Electronic Medication Order Entry will Optimize Patient Safety

Leading the effort for electronic medication order entry are, left to right, Elora Hilmas, PharmD, BCPS; Mark Kelemen, MD; Ronetta Lambert, RN; and Anna E. Schoenbaum, RN, MS, CCRN.

The countdown has begun toward an important patient safety milestone for the Medical Center — 100 percent electronic order entry for all tests and medications by October 2007. To achieve that goal, the Medical Center has launched Cerner Millennium Optimization, a program that involves physicians, nurses, pharmacists, information technology staff and administrators from throughout the Medical Center.

“The Millennium Optimization program will fulfill our vision of a paperless order entry system at the Medical Center. This will serve as the critical foundation for many of our patient safety and quality initiatives going forward,” says Timothy Babineau, MD, MBA, chief medical officer and executive sponsor of the program.

“This important effort will involve practically all of our clinical staff, and many are now helping to plan and design the system. I cannot over-emphasize the crucial role that Millennium Optimization will play in our overall patient safety strategy,” Babineau adds.

The Medical Center has been moving closer to completing all orders electronically over the past two years. Computer-based order entry is already on line for laboratory and radiology tests, and three units have electronic medication orders: the Full-Term Nursery, Labor and Delivery and the Mother/Baby unit. But instituting electronic medication orders throughout the Medical Center will be a challenge, since they account for more than 95 percent of all orders in our hospital.

“Millennium Optimization will have many benefits for our patients and staff, including faster processing and delivery of medications,” says Mark Kelemen, MD, the physician leading the project. “The system will also help our doctors choose the best medications at optimal doses. As they order medications on line, the system will alert them if a patient is already on a similar drug or has an allergy. There will also be evidence-based information on selecting the best drugs for certain diagnoses,” adds Kelemen.

“Electronic medication order entry is a critical step toward our departmental goal of spending more time on patient care units, participating in rounds and supporting clinicians on patient care floors,” says Elora Hilmas, PharmD, BCPS, who is manager of the Women’s and Children’s Pharmacy and lead pharmacist for the Millennium Optimization project.

Hilmas explains that the new system will enable pharmacists to process and validate medication orders from any computer, instead of being tied down next to a fax machine where orders are currently sent. She adds that the system will eliminate delays that can occur in faxing orders from units to the pharmacy, which will mean that medications can get processed sooner and be sent to the units faster.

A lot of preliminary work needs to be done before the launch of the new system. Teams are working on designing the system, reviewing all order sets, updating policies and procedures, determining the number of computers that will be needed and developing training for all users.

One of the goals of Millennium Optimization is to improve unit work flow, according to Ronetta Lambert, RN, a senior partner on 11 East who is the lead nurse for the project. In the context of medication orders, work flow refers to all of the steps involved from the time a physician orders a drug to when it is administered. “The work flow process varies from unit to unit, depending on the unique needs of each of our patient populations. As a result, the system is being tailored to accommodate the needs of clinicians in different units, and the design committee for the new electronic medication order entry program includes about 25 nurses representing different areas,” says Lambert.

The next step will be for clinicians to have a hands-on demonstration of the preliminary design of the electronic medication order system. The sessions will be offered for five days in mid-December.

“These sessions will be important because they will help us to validate the design decisions made so far by various committees,” says Anna E. Schoenbaum, RN, MS, CCRN, senior project manager from the Information Technology Group. “We want the input of the end users, who include attending physicians, residents, nurses and other staff.”

“When we implement Millennium Optimization, we will be among a small percentage of hospitals nationwide that are leaders in this important patient safety initiative,” says Babineau.

Shock Trauma Center Expands to Meet Statewide Need

Hospitals statewide are sending more patients to Shock Trauma for its concentration of resources and expertise.

The sixth floor of the Shock Trauma Center will be transformed into a critical care and intermediate care unit, where Angela Weir, RN, BA, and other staff will provide a more intense level of nursing.

