innovation & patient-centered care - Stamford Health

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20 1 5 CLI NI C A L A N N UA L R E P O R T

innovation &

patient-centered care

A NNUA L R E P O R T 2 0 1 5

W

hen I assumed the position of Chair of the Medical Staff in 2014, it was with the knowledge that I would have the honor of working with an exemplary medical staff with a history of successes and accomplishments. As 2015 draws to a close and I look back on what was achieved during the year, it is clear that this tradition of excellence has continued. If I may, I would like to highlight a few of these accomplishments: • HCAHPS Physician Communication scores that are consistently at the CMS target or higher. • Planned implementation of a pilot program to address the growing healthcare needs of the geriatric population by the early identification and management of patients with cognitive impairment and delirium. • Selection of Michael Bernstein, MD as the 2015 recipient of the Dr. Melville G. Magida Award. • Recognition of four physicians for their commitment to their patients and the Stamford Community as “Physician of the Quarter” — Kevin Dwyer, MD, Jennifer Henkind, MD, Sarah Kahn, MD, and Kirsten Hohmann, MD. • Successful accreditation surveys by the Department of Health, Joint Commission Triennial Accreditation, and Recertification of programs in Stroke, Joint Replacement and Spinal Fusion, in large measure to the quality of medical staff and the care provided to patients. Re-accreditation of Breast Center and Heart Failure Program. • Successful implementation of ICD-10 that could not have been achieved without the full cooperation and leadership of the medical staff. • Expansion of SHIP. • Medical staff that is extremely loyal to Stamford Hospital as evidenced by the results of the Physician Engagement Survey that showed that almost two-thirds of the medical staff are either employed, closely affiliated or closely aligned with the Hospital. • Appointment of Suzanne Rose, MS, PhD, as Director of Research, to provide support to the medical staff in their research and scholarly pursuits. • Outstanding clinical faculty that helped achieve 100% match in the Hospital’s residency programs. There is little doubt that 2016 will be another stellar year, despite the challenges that we face due to external financial constraints beyond our control. In early fall, we will have a fully operational, state-of- the-art, technologically superior hospital that will enable our organization to fulfill its commitment to patient safety and quality. But, in the end, Stamford Hospital is comprised of more than bricks and mortar. The members of the medical staff, under the guidance of their Department Chairs, are the heart and soul of the organization. From the bottom of my heart, I want to thank each of the Department Chairs for their leadership, commitment and hard work. To the division chiefs that support their chairs in their work, a special thanks is extended too. I look forward to working with you all in the coming year in a spirit of collegiality and mutual respect. My very best wishes to you and your families for a healthy and happy New Year.

Joshua Herbert, MD Chair, Medical Staff

2015 CL INICA L A NNUAL R E POR T | 3

A NN UA L R EP O R T 2 0 1 5

T

his year, the focus of our Clinical Annual Report is on Innovation & Patient-Centered Care — two areas that define our 10 clinical departments. Over the last year, innovation has been in the addition of several new procedures, including: FATE (focused assessment transthoracic echocardiography); TAVR (transcatheter aortic valve replacement); Convergent; CardioMEMS™; Fuse® endoscopes in GI; and a new state-of-the-art “robot” to advance minimally invasive surgery. At the same time, we have fostered excellence in the patient experience with multidisciplinary programs, such as: new ED staffing models; new collaborative pain management approaches; safer imaging techniques; and the delivery of efficient lung cancer screening. We have also added the first Office of Research at Stamford Hospital and this will pave the way for even more advanced approaches. The Chairs open with a year in review, which provides a sense of the scope of the departmental efforts and strategy. The overarching theme that emerges is one of collaboration and teamwork for the purpose of providing world-class quality patient care. This is exemplified in the development of new programs and the expansion of others; recruitment of new talent; medical education and research; and many, many accreditations and accolades. Of note, this year we have added two new full-time department chairs — in Family Medicine and Radiology — reflecting the changing dynamics in our market and the need for focused clinical leadership in strategic areas. Additionally, we have added 49 new medical staff in nine departments. Of these three unique physicians serve on committees to advance patient care at Stamford Hospital. Our mission, “Together with our physicians, we provide a broad range of high-quality health and wellness services focused on the needs of our patients,” comes to life on the pages that follow. Toward this end, this year we completed the first physician engagement survey of the medical staff. Participation was significant with 50% of responses from independent physicians. We learned that there is a divergent opportunity to engage and align our staff based on their professional relationships with Stamford Hospital, and the Chairs have initiated plans to address the feedback from the medical staff. Of note however, is that nearly 76% of physicians strongly/ agree that they are proud to work at Stamford Hospital. I want to thank the medical staff, the Chairs and all the Hospital departments for this incredible body of work. Together we move forward faster, and I look forward to continuing to share this journey with each of you. Sharon C. Kiely, MD, MPM Senior Vice President, Medical Affairs Chief Medical Officer Patient Safety Officer

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A NNUA L R E P O R T 2 0 1 5

table of

contents 6

Anesthesiology Emergency Medicine

12

Family Medicine

20

Medicine

28

Obstetrics & Gynecology

58

Pathology

68

Pediatrics

76

Psychiatry

86

Radiology

92

Surgery

100

2015 CL INICA L A NNUAL R E POR T | 5

i nn ov a t io n i n

a n e s t h e s i o lo g y

Recognized as the only Center of Excellence for regional anesthesia in the Northeast.

6 | DEPAR TM ENT O F A N E S T H E S I O LO G Y

D EPA R T M EN T O F AN E S T HE S I OLOG Y: A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Betty-Ann Robustelli, MD Chair, Department of Anesthesia

I

t is with great pleasure that I write my first annual report as Chairman of the Department of Anesthesiology. I began working for Stamford Anesthesiology in 2003 after completing my residency at Mount Sinai Medical Center. For the past two years, I have been the Associate Chair and also held the role of the Medical Director at the Tully Health Center. In October of this year, I took over for Dr. Theresa Bowling, who successfully led our department for the past two years. Everyone at Stamford Anesthesiology greatly appreciates all of her hard work and dedication. Dr. Steven Finkel has been appointed the Associate Chairman as well as the Medical Director of Tully. Dr. Finkel joined Stamford Anesthesia after completing his residency at Cornell in 2005. Both of us are excited for the future and look forward to the growth and expansion of our Department into the new hospital opening in 2016. 2015 has been an exciting year for the Department of Anesthesiology. The Department has continued to grow to support the expanding and new service lines that Stamford Hospital has been developing. We have recruited talented new staff who have come to us from some of the finest institutions in the country. We have also trained our existing staff in progressive new techniques to improve outcomes especially for our sickest patients in order to continue to provide the safest anesthesia possible. The Department has also joined the Anesthesia Quality Institute, AQI, a quality management program that was created by The American Society of Anesthesiology. AQI data will be useful for activities ranging from faculty education to outcomes measurement to emerging federal efforts to ensure performance improvement. With the approval of electronic medical records (EMR) for

our Department in 2016, data will now be automatically uploaded into a national registry to allow comparison to millions of other anesthetics performed in the country. In 2016, the Department will be able to routinely present the anesthesia quality score card to committees and the data can be adjusted as core measures are changed in time. In response to increasing volume in the cardiac surgery operating room and the development of the structural heart program, we have redesigned the cardiothoracic anesthesia coverage model to now include four fellowshiptrained cardiothoracic anesthesia doctors. Our cardiac anesthesia team includes Drs. Amy Crane, Margot Denham, Vlad Frenk and Andrew Sosa. These physicians are not only experts in delivering anesthesia for our sickest patients undergoing open heart surgery, but they are also all board certified in transthoracic echocardiography including the use of 3D echocardiography which has become the standard of care for cardiac valve replacement surgery. The structural heart program has successfully launched the transcatheter aortic valve replacement (TAVR) program this year. It has allowed patients who are non-operative candidates for valve replacement to successfully replace their valves percutaneously. The multidisciplinary procedure has strengthened our growing cardiac program and we are happy to play such a large role. In February of last year, 30% of our Department became certified to perform a Focused Assessment Transthoracic Echocardiogram exam (FATE). FATE is a non-invasive procedure that assesses cardiac function in the real time prior, during and after an anesthetic to assist in tailoring the anesthetic to a patient who is acutely unstable and when there is no time to have a complete cardiac exam by a cardiologist. This has been shown to decrease mortality in certain patient populations compared to controls most notably in patients undergoing hip fracture repair surgery. We have utilized this modality to avoid surgical delays. Our Department continues to offer unique anesthetic solutions for complex medical problems even outside the operating room. This past year we started offering our patients with fractured hips, who wanted to avoid surgery, the option of a continuous peripheral nerve block to treat pain. These patients require little to no narcotics and can thus avoid the negative side effects of narcotics such as delirium. The program has been an enormous success with our elderly patients and their families, who can now bring their loved ones home in a few days and avoid surgery.

