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MERCY MEDICAL CENTER Cedar Rapids, Iowa

Surgery Department of the Medical Staff

Wednesday, January 8, 2014 0700 – St. Luke’s Schwartz Center

I. Call to Order

II. Guest Speakers – Dr. Hodgman & Dr. Walsh (Perio perative Aspirin Discussion) (pg. 2)

III. Approval of November 6, 2013 Minutes (pg. 3-5)

IV. Committee Reports a. MEC Excerpts & Follow-Up (December 2013 & Januar y 2014) – Dr.

Vander Zee (pg. 6-9) b. Administrative Report – Dr. Valliere (pg. 10) c. Medication Management Newsletter (Oct/Nov 2013) – Dr. Vander Zee

(pg. 11-12)

V. Quality Reports a. SCIP Quality Measures – Kathy Swift (pg. 13-14)

VI. Old Business

a. ED On-Call Ad Hoc Committee Updates – Dr. Vander Zee

VII. Next Meeting Wednesday, March 5, 2014, 0700 in Mercy Neuhaus Board Room

VIII. Adjournment

DATE: November 8, 2013

TO: All Healthcare Providers & Staff

FROM: Cam Campbell, MD Cardiovascular Medical Director

Chris Walsh, MD Anesthesiology Medical Director

SUBJECT: Perioperative Aspirin Administration

Recently a new NATIONAL consensus statement was released from the societies of

Anesthesia, Medicine, Cardiology and Surgery in regards to continuing perioperative

Aspirin in specific patient populations.

This recommendation is divided into two categories; PRIMARY prophylaxis (e.g.

patients taking Aspirin in the absence of an established diagnosis of cardiovascular disease)

& SECONDARY prophylaxis (e.g. patients taking Aspirin in the presence of overt

cardiovascular disease or conditions conferring particular risk).

Stopping Aspirin in patients taking this medication for overt cardiovascular disease or

conditions needs an explicit discussion with the patient and patient’s primary care

physician, cardiologist, neurologist, or vascular physician.

The following verbiage in the PASE ordersets was agreed upon at Anesthesia &

Cardiovascular Section as well as the Medical Executive Committee at Mercy Medical Center.

If on Aspirin for an established diagnosis of cardiovascular disease, stroke, peripheral vascular

disease; continue Aspirin in the perioperative period. If preferred, the Aspirin may be

decreased to 81 mg.

Please don’t hesitate to contact Cam Campbell, MD with any questions at

cfcampbell@mercycare.org or Chris Walsh, MD at iowasleepdoc@yahoo.com

Date: November 6, 2013

Discussion/

Leader

Expected

ResultContent/ Agenda Item Meeting Notes/Decisions/Actions or Assignments

Dr. Vander Zee Action Call to Order Dr. Vander Zee, called this regularly scheduled meeting of the Surgery Department of Mercy Medical Center, a peer review committee, to order at 0700.

Dr. Vander Zee Action Approval of September 4, 2013 minutes. The minutes were reviewed and approved as distributed.

Committee Reports

Dr. Vander Zee Information Medical Executive Committee (October & November 2013) Dr. Vander Zee noted the case review criteria additions were approved at the November MEC. These additions include: discrepancy between pre-operative and post-operative diagnosis, transfer to higher level of care or transport to another facility, and readmission within 30 days. Also noted the OB/Gyn department removed abdominoplasty from their privileges.

Cynthia Lewis Information Administrative Report (November 2013) Mary Brobst, the new CNO was introduced to the group. Also noted fall physician forums are scheduled, Dr. Matsuda, Pediatric Hospitalist joined Mercy, and noted changes to the OR lounge.

quality reports

Kathy Swift Discussion/Action SCIP Quality Measures

Ms. Swift discussed the SCIP outcomes for 2nd Quarter 2013. It was noted there was a beta block failure. The last dose was not documented. Also noted the timing issues in EPIC has been fixed.