The R Adams Cowley Shock Trauma Center does whatever it takes to save the lives of Maryland’s most severely injured patients. For the next several years, that will include expanding its facilities to accommodate a growing number of patients each year.

The Medical Center is beginning an $83 million initiative to increase Shock Trauma’s bed capacity; improve the electrical, heating, ventilation and air conditioning systems; and upgrade clinical technologies. The expansion and improvements are necessary to address an increased need throughout the region for the highest level of trauma care for the most severely injured patients.

“We already exceed our occupancy on a daily basis,” says John Spearman, who is the Medical Center’s vice president for Shock Trauma. “We will receive 8,800 patients a year by 2011. That’s what’s driving these renovations.”

The projected growth in patients indicates Shock Trauma would need to grow from its current 94 beds, which include the TRU, to a total of 141. However, some of those acute-care beds can be accommodated within other units of the Medical Center adjacent to Shock Trauma, while Shock Trauma converts existing beds and adds 12 more beds for critical care on the third floor. The current Shock Trauma facilities were built in 1989 to handle about 3,500 patients each year. Today, the annual admissions exceed 7,000 patients.

There are days when Shock Trauma already operates at up to 112 percent capacity. Shock Trauma is able to do that because the trauma resuscitation unit (TRU) bays are all designed to accommodate two beds, when necessary. This design was originally adopted in the 1980s to be able to rapidly and routinely shift to mass-casualty capability, but it has also allowed the hospital to keep up with admissions for now.

“After the TRU and, often, surgery, our patients nearly always need to go to a critical care unit, and this is where we most immediately need to expand the number of beds,” says Thomas M. Scalea, MD, physician-in-chief of the Shock Trauma Center.

For this reason, the sixth floor of the Trauma Center is being transformed from an acute care unit, to more intensively staffed critical care and intermediate care beds.

“The sixth floor conversion includes promoting the knowledge and skills of the current staff of the acute care unit nurses in preparation for critical care,” says Theresa DiNardo, RN, MSN, CCRN, patient care services manager for the sixth floor. “We’re providing education, helping nurses enhance their certification and pairing them with mentor nurses who already work in critical care.”

“The patients the other hospitals are transferring here are going to be primarily critical care cases,” says Spearman. “We need more critical care bed capacity right away.”

As those patients improve, they need acute care beds, so part of the expansion will include more acute care beds as well.

“Once we increase our capacity, we will be at about 87 percent occupancy, which is optimal,” Spearman says.

Funding and Construction

The plan is to fund this expansion through a combination of University of Maryland Medical Center funds as well as a multi-year committment from the state of Maryland. Additional funds from federal sources are also expected.

Construction is set to begin this year with the relocation and expansion of the trauma ambulatory clinic, from the first floor of the Shock Trauma Center to a larger space on the ground floor formerly occupied by several groups including Clinical Engineering, Maryland ExpressCare and Respiratory Care Services.

This expansion will have a positive domino effect. Expanding the capacity for follow-up care after discharge will allow more beds in the hospital to be available for new, severely injured patients. No units will be shut down during the work, Spearman says, with as few rooms as possible out of use at a time.

The increase in critical-care patients is expected to include people who are transferred from other medical centers that don’t have the level of ondemand resources found at Shock Trauma. Other hospitals have, in the past, had to send patients to Shock Trauma because they did not have enough surgeons—in particular, orthopedic surgeons, neurosurgeons and oral-maxillofacial surgeons—available on a 24-hour basis.

The Trauma Resuscitation Unit TRU) of Shock Trauma was recently renovated and expanded with three more bays.

Several hospitals have felt compelled to consider whether and how to keep their trauma centers open over the past four years. When Washington County Hospital’s trauma center actually did close for four months in the summer of 2002, Shock Trauma received 250 more patients than usual during that period, Spearman says.

