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May 2018 Edition 


Highlights of the May 2018 Edition:

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  • How to Achieve Hightest Patient Safety and Provider Educational Feedback
  • Clinical Documentation Integrity Tips- Medical Staff Education
  • CMS 2MN Rule, Inpatient vs. Outpatient- Medical Staff Education
  • Communication: Residency Patient Handoff
  • Continuing Medical education Activities, link
  • Formation of Pain Management Stewardship- Medical Staff Leadership
  • Transfer Center Go-Live & External Transfer Order


How to Achieve Highest Patient Safety and Provider Educational Feedback

Over the past year, the Medical Executive committee has been working on updating the committee structure to assist the medical staff conduct, Professional Practice Evaluations (PPE) and improve the QI system. The goal was to make the process more educational, rather than punitive, and to help the administration keep track of the focused and ongoing reviews of medical staff performance. Last month the Medical Executive committee finalized these changes and the hospital Board approved them, allowing us to move forward with this new system.

The system is not a radical change to how things have been done in the past. In fact, it serves to formalize the process that has been informally practiced for several years. By formalizing this process, it helps improve the educational feedback given to practitioners in the QI process, while maintaining confidentiality, and empowering the individual QI department to focus on what they feel is important to their particular specialty. It will also improve the credentialing of practitioners by making the process much more efficient and helps us meet Joint Commission standards on credentialing and monitoring of medical staff quality.
The medical leadership believe this program will help our institution continue to maintain the highest standards in patient care, and if you have questions regarding this new structure, please don’t hesitate to reach out to me or anyone in the Medical Staff Office. Kyle Garner, MD – Chief of Staff

Clinical Documentation Integrity Tips

1. Prescribing antibiotics "to cover" for a possible organism

  • OBSERVATION: Documentation such as "To Cover" is commonly used in the medical record when documenting treatment for suspected infections: For example: "will order Zosyn TO COVER for gram negative infection" - there are NO ICD 10 codes to capture this verbiage
  • SUGGESTION:  In order to capture the possible diagnosis being treated, and accurately reflect the patient's clinical picture, and severity of illness and risk of mortality, suggestion would be to document: "Possible gram negative pneumonia - will begin zosyn"

 2. To reflect your patient's severity of illness and level of care: Is your patient requiring TOTAL CARE?

  • OBSERVATION: UNRESPONSIVE; NON-RESPONSIVE; UNAROUSABLE- there are NO ICD 10 codes to capture this verbiage
  • SUGGESTION: USE GLASGOW COMA SCALE (GCS) To reflect your patient’s severity of illness and level of care required, suggest the following terms if more than a transient altered level of consciousness: to quantify severity of illness Unconscious; Somnolence; Obtundation; Stupor; Semi-Coma or Coma/Comatose; and include any associated intracranial/skull injuries if present. Especially IMPORTANT in patients with: Subdural hematoma * ICH, Closed head injury / skull fracture / TBI * Encephalopathy / Poisoning / Organ failure / Anoxia
    NOTE: Coma is not integral to the death process, and can be an additional diagnosis when a patient expires.

CMS' 2MN Rule, "Inpatient vs. Outpatient"

Submitted by John R. Moritz, DO, FACP* as Demystifying the 2 Midnight Rule

Sarasota Memorial Hospital has made substantial gains with respect to CMS compliance and fiscal stewardship. This is mission critical if SMH is to remain a leading regional provider and remain financially viable. Starting in early 2018 the Integrated Case Management department underwent substantial retooling to comply with the new CMS directive regarding the 2 Midnight Rule and CR 10080. Medicare does not count hours, only midnights.