Mercy Medical CenterCedar Rapids, IA

Meeting Minutes for: Surgery Department MeetingChair: Dr. Vander Zee / Recorder: Heather Vasquez

Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports

Present: Drs. Dempewolf, Huebsch, Kopesky, Krivit, Nielsen, A. Nowell, Reid, Renz, Royer, Vander Zee, and Wallace. Also present: Peggy Beck, Sue Helle, Jennifer Vander Zee, Kathy Swift, Mary Brobst, Nancy Shade, Cynthia Lewis, and Heather Vasquez.

Call To OrderCall To OrderCall To OrderCall To Order

Approval of MinutesApproval of MinutesApproval of MinutesApproval of Minutes

Start Time: 0700

Date: November 6, 2013

Mercy Medical CenterCedar Rapids, IA

Meeting Minutes for: Surgery Department MeetingChair: Dr. Vander Zee / Recorder: Heather Vasquez

Present: Drs. Dempewolf, Huebsch, Kopesky, Krivit, Nielsen, A. Nowell, Reid, Renz, Royer, Vander Zee, and Wallace. Also present: Peggy Beck, Sue

Start Time: 0700

Dr. Vander Zee Discussion/Action Updates on ED Call ScheduleThe ad hoc committee had their first meeting. Future updates will be brought as available.

Dr. Vander Zee Discussion/Action Chair/Vice Chair Election (Jan 2014-Dec 2015)

The group is currently off cycle from the bylaws election schedule. Group discussed numerous options for chair elections including ballots and bylaws rules regarding elections. It was proposed, voted, and approved for Dr. Vander Zee to continue as chair until the July 2014 meeting at which point Dr. Kopesky will become chair and a vote will be held for vice chair through the end of 2015.

Peggy Beck Discussion/Action CMS New Two-Midnight Rules

Group reviewed the new CMS rules effective Oct. 1st and the EPIC order set to correspond with the changes. Ms. Beck noted the 2 midnight rule. Admission orders will prompt to estimate the length of stay and to sign a certification statement. Action: Contact the Care Coordination team with any questions.

Dr. Vander Zee Discussion/ActionPerioperative Aspirin Administration and Preoperative Testing Guidelines

Group reviewed the proposed recommendations regarding perioperative Aspirin administration. Discussion surrounded inviting a Cardiovascular representative to the January meeting to discuss data, sources, and common practices around the community regarding prophylaxis. Action: A representative will be invited and topic added to the next agenda.

New BusinessNew BusinessNew BusinessNew Business

Old BusinessOld BusinessOld BusinessOld Business

Date: November 6, 2013

Mercy Medical CenterCedar Rapids, IA

Meeting Minutes for: Surgery Department MeetingChair: Dr. Vander Zee / Recorder: Heather Vasquez

Present: Drs. Dempewolf, Huebsch, Kopesky, Krivit, Nielsen, A. Nowell, Reid, Renz, Royer, Vander Zee, and Wallace. Also present: Peggy Beck, Sue

Start Time: 0700

Dr. Reid Discussion/Action M&M Conference and Peer Review Process

Dr. Reid invited the group to attend the M&M Conferences held the last Friday of each month. This conference is for educational purposes and process improvment opportunities. Members were encouraged to bring cases of interest. Action: It was suggested to change the meeting time from 7am to 6:30am to increase attendance. Dr. Reid also discussed the current peer review process and proposed a new process. He suggested forming a group with a member from each specialty that initial looks at each case review through a blind process. This group will make a recommendation that will then be sent to the department chair for final recommendation. Group discussed current bylaws and review process. Action: It was decided to discuss more at a future meeting.

Dr. Vander Zee Information Physician Annual MeetingThe Annual Physician Meeting will be held December 3, 2013 at 6pm in St. Luke's Nassif Heart Center.

Dr. Vander Zee InformationThe next meeting will be held on January 8, 2014 @ 0700 in St. Luke's Room 163.

