treated. Lot of Therapy = 3.3 days. Approximately 50% of the patients, who receive IV Ciprofloxacin, are able to take Ciprofloxacin orally, which is the preferred route. Of this number, 54% were converted to oral therapy via a chart note. Ciprofloxacin should be reserved for aerobic gram-negative bacilli (re: Pseudomonas, Enterbacter, Suratia) resistant to standard therapy.

WHEN, WHAT AND FOR HOW LONG

Surgical Prophylaxis Reviews- Timing, Agent and Duration.

Table 1 depicts results of a review of surgical prophylaxis in OB/GYN and Vascular cases. Results will be forwarded to Section Chiefs for discussion.

TABLE 1 -Surgical Prophylaxis DUE

Procedures Vascular OB/GY~~

Number of patients receiving antibiotics/total patients 0175 45/69

Recommended agent chosen (Cefazolin) 2 (89%) 28 (67%)

Timing of dose within 2 hours of incision 0 (100%) 45 (100%)

Signs of Infection or complication 81 (11 %) 51 (7%)

Duration ..S. 24 hours 4()2 (65%) 25 (63%)

1. Patients with signs of infection were excluded from prophylaxis calculations. 2. The majority of the therapy > 24 hours was in amputation cases where there is no clear consensus of length of therapy.

)

Famotidine IV to PO - When the Gut Works )The following data were presented on Famotidine IV conversion.

Period Covered June/July- 1993

Number courses reviewed 274

Number courses meeting conversion eligibility criteria 1 128 (46%)

Number converted 87 (67%)

Number discontinued2 10 (8%)

Cost savings3 I $1300

1. Number patients taking 2:.. 2 scheduled (not prn) oral meds. 2. Patients whose therapy was discontinued after note placed on chart. 3. Cost savings are stated in terms of drug acquisition only.

Savings are actually greater when IV sets, supplies, and labor are considered.

THE LATEST IN FLUSH THERAPY The committee approved the following table which standardizes the heparin concentration, volume, and

)Saline to be used on appropriate patients. (including home care)

Catheter Heparin Flush Frequency, if Type Conc/cc volume catheter not

and volume after used infusion with PF NaCI2

eve 10 units-1 cc lee Q8H/Heparin

Hickman 10 units-Sec Sec Daily/with Heparin

Groshong Sec Daily (Saline)

Implanted 10 units-Sec Sec Q week Ports accessed

Q 4 wks unaccessed

Intermittent 2cc Q8H Peripheral Int/Heplok

PICC 100 units- 3cc Q12H 3cc

Same as table. 1. 2. PF NaCI- Preservative Free Sodium Chloride 0.9%

Blood Samplingl Syringe Size

Discard Flush (Volume) Volume

after blood

Sec lOcc

Sec lOcc lOcc

Sec lOcc lOcc

Sec lOcc lOcc

Do not use lOcc Vacutanier when drawing blood

ALLERGY DOCUMENTATION UPDATE The committee was informed that all three major disc~plines (Physicians, Nurses, Pharmacists) are not consistently following the new process approved to coincide with PHAMIS conversion. The committee approved a reeducation effort to get all disciplines in compliance. The purpose of

the policy is to accurately identify allergies (by including symptoms), distinguishing intolerances and adverse effects, and to reduce the potential for patients being given meds to which they are allergic. More to follow.

STANDARD DILUENT LIST EXPANDED Several epidural and IV PCA products were approved for addition to the Standard Diluent List with standardized diluents, concentrations, and sizes. Physicians are reminded that it is not necessary to order diluents, volumes or concentrations for these products.

Dll1g Standard Concentration .cC

Fentanyl/Bupivacaine 1 Omcg/ml and 0.1%

Meperidine IV 10mg/ml

Morphine Epidural 0.1mg/ml (100mcg/ml)

UPS, DOWNS AND OUTS Heparin Infusions- All therapeutic heparins with flow rates of...::;. 1040 units/hr will be changed daily at 1400 hours. This change is procedural only and has no impact on starting infusions or changing rates.

Flosequinan (Manoplax, Boots) - Has been withdrawn from the market due to increased hospitalization rates and adverse mortality data.

Hydralazjne Injection (Apresoline, Ciba) - The injectable solution will be available only on an emergency basis via overnight delivery until a

Standard· Diluent .. Standard Size

NSS 1 OOmg Bupivacaine/1 OOmcg Fentanyl in 100ml

NSS 1 OOOmg/1 OOml

NSS 10mg/100ml

lyophilized formulation is introduced later this year. There are no other manufacturers of hydralazine injection.

Mivacurium (Mivacron, B-W) -·The premixed solution has been deleted from the formulary due to the potential for mixups with other intermittent solutions. There have been reports of serious morbidities and mortality in the lay press due to misadministrations. Vials will continue to be stocked for use by Anesthesia.

ehigh Valley Hospital is considering becoming an "open site" Seminar Center, offering teleconferences to the community.