  • The medical documentation should support the expectation of time and the determination of the underlying need for medical care at the hospital. We recognize that there is frustration amongst some medical staff regarding how their patients are assigned: Observation vs. Inpatient (IP)
  • If a physician believes that their Medicare patient will be hospitalized > 2MN, documenting such on the H&P and entering an IP order are totally appropriate. The better the documentation, the less likely your patient will be denied, and the documentation should fully encompass the decision-making process that led to the admission.
  • There are 5 exceptions to the 2 MN rule. These are death, enrollment into Hospice care, transfer to a higher level of care, a spectacular recovery that was much quicker than predicted, or mechanical ventilation initiated during present visit. Apart from these 5 exceptions cited above, please refrain from placing an IP order in Medicare patients that are NOT anticipated to be hospitalized for 2 MN.
  • In the coming weeks we will endeavor to roll out educational material to help guide you in assigning status for your Medicare patients. When in doubt, you can always admit "per ICM protocol" and your well-trained case managers will ensure appropriate status assignment.

Summary: Any questions or concerns, ask the case manager to Voalte the Physician Advisor on call.
     • Inpatient Order on Admission- Patient may be here 2MN, document the clinical reason
          - If patients stays 2MN (second midnight), no further action.
          - If patient does not stay 2MN, document reason-rapid recovery, death, hospice, etc.
     • Observation Order on Admission- Patient will be here less than 2MN.
          - If patient leaves before the 2MN (second midnight), no further action
          - If patient Stays for the 2MN, change patient status to inpatient and input order(s).

Communication: Residency Patient Handoff

In order to maximize our Resident’s educational experience, the Internal Medicine residency program leadership has requested that attending/consultants with patients on the teaching service contact the residents via Voalte or cell phone. The goal is to improve communication and to allow the residents gain experience on their shared patients. All residents are listed in the SMH App, allowing medical staff to reach the residents either by Voalte or by their cell phones. 

Continuing Education Activities

see full calendar here

May 10, 12:00 pm -1:00 pm, The New Paradigm of Sepsis, presented by Philip A. Efron, MD
May 16, 12:00 pm - 1:00 pm, Stroke Intervention Update, presented by Daniel Case, MD
May 18,  8:00am - 9:00am, Sentinel Node Biopsy and Endometrial Cancer, presented by Richard Boothby, MD
June 14, 12:00 pm - 1:00 pm, Trauma Success Stories II, presented by Alan Brockhurst, MD
July 20, 8:00am - 9:00am, DVT's, presented by Michael Jaglal, MD
August 17,  8:00am - 9:00am, Chimeric Antigen Receptor T-Cell Therapy, presented by Luis Chu, MD
Future Dates (as of May 4): June 15, July 12, August 9

Pain Management Stewardship

The newly formed multidisciplinary Pain Management Stewardship Committee is working on several initiatives to address the growing concern of opioid misuse and abuse, new Joint Commission Standards and parenteral opioid shortages. If you have questions regarding this initiative, please don’t hesitate to reach out to

  • Updating order sets to encourage the use of non-opioid therapies and oral routes
  • Identification of patients with risk factors for opioid-related adverse events
  • Clinician education on and access to prescription drug monitoring program database
  • Education for patients and caregivers about potential risks and side effects of opioid therapy and available alternatives in addition to setting realistic goals for expected course of recovery
  • Improve flow of information to prescribers regarding inpatient opioid use to help individualize discharge prescriptions

Reference: Herzig, S, et al. Improving the safety of opioid use for acute noncancer pain in hospitalized adults: a consensus statement from the society of hospital medicine. Journal of Hospital Medicine 2018; 13:263-271.

Transfer Center Go-Live & External Transfer Order

The SMH Transfer Center now facilitates all admitted patient transfers out of SMH.

  • Previously, this process was initiated by an ICM consult order in SCM and then the completion of a paper document titled Physician Certificate of Transfer. Those two elements have now been combined into one SCM order.
  • The order is titled External Transfer Order and can be electronically signed by the ordering physician. Once the order is entered, the SMH Transfer Center will connect the sending physician with the accepting hospital, in order to quickly and efficiently transfer the patient. 
  • For assistance with the process, or if you have any questions, please contact the unit Case Managers, the Transfer Center at X3900, or Transfer Center Leadership Jodi Beachy X4370 and Susan Grimwood X7314

Official end of flu season was announced (4/17/18) we can stop wearing our masks.

Thank you all for protecting our patients and team members, 

Kyle Garner, MD

Chief of Staff