Franciscan Health System. Aug P u b l i s h e d f o r o u r M e d i c a l S t a f f

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1 Connections P u b l i s h e d f o r o u r M e d i c a l S t a f f Franciscan Health System Aug St. Elizabeth Hospital St. Anthony Hospital Franciscan Medical Group I n s i d e CMS introducing new quality measures News Notes Pharmacy News Medical staff and CME calendar Medical staff newsletter readership survey starts later this month Franciscan Health System values the opinions of its medical staff members. Starting this month, Franciscan will ask its medical staff to participate in a brief online survey regarding the usefulness of this monthly newsletter and how it could be improved. So watch your for the link to the questionnaire and we look forward to your responses. Thank you. Emerging blood thinners inspire question: Is newer better? By Rebecca Vigil, RN Transfusion-Free & Program Dabigatran etexilate mesylate (Pradaxa ) is a direct thrombin inhibitor that is FDA-approved to reduce the risk of stroke and systemic embolism in patients with atrial fibrillation. Pradaxa has become a popular alternative to warfarin therapy because it does not require laboratory monitoring, dose adjustments or diet modification. While Pradaxa provides excellent anti-coagulation for the approved indication, there are risks. For example, there is no antidote in the event of accidental overdose or hemorrhagic complications. Recommended treatment in these situations is to discontinue Pradaxa, investigate the source of bleeding, and maintain adequate diuresis (Pradaxa is primarily excreted in urine). There are also suggestions that 1) dialyzing the patient over 2-3 hours, 2) surgical hemostasis, 3) transfusion of fresh frozen plasma (FFP) or red blood cells, or 4) administering activated prothrombin complex concentrates (PCC), recombinant Factor VIIa or coagulation factors II, IX or X, may prove beneficial. The usefulness of these treatment regimens has not been established in clinical settings. Dabigatran is on the Franciscan formulary for its FDA-indicated use. On July 1, 2011 the FDA approved the oral anticoagulant rivaroxaban (Xarelto ) to reduce the risk of blood clots, deep vein thrombosis and pulmonary embolism following knee or hip replacement surgery. Xarelto inhibits coagulation Factor Xa and has a halflife of 5-9 days. There is no known While the medical community has welcomed new medications, their use is not without risks. reversal agent for Xarelto in the event of a hemorrhagic complication and, due to the high plasma protein binding, rivaroxaban is not expected to be dialyzable. Administration of blood products or factor concentrates may be helpful but have not been studied. Rivaroxaban will be reviewed by the PT&T Committee in September or October Prasugrel (Effient ) is a P2Y12 platelet inhibitor indicated for the reduction of thrombotic cardiovascular events (including stent thrombosis) in patients Continued on page 2 Connections August 2011 Advanced. Trusted Care. 1

2 Medical staff Leadership FHS Medical Executive Committee Kim L. Moore, MD Medical Staff President Charles Leusner, MD Vice President-elect, SFH Navdeep S. Rai, MD Member-at-Large, SFH Kevin E. Braun, MD Vice President, SCH Brian A. Folz, MD Member-at-Large, SAH Byron L. Hutchinson, DPM Member-at-Large, SFH William B. Cammarano III, MD Vice President-elect, SJMC Peter R. Kesling, MD Member-at-Large, SAH Ulrich Birlenbach, MD Member-at-Large, SCH FHS Credentials Committee Norman H. Burns, MD David S. Cho, MD Richard K. Gould, MD, Chair Youl Choi, MD Brian Folz, MD Section Chiefs Gail C. Venuto, MD Keith E. Demirjian, MD Peggy Dunlop, CNM Midwifery Eugene S. Cho, MD Tejinderpal Singh, MD G. Gordon Benjamin, MD Diagnostic Imaging Section Chiefs Jeffrey M. Cortazzo, MD W. Mark Hassig, MD Linda M. Petter, DO Kevin J. Ward, MD