With there being no further business, the meeting adjourned at 0800.

Adjournment & Next Meeting:Adjournment & Next Meeting:Adjournment & Next Meeting:Adjournment & Next Meeting:

AnnouncementsAnnouncementsAnnouncementsAnnouncements

Respectfully submitted by,A. John Vander Zee, MD

MERCY MEDICAL CENTER Cedar Rapids, Iowa

Medical Executive Committee Excerpts

December 3, 2013 Cedar Rapids Medical Education Foundation Executive Director Dr. Beck introduced Dr. Jennifer Holmes Latterell to the committee. Dr. Holmes Latterell is the newly hired Executive Director of CRMEF. Credentials Committee The Credentials Committee meeting report of November 19, 2013 was given. The following physicians were recommended for membership and privileges: • Jennifer Holmes Latterell, DO – Family Medicine joining Cedar Rapids Medical Education

Foundation. • Arnold Honick, MD – Radiology rejoining Radiology Consultants of Iowa. Carrie Campbell, ARNP was recommended for Category I ARNP status and privileges in the Surgery department. The below practitioners were recommended for employed surgical assistant activities. • Shayla Baird, RN – Birthplace • Kristyn Francksen, RN – Birthplace • Lisa Jaschen, RN – Birthplace • Amy Steger, RN – Birthplace • Courtney Upah, RN – Birthplace • Julie Wittman, RN – Birthplace • Michelle Erickson, Surgical Technologist – WEO/PRN The committee reviewed the list of reappointments for the 4th quarter 2013. The following physicians were recommended for Advancements: • Jessica Kelley, MD – Anesthesiology • Jody Harmsen, MD – Family Medicine • Joseph Kennedy, DO – Family Medicine • Thomas Serbousek, MD – Family Medicine • Amanda Sommerfeldt, MD – Family Medicine • Muhammad Anwer, MD – Internal Medicine • Jason Cogdill, MD – Internal Medicine • Karim Nahra, MD – Internal Medicine • Alice Fagin, MD – Surgery • Nora Royer, MD – Surgery

Medical Executive Committee Excerpts December 3, 2013 Page 2 The committee accepted the following resignations: • David A. Brickey, DO – Internal Medicine/Pulmonology • Stephen Sladek, MD – Family Medicine • Mary Eyanson, MD – Pediatrics • Richard Kahn, MD – Internal Medicine – did not apply for reappointment The committee recommended the revisions to Therapeutic Flexible Fiberoptic Bronchoscopy privilege criteria as submitted. Eduardo Celis, MD was recommended for Bronchial thermoplasty privileges. The committee accepted the department’s review of the current delineation of privileges for Orthopedics and Emergency Medicine and recommendation of no changes to these requirements. The Credentials Committee reviewed the summary report of the FPPE conducted in 4th quarter 2013 and their respective department chair recommendations. No quality issues were identified. James Howe, MD – Surgery was recommended for a full two year reappointment. Dr. Valliere updated the Credentials Committee on the outcome of the conflict resolution vote. The vote was 152 to 56 in favor of discontinuing NRP requirement for obstetricians. The Credentials Committee recommended removal of the requirement from the OB privileging criteria. The Allied Health Practitioner Committee meeting report of October 23, 2013 was given. Applicants recommended for approval: • Sarah Cole, ARNP – UnityPoint Multi-Specialty Clinic (Dr. Paynter) Practitioners recommended for advancement: • Rhonda Bridgewater, ARNP – Mercy Cardiology Clinic (Dr. Campbell) • Mackenzie Groteluschen, ARNP – Linn County Emergency Medicine (Dr. P. Peraud) • Sarah Kluesner, ARNP – PCI Orthopaedic/Podiatry (Dr. Hart) • Nicole Miller, ARNP – Oncology Associates at Mercy (Dr. Wilbur) • Anne Nugent, ARNP – Mercy Cardiology Clinic (Dr. Campbell) • Patricia O’Donnell, ARNP – Internist Associates of Iowa (Dr. Yacoub) Practitioners recommended for re-registration: • Carolyn Hosch, RN – Cedar Valley Hand Surgery (Dr. Johns) • Kevin Huddleston, CA – Biotronic for Intraoperative Monitoring Services (Dr. Maggio) • Katie Kavanaugh, ARNP – Respiratory and Critical Care Associates (Dr. Cowden) • Mindy Martin, ARNP – The Ghosh Center for Oncology and Hematology (Dr. Ghosh) • Kristina Nystrom, RA – Radiology Consultants of Iowa (Dr. Hammer) • Matthew Pilsner, CA – Biotronic for Intraoperative Monitoring Services (Dr. Maggio)