2015 CL INICA L A NNUAL R E POR T | 7

D EPA R T M ENT O F AN E S T HE S I OLO G Y: A N N UA L R E P OR T 2015 Our nerve block program continues to be recognized nationally and remains as the only Center of Excellence for regional anesthesia in the Northeast. Each month we teach a multidisciplinary course focusing not only on the technique of regional anesthesia and ultrasound guided nerve blocks, but also on how to develop a successful acute pain management service. This year we taught physicians from various places across the county, including New Mexico and the University of Alabama. The (Stamford) Advocate highlighted our progressive regional anesthesia program in a front-page article on September 10, promoting our “almost pain-free” surgical approach. As you can see in Figure 4, our block program is continuing to grow and thrive, and we expect this trend to continue. We have also seen an increase in patient and surgeon satisfaction with acute post-op pain management due to this program.

Figure 1: Overall Anesthesia Case Volume FY2015

CASES Hospital

Tully

October-14

774

1010

November-14

740

889

December-14

789

1051

January-15

700

884

February-15

648

804

In response to the growing need for anesthesia services outside the operating room in locations like the Cardiac Catheterization Lab, CT Scan/MRI, VIR, and Endoscopy, the Department now offers anesthesia services 40 hours a week in these locations.

March-15

780

1010

April-15

722

972

May-15

724

917

SCOPE OF CLINICAL SERVICES

June-15

787

940

The Department of Anesthesia provides services throughout Stamford Hospital. In addition to supporting basic surgical needs, the Department is an integral part of obstetrical and maternity cases in Labor and Delivery, Endoscopy, Interventional Radiology, MRI and CT scan studies, the Cardiac Catherization Lab, EP Studies and the Emergency Room. Each day we staff 22 locations with 22 anesthesia providers on two different campuses. As shown in Figure 1, overall case volume for FY2015 was 20,065, up from 19,135 in FY2014.

July-15

727

908

August-15

779

855

September-15

782

873

8,952

11,113

8 | DEPAR TM ENT O F A N E S T H E S I O LO G Y

Total

D EPA R T M EN T O F AN E S T HE S I OLOG Y: A N N UA L R E P OR T 2015 Figure 2 highlights our surgical case volume by campus. Figure 2: Surgical Case Volume by Campus FY2015

Figure 3: Obstetrical Volume – Stamford Hospital

CASES Cardiac

OB

OR

As shown in Figure 3, Stamford Anesthesiology delivered anesthetics to 98% of the total 2,298 Labor and Delivery cases for FY15.

NORA

Total Deliveries w/ Anesthetic

Labor Epidural

Emerg. C-Section

Planned C/S

October-14

187

108

19

60

November-14

198

111

28

59

December-14

211

105

34

72

January-15

186

108

27

51

February-15

156

88

16

52

March-15

195

112

20

63

April-15

156

82

20

54

May-15

194

105

25

64

June-15

171

96

20

55

July-15

180

102

26

52

August-15

221

130

31

60

September-15

220

120

26

74

Total

2,275

1,267

292

716

ENDO

Main Hospital October-14

4

187

497

34

52

November-14

9

198

444

37

52

December-14

6

211

476

36

60

January-15

7

186

408

46

53

February-15

5

156

394

36

57

March-15

6

195

473

46

60

April-15

8

156

453

50

55

May-15

6

194

432

38

54

June-15

7

171

509

43

57

July-15

8

180

442

51

46

August-15

3

221

445

36

74

September-15

12

220

448

43

59

Total

81

2,275

5,421

496

679

Tully October-14





447



563

November-14





410



479

December-14





492



559

January-15





401



483

February-15





366



438

March-15





488



522

April-15





429



543

May-15





404



513

June-15





416



524

July-15





399



509

August-15





390



465

September-15





386



487

Total





5,028



6,085

2015 CL INICA L A NNUAL R E POR T | 9

D EPA R T M ENT O F AN E S T HE S I OLO G Y: A N N UA L R E P OR T 2015 Our Nerve Block program continues to grow each year, as is shown in Figure 4. In FY14, Stamford Anesthesiology provided 1,961 blocks, compared to the 2,537 blocks in FY15, and we expect this number to continue to rise

as more surgeons and patients are pleased with the outcomes. Our regional program has expanded to provide benefits to every surgical specialty and we are excited to share this with the Hospital community.

Figure 4: Nerve Block Growth Single Shot Blocks CPT code

Description

FY2014

FY2015

# of Procedures

# of Procedures

62310

Cervical or Thoracic

1

12

62311

Lumbar or Scaral (Caudal)

10

12

64413

Cervical Plexus

0

2

64415

Brachial Plues

291

386

64420

Intercostal Nerve

21

28

64421

Intercostal Nerve, Multiple

642

0

64425

Ilioinguinal, Iliohypogastric Nerve

59

79

64445

Sciatic Nerve

143

86

64447

Femoral Nerve

115

81

64450

Other Peripheral Nerve or Branch

278

619

64520

Lumbar or Thoracic (Paravertebral Sympathetic)

1

55

64530

Celiac Plexus

1

1

64486

Transversus Abdominis Plane, Unilateral w/US

N/A

253

64488

Transversus Abdominis Plane, Bilateral w/US

N/A

245

1,562

1,860

2014 Productivity (Aug to Dec)

2015 Productivity (Jan to Sept)

# of Procedures

# of Procedures

Continuous Infusion CPT code

Description

62318

Cervical or Thoracic, Indwelling Cath, Continuous Infusion

38

60

62319

Lumbar or Sacral, Indwelling Cath, Continuous

9

37

64416

Brachial Plexus, Continuous Infusion

191

237

64448

Femoral Nerve, Continuous Infusion

161

247

64487

TAP by Continuous Infusions, Includes US

0

8

64489

TAP Bilateral by Continuous Infusions, w/ US

0

88

399

677

1 0 | DEPAR TM ENT O F A N E S T H E S I O LO GY

Old Tap Code

New SS Tap Codes

Continuous Tap Codes

D EPA R T M EN T O F AN E S T HE S I OLOG Y: A N N UA L R E P OR T 2015 MEDICAL STAFF New Staff:

• Shahid Rafiq, MD • Betty Ann Robustelli, MD • Nousheh Saidi, MD

The Department of Anesthesiology welcomed the following physicians and CRNAs in 2015:

• Brian Sullivan, MD

• Ewelina Gibek, CRNA

• Shiry Weisberg, MD

• Elyse Goldblum, MD

• Thomas Wong, MD

• Maria Mazzeo, MD • Donna Nunno, CRNA • Elizabeth Rozen, MD • Jeffrey Sheehan, CRNA • Andrew Sosa, MD • Brian Tevlin, MD

Active Staff: • Theresa Bowling, MD • Kirsten Butkovsky, CRNA • Jen Hwei-Cheng, CRNA • Amy Crane, MD • Joseph D’Agosto, MD • Margot Denham, MD

• Benjamin Unger, MD

Hospital Committees: • Credentialing Committee — Theresa Bowling, MD, Chair and Steven Finkel, MD • Trauma Committee — Brian Sullivan, MD and Tara Doherty, DO • Pharmacy & Therapeutics Committee — Rodrigo Mendes, CRNA • Resuscitation Committee — Theresa Bowling, MD • Culture of Safety Committee — Benjamin Unger, MD • Quality & Safety Committee — Shahid Rafiq, MD • OR Committee — Theresa Bowling, MD • Total Joint and Spine Committee — Vlad Frenk, MD • Peer Review Committee — Betty Ann Robustelli, MD, Chair

• Kaili Dilts, MD

Publications and Lectures:

• Tara Doherty, DO

• Vlad Frenk, MD — “Multimodality Perioperative Analgesia with Paravertebral Nerve Block and Gabapentin Reduces Narcotic Use and Hospital Length of Stay in Mastectomy Patients” Poster Presentation at the San Antonio Breast Cancer Symposium.