Michael S. Davidov, MD Section Chiefs David R. Kennel, MD David R. Munoz, MD Youl Choi, MD GYN Mark S. Yuhasz, MD Radiology Linda D. Burkhardt, MD St. Anthony Hospital Section Chiefs Gary R. Pingrey, DO Linda D. Burkhardt, MD Raed N. Fahmy, MD Thomas J. Minter, MD Cynthia M. Mosbrucker, MD Charles M. Piatok, MD GYN Jason W. Allen, MD Robert A. Yancey, MD Radiology St. Elizabeth Hospital Medical Staff Officers Jude Verzosa, MD Medical Staff President Allen H. Yu, MD Vice President-elect, SCH Wendy Weeks, MD Member-at-Large, SJMC Neville A. Lewis, MD Member-at-Large, SJMC Robert T. Middleton, MD Vice President, SFH Thomas J. Minter, MD Vice President, SAH Daniel G. Nehls, MD Vice President, SJMC Donald L. George, MD Vice President-elect, SAH Micheal W. Vier, MD Member-at-Large, SCH W. Mark Hassig, MD Paul W. Hildebrand, MD Bruce Wilson, MD H. James Yamashita, MD Mark Yuhasz, MD William B. Cammarano III, MD Allister Stone, DO J. Dale Howard, MD Mental Health Linda D. Burkhardt, MD Martin V. Cieri, MD Pediatrics Charles Leusner, MD Diagnostic Imaging Andrew M. Elizaga, MD Mohinder S. Badyal, MD Pediatrics Linda D. Burkhardt, MD Kim L. Moore, MD Keith A. Weissinger, MD Pediatrics Charles M. Piatok, MD Steven G. Duras, MD Steve Atkinson, MD Vice President Franciscan Health System is guided by the Ethical and Religious Directives for Catholic Health Care Services. Coming in January 2012: New CMS quality core measures Beginning Jan. 1, 2012, two new CMS quality core measures will be added and Franciscan Health System will report its results for both. These will be Imm-1: Pneumococcal Immunization and Imm- 2: Influenza Immunization. The new global measures with retire the current pneumonia measures, PN- 2: Pneumococcal Vaccination and PN-7: Influenza Vaccination. The addition of the two quality measures will expand the inpatient population targeted for screening and vaccinating. Pneumococcal Immunization Measure The patient numerator captures two activities screening and intervention of vaccine administration, when indicated. The measure includes inpatients 65 years of age and older; 9-64 years of age with a principal diagnosis of asthma; and patients 6-64 years of age with a principal or other diagnosis of diabetes, nephritic syndrome, ESRD, HF, COPD, HIV or asplenia. Influenza Immunization Measure Just as the pneumococcal vaccine measure does, the patient numerator specifies two activities, blood thinners, from page 1 with acute coronary syndrome (ACS) who are managed with percutaneous coronary intervention. Clopidogrel bisulfate (Plavix ) is another P2Y12 platelet inhibitor indicated for ACS, recent myocardial infarction/stroke or established peripheral arterial disease. Quality & Safety Club100 Quick Tip screening and intervention of vaccine administration, when indicated. The measure includes inpatients age 6 months and older, discharged during September through March, with any diagnosis. The new global pneumococcal and influenza immunization measures require a revision of the Nurse Initiated Vaccine Assessment Order (NIVAO) form and guidelines. Updates are currently in the process and will be completed by Sept. 1, 2011 in order to prepare clinical staff and providers for measure reporting starting in January For more information about the quality measures or to request a free copy of the Franciscan Quality Indicators booklet, please contact Whende Martin, RN, Franciscan Clinical Effectiveness, or by at whendemartin@fhshealth.org. Quick Tip is published in each edition of this newsletter to help Franciscan medical staff members achieve 100-percent compliance with CMS clinical quality indicators for acute myocardial infarction, pneumonia, heart failure and the Surgical Care Improvement Project (SCIP). Both inhibit platelet aggregation for the lifetime of the platelet (7-10 days), thus withholding a dose will not be useful in managing a bleeding event nor mitigating bleeding risk associated with an invasive procedure. For both drugs, platelet transfusion at least 2-4 hours after the Continued on page Advanced. Trusted Care. August 2011 Connections

