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Important message from Dr Sarah Temple - Chief of Staff

SMH-Sarasota COS Newsletter – June 2024

#1 Message from Dr. Sarah Temple – SMH-Sarasota Chief of Staff

It is hard to believe the year is almost half over! Congratulations to everyone in weathering another "season" with record patient volumes, long ECC wait times and an increasingly busy and complex OR schedule. It is in large part thanks to the SMH medical staff that we continue to be able to offer the highest quality care to our patients and the community in the midst of constant pressures. And as one "season" closes another is beginning. We all need to ensure we are ready to weather a different kind of storm as the Hurricane season has begun. Let us all be sure we prepare for the worst while hoping for the best. Please review the rest of the newsletter below for lots of important information and as always, do not hesitate to reach out to me if I can help in any way or if you have questions or concerns.

#2 Policy Update

Please click on the link below to review the updated policies for Affiliate Medical Students, and the new policy for Observers for physicians and Advanced Practice Professionals.

00.MD.06 Affiliate Medical Students Policy

Observer Policy

# 3 Physician Hand Hygiene Data

In our ongoing efforts to keep our patients and staff safe, we monitor the hand hygiene compliance of our healthcare workers and physicians with a goal of 95% compliance. As you can see, physicians have an opportunity for improvement, particularly with Indications 1 (entering the patient zone) and 4 (leaving the patient zone). Please help us in our efforts to keep everyone as healthy as possible!

Physician Hand Hygiene Data

# 4 Quality Newsletter – May 2024

Please click on the link below to access information regarding important information from the Quality Department.

May 2024 SMHCS Quality Department Newsletter

# 5 Hurricane Preparedness Helpful Information

Please click the link below for valuable information you can share with your patients and use as tips for the 2024 hurricane season in Florida.

Hurricane Preparedness Tips flyer

#6 Alcohol Beverages @ Sarasota Memorial Healthcare System

The Pharmacy and Therapeutics Committee and Nutrition Support Committee have approved the removal of all alcoholic beverages from the hospital effective June 17, 2024. Patients will not be allowed to bring their own supplies.

SMH data: Data was reviewed by the committees. Over a one-year time period, 130 orders were placed by 64 different providers. Of these, 100 were ordered either as “once’ or “daily” suggesting that alcohol is being used as patient courtesy rather than to treat or prevent alcohol withdrawal. The majority of these orders were also in combination with other CNS depressants including benzodiazepines, opioids, methocarbamol, and levetiracetam. For example, one patient was ordered 2 beers with each meal at the same time as the Alcohol Withdrawal protocol and a diazepam taper 10mg q12h. Seven patients experienced falls prior to admission yet alcohol continued to be ordered as an inpatient.

Guidelines: The 2020 American Society of Addiction Medicine states “Oral or intravenous alcohol should not be used for the prevention or treatment of alcohol withdrawal.” The 2021 US Department of Veterans Affairs and DoD Clinical Practice Guideline on Management of Substance Use Disorders also recommends against the use of alcohol as an agent for medically supervised withdrawal stating no solid evidence exists to support this practice. Best practice recommends patients at risk of developing severe/complicated alcohol withdrawal or complications from alcohol withdrawal, and preventative pharmacotherapy should be provided with first-line treatment being benzodiazepines.

Decision: Due to safety concerns from the co-administration of sedating medications, the potential increased risk of falls, and the lack of guidelines supporting alcohol administration, the P&T Committee unanimously voted to eliminate alcoholic beverages for patient administration.

#7 New National Patient Safety Goal to Improve Health Care Equity

Please click on the link below to view the flyer on screening questions and health care equity being implemented.

NPSG 16 Flyer

#8 New SCM Diet Orders for Preventing or Improving Nutritional Status

Please click on the link below to view the flyer discussing the diets for patients that require additional nutrition for the prevention or treatment of malnutrition.

New SCM Diet Orders

# 9 Adverse Drug Rection (ADR) Medication Hotline Turned Off

As of April 2024, the ADR-Medication Safety Hotline was retired. We encourage reporting via the Patient Safety Reporting link found on the Pulse Page.

2024-2026 Medication Management Guide. This guide (aka “flipbook”) is also posted on the Pulse page at >Nursing Resources>Med Safety>Documents>Guide to Medication Management

# 10 Adverse Drug Reactions - Reporting

The World Health Organization defines an adverse drug reaction (ADR) as “any response to a drug which is noxious and unintended, and which occurs at doses used in humans for prophylaxis, diagnosis, or treatment. In contrast, drug withdrawal, drug-abuse syndromes and overdoses, accidental poisonings, and transfusion-related reactions are not considered ADRs.

ADR reports are used to improve patient care. Data collected will aid the Pharmacy and Therapeutics Committee in its assessment of drug use and may provide the basis for formulary changes, procedural changes, or staff education, to name a few, with the goal of minimizing adverse events. Unfortunately, ADR reporting is very low (137 reports in 2023). Therefore, we would like to educate all staff involved in the medication use process on the importance or reporting.

Did you know: “According to AMA Principles of Medical Ethics: A physician who suspects that an adverse reaction to a drug or medical device has occurred has an ethical responsibility to: Communicate that information to the professional community through established reporting mechanisms.”

Our process utilizes the online occurrence reporting system, Vigilanz, which was implemented in December 2023. Reporting is now streamlined and easier than previously. Vigilanz can be accessed directly by any hospital employee from the Patient Safety Reporting Icon on the Pulse page or by using Tools icon in SCM. (See Item #9 above)

How can you help? If your patient experienced and adverse drug reaction, please ask the nurse to report the event. When in doubt, it is better to report than not report.

Pharmacy and Risk Management appreciate your support.

#11 The Joint Commission Review for Medical Practitioners

Please click the link to the document to view the Joint Commission Review for Medical Practitioners.

Joint Commission Review for Practitioners

#12 Medical Staff Observation Opportunities

Sarasota Memorial Healthcare System welcomes observers! To apply to observe a physician or APP, a full and complete application must be submitted to the Medical Staff Office a minimum of 10 days prior to the intended start date. For more information, please visit the Observation page.

Observer Dashboard.

#13 SMH-Sarasota Parking Update

As Sarasota Memorial Healthcare System continues to grow please see below for parking availability on the Sarasota Campus:

South Garage:
Physician designated spaces are located in the gated lot on the first floor, and spaces labeled as “Physician Only” located on the 3rd floor
Please refrain from parking in spaces labeled Medical Arts (unless your practice is located in that building)

Waldemere Garage
Physician designated spaces on the 3rd floor

North/Lasula Garage
Physician designated spaces on the 1st floor, or 4th floor and above (not designated)

West Garage
2nd floor and above (not designated)

Floyd Street Garage
We encourage everyone to check out the new Floyd Street garage where there is ample parking for all
Please refrain from parking in spaces labeled Valet, Patient, or Visitor
In the event that you unable to find parking, you are welcome to Valet your vehicle free of charge

Thank you,
Sarah Temple, MD
Chief of Staff