• Steven Finkel, MD • Jay Freilich, MD • Vlad Frenk, MD • Ronald Giannotto, MD • Juliet Jackson, MD • Eric Jankelovits, MD • Jeffrey Klein, MD • Alla Koorn, MD • Richard Libutti, CRNA • Adnan Malik, MD • Sergio Manimbo, MD • Rodrigo Mendes, CRNA

• Vlad Frenk, MD — “Multimodal Pain Management Protocol Reduces Opioid Use and Shortens Length of Stay After Major Breast Surgery” Presented to the American Society of Regional Anesthesia. • Vlad Frenk, MD — “Paravertebral Catheters Reduce Post-Breast Surgery Use and Hospital Length of Stay” Published in Anesthesiology News. • Vlad Frenk, MD — “Basic Focused Assessed Transthoracic Echocardiography (FATE) Course” Lecture at Hospital for Special Surgery (HSS).

• Richard Morgulis, MD • Yevgeniy Printsev, MD

2015 CL INICA L A NNUAL R E POR T | 11

i nn ov a t io n i n

emergency medicine

Performing in the top 10% of hospitals in the state, with door-to-provider time well under the 30-minute benchmark.

1 2 | DE PA R TM ENT O F E ME R G E N C Y ME D I C I N E

D EPA R T M EN T O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Andrew Jenis, MD, FACEP Director & Interim Chair, Department of Emergency Medicine

T

he Department of Emergency Medicine (ED) is charged with maintaining the well-being of the Stamford community when the community has nowhere else to turn. In 2015, the staff of the Department evaluated and treated patients during more than 76,000 acute care visits (Figure 1). With an overall admission rate of 20 percent — representing more than 50 percent of all Hospital admissions — the Emergency Department truly is the front door of the Hospital. We have built on last year’s successes with the medical staff remaining well-satisfied with the service that we provide to their patients.

Stamford Hospital has one of the best door-to-balloon times in the NewYork-Presbyterian Healthcare System, as well as in the state of Connecticut (under 90 minutes for all cases in the past three years), and we continue to work to improve outcomes. The Department has also been integral to the successes seen in the treatment of sepsis. As part of a multidisciplinary team created to investigate ways to improve patient outcomes in this patient population, we have seen dramatic reductions in mortality as well as decreasing overall length of stay (LOS) for these patients. Further, collaboration with the Department of Neurology has facilitated focus on the management of patients who might be suffering the effects of an acute stroke. It is well-known that time is of the essence when dealing with this debilitating illness, and the Department is working diligently to ensure the best possible outcomes for the people of this community. Overall Departmental volume for FY15 decreased by less than 1%. Volume decreased at the Immediate Care Center (ICC) by .5%, and volume at the main ED decreased by 1.2% as compared to FY14. However, our volumes dropped far less than are being reported nationally, with an 8 – 10% decrease in ED volume being reported.

The Department continues to perform far above national benchmarks in its treatment of acute coronary syndrome.

Figure 1: Total Visits to the Main ED and Immediate Care Center (ICC)

2015 CL INICA L A NNUAL R E POR T | 13

D EPA R T M ENT O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 SCOPE OF CLINICAL SERVICES Emergency Medicine Physicians (EMP) is a physicianowned group that provides physician staffing of the Emergency Department. Founded in 1992, the group’s sole mission is “To Care for Patients.” EMP has staffing agreements with more than 70 hospitals nationally and has partnered with Stamford Hospital since 2002. Since initiating this partnership, the Department has seen great success. Working in a dynamic environment presents challenges for the practice, patients and hospital partners. As owners, EMP physicians are motivated to solve problems, find opportunities and create successes. Implementation of the “Physician First” staffing model is one example. In this model of care delivery, a boardcertified physician is the initial point of contact for the majority of patients who arrive at the ED. Through this process, there has been a dramatic decrease in the time between a patient’s arrival and the time seen by a qualified medical provider, a metric that is posted on the CMS Hospital Compare website. Nationally, the goal for door-to-provider time is 30 minutes, and in 2013 the national average for an ED of Stamford Hospital’s size was 30 minutes. Stamford Hospital was recently recognized as performing in the top 10 percent of hospitals in the state for this metric, with a door-to-provider time well under the 30-minute benchmark. As a nationally recognized group of emergency physicians, EMP is able to recruit high-caliber talent from emergency medicine residencies across the country. This enables EMP to build exceptional teams for its hospital partners — like the one currently in place at Stamford Hospital. Over the past year, Department members have participated on multidisciplinary committees in order to improve overall outcomes for patients. One such committee is the Sepsis Committee. Working with the Infectious Disease physicians, hospitalists and nursing leadership, we have developed tactics to standardize the approach to management of these patients when they present to the ED. Through this partnership, we expect mortality to further improve and reduce the overall length of stay for this patient population. Another aspect of care that was improved by a team approach is ED throughput. Partnering with ED nursing leadership, we have streamlined patient flow to our fast track. Now, these less acutely ill patients will be directly sent from triage to see an advanced practice provider. This process change has led to decreases in their overall 1 4 | DEPAR TM ENT O F E ME R GE N C Y ME D I C I N E

ED and fast track length of stay. This change allows the Department to function more efficiently. We continue to refine our teletracking capabilities and investigate ways to further streamline processes, so that we continually improve on the work that has already been done.

MEDICAL STAFF

Suzy Shukovsky, MD Assistant Director

Alexandr Rafailov, MD Director, Quality Assurance

Douglas Gallo, MD EMS Director

Samuel Maryles, MD, FACEP Clinical Operations Director

D EPA R T M EN T O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 Full-Time Physicians

Advanced Practice Providers / Physician Assistants

• Miriam Ambalu, MD

Full-time

• Vanessa Brown, MD

• Debbie Clarke, PA-C

• Michael D’Angelo, MD

• Sarah Feigenbaum, PA-C

• Amy Gandhi, MD

• Anthony Giannuzzi, PA-C

• Randall Grant, DO

• Lawrence Louis, PA-C

• Michelle Maly, DO

• Michael Moi, PA-C

• Samuel Maryles, MD

• Joy Mullins, PA-C

• Ryan Mazin, MD

• Maria-Claire Pietak, PA-C

• Jayson Podber, MD

• Shahin Shaikh, PA-C

• Michelle Tomassi, MD

• Mary Sweeney, PA-C

• Dorothy Turnbull, MD • Sarah Vitello, DO • Kim Zeh, MD

Part-time Physicians • Carol Allen, MD • Maria Brea, MD, FACEP • Antonio Dajer, MD • Jason Fischel, MD • Jose Mejia, MD • Adora Ozumba, MD • Kathy Park, MD, FACEP • Shivani Patel, DO • Sue Schemel, MD