3 Blackwell accepts leadership post in Pennsylvania Fran Blackwell, vice president for outpatient services for the Franciscan Health System, has accepted the position of senior vice president for ambulatory services at Lehigh Valley Health Network in Pennsylvania. This change will afford her and her husband the opportunity to relocate close to their families. Her last day with Franciscan is Aug. 26, Since joining Franciscan in 2005, she has advanced the organization s hospice and palliative care programs, diagnostic imaging services, rehabilitation therapies, sleep therapy programs, occupational health, cardiopulmonary, wound care, hyperbaric, and neuroscience services. She also helped lead Franciscan's collaboration with TRA Medical Imaging and the MultiCare Health System to establish the Carol Milgard Breast Center in Tacoma. Her successor has not yet been announced. St. Anthony president will lead Colorado hospital Carole Peet, president of St. Anthony Hospital in Gig Harbor, has accepted the position of president and chief executive officer at St. News notes F. Blackwell C. Peet Anthony North Hospital, a 196-bed facility in the Denver suburb of Westminster. This move will not only allow Peet to be close to her son s family, including her grandchildren, but allow her to remain associated with the ministry of Catholic Health Initiatives (CHI). The Colorado hospital is part of Centura Health and, like Franciscan Health System, is affiliated with CHI. Her last day with Franciscan will be Sept. 2, Peet, who helped to open the Gig Harbor hospital in 2009, is also the service line executive for Franciscan's nephrology and mental health services. Her successor will be announced at a later date. St. Elizabeth president announces plan to retire St. Elizabeth Hospital President Dennis Popp, who has successfully led efforts to expand medical services on the Enumclaw Plateau for 25 years, has announced his intention to begin transitioning toward retirement. He has not set a specific date to retire, giving the Franciscan Health System sufficient time to recruit his successor as president of Enumclaw s only hospital. Until a new president for St. Elizabeth is found, it s business-as-usual, said Franciscan Chief Operating Officer Cliff Robertson, MD. D. Popp I would not trade the past 25 years for anything, said Popp, who received the 2008 Joe Hopkins Memorial Award for leadership from the Washington State Hospital Association. Northwest Vascular Center expands vascular ultrasound Northwest Vascular Center-Enumclaw, a part of the Franciscan Medical Group, now provides outpatient vascular ultrasound services for St. Elizabeth Hospital and medical group patients on the Plateau. Northwest Vascular Center-Enumclaw also provides inpatient and emergency vascular ultrasound services at St. Elizabeth. For more information, contact clinic Manager Marilyne Tweit at or by marilynetweit@ FHShealth.org. TRA provides after-hours imaging studies at Enumclaw TRA Medical Imaging now provides after-hours interpretations of urgent imaging studies for St. Elizabeth Hospital in Enumclaw. The change, which took effect July 14, is expected to improve turnaround time for reports. Until now, the after-hours support was provided by an out-of-state call service. David Rice, MD, and Lon Hayne, MD, are the radiologists at St. Elizabeth. For more information, contact Rich Rosser, diagnostic imaging manager, at or by at richardrosser@fhshealth.org. Medical office space open on St. Joseph campus Seeking medical space to lease on the campus? An office (2,176 square feet) is available in Suite 201 of the St. Joseph Medical