With a concentration of highly trained and experienced clinical staff, Shock Trauma has always been the core of trauma care in the state—and even more so now. “This is very much linked to a state-wide trauma system we have built in Maryland, and Shock Trauma’s role [as both the core and the safety net] in that system,” Spearman says.

Already, one expansion has taken place partly to address the need for more space, but also to accommodate the latest technology, the Statscan machine, a low-dose X-ray scanner that, in 13 seconds, produces a full-body image. For patients with multiple injuries, the scan allows quick detection of any broken bones and potentially fatal softtissue injuries.

Between 2003 and 2006, the new Mirmiran Diagnostic Imaging Suite was added, and the TRU was expanded from 10 bays to 13 bays. One of those 13 bays is dedicated to the Statscan machine, so that patients don’t have to be moved out of the TRU for imaging, saving precious minutes.

For decades, Shock Trauma has served as the core institution for the statewide emergency medical system, and was given that formal designation in 1993 by the Maryland General Assembly in House Bill 1222. The National Highway Traffic Safety Administration (NHSTA) did a review of the Maryland system to determine how it could serve as a model for other states.

“The key thing is the Maryland system is changing in response to challenges in health care. The Shock Trauma Center has to change as well,” Spearman says. “This plan is going to give us the ability to continue to meet those challenges.”

News

UMMC Leaps Into Top 50 Hospitals Nationwide for Safety, Quality and Affordability

It was icing on the cake when the Leapfrog Group released its first-ever ranking of the top 50 acute care hospitals in the country on Oct. 16— and the Medical Center was on the list.

The cake, of course, is a detailed report available on the organization’s Web site giving the Medical Center very high ratings in patient safety and quality of care. The Leapfrog Group uses objective criteria to rate hospitals based on outcomes and volume of selected high-risk procedures, adequate staffing of units and specific measures taken to ensure patient safety.

For example, the Medical Center has intensivists staffing nearly all its ICUs—including surgical, medical, neuro, cardiac surgery, multi-trauma and pediatric ICUs. (The Cardiac Care Unit is staffed by cardiologists.)

“The Medical Center earned the highest possible score on taking actions to address adequate staffing of nurses, and working to prevent infections, medication errors, complications and mistakes,” says Jeffrey A. Rivest, president and CEO of the Medical Center.

And for most of the high-risk procedures used as a gauge, the Medical Center exceeded the Leapfrog standards for the number of procedures done in a year. Evidence has shown that the higher the number of these procedures performed at an institution, the better the outcomes. For example, the Medical Center recorded 764 cases of percutaneous coronary intervention (such as balloon angioplasty) in a year, and the Leapfrog standard was 400.

Aside from the whimsical name, Leapfrog is serious business, founded in 2000 by the Business Roundtable to use the collective leverage of the nation’s largest corporations and public agencies who buy health benefits. Medical Center leaders submitted data and documentation for the Leapfrog Hospital Quality and Safety Survey in the spring and summer, before knowing a list would be released, says Timothy J. Babineau, MD, MBA, the Medical Center’s senior vice president and chief medical officer. More than 1,200 hospitals participated in the survey.

“We submitted an enormous amount of data,” Babineau says. “The consumer demands transparency from an institution, and this is one way to achieve it.”

Among all the report cards that exist for health care institutions, Leapfrog has the most to do with actual results, Babineau says.

“I think this has the most validity because it’s founded on evidencebased medicine, and on actual clinical processes and clinical data,” Babineau says. “The others, such as US News & World Report and HealthGrades, are more subjective.”

“We are not in one of the states where employer groups have urged hospitals to complete this survey, but we decided to do it because a couple of the insurers had started asking about it, and Dr. Babineau encouraged the assessment,” says Ingrid Connerney, DrPH, MPH, RN, director of quality and safety, who coordinated the submission.