Recendy, Lehigh Valley Hospital has had a new satellite antenna system installed that is capable of downlinking a variety ofhealthcare related programs known as teleconferences that are cu.rrendy viewed by employees and staff.

Teleconferencing is a cost-effective, state-of-the-art method of attending educational seminars from anywhere around the world via a 'TV monitor hook up system.

After receiving nwnerous inquiries from the community about the new system and program offerings, Lehigh Valley Hospital is considering making these teleconferences available to a wider audience.

If you or your staff are interested in these programs, please take a few moments to complete and retum the attached questionnaire.

Teleconference Topics Include:

• Nursing

• Physical Therapy

• Occupational Therapy

•laboratory

• Respiratory Care

•AIDS

• Psychiatry

• Medical Records

• Management Development

•Safety

• Customer Service

• Physician Relations

• Wellness Center

•JCAHO

Pleue complete the questionnaire to the right end retum it by October 1 to Jack Dunluvy. Prognun Coordinator. Human Resource Development. Lehigh Valley Hospital. 17th & Chew. P.O. Box 7017. Allentown. PA 18106-7017.

• : 1. I am interested in teleconferences offered

at Lehigh Valley Hospital: • • • • • DYES D NO

• 2. The amount of time I would be available is: • • D 1·2 hours 0 Entire Day (8 hours) : D 2-4 hours 0 Monday· Friday : 0 Saturdap • • • 3. I would be interested in CEUs: • • • •

DYEs D No

• 4. The price per program I am willing to pay: • 0 $10-$25 0 $50-$75

0 $25- $SO 0 $75. $100 • • • • • • 5. I am interested in the following topics: • • Numng Allied Health : D EMERGENCY CARE 0 PHYSICAL THERAPY : 0 MED/SURO 0 OCCUP. THERAPY : 0 OB/GYN D RESPIRATORY CARE • 0 PEDIATRICS D AIDS UPDATES • • D GERIATRICS 0 MEDICAL RECORDS : D TRAUMA 0 LABORATORY : D ONCOLOGY • D LEGAL ISSUES • • 0 SUBSTANCE ABUSE • • Other Progrmns : D MANAGEMENTDMLOPMENT • D PHYSICIAN RElAnON

D JCAHO UPDATES D PtAmC SURGERY UPDATES 0 WEUNESS D SAFETY UPDATES 0 ETHICS 0 PSYCHIATRY

LEHigJIVAILEY HOSPIOO.

Cedar Crest & 1-78 P.O. Box 689 Allentown, PA 1810S-1SS6

Joseph A. Candio, M.D. President, Medical Staff

John E. Castaldo, M.D. President-elect, Medical Staff

John Jaffe, M.D. Past Presideat, Medical Staff

John w. Hart Vice President

RitaM. Meet Medical Staff Coordinator

Janet M. Laudeaslaaer Physician RelatiODB Managing Editor

JOMpb A. CaDdio, M.D. Jolm E. Cutaldo, M.D. llobert V. Cumalioia, M.D. Carl F. D'Anplo, M.D. llobert B. Doll, M.D. Jolm D. F....U, M.D. Jolm P. YllZJibbooa, M.D. Mart A. Oildomaa, M.D. J._. J. Oooclreau, M.D. Tlaomu A. llntebilllon, M.D. Jolm Jaft'o, M.D. Miohael W. :Kaufmuua, M.D. Gina S. ICJatzer, M.D. Mart C. l.elt.or, M.D. ll.oaald A. Lutz, M.D. Alpboaae A. Maftilo, M.D. llobert X. Murphy, Jr., M.D. Paul E. Nurick Walter J. Olamaki, M.D. Mart A. Otbome, M.D. IWidy A. RoleD, M.D. Normaa S. Sancbek, M.D. Jolm J. Sbaao, M.D. Jolm D. Vadratle, M.D. Headley S. While, M.D. Geary L. Yoialoy, M.D. Jolm S. ZioJior, D.D.S.

Non-Profit O..g. u.s. Poetqe

PAID Allentown, PA

Permit No. 1822

• ..., _,.,..... Nllla is published IIIOidbly to inform the Lebip Valley Hospital Medical Staff and flllploy• of importaat--CODtel'llilll the Medical Starr. Articles should be submitted to Jaaet M. ,., ........... , JllaysiciaD Relatioal, 1243 s. Cedar Cn!l!lt Boulet-atd, Alleatown, PA 18103, by the lint of IIICh IIIOIIth. If you ha~e uy questioDs about the newsletter, please call MI. Laudenslaaer at 401-9853.

Lllllgh Vollq Hoqllill il Gil eqlllll oppoTtulllJ1 .,.,,.

MIFIHIV

hospital medical staff progress notes

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