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In This Issue
Message from the Chief of Staff
April is Organ Donor
Awareness Month
Who's New
A Special Event for Physicians
PICC Placement
Standing Order Set
Anesthesia MRI Efficiency Enhancement Project Report
EMR Update for Prescribers
March 2011

Who's New
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Please welcome these new members of the Medical Staff:

Karen Raimer, MD
Division of Pediatric Surgery, Section of Gynecology,
Maternal Fetal Medicine

Jeremy Ringewald, MD
Division of Pediatric Cardiology

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A Special Event
for Physicians
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All physicians are invited to join us for a special physician event on Saturday, April 2, marking a new chapter in All Children's history: Joining Forces with Johns Hopkins Medicine. The program, to be held in the Outpatient Care Center, will begin at 8:45 a.m. and conclude at 11:30 a.m.

Jonathan Ellen, M.D., will discuss "The Integration of All Children's Hospital and Johns Hopkins Medicine" and lead an open forum entitled, "How Does the Johns Hopkins Integration Affect You and Your Practice?" Dr. Ellen will be Vice Dean of Johns Hopkins University School of Medicine at All Children's Hospital and Physician-in-Chief. He currently serves as Chairman of Pediatrics at Johns Hopkins Bayview, Vice Chair of Pediatrics at Johns Hopkins University School of Medicine (JHUSOM), and Director of the Johns Hopkins Center for Child and Community Research.

David G. Nichols, M.D., Vice Dean of Education for JHUSOM, will discuss "The Future Physician: From Genes to Society." Dr. Nichols oversees undergraduate, graduate, residency, postdoctoral and continuing medical education at JHUSOM.

Peter J. Pronovost, M.D., Ph.D., will discuss "From Rhetoric to Reality: Improving Patient Safety in the Private Practice and Hospital Settings." Dr. Pronovost is Medical Director for the Center for Innovation in Quality Patient Care at Johns Hopkins and is internationally respected for his efforts in advancing the science of patient safety.

Advance registration at is required for this program. We hope you will join us.

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PICC Placement
Standing Order Set
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The PICC Placement Standing Order Set is now available in Cerner for use by the Vascular Access Team (VAT). This is a standing order set that the VAT members can use to order the proper radiology studies, nursing care, and pharmacy/therapeutic interventions needed for placement and use of PICC lines. Physicians who wish to have a PICC line placed by the VAT need to order an IV Team Consult for PICC placement only. The VAT will then assess the patient, place the appropriate orders from the PICC Placement Standing Order Set for the procedure, and place the PICC line. There is also an order built in that gives permission to use the PICC line if placement is confirmed after x-ray reading by radiology. These standing orders will then show up in the ordering physician's inbox for signature.

Stephen Kennedy, M.D.

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Message from the Chief of Staff
On the eve of the merger with Johns Hopkins Medicine, I feel more strongly than ever that we are becoming more united as a Medical Staff. I want to thank everyone who attended the social event at the Local 662. It was an entertaining evening with good music and even better company and I look forward to seeing even more colleagues at the many upcoming events. I was also extremely pleased at the turnout for the introduction of Jon Ellen, M.D. as incoming physician-in-chief. I have spoken to many Medical Staff members and the response to the meeting was overwhelmingly positive. I am aware that some expected more specifics and detailed plans; and while I know that this will be forthcoming, I really encourage everyone to become actively engaged in this transformation. Johns Hopkins Medicine will provide an excellent framework and structure upon which we can build a truly outstanding academic childrens hospital but the lions share of the work, ideas, and solutions are going to come from within our own Medical Staff. My tenure as Chief of Staff has been one highlighted by change, first with the move into our new facility and now with the merger with JHM, and so I want to draw on the words of King Whitney, Jr., who said: "Change has a considerable psychological impact on the human mind. To the fearful it is threatening because it means that things may get worse. To the hopeful it is encouraging because things may get better. To the confident it is inspiring because the challenge exists to make things better." In the coming weeks there are going to be many gatherings to kick off our new relationship with Johns Hopkins and as always I encourage everyone to attend as many of these events as possible. It is important that the Medical Staff provide the leadership to our staff and the community as we enter this exciting new era at All Children's Hospital.

Gregory Hahn, M.D.

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April is Organ Donor Awareness Month

In recognition of Organ Donor Awareness month, we are celebrating the dramatic advances that have been made in organ donation rates — and lives saved — over the past three years at ACH. These achievements were the result of enhanced professional education and improved communication and collaboration between LifeLink and the staff at ACH. Much of the credit for increasing organ donation at ACH goes to the Donation Advisory Committee (DAC), which was created in April 2008. The DAC is comprised of members from ACH Nursing, Medical Staff, Pastoral Care, Social Work Services and Administration, as well as LifeLink Donor Coordinators, Physicians, and Administrators.