One of the criteria for earning top honors was a move toward 100 percent electronic order entry, which the Medical Center is currently completing, says Babineau. (See cover article on Millenium Optimization) Of the 1,200 responding hospitals, fewer than one in 10 had implemented computer physician order entry to Leapfrog’s standard.

It happens that the driving force behind electronic order entry is the same as the driving force behind Leapfrog.

“It’s all about patient safety,” Babineau says.

“Of the 27 categories that Leapfrog scores, the one called ‘creating a culture of safety’ receives the most weight,” Connerney says. “It is about being accountable and taking action to improve.”

The quality of care that has led to the Leapfrog ranking results from efforts by leaders from across the Medical Center, including Hugh Mighty, MD, president of the medical staff and chief of obstetrics, gynecology and reproductive sciences; Reuben S. Mezrich, MD, PhD, chief of radiology and chairman of the Performance Improvement Committee; and Mary Beth Esposito-Herr, PhD, RN, interim senior vice president and chief nursing officer.

“Making the list of the top 50 hospitals represents a significant achievement for the clinical staff here,” says Mighty. “This ranking demonstrates how a strong partnership between all care providers—physicians, nurses pharmacists, therapists and others—can produce excellence.” For more information, go to www.leapfroggroup.org.

E. Albert Reece, MD, PhD, MBA, Appointed Dean of University of Maryland School of Medicine

Dean Reece with Jeffrey Rivest, President and CEO

Developing and expanding the partnership that has existed between the Medical Center and the University of Maryland School of Medicine will advance both institutions toward a shared vision of excellence, says E. Albert Reece, MD, PhD, MBA, the new dean of the School of Medicine and vice president for medical affairs for the University of Maryland, Baltimore.

“We have quite a lot of opportunities to maximize our partnership,” says Dean Reece. “I look forward to working collaboratively with the faculty, Medical Center and system leadership and campus leaders to advance the academic and clinical enterprise to the next level of excellence. I am indeed gratified by the strong support and warm welcome I have received.”

“Dean Reece has brought with him a spirit of collaboration and partnership between the Medical Center and the School of Medicine,” says Jeffrey A. Rivest, president and chief executive officer of the Medical Center. “The School of Medicine will be very well served, indeed, by his leadership.”

“The success of the School of Medicine and the Medical Center are entwined,” Dean Reece says. “Research enhances the quality of the faculty, and the quality of patient care.”

Dean Reece is writing a series of open letters to the faculty, the Medical Center and others in the community, to express his vision. Among his goals is to increase the number of clinical magnet areas, which are centers of excellence that draw patients and top researchers here. He also wants to target diseases with the highest morbidity and mortality—such as diabetes and cardiovascular disease—for enhanced research and patient care.

Before coming to Maryland, Dean Reece had been vice chancellor of the University of Arkansas for Medical Sciences (UAMS) and dean of the University’s College of Medicine. He was also a professor in the departments of obstetrics and gynecology, internal medicine, and biochemistry and molecular biology.

His previous appointments include: Abraham Roth Professor and Chair of the Department of Obstetrics, Gynecology and Reproductive Sciences at Temple University School of Medicine in Philadelphia, and faculty member at Yale University School of Medicine in New Haven, Conn.

His research focuses on the effects of diabetes during pregnancy, on birth defects, and on prenatal diagnosis. An expert on the mechanism of diabetes-induced birth defects, Dean Reece and his research collaborators pioneered research on the dominant biochemical and molecular mechanisms underlying the cause of these birth defects, as well as methods to prevent or diagnose them.

New Robotic Program Includes Cardiac and Urologic Surgery

Region's First Robot-Assisted, Multiple-Vessel Heart Bypass Surgery Performed at UMMC Heart Center

The Medical Center—with a newly created robotic surgery program—became the first hospital in Maryland, Delaware, Virginia and DC to perform minimally invasive, multiple-vessel coronary artery bypass surgery with robot-assisted technology. For these procedures, the medical center has acquired the most advanced robotic technology, the da Vinci S Surgical System.