DEPARTMENTAL SAFETY AND QUALITY Members of the Stamford Hospital Department of Emergency Medicine play key roles in ensuring and furthering the safety and quality of care we deliver. Assistant Medical Director Suzy Shukovsky, MD, is responsible for day-to-day operations of the Immediate Care Center (ICC) and works with nursing leadership on ways to improve care delivery. Through her collaboration with the ICC staff, she has worked to improve the efficiency of the Department, and is focusing her efforts on mechanisms to improve the overall patient experience at the ICC. As Chair of the ED Quality Review Committee, Alex Rafailov, MD, oversees all quality-related reviews conducted by the Department. Partnering with nursing leadership, he revises and improves various departmental policies to

Figure 2: CT Utilization per 100 Volume

2015 CL INICA L A NNUAL R E POR T | 15

D EPA R T M ENT O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 ensure that we deliver the highest possible quality of care. In addition, Dr. Rafailov reports to EMP monthly to ensure that the clinicians are abiding by all clinical policies set by the company. As the following data from the Emergency Department Benchmark Alliance demonstrates (Figure 2), the Department is performing better than the national average for its cohort when it comes to CT utilization, and will continue to curtail unnecessary testing when evidence-based practice allows it. As the EMS Medical Director for the Hospital, Douglas Gallo, MD is responsible for working with various

community-based EMS services to ensure the highest quality of training and medical oversight of crews responding to those in need. As the Department transitions to the new hospital and considers application to be an ACS-accredited Level 1 Trauma Center, Dr. Gallo’s leadership will help to make the transition as seamless as possible. One of the main goals in the Emergency Department is to provide care in a timely manner. Through the “Physician First” staffing model, a board-certified emergency physician is in triage during the busiest times of the day,

Figure 3: Triage Time to Seen by ED Physician (min.)

Figure 4: Length of Stay for Treat-and-Release Patients from Triage Time to Discharge Time (min.)

1 6 | DEPAR TM ENT O F E ME R GE N C Y ME D I C I N E

D EPA R T M EN T O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 serving as the first point of contact for patients arriving at the ED. As a result, the Department’s door-to-provider time has been reduced to below the national benchmark of 30 minutes from patient arrival (Figure 3). Treat-and-release times for discharged patients remain relatively static, and are comparable to hospitals of Stamford’s size and acuity. Changes have recently been implemented, which we are confident will improve this metric in the months ahead (Figure 4).

The success of our physician in triage process is reflected in stable treat and release times, despite an increase in the discharge from triage volume (Figure 5). The rates of patients who leave the ED without treatment continue to be significantly better than the national benchmark of 3%. There has been a slight increase in the percentage at the ICC and changes to the practice model have been made to correct this issue (Figure 6).

Figure 5: Volume of Patients Discharged From Triage

Figure 6: Left Without Being Seen (%)

2015 CL INICA L A NNUAL R E POR T | 17

D EPA R T M ENT O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 Patient satisfaction scores have shown dramatic improvement in the ICC. Emergency department scores have decreased, we have made operational changes that we expect will take it ends in 2016 (Figure 7).

DEPARTMENTAL EDUCATION AND TEACHING ACTIVITIES As work on the new Stamford Hospital Emergency Department advances, we are working to ensure that patients receive the best possible care even before they arrive at the ED. To this end, the Department provides medical oversight of the Stamford EMS system as well as volunteer EMS providers in the surrounding area. The Department also serves as a teaching center for Quinnipiac and Bridgeport University physician assistant students, as well as for both Internal Medicine and Family Practice residents. Additionally, we also have medical students from Columbia rotating through the Department as a part of their educational experience. Recently we were contacted by Fairfield University to have their students rotate through our Department as well, and Sacred Heart University physician assistant students will be rotating through the ED in 2017.

Outcomes Providing excellent care to our patients is the basis for everything we do in the Department. We continually monitor and strive to outperform ED-specific national benchmarks. As can be seen in Figures 8 and 9, we continue to excel in our door-to-balloon times for patients who are suffering from an acute myocardial infarction. We have been able to achieve this by developing a process that is both easy to follow and reproduce, without regard to external variables. We have brought this same approach to the management of patients with an acute ischemic stroke, such that our performance for door-to-tPa time illustrates success with this approach. Nationally, an acceptable Left Without Being Seen rate is approximately 3%. Despite having seen minor increases in our rate during times of high ED utilization (we averaged 146 patients per day in September in a Department designed for half that number of visits), we continue to perform far below the national average with regard to this measure. We have achieved superior results by the implementation of the Physician First process, in which we have a physician in the triage area to evaluate all walk-in arrivals within minutes of their presentation to the Department.

Figure 7: Patient Satisfaction Press Ganey Raw Score and Percentile Ranks

1 8 | DEPAR TM ENT O F E ME R GE N C Y ME D I C I N E

D EPA R T M EN T O F E M E RGE N C Y M E DICIN E : A N N UA L R E P OR T 2015 Figure 8: Door-to-Balloon

Figure 9: TPA Within 4.5 Hours

2015 CL INICA L A NNUAL R E POR T | 19

i nn ov a t io n i n

fa m i ly m e d i c i n e

Home to one of only three Family Medicine Residency Programs in the state.

2 0 | DE PA R TM ENT O F FAMI LY ME D I C I N E

D EPA R T M EN T O F FAM I LY M E D ICIN E : A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

The top DRGs for admissions by Department members in 2015 were: • Sepsis • Pneumonia • Chest pain • Kidney and urinary tract infections

Joseph Connelly, MD

• Coronary artery disease

Chair, Department of Family Medicine

• Congestive heart failure • Atrial fibrillation • Myocardial infarction

2

• Renal failure

015 was a big year for physicians in general, and for family physicians in particular. Medicare’s sustainable growth rate formula was finally repealed by Congress thus removing the annual threat of major cuts for Medicare reimbursements for physicians. There is still work to be done to ensure fair compensation for the valuable work primary care physicians do for their increasingly complicated patients, but this is a step in the right direction. The other monumental development for physicians this year was the roll out of ICD-10. So far, it appears that office EMRs were up to the challenge and most physicians had a seemingly smooth transition. The next few months will be telling as we see whether reimbursements will be affected by the new system.

• Cellulitis

Members of the Department of Family Medicine continued to have an enormous impact on the health and well-being of their individual patients and the Stamford community in general. The unique and special relationship of the Family Physician with his or her patient continues to be one of the most important and meaningful of all human relationships. Family physicians strive daily to limit the intrusions and obstructions that threaten to impact the care they give to and for their patients.

• Medical IT

Members of the Department of Family Medicine admitted 535 patients in fiscal year 2015. This was a 3% increase from FY14. Of these patients, 452 were adults, 10 were children and 73 were newborns.

The geographic area served is from North Stamford to the South End, from New Canaan to the West Side. The patients cared for include newborns, children, teens, maternity patients, adults, nursing home patients and palliative care patients. The settings in which care is provided range from solo, partnerships and group practices to Stamford Health Integrated Practices (SHIP) and community health centers. Some members of the Department continue to admit their patients to

• Syncope

SCOPE OF CLINICAL SERVICES The members of the Department of Family Medicine continue to provide a wide range of essential health services to the Stamford community and Stamford Hospital and serve in a variety of roles including: • School health physician • Palliative care • Geriatrics and nursing home practice • Public health director • Indigent care • Hospitalists • Integrative medicine • Medical missions abroad • Graduate medical education • Graduate nursing education

2015 CL INICA L A NNUAL R E POR T | 21

D EPA R T M ENT O F FAM I LY M E DI CIN E : A N N UA L R E P OR T 2015 the Hospital while others use the increasingly popular hospitalist service for their inpatients. Stamford Hospital is fortunate to have one of the three Family Medicine residency programs in Connecticut. At this time, 16 of the 30 current members of the Department of Family Medicine have come from this residency program. With the country in the midst of an increasing shortage of primary care physicians, the value of the Family Medicine Residency Program as a “feeder” of primary care physicians into the community continues to increase. This is an important factor in insulating the Hospital and community from the serious quality and cost problems seen in areas with a dearth of primary care physicians.