Pavilion, 1802 S. Yakima Ave. Call Franciscan Property Management: Franciscan Foundation awards 33 scholarships to employees The Franciscan Foundation recently awarded scholarships to 33 Franciscan Health System employees who are pursuing undergraduate or graduate degrees or certificates in health care and other career-related subjects. The scholarships totaled $64,400. Since 1996, the Foundation has given 314 scholarships to Franciscan staff totaling $497,300. All scholarships are funded through charitable gifts to the Foundation. Connections August 2011 Advanced. Trusted Care. 3

4 P h a r m a c y N e w s Contact: Franciscan Pharmaceutical Services, Dronedarone (Multaq ): two-fold increases in stroke and Increased risk of death and cardiovascular adverse events The FDA is reviewing data from a clinical trial evaluating the effects of the antiarrhythmic drug dronedarone (Multaq ) in patients with permanent atrial fibrillation. The study was stopped early after the data-monitoring committee found a two-fold increase in death, as well as hospitalization for heart failure, in patients receiving Multaq compared to those taking a placebo. Multaq is approved for reducing the risk of cardiovascular hospitalization in patients with paroxysmal or persistent atrial fibrillation (AF) or atrial flutter (AFL), with a recent episode of AF/AFL and associated cardiovascular risk factors, who are in sinus rhythm or who will be Table 1: PALLAS study events as of June 30, 2011 Multaq N=1572 n (%) CV death, myocardial infarction, 32 (2) stroke, systemic embolism* Death, unplanned CV 118 (7.5) hospitalization* Death 16 (1) Myocardial infarction 3 (0.2) Stroke 17 (1.1) Heart failure hospitalization 34 (2.2) Placebo N=1577 n (%) 14 (0.9) 81 (5.1) Hazard Ratio p-value (0.4) 3 (0.2) 7 (0.4) 15 (1) *Co-primary endpoints References Hohnloser SH, Crijns HJ, van Eickels M, et al. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med 2009 Feb 12;360(7): Source: SDI, Vector One : National (VONA) and Total Patient Tracker (TPT). July 2009-June Extracted Weight (kg) 15 kg or less 16 kg thru 23 kg 24 kg thru 40 kg 41 kg or more Weight (lbs) 33 lbs or less 34 lbs thru 51 lbs 52 lbs thru 88 lbs 89 lbs or more Treatment dosing for 5 days 30 mg twice 45 mg twice 60 mg twice 75 mg twice Table 2: New Tamiflu Dosing Chart Prophylaxis dosing for 10 days 30 mg once 45 mg once 60 mg once 75 mg once Volume of oral suspension (6 mg/ml) for each dose* 5 ml 7.5 ml 10 ml 12.5 ml cardioverted. From approval in July 2009 through June 2011, approximately 1 million Multaq prescriptions were dispensed by outpatient retail pharmacies in the U.S. Approximately 241,000 individuals received Multaq prescriptions. The Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy Study (PALLAS), sponsored by Sanofi Aventis, was being conducted to assess the potential clinical benefit of Multaq in patients over 65 with permanent atrial fibrillation in the reduction of: Major cardiovascular (CV) events Unplanned cardiovascular hospitalization, or death from any cause. A critical question is whether and how unfavorable results of the PALLAS study, obtained in patients with permanent atrial fibrillation, apply to patients who use Multaq for approved indications (i.e., nonpermanent atrial fibrillation, also known as paroxysmal or persistent atrial fibrillation). Number of bottles of for oral suspension to dispense 1 bottle 2 bottles 2 bottles 3 bottles Number of capsules and strength to dispense 10 capsules 30 mg 10 capsules 45 mg 20 capsules 30 mg 10 capsules 75 mg *A 10 ml oral dosing dispenser is provided with the oral suspension. In the event that the dispenser provided is lost or damaged, another dosing dispenser may be used to deliver the volume. Delivery of this Tamiflu oral suspension dose requires administering 10 ml followed by another 2.5 ml. References U.S. National Library