The robotic arms of the da Vinci S Surgical System allow the surgeon to operate with even more precision than possible with the human hand alone.

Robert S. Poston Jr., MD, a cardiac surgeon at the Medical Center and an assistant professor of surgery at the University of Maryland School of Medicine, performed the landmark bypass procedure in September.

Bypass surgery is a new use for the da Vinci system, which has been used in recent years to perform prostate cancer surgery. Surgeons at the Medical Center are using the robotic system for both cardiac and prostate cancer procedures.

James F. Borin, MD, joined the Medical Center in September as director of robotic surgery. Borin is a urologist and assistant professor of surgery at the School of Medicine.

He is among only a few surgeons in the country who are fellowshiptrained in robotic surgery. He completed a two-year fellowship in laparoscopic and robotic surgery at the University of California, Irvine (UCI). There, he also served as an instructor at the Astellas Center for Urological Education, one of the two largest robotic training centers in the United States.

“The robotic system adds a new dimension of surgical precision because it gives us the ability to maneuver instruments beyond the natural range of motion of the human hand,” Borin says. “Therefore, the technology enables us to perform a more complex set of movements compared to what we can do with traditional instruments used in minimally invasive procedures.”

Robot-assisted bypass surgery enables patients to go home from the hospital within only a few days of surgery and rapidly resume their normal activities. They have much less discomfort following the surgery and a reduced risk of infection, says Poston, who has used the da Vinci robot to perform three coronary artery bypass surgeries as well as several other types of heart surgery.

“The robot enables us to perform even the most complicated multiple-vessel bypass cases, with results equal to traditional, open heart surgery,” says Poston. “But because robot-assisted surgery is done in a minimally invasive way, there are significant benefits for patients.”

Surgeons control the robotic arms of the da Vinci system from a computer console in the operating room, which allows them to operate tiny instruments and a three-dimensional, high-resolution camera placed inside the patient. For coronary artery bypass surgery, the instruments and camera are placed in the patient’s chest through three dime-sized openings. The surgeon uses the robot to retrieve a blood vessel (known as a graft) from inside the chest and attach it to the heart in order to bypass or go around an obstructed heart artery. These blocked arteries may cause chest pain or a heart attack by impairing the normal flow of blood that carries oxygen and nutrients to the heart.

Roger P. Suter, 58, of Pasadena, Md., was one of the first patients to undergo robot-assisted bypass surgery at the Medical Center, on Sept. 27. He had the surgery to open two blocked arteries and went home from the hospital four days later. The usual hospital stay after a traditional, “open” heart bypass procedure is about 6 to 7 days, and it takes about one to two months at home before patients can feel well enough to resume their normal activities.

Suter says the way he feels now, compared to how he felt before surgery, is like night and day. “I feel so much better now,” Suter says. “I have much more energy and I haven’t felt this good in a long time. I can sure tell the difference now.”

For Your Benefit

Open Enrollment for Flexible Spending Accounts Until Nov. 22

Flexible spending accounts (FSAs) help you set aside money for health care or child care in a way that reduces your taxes. You have until Wednesday, Nov. 22, to make plans for 2007.

Unlike most other benefits, re-enrollment is not automatic for FSAs. Even if you have been enrolled in an FSA for 2006, you must re-enroll and stipulate how much you want to set aside for 2007.

With an FSA, you can have money deducted from your paycheck for certain health or dependent care expenses before taxes are calculated. The money is set aside in a special account, from which you can be reimbursed during the year.

Because the money is deducted before taxes, you reduce what you pay in taxes and increase your take-home pay. However, if you do not use the money you ask to set aside, you will lose it, so plan carefully.

Enrollment kits are available in Human Resources, the Learning Center and on the Intranet.

Forms should be returned to Human Resources, 110 S. Paca St., Suite 101 (note that HR moved over the summer). You may also enroll on line.

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