Medical Executive Committee Excerpts December 3, 2013 Page 3 Practitioner resignations: • Holly Copeland, ARNP – PCI ENT (Dr. Krivit) • Jody Kolb, ARNP – Mercy Psychiatry (Dr. Munagala) • Evan Lawrence, CA – Biotronic for Intraoperative Monitoring Services (Dr. Davis) • Lesley Vancura, ARNP – PCI Hematology & Oncology (Dr. Warren) Change in Supervising Physician: • Kristina Nystrom, RA – Radiology (Dr. Hammer) • Sarah Kluesner, ARNP – Orthopedics (Dr. Hart) The Allied Health Practitioner Committee reviewed and recommended approval of the revisions to the Scope of Practice section of the Radiologist Assistant Policy along with the accompanying criteria for the new activities with the additional clarification that the hysterosalpingogram interpretation will be preliminary and that all final interpretations will be performed by the supervising radiologist. Kristina Nystrom, RA and Shellie Pike, RA were recommended for the activities of joint injection/aspiration under fluoroscopy of the hip and of the wrist. The Credentials Committee discussed the expanded Radiologist Assistant activities recommended by the Allied Health Practitioner Committee. Discussion included: • Education, training and experience of the practitioners • Complications risk and the practice model for follow up care of complications • Communication with the referring physician The Credentials Committee tabled recommendation of the additional Radiologist Assistant activities, requesting feedback from the orthopedics department be presented at the next regularly scheduled meeting of the committee. The Medical Executive Committee discussed the expanded activities and the Orthopedic Department Chair will seek feedback from his department members and report at the next meeting. It was also noted that Allied Health Practitioner activities are granted by the Allied Health Committee, a subcommittee of the Board of Trustees and do not require Medical Staff approval. Bylaws Committee The Bylaws Committee meeting report of November 13, 2013 was given. The committee has identified 16 free standing Medical Staff policies where a significant part of the policy now resides in the recently revised Medical Staff Bylaws. The Committee recommended these policies be archived due to their redundancy. This will be presented to the Medical Staff for a vote at the same time as the Medical Staff Rules and Regulations revisions.