MEDICAL STAFF

Milestones The following Department members celebrated milestone anniversaries as members of Stamford Hospital’s Medical Staff: • Sadna Alaigh, MD — 20 years • Joseph Connelly, MD — 30 years

New Staff The Department of Family Medicine welcomed the following physicians in 2014 – 15: • Anna Jamrozik, MD, Stamford Health Integrated Practices (SHIP) • Kamilah Rose, MD, Stamford Health Integrated Practices (SHIP)

Henry Yoon, MD Associate Chair

These physicians bring the total Department membership to 31. • 26 are members of the active staff and five are members of the affiliate staff • Nine Department members continue to care for patients in the Hospital (unchanged from one year ago) • 10 members are in private practice, two work for community health centers, 10 work for the Hospital and nine work for Stamford Health Integrated Practices (SHIP) (up from six last year)

J. Robert Shapiro, MD Member at-Large to Department Executive Committee

Honors and Recognition • Drs. Rod Acosta and Angelo Mallozzi were selected by Connecticut magazine as “Top Docs.” • Drs. Rod Acosta, Alan Falkoff, Joshua Herbert, Angelo Mallozzi and Ann Williams were listed as a “Top Doctor” by Castle Connolly.

Kathleen Nurena, MD Member at-Large to Medical Executive Committee

• Dr. Lawrence Liebowitz served as Health Director of the Town of Redding and as the advisory physician for the town’s elementary and middle schools. • Dr. Joshua Herbert was selected as Chair of the Medical Staff. • High Ridge Family Practice (Dr. Alan Falkoff ) was designated as a High Performance Practice by the Medical University of South Carolina.

2 2 | DEPAR TM ENT O F FAMI LY ME D I C I N E

D EPA R T M EN T O F FAM I LY M E D ICIN E : A N N UA L R E P OR T 2015 • Dr. Joseph Feuerstein was selected as the winner of the Fairfield County Business Journal Excellence In Medical Research Award. • Dr. Rod Acosta was appointed President of Stamford Health Integrated Practices (SHIP).

Hospital Committee Participation • Continuing Medical Education Committee — Drs. Joseph Connelly, Henry Yoon • Credentials Committee — Drs. Joshua Herbert, Henry Yoon, Jack DiTeodoro • Graduate Medical Education Committee — Drs. Joseph Connelly, Henry Yoon • Information Technology Leadership Council — Dr. Henry Yoon

• Quality Assurance Committee (SHIP) – Dr. Clarke Latimer • Utilization Management Committee — Dr. Joseph Connelly

DEPARTMENTAL EDUCATION AND TEACHING ACTIVITIES The Family Medicine Residency Program had another successful year in 2015. For the fourteenth straight year, the program filled completely in the match with excellent candidates. The additions to the residency staff include: • Jacky Chen, MD • Patrick Khalaf, MD • Durvi Patel, MD • Krupa Patel, MD

• Infection Control Committee — Dr. Clarke Latimer

• Alyssa Sader, MD

• Internal Medicine/Family Medicine Performance Improvement Committee — Drs. Henry Yoon (co-chair), Anne Brewer

Five physicians graduated from the residency program in 2015 and all satisfactorily passed the American Board of Family Medicine certification exam. Additionally:

• Medical Executive Committee — Drs. Joshua Herbert (Chair), Rod Acosta (Outgoing Chair), Joseph Connelly, Kathleen Nurena

Dr. Lawrence Liebowitz was re-appointed Clinical Assistant Professor of Medicine at NYMC.

• Medical Ethics Committee — Drs. Joseph Connelly, Anne Brewer

Dr. Alan Falkoff had faculty appointments at NYU, Columbia, Sacred Heart, Pace University and Quinnipiac University.

• Ancillary Provider Committee — Dr. Jack DiTeodoro (Chair)

Dr. Clarke Latimer had faculty appointments at UCONN and Quinnipiac University.

• Obesity Task Force — Dr. Anne Brewer

Dr. Marc Brodsky has a faculty appointment at Columbia University.

• Palliative Care Committee — Drs. Anne Brewer, Joseph Connelly • Pediatric Peer Review Committee — Dr. Kathleen Nurena • Perinatal Infectious Disease Committee — Dr. Anne Brewer • Pharmacy and Therapeutics Committee — Dr. Shanthi Devaraj • Planetree Committee (SHIP) — Dr. Lawrence Liebowitz • Primary Care Committee (SHIP) — Dr. Lawrence Liebowitz • Primary Care Integration Steering Committee — Dr. Henry Yoon

Dr. Joseph Feuerstein has a faculty appointment at Columbia University. Dr. Katie Takayasu has a faculty appointment at Columbia University. Dr. Joseph Connelly has a faculty appointment at Columbia University. Dr. Kathleen Nurena organized a medical grand rounds presentation on the association between domestic violence and animal abuse. Dr. Joseph Feuerstein lectured about Integrative Medicine in the Stamford Hospital Mini-Medical School and at Grand Rounds at Silver Hill Hospital. 2015 CL INICA L A NNUAL R E POR T | 23

D EPA R T M ENT O F FAM I LY M E DI CIN E : A N N UA L R E P OR T 2015 DEPARTMENTAL RESEARCH AND SCHOLARLY ACTIVITIES High Ridge Family Medicine participated in various research projects in primary care with PPRNet.

COMMUNITY OUTREACH Dr. Anne Brewer went to the Dominican Republic in January for a medical mission trip, her seventh to this country.

Dr. Kathleen Nurena prepared a poster on interdisciplinary education of state agencies.

Dr. Henry Yoon served as School Medical Advisor to the Stamford Board of Education as well as to the Stamford Department of Public Health.

Dr. Joseph Connelly co-authored a chapter for the most recent edition of Rakel’s Textbook of Family Medicine.

Dr. Marc Brodsky coordinated the Athletes and the Arts program at Chelsea Piers Connecticut.

Dr. Joseph Feuerstein published an article in Current Nutrition and Food Sciences entitled “Teaching a Lifestyle Modification Program to a Cohort of Local MDs to Treat Obesity and Hyperlipidemia and Hypertension.”

Dr. Henry Yoon served on the board of directors for Smith House and the Shelter for the Homeless.

Three Family Medicine residents submitted articles and/or questions to the Core Content Review of Family Medicine. Dr. Shakiella Howell presented a poster on the Optimus Integrative Medicine Clinic at a national conference on care for the underinsured. Dr. Lawrence Liebowitz completed a two-year fellowship in Integrative Medicine sponsored by the University of Arizona. Dr. Joseph Feuerstein presented a poster at the International Congress on Integrative Medicine & Health in Las Vegas on “The use of hypnosis and acupuncture in the treatment of anxiety disorders — a case series.” Dr. Katherine Takayasu presented several lectures and Grand Rounds to attending physicians and residents at Stamford Hospital, Columbia University and New York Medical College. Dr. Marc Brodsky is the principal investigator of a study based at the Wilton Y comparing a particular stretching exercise program to self-care for patients with back pain.

2 4 | DEPAR TM ENT O F FAMI LY ME D I C I N E

Dr. Henry Yoon was Coordinator of Stamford Hospital’s Mini-Medical School. Dr. Joseph Connelly served on the board of directors for Optimus Health Care. Dr. Lawrence Liebowitz served as Director of Health of the Town of Redding. Drs. Joseph Feuerstein appeared on News 12 Connecticut to discuss integrative medicine and wellness. Dr. Robert Shapiro served as co-medical director of the AmeriCares Stamford mobile van. Dr. Lawrence Liebowitz served as Camp Director for summer camps in Stamford, Ridgefield and Redding. Dr. Alan Falkoff continues coaching and playing for the Stamford Mets. Dr. Katherine Takayasu made several presentations about chronic pelvic pain to physicians, as well as in the communities of Norwalk, Darien, Wilton, New Canaan and Stamford.