of. National Institutes of Health. Drug Monograph-Oseltamivir. Available at meds/a html. Accessed April 15, At this time, patients taking Multaq should talk to their health care provider about whether they should continue to use the product for non-permanent atrial fibrillation. Health care professionals should not prescribe Multaq to patients with permanent atrial fibrillation. FDA is evaluating whether and how the preliminary results of the PALLAS study apply to patients taking Multaq for paroxysmal or persistent atrial fibrillation or atrial flutter. PALLAS results (Table 1) are considered preliminary since the data have not undergone qualityassurance procedures nor been completely adjudicated. 2 Changes to oseltamivir phosphate (Tamiflu ) for oral suspension The FDA has informed the public and health care practitioners of important product safety changes to the influenza drug oseltamivir (Tamiflu ) for oral suspension. These changes will reduce the prescribing and dosing confusion that can lead to medication errors. FDA has worked with the manufacturer, Genentech, to make these changes. Tamiflu is used to treat some types of flu in adults and children (older than 1 year) who have had symptoms for no longer than two days. It also is used to prevent some types of flu in adults and children (older than 1 year) when they have spent time with someone who has the flu or when there is a flu outbreak. Changes to Tamiflu oral suspension and the product label include: Changing the concentration of from 12 mg/ml to 6 mg/ml. The Continued on page Advanced. Trusted Care. August 2011 Connections

5 Franciscan Medical Staff Additions December 2010 June 2011 (Listed by name, specialty, primary hospital) Adam Balkany, DO Faye Buloan-Siek, MD Palliative Khalil Carter, MD Jay Casino, MD St. Anthony Hospital Youssef Chami, MD Cardiology Meghana Doreswami, MD Neurology Boguslawa Grazyna, MD Patrick Fisher, MD Cardiovascular Disease Marilyn Gage, MD Prashanthi Ganathi, MD Rebecca Houseman, MD Muhammad Husainy, DO Dana Hunter, MD Ghalib Husseini, MD Orthopedic Colin Iosso, MD Neurology Barbara Lazio, MD Neurological Sarah Maitre, MD Family Margaret McKee, MD Pulmonary Disease Hiroki Mitsuyama, MD Radiation Oncology Daniel Moore, MD Gregory Moore, MD Alex Moreano, MD ENT In Kwon Park, MD Grazyna Perczak-Dudkowska, MD Nasir Rashid, MD Neonatology Linda Rimkunos, MD Richard Rybarczyk, MD Eve Shank, MD ENT Matthew Shepherd, MD St. Anthony Hospital Amanda Steen, MD Physical & Rehabilitation Bobby Stevens, DO General Catherine Thompson, MD Nephrology Kenneth Tyson, DO Gynecology Richard Urbon, MD David Vance, MD Urology Michael Vaughn, MD Nephrology Umesh Chitaley, MD Wei Guo, DDS Oral/Maxillofacial Gregory Lamberton, MD Urology Jennifer Muldoon, MD Suraj Singh, MD Radiation Oncology St. Anthony Hospital Troy Wadsworth, MD Jasmine Daniels, MD Ali Habib, MD Neurology Maggie Likes, MD Pediatric Cardiology Keven Nevil, MD Gynecology Stirling Smith, DO Neil Wang, DO Lakshmi Datla, MD Sabrina Hart, MD Family Gabriela Loperena Oropeza, MD Endocrinology Kurt Norman, MD Kenneth Son, MD Xinda Wang, MD Helene DeHaan, ARNP Family Nurse Practitioner Scott Harriage, MD Gynecology Emily Luerssen, MD R. Steven Norton, MD Trauma Douglas Sorenson, MD ENT Sarah Waverveld, DPM Podiatry Trevor Dennie, MD Susanne Hopkins, MD Carlos Justiniano, MD Trauma Gabriela Oropeza, MD Endocrinology Patricia Spitale, MD Neonatology Marjan Zarghami, MD Pharmacy News, from page 4 lower concentration is less likely to become frothy when shaken, which helps ensure an accurate measurement. The 12 mg/ml concentration will not be marketed after current supplies are used. Changing measurements of the oral-dosing device from milligrams (mg = weight) to milliliters (ml = volume). Changing the dosing table to include a column for the volume (ml) based on the new 6 mg/ml concentration (see Table 2). Revising container labels and carton packaging Revising compounding instructions for pharmacies to prepare a 6 mg/ml oral suspension from Tamiflu capsules in an emergency situation only if commercially manufactured Tamiflu for oral suspension is unavailable. Genentech planned to begin distribution of the new 6 mg/ml product in July The company has instituted a voluntary Take Back Program for wholesale buyers, distributors and pharmacies to remove the 12 mg/ml product from the marketplace. emerging blood thinners, from page 2 last dose may restore clotting ability. While the medical community has welcomed these new medications to the market and current practice employs them regularly, it is clear that their use is not without risks and these must be assessed on a case-by case basis. At the Franciscan Health System, we see about 4,500 patients a year who refuse transfusion of allogeneic blood products due to personal beliefs. For them, the use of fresh frozen plasma or red blood cell transfusions is not an option. Moreover, PCC, cryoprecipitate or other coagulation factors may or may not be acceptable to them. Therefore, these anticoagulants may be contraindicated in this patient population as the risks could outweigh the benefits. *Sources for this article included prescribing information for Pradaxa, Xarelto, Plavix and Effient. Connections August 2011 Advanced. Trusted Care. 5

6 Medical Staff Calendar August 1 Credentials Committee, SJMC, 7 a.m., Portview Conference Room Journal Club, SCH, cancelled, no lunch Grand Rounds, SEH, 5:30 p.m. 7 p.m. Clinical Cardiac MRI: Established & Emerging Applications, Jeffrey Rose, MD, and Negar Knowles, MD, Rainier Room. RSVP to Pelvic Floor Disorder Conference (not Category I), SJMC, 6 8 p.m., Lagerquist A&B 2 Neuro/Gamma Knife Conference, SJMC, 7 8 a.m., Neuro/Gamma Knife Conference Room CME Committee, SJMC, cancelled Chief Medical Officer Advisory Council, SJMC, 5:45 p.m., Lagerquist A&B 3 Tumor Board, SJMC, 7 8 a.m., Dining Rooms 1&2 4 Pierce County Breast Conference, 10 Tumor Board, SJMC, 7 8 a.m., Dining Rooms 1 & 2 11 Pierce County Breast Conference, Breast Care Conference, SFH, 12 p.m., Grand Rounds, SJMC, cancelled for FHS Medical Executive Committee, SJMC, 5:45 p.m., Lagerquist A&B 12 Grand Rounds, SFH, cancelled for SAH Medical Staff Operating Committee, SAH, 7 a.m., Smalling Conference Room 15 Journal Club, SCH, cancelled, no lunch 16 Neuro/Gamma Knife Conference, SJMC, 7 8 a.m., Neuro/Gamma Knife Conference Room Franciscan Health System Connections 1717 South J Street, Tacoma Neurological Sciences Grand Rounds (not Category I), SJMC, 6 p.m., Dining Rooms 1 & 2 17 Tumor Board, SJMC, 7 8 a.m., Lagerquist A 18 Pierce County Breast Conference, 19 Tumor Board, SFH, 12 p.m., 22 Journal Club, SCH, cancelled, no lunch 23 Medical Research Evaluation Committee, SJMC, 12 p.m., Lagerquist C 24 Tumor Board, SAH, 7 8 a.m., Larson Conference Room Tumor Board, SJMC, 7 8 a.m., Lagerquist A SCH Medical Staff Operating Committee, SCH, 6 p.m., Classrooms A&B 25 Performance Quality Leadership Group, cancelled Pierce County Breast Conference, Breast Care Conference, SFH, 12 p.m., Grand Rounds, SJMC, cancelled for 26 GU Conference, SFH, 12 p.m., Grand Rounds, SFH, cancelled for 29 Credentials Committee, SJMC, 7 a.m., Portview Conference Room (rescheduled from Sept. 5) Journal Club, SCH, cancelled, no lunch 31 Tumor Board, SJMC, 7 8 a.m., Dining Rooms 1&2 Legend: SJMC=; SFH=; SCH=; SAH=St. Anthony Hospital; SEH=St. Elizabeth Hospital; MOB=Medical Office Building; Carol Milgard Breast Center is at 4525 S. 19th St., Tacoma N o n p r o f i t O r g. U. S. P o s t a g e Pa i d Ta c o m a, WA P e r m i t N o Please note: Journal Club and lunch have been permanently cancelled for the 2nd Monday of each month. Printed on Recycled Paper Advanced. Trusted Care. 6 August 2011 Connections