Medical Executive Committee Excerpts December 3, 2013 Page 4 Treasurer’s Report Dr. Anderson presented the Treasurer’s Report. Current savings account balance is $0 and checking account balance is $54,635.58. $43,925.00 was received in revenue from membership dues assessments. This revenue was dispersed to pay $10,000.00 for Medical Staff Officer Compensation, $21,850.00 for Medical Staff gifts, $8,149.25 in legal fees and $607.38 in miscellaneous expenses. The Treasurer’s Report was accepted as submitted. Medical Staff Leadership Compensation Dr. Wilbur then turned the chair over to Gordon Baustian, MD, Vice President. Dr. Wilbur reviewed with the committee the various increases to the time obligations of the Medical Staff Officer positions. It was approved to compensate the Medical Staff Leadership as follows: • Medical Staff President $12,500 annually • Medical Staff Vice President $7,500 annually • Medical Staff Secretary/Treasurer $2,500 annually • Medical Staff Bylaws Committee Chairperson $1,250 annually • Medical Staff Credentials Committee Chairperson $1,250 annually Charitable Giving The following gifts were approved: • Sisters of Mercy 3,000.00 • Willis Dady House 1,500.00 • Tanager Place 1,500.00 • Catholic Worker House 1,500.00 • Madge Phillips Center 1,500.00 • St. Vincent DePaul 1,500.00 • His Hands Free Medical Clinic 1,500.00 • Community Health Free Medical Clinic 1,500.00 • Community Health Free Dental Clinic 1,500.00 • Mission of Hope 1,500.00 • H.D. Youth Center 1,500.00 • Catherine McAuley Center 1,500.00 • St. Luke’s Dental Health Center 1,000.00 Orientation of Medical Staff Department Chairs Orientation for new department chairs will be held Tuesday, January 7, 2013 at 5:00 p.m. Mercy Neuhaus Board Room followed by the regularly scheduled Medical Executive Committee meeting. Returning chairs are strongly encouraged to attend as well, to reacquaint themselves with the expectations and duties and assist in the orientation process.

ADMINISTRATIVE REPORT December 2013

PROVIDER ENGAGEMENT SURVEY COMING IN JANUARY!

Mercy Medical Center will be administering a provider engagement survey with The Advisory Board Company beginning

on January 20, 2014. As a leader at Mercy Medical Center, you play an instrumental role in ensuring your peers

understand the value and logistics of the survey so we can generate a robust dataset.

We are committed to making our organization a best-in-class place to practice medicine for physicians and mid-level

providers like you. We want to understand how we can help improve your work environment and enhance the quality of

care provided to your patients. This survey will help us assess where to target our efforts to accomplish this goal. The

information we gather will help define our strategic priorities for the coming year.

What’s different about this year’s survey? While our previous surveys measured physician satisfaction with

Mercy Medical Center, this year’s survey is designed to measure physician engagement with the hospital.

Engagement goes beyond simple satisfaction to include commitment to and connection with Mercy Medical

Center. We think this is an important change to make as we look to partner more closely with physicians and

mid-level providers.

How long will the survey take? The survey should take no more than 5 minutes to complete. We have

intentionally chosen a short, concise survey as we know how valuable your time is.

***How do I take the survey?*** You will be emailed a link to the survey on January 20th

when the survey is

opened. Clicking on the link will take you to the survey page. Of course, we will also post the link and

instructions on our new provider website, p.mercycare.org, just in case you misplace the email.

If you don’t receive an email on January 20th

that means we don’t have your email address on file. To change

that, contact Andrea Ault at aault@mercycare.org or (319) 558-6405 to have your name added to the “All

Providers” email distribution list. You’ll also see plenty of signage on physician workstations, in the physician

lounges, among other places.

Where should I take the survey? You can complete the survey from any computer, smartphone or tablet with

Internet access.

Will anyone ever see my responses? Your responses to the survey are completely confidential. The aggregate data will

be analyzed and developed into action plans to work toward continuous improvement.

What happened since the last survey?

• Launch of Mercy’s one-patient, one-record Epic Initiative

• UpToDate purchased and implemented for all Providers

• Expansion of Clinical Grand Rounds to enhance clinical education opportunities

• Attend, Admit and Consulting Policy Established

• Better Nursing Communication through SBAR Practices

• Establishment of Physician Leadership Council

• Participation by physicians in the Capital Budgeting Scoring Process

• Epic Physician Advisory Council

• Physician Forums continued to enhance communication with administration

• Additional Updates & Information via NEW Provider Website, p.mercycare.org

MMC Annual Report now available online:

Go to: https://www.mercycare.org/app/files/public/5428/Mercy-Annual-Report-2013.pdf

The Medication Management Committee of Mercy Medical Center

Cedar Rapids, Iowa (Formally P&T)

October & November 2013

Prothrombin Complex Concentrate (Kcentra) ADDED TO FORMULARY Kcentra is a hemostatic agent that provides an increase in the levels of the vitamin K-dependent coagulation factors (II, VII, IX, and X) with the addition of protein C and S. It’s used for urgent reversal of acquired coagulation factor deficiency induced by Wafarin in patients with acute major bleeding. Prothrombin Complex Concentrate (Kcentra) added to formulary.