D EPA R T M EN T O F FAM I LY M E D ICIN E : A N N UA L R E P OR T 2015 INTEGRATIVE MEDICINE

Patients

Overview

The Center treats children, adolescents and adult patients. Most patients are referred for consultation by physicians and word of mouth. CIMW practitioners conduct over 9,000 patent visits per year.

The Center for Integrative Medicine & Wellness (CIMW) at Stamford Hospital is comprised of a Hospital-based clinic that offers an integrative medicine consultation service. It is situated in the Tully Health Center. The Center’s model is a high-volume, outpatient, sub-specialty medical clinic that provides the following integrative medicine services: 1. Pain management 2. Nutrition and supplement consultation 3. Mind-body stress reduction 4. Lifestyle medicine Medicare and all private insurances are accepted, and visits are processed through insurance. In addition to consultative care, the Center offers programs and education to patients, Hospital employees and the community. The Center also provides educational opportunities to medical practitioners.

Philosophy The philosophy of the CIMW is well-aligned with the Planetree philosophy that is based on the simple premise that all care should be organized around the needs of patients. CIMW focuses on its patients as people, how they live and what their personal goals may be, as well as how their lifestyle affects illnesses, injury and chronic medical conditions. The CIMW treats the whole person — body, mind and spirit — using a safe and evidence-based approach customized for each individual. Working in collaboration with the patients and their medical teams, CIMW offers patient-centered care that blends conventional and complementary medicine tailored to achieve the patient’s personal needs and goals for health and wellness.

Practitioners The CIMW employs three full-time board-certified Family Physicians who provide all treatments. The physicians oversee interdisciplinary aspects of care by conventional and complementary practitioners, both Hospital- and community-based. Practitioners who share common patients with the CIMW physicians are vetted to assure proper credentialing and are included in a monthly meeting at the Center to discuss the care of mutual patients, improve communication among practitioners and optimize patient outcomes.

Services Offered The Center offers the following Integrative Medicine programs: Pain Management — The pain management service accounts for the majority of patient visits and revenue for the CIMW. Most patients with pain are seen for neck pain and associated symptoms to include headache. Other conditions include low back pain, occupational- and sports-related overuse injuries, osteoarthritis, neuropathy, fibromyalgia and autoimmune-related and cancer-related pain conditions. Nutritional/Supplement Consultation — Weight loss is the most common condition that is treated in the nutritional consultation service. The weight loss plan is made up of three components: a personalized diet, referral to a medical fitness program and behavioral strategies. Nutrition is an important aspect in the treatment plan of all patients and includes attention to metabolic syndrome, digestive symptoms, autoimmune and cancer-related conditions and attention deficit and hyperactivity disorders. Dr. Joseph Feuerstein collaborated with Stamford Health Integrated Practices (SHIP) physicians to offer his eating plan to patients and the community.

2015 CL INICA L A NNUAL R E POR T | 25

D EPA R T M ENT O F FAM I LY M E DI CIN E : A N N UA L R E P OR T 2015 Women’s Health — In addition to issues related to reproductive health such as pelvic pain, fertility, childbearing, perimenopause and menopause, the Center complements standard care in the treatment of female patients with depression, heart disease risk factors, arthritis and digestive issues. Dr. Katherine Takayasu led a multidisciplinary biopsychosocial pelvic pain program that included meetings with specialists, community presentations and presentations at national meetings to improve the quality of life of patients suffering with this very challenging problem. Stress Reduction — The CIMW provides patients with the tools to support lifestyle changes, such as Mindfulness Meditation. The program also helps patients reduce anxiety and pain through hypnosis and guided imagery. The Athletes and the Arts Program — The Athletes and the Arts Program was created by the CIMW in conjunction with specialists in Orthopedics and Sports Medicine to optimize performance in sport athletes and performing artists. The focus of the program is to prevent and treat injuries, inform athletes and performers about optimal nutrition and hydration and reduce performance anxiety. Treatment methods may include lifestyle approaches to include instruction in self-care acupressure and stretching exercises, physician-administered acupuncture, trigger point injections, non-opioid pain medication recommendations, nutritional counseling, botanical and supplement consulting and physician-administered mindbody stress-reduction therapies.

Education and Research The clinical stories and patient care outcomes at the Center offer a rich resource for teaching Integrative Medicine Fellows at the CIMW as well as for learning activities for medical students and medical residents. A full-time, two-year Integrative Medicine Fellowship provides a unique clinical experience in evidence-based complementary therapies in pain management, nutrition/ supplement consultation and mind-body stress reduction with guided imagery and mindfulness meditation. Fellows are funded to complete the 1,000-hour University of

Arizona distance learning and residential Fellowship in Integrative Medicine curriculum, as well as a 300-hour CME acupuncture program. Fellows spend 50% time at the CIMW and 50% time at Optimus, a Federally Qualified Health Care Center that is affiliated with Stamford Hospital and primarily funded by U.S. Department of Health and Human Services. The CIMW receives no research funding. Center physicians participate in quality improvement initiatives and frequently present the findings in peer-reviewed publications and as abstracts at conferences. Presentations at national conferences have included data on a breast pain program in collaboration with the Women’s Breast Center and the effects on a dietary approach to reducing cardiac risk factors.

Financial Data Philanthropic funding originally helped open the CIMW seven years ago, but the clinic is now self-sustaining. Philanthropy continues to support the education of Center Fellows at University of Arizona and the acupuncture course. There were over 9,300 patient visits during the year in the pain management, mind-body stress reduction and nutrition evidence-based services. Services at the CIMW are covered by most major medical insurance plans, including Medicare.

Collaborations A key strategy of the Center is to build relationships within the Hospital system and community. The CIMW is engaged in the following collaborative process improvement programs: 1. Breast pain with breast surgeons 2. Pelvic pain with gynecologists 3. Cancer and pain with oncologists 4. Dietary approaches to reducing cardiac risk factors with primary care physicians and specialist physicians 5. Concussion program with neurologists, neuropsychology and physical therapy 6. The Athletes and the Arts program with Orthopedics 7. Reducing perioperative anxiety as part of the standardized pre-operative process with surgeons throughout the hospital

2 6 | DEPAR TM ENT O F FAMI LY ME D I C I N E

D EPA R T M EN T O F FAM I LY M E D ICIN E : A N N UA L R E P OR T 2015 STRATEGY/FUTURE DIRECTION The members of the Department of Family Medicine are proud of the many achievements of Stamford Hospital over the past year and are gratified to be part of these successes. We value our relationship with the Hospital as we collaborate to maintain and improve the health of our patients and the community. The presence of a strong Department of Family Medicine will become even more important as the healthcare system evolves. We look forward to continuing to work with the Hospital to provide excellent care to our patients, strengthen our practices, and move our community’s overall health forward in the face of the changes taking place around us.

2015 CL INICA L A NNUAL R E POR T | 27

i nn ov a t io n i n

medicine

The only provider in Fairfield County to offer TAVR, a minimally invasive option for patients with aortic stenosis who are not candidates for open heart surgery.

2 8 | DE PA R TM ENT O F ME D I C I N E

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

up the Department of Medicine are detailed in their respective annual reports and presented under the Scope of Clinical Services.