Some of the specific improvements include:

Collaborative development of ACH clinical triggers for LifeLink referrals
Expansion of the referral process from one discipline to multiple disciplines
Revision of ACH policies on Organ Donation
Development of Donor Management Order Sets
Ongoing staff education for all shifts
Increased presence of LifeLink Coordinators at ACH, including rounds in PICU

Through the generosity of the donor families and the tremendous support and dedication of the staff at ACH, more lives are being saved every year.

Organ Donors
Organs Donated
Lives Saved

Thank you to all of you who make this possible.

Sharon A. Perlman, M.D.
Member, DAC

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Anesthesia MRI Efficiency
Enhancement Project Report

1. As tasked by the Chief, Division of Anesthesiology, I have pursued the process from parent receiving prescription to completion of MRI examination. I have interviewed individuals in MRI Scheduling, Pre-registration and MRI Nursing to compile a detailed step-by-step evaluation of the process.

2. I am delighted to report that the backlog of patients needing MRI exams is minimal. The schedulers attribute this to the strong efforts by the Division in providing additional scheduled days where anesthesia is available on 2 scanners. Current time to sedation: first appt is 2-3 days, time to 3rd appt is 5-6 days, time to first morning appt is 10 days. Nonsedate appointments are available the same day or next day. These times come from multiple checks by the schedulers over the last 2 weeks.

3. In addition, the provision of additional anesthesia resources as soon as the first additional anesthesiologist is available has facilitated scanning of patients on the daily schedule and on the add-on list, allowing children to be scanned earlier than would otherwise have been possible. Number of add-on sedation patients varies from 0-13 in a single day, with the shortest scan time of about 60 minutes. This variability of patient numbers is a significant on-going challenge on a daily basis.

4. The MRI technologists and nurses do a heroic job in managing the flow of multiple patients for multiple tests on the 3 scanners. This job is made more challenging by the fact that some exams and some patients must be done on specific scanners (i.e., 3T vs. 1.5T magnet). Thus, much juggling is required to get the appropriate patient on the appropriate scanner without delaying care for another patient on a different scanner and without having a scanner go unutilized for long periods of time. The MRI technologists scan for very long hours without relief in order to meet operational requirements.

5. The most rate-limiting factor at this time may be insurance authorization for routine MRI examinations. Although Medicaid and some private insurance companies do not require preauthorization, many do. Time to obtain preauthorization often exceeds the time to 1st available appointment. Another ongoing project that is being pursued at both ACH and at All Children's Specialty Care of Tampa will help to define the causes of "holes in the schedule", scheduled patients whose examination time is blocked but unused due to lack of authorization, no-show, NPO violation, or other causes — this is being tracked. Although some of those "holes" are inevitable; children being sick on the day of their MRI exam and requiring rescheduling, there are likely opportunities to fine-tune the system and reduce the number of unutilized anesthesia slots. The "hole project" will provide objective data that can be evaluated to further enhance throughput on the MRI scanners.

6. Please remember that a physician phone call to MRI for urgent and emergent cases is important for appropriate patient triage as there are as many as 14 add-ons into a full schedule on a given day. Recognition early in a hospitalization that an MRI is necessary during that hospitalization and an early phone call to MRI 7-8434 will allow for better scheduling and patient care than waiting until the last minute to try and get a patient worked in.

Linda Rice, M.D.
EMR Update for Prescribers
March 2011
1. "Add Note Functionality": Several Advanced Care Providers (ACPs) have utilized a right click option in the medical notes tab to create a new document. This feature is however linked to a privilege "to sign transcribed documents" and ACPs do not have that privilege at All Children's Hospital. Any documents created by ACPs utilizing this function, therefore, cannot be saved to a patient's EMR. The recommendation for all ACPs is to only utilize PowerNotes for the creation and saving of any documents. Drs Major and Amin are available to demonstrate how to utilize existing PowerNotes and to customize for specific needs.

2. Cerner Upgrade and New Functionality in Orders.

a. When you add an order for a medication, a selection box of several sentences opens. With the upgrade you can drag open this dialogue box (to allow full viewing of sentences) and it will stay that way for any future orders.

b. When you want to change a dose of a medication that was previously entered using the dose calculator (for sentences that are mg/kg based), with the upgrade the dose calculator automatically pops open again even if you have chosen entered an "exact dose change." We have asked for Cerner to "suppress" this but in the interim encourage everyone to choose the new dose also using the dose calculator.

3. Problem List: The Problem List is an important tool in the EMR that improves patient safety and allows concise communication with the patient at discharge and also provides "continuity of care" documentation to be sent to the next provider. As part of the Federal Stimulus funding to demonstrate "Meaningful Use of the EMR," hospitals have to show that at least 80% of patients admitted to the hospital have Problems identified in a structured format (Problem List). All Medical groups/services at ACH are encouraged to maintain a Problem/Diagnosis List for all their patients and for consultants to add the problems/diagnoses they have identified. Drs. Amin and Major are available to meet each group to demonstrate this functionality as well as how to create favorites for easier use. Please email us to set up a session with your group. Please click on this link to learn more about Problem List use and maintenance.

(Problem List link to document will be provided to Darrell Lee to BeACH)
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