Dexmedetomidine (Precedex) ADDED TO FORMULARY Precedex is a selective alpha2-adreonceptor agonist with anesthetic and sedative properties thought to be due to activation of G-proteins by alpha2-adreonceptors in the brainstem resulting in inhibition of norepinephrine release. It’s approved uses include:

• Sedation of initially-intubated and mechanically-ventilated patients during treatment in an intensive care setting

• Procedural sedation prior to and/or during awake fiberoptic intubation • Sedation prior to and/or during surgical or other procedures of non-intubated patients

Dexmedetomidine (Precedex) added to formulary.

LATEST DELETIONS

DELETED REASON

Hetastarch (Hespan) The FDA has included a boxed warning on increased mortality and severe renal injury, and an additional warning on risk of

bleeding for use of hydroxyethyl starch solution in some settings.

Pilocarpine (Pilopine) HS Gel Discontinued by manufacturer. Thrombin 20,000 unit topical spray No use. Thrombin 5,000 unit topical spray No use. Ticlopidine (Ticlid) 250 mg tablet No use.

Ethosuximide (Zarontin) 250 mg capsule No use.

Formulary Addition Request Form

A form has been approved to assist providers who want to propose a medication addition to formulary. This form can be found on the pharmacy website and may be send to the Medication Management Committee for review.

IV to PO Therapeutic Conversion Protocol

A protocol was approved to allow pharmacy to automatically convert patient from IV medication to PO for the listed medications when the guidelines are met.

Guidelines:

1. The patient is taking other oral medications or is tolerating an oral diet (this includes a liquid diet). 2. The patient does not have severe diarrhea or a malabsorptive syndrome. 3. There is no active nausea and/or vomiting—defined as not receiving an anti-emetic in the last 24 hours or no

active vomiting in the last 24 hours. 4. If the medication in question is an antibiotic:

a. WBC is within normal limits or decreasing towards normal. b. The patient is afebrile (< 38⁰C or < 100.4⁰F) for at least 24 hours. c. Patients with meningitis, endocarditis/endovascular infections, osteomyelitis, brain abscess, or other

central nervous system infection are excluded from the program. 5. If the medication in question is pantoprazole:

a. There is no documented gastrointestinal bleed on this admission.

If all applicable guidelines above are met, convert the IV medication to PO based on the table below: Drug IV:PO Conversion Bioavailability of PO Pantoprazole 1:1 80% Famotidine 1:1 45% Azithromycin 1:1 37% ̂Levofloxacin* 1:1 99% Metronidazole 1:1 100% Fluconazole 1:1 90% Sulfamethoxazole/trimethoprim 1:1 based on trimethoprim

component 90-100%

Clindamycin 2:1 with same frequency (example: 600 mg IV q 6 hours converts to 300 mg

PO/NG q 6 hours)

90%

Linezolid 1:1 100% ^Although azithromycin has a low bioavailability, it is well-distributed into tissues. *Separate oral administration by at least 2 hours from products that contain magnesium, calcium, aluminum, or iron (antacids, sucralfate, supplements).

Members of the Medication Management Committee

Dr. Fadi Yacoub, Chair Dr. Schweta Diwaker Dr. Susan Schima Dr. Vincent Reid Dr. Martin Cearras

Dr. Mark Valliere Sarah Schloss Stephanie Hoenig Taylor Felker Lauren Cuming

Kathy Smelser LeAnn Tatman Becky Prier Brianna Stueck