A

The continued growth of the Department has resulted in the largest number of physicians on its staff, in its history. There are a total of 254 medical practitioners representing 16 primary care and specialty divisions. This has been the result of a concerted effort by Stamford Hospital to develop primary care centers in adjacent communities where patients historically might have related to other hospitals. The growth of hospitalism has also contributed substantially to these large numbers. The parallel growth of Stamford Health Integrated Practices (SHIP), and the commitment of new physicians to be a part of this multidisciplinary organization has been a catalyst to the advancement of primary care. A parallel increase in the Ancillary Staff took place with 22 members now serving in that capacity. (Figure 1)

Noel I. Robin, MD Chair, Department of Medicine Professor of Clinical Medicine and Associate Dean at the Stamford Health System Columbia University College of Physicians and Surgeons

s a “department of departments,” the Department of Medicine is involved in a wide range of clinical care, medical education and research. The achievements of the individual departments that make

Figure 1: Medical Staff Specialty Representation in the Department of Medicine Active Staff

Courtesy Staff

Affiliate Staff

Ancillary Staff

Internal Medicine

69

1

12

2

7



3

Allergy and Immunology

3

4











Cardiovascular Disease

18

6





2



7

Clinical Cardiac Electrophysiology

3











1

Dermatology

13







1





Endocrinology

5

2

2

1







Gastroenterology

10

1

2









Hematology and Oncology

8





4







Infectious Disease

6

2



1





1

Interventional Cardiology

6

1











Nephrology

4

2





1





Neurology

4

3





1





Pulmonary Medicine

6

1





1





Rheumatology

4







2





Physical Medicine and Rehabilitation

10



1









Hospitalist

21

1





5

3

2

190

24

17

8

20

3

14

Specialty

Total

Provisional Provisional Provisional Active Affiliate Ancillary

2015 CL INICA L A NNUAL R E POR T | 29

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 Admissions, by Diagnosis, to the Medical Service Figure 2 demonstrates a modest increase in the number of inpatients from 5,710 (2013) to 5,855 (2014) to 5,860 (2015), but with an overall slight decrease in the number of patient days from 32,068 (2013) to 32,418 (2014) to 31,688 (2015). The net effect was a decline in average length of stay from 5.62 (2013) to 5.54 (2014) to 5.41 (2015). The average length of stay for observation patients remained relatively static: 1.44 (2013) to 1.36 (2014) to 1.40 (2015).

A significant change in the attending physician care of inpatients was noted with increasing numbers of patients admitted to the hospitalist service: 5,013 (2013), 5,201 (2014), 5,235 (2015), and decreasing numbers of patients admitted by primary care physicians: 643 (2013), 593 (2014), 553 (2015).

Figure 2: Inpatient/Observation Volume FY15 Medical Specialty

FY14

FY13

# Inpts

# Pt Days

# Inpts

# Pt Days

# Inpts

# Pt Days

Hospitalist

5,235

28,135

5,201

28,325

5,013

28,028

Medicine

553

3,273

593

3,788

643

3,794

Cardiology

48

188

39

200

32

140

GI

1

1

2

4

2

8

Hem-Oncology

18

86

16

93

9

37

Infectious Disease

3

3

2

5

4

20

Nephrology

0

0

0

0

0

0

Neurology

0

0

2

3

1

5

Pulmonary

2

2

0

0

3

31

Anesthesiology

0

0

0

0

3

5

5,860

31,688

5,855

32,418

5,710

32,068

Total ALOS

5.41 Medical Specialty

5.54

5.62

# Obsv

# Pt Days

# Obsv

# Pt Days

# Obsv

# Pt Days

Hospitalist

1,457

2,040

1,426

1,925

1,452

2,072

Medicine

83

127

70

96

106

172

Cardiology

4

4

28

44

17

26

GI

6

10

19

31

25

37

Hem-Oncology

2

2

1

1

0

0

Infectious Disease

2

2

1

1

2

3

Nephrology

1

1

1

1

0

0

Neurology

2

3

0

0

1

1

Pulmonary

2

3

1

2

2

2

Anesthesiology Total ALOS

0

0

0

0

1

1

1,559

2,192

1,547

2,103

1,606

2,314

1.4

1.36

1.44

Admissions, by Diagnosis, to the Medical Service — Comparison Figure 3 represents inpatient admission numbers by descending order of rank, with septicemia or severe sepsis

3 0 | DEPAR TM ENT O F ME D I C I N E

remaining the most common DRG, now comprising 6.8% of admission to the medical service.

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 Figure 3: Department of Medicine, Comparison of Most Common DRGs DRG

DRG Description

FY15 Rank

IP Dc

% of All Inpts

FY14 Rank

IP Dc

% of All Inpts

FY13 Rank

IP Dc

% of All Inpts

FY12 Rank

IP Dc

% of All Inpts

871

Septicemia or severe sepsis w/o MV 96+ hours w/MCC

1

397

6.8%

1

301

5.1%

1

253

4.4%

1

190

4.0%

291

Heart failure & shock w/MCC

2

157

2.7%

3

146

2.5%

4

126

2.2%

8

93

1.9%

872

Septicemia or severe sepsis w/o MV 96+ hours w/o MCC

3

142

2.4%

8

105

1.8%

12

78

1.4%

25

50

1.0%

392

Esophagitis; gastroent & misc digest disorders w/o MCC

4

132

2.3%

5

138

2.4%

3

141

2.5%

2

136

2.8%

603

Cellulitis w/o MCC

5

125

2.1%

2

158

2.7%

2

191

3.3%

3

134

2.8%

292

Heart failure & shock w/CC

6

118

2.0%

6

114

1.9%

6

122

2.1%

5

106

2.2%

378

G.I. hemorrhage w/CC

7

118

2.0%

9

97

1.7%

10

94

1.6%

9

85

1.8%

812

Red blood cell disorders w/o MCC

8

105

1.8%

7

111

1.9%

7

116

2.0%

4

109

2.3%

897

Alcohol/drug abuse or dependence w/o rehab therapy w/o MCC

9

103

1.8%

4

141

2.4%

5

126

2.2%

6

96

2.0%

683

Renal failure w CC

10

101

1.7%

10

97

1.7%

9

106

1.9%

17

61

1.3%

690

Kidney & urinary tract infections w/o MCC

11

86

1.5%

12

90

1.5%

17

71

1.2%

11

80

1.7%

682

Renal failure w/MCC

12

82

1.4%

22

58

1.0%

15

76

1.3%

37

37

0.8%

247

Perc cardiovasc proc w/ drug-eluting Stent w/o MCC

13

81

1.4%

16

84

1.4%

23

60

1.1%

18

58

1.2%

194

Simple pneumonia & pleurisy w/CC

14

75

1.3%

11

95

1.6%

8

114

2.0%

7

94

2.0%

310

Cardiac arrhythmia & conduction disorders w/o CC/MCC

15

74

1.3%

17

83

1.4%

13

77

1.3%

10

80

1.7%

193

Simple pneumonia & pleurisy w/MCC

16

71

1.2%

15

86

1.5%

22

62

1.1%

16

61

1.3%

65

Intracranial hemorrhage or cerebral infarction w/CC

17

70

1.2%

18

81

1.4%

16

73

1.3%

14

65

1.4%

689

Kidney & urinary tract infections w/MCC

18

69

1.2%

32

49

0.8%

33

49

0.9%

31

42

0.9%

641

Misc disorders of nutrition; metabolism; fluids/electrolytes w/o MCC

19

67

1.1%

13

89

1.5%

14

76

1.3%

21

54

1.1%

638

Diabetes w/CC

20

61

1.0%

30

52

0.9%

47

32

0.6%

36

38

0.8%

309

Cardiac arrhythmia & conduction disorders w/CC

22

60

1.0%

14

88

1.5%

11

91

1.6%

15

63

1.3%

312

Syncope & collapse

27

52

0.9%

1.4

65

1.1%

25

56

0.9%

20

55

1.1%

918

Poisoning & toxic effects of drugs w/o MCC

41

38

0.6%

5.5

60

1.0%

40

42

0.7%

27

46

1.0%

313

Chest pain

62

22

0.4%

1.4

47

0.8%

18

70

1.2%

26

48

1.0%

SUBTOTAL

2,406

41.1%

4.7

2,435

41.5%

2,302

40.2%

1,881

39.4%

Total Inpatient Discharges

5,860

1.4

5,855

5,710

4,788

Inpatient Days

31,688

4.3

32,418

32,068

26,584

5.4

1.4

5.5

5.6

5.6

Total Observation Discharges

1,559

5.5

1,547

1,606

1,812

Observation Days

2,192

1.4

2,103

2,314

2,554

1.4

4.7

1.4

1.4

1.4

Inpt ALOS

Obs ALOS

2015 CL INICA L A NNUAL R E POR T | 31

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 SCOPE OF CLINICAL SERVICES ALLERGY AND IMMUNOLOGY

Paul S. Lindner, MD Director, Allergy and Immunology Assistant Clinical Professor of Medicine, Columbia University College of Physicians and Surgeons

Active Staff: • Denis A. Bouboulis, MD • Ora Burstein, MD • Leslie R. Coleman, MD • Mitchell R. Lester, MD Members of the Department of Allergy and Immunology with active full staff privileges include: Denis A. Bouboulis, MD; Ora Burstein, MD; Leslie R. Coleman, MD; Mitchell R. Lester, MD; and Paul S. Lindner, MD. The physicians in the Department function in an outpatient setting and also provide inpatient consultations, treating patients for a variety of allergic and immunologic conditions. These include: allergic rhinitis; asthma; sinusitis; skin disorders such as urticaria, contact dermatitis and eczema; food allergy; stinging insect allergy; drug allergy; and immunodeficiency. In this specialty, specific allergens causing an allergic response are pinpointed through the use of various techniques that include skin testing, patch testing, in-vitro analysis of antigen-specific IgE, oral and parenteral challenges. In addition to avoidance techniques and allergy/asthma medications, we offer a program of desensitization that helps patients develop immunologic tolerance to offending allergens. Desensitization can be provided for all major environmental allergens such as dust mites, molds, pollens and cat and dog dander. Individuals can be desensitized for bees, hornets, wasps and yellow jackets, antibiotics and other medications including penicillins, cephalosporins and chemotherapy agents. A major push toward developing desensitization techniques for food allergens such as peanuts is underway in many academic centers due to the rising prevalence of food induced anaphylaxis over the past two decades.

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Allergists in our community work closely with other subspecialists and general practitioners to provide comprehensive care of the allergic patient. We work with pulmonologists to provide asthma care, dermatologists can obtain input regarding potential food allergies as a trigger for eczematous conditions and otolaryngologists are helped by having the allergist identify and treat the allergic triggers, which can often complicate a case of chronic sinusitis and nasal polyposis. Many of our allergists are involved in clinical research projects. Dr. Paul S. Lindner published original research in the field of asthma recently, “Gender Differences in Asthma Inhaler Compliance,” Connecticut Medicine 4/2014: 78(4):207-210. Allergists in the Department also diagnose and treat a variety of primary and secondary immunodeficiencies. The most prevalent immune disorder treated is common variable immunodeficiency (CVID) which responds well to Intravenous Immunoglobulin (IVIG) therapy. The newest form of gammaglobulin therapy is through the subcutaneous (SCIG) route. With SCIG, patients no longer need to spend time at an outpatient infusion center and can administer their own gammaglobulin therapy at home. The latest developments in the treatment of allergic disorders are the newly approved therapies for hereditary angioedema including purified human C1 esterase inhibitor (Berinert — for acute attacks, Cinryze for maintenance prevention) and a reversible kallikrein inhibitor, Kalbitor (ecallantide) for acute attacks. A newly approved selective bradykinin B2 receptor antagonist, Firazyr (icatibant) has also been found useful in reversing acute angioedema attacks. Newer forms of immunotherapy are in current development. The first monoclonal anti-IgE antibody to be released is Xolair (omalizumab), which has been shown to improve asthma control while decreasing the need for systemic and inhaled steroids. Xolair theoretically will also work for allergic rhinitis and food allergies by decreasing total IgE on mast cells, however these additional indications are currently being evaluated. Xolair has just been approved for treating severe chronic idiopathic urticaria. Studies looking at a variety of future immunotherapy options include the use of T-cell peptides to stimulate a preferential TH1 vs TH2 response, the use of adjuvants such as lipopolysaccharide and DNA oligonucleotides, and immunotherapy with bacterial DNA oligonucleotides containing an abundance of CPG motifs to enhance a TH1 protective response. Other monoclonal antibodies on the horizon include anti-IL5 for hypereosinophilic syndromes and anti-IL4, anti-IL13 for asthma.

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 The Department of Allergy and Immunology has an active role in the teaching program for medical students, interns and residents at Stamford Hospital. Residents spend many weeks with our physicians in elective rotations. As part of their outpatient internal medicine experience, interns spend an afternoon every other week with one of our private allergists in the community learning about the practice of outpatient medicine as well as increasing their understanding of common allergic disorders seen on a daily basis by the typical internist. The Department provides lectures for Grand Rounds in Medicine as well as lunch conferences for Residents and Medical Students. This year, Dr. Mitchell Lester presented a talk about many of the misconceptions and fallacies in the field of allergy as part of the Medical Grand Rounds series in August.

• John Fisher, MD

In the coming year, our Department looks forward to providing excellent care in the field of Allergy and Immunology as clinicians and educators, and will continue to bring the latest developments in our specialty to the greater Stamford Hospital community.

• Maria Palvis, MD

David H. Hsi, MD, FACC, FASE Chief of Cardiology Co-Director of the Heart & Vascular Institute, Stamford Hospital

Active Staff: • Samuel Brodsky, MD • Salvatore Carbonaro, MD • Joonun (Chris) Choi, MD • Antonio Colombo, MD • Nicola Corvaja, MD • Evelyn Cusack, MD • Sandhya Dhruvakumar, MD • Susan Eysmann, MD • Kevin Ferrick, MD

• Jeffrey Green, MD • Mark Heiman, MD • Steven F. Horowitz, MD, FACC • Robert Jumper, MD • Robert Labarre, MD • David Lomnitz, MD • David Lorenz, MD • Wayne Miller, MD • Thomas Nero, MD • John Novella, MD • Michael Pittaro, MD • Edward Schuster, MD • Joseph Tiano, MD • Anja Wagner, MD

CARDIOLOGY

• Gregory D’Onofrio, MD

• Glenn Gandelman, MD

The Cardiology Division of Stamford Hospital provides comprehensive clinical services for a wide variety of cardiovascular problems. The last decade has seen a marked upgrade and expansion of cardiac services at the Hospital. This has included state-of-the-art Cardiac Catheterization and Electrophysiology Laboratories, nuclear cardiology cameras and 3-D echocardiography, along with the opening of a hybrid operating room for special procedures. Stamford Hospital is the region’s only full-service cardiovascular center in Fairfield County. The transcatheter aortic valve replacement (TAVR) program operates under the joint leadership of Stamford Hospital’s Interventional Cardiology and Cardiac Surgery teams. Interventional Cardiologists Dr. Antonio Colombo, world-renowned expert in TAVR, and Dr. Nicola Corvaja, Medical Director of the Structural Heart Disease Center and Valve Clinic, work closely with cardiac surgeons Dr. Michael Coady, Chief of Cardiac Surgery, and Dr. William Feng, both of whom have proven records of experience and expertise in the surgical management of aortic valve disease. TAVR improves the survival and quality of life of patients with severe aortic stenosis who would otherwise have limited choices to treat this serious medical condition. The Heart & Vascular Institute (HVI) is proud to announce that Dr. Antonio Colombo, Attending Cardiologist at Stamford Hospital and a Visiting Professor of Medicine at NewYork-Presbyterian Healthcare System/Columbia 2015 CL INICA L A NNUAL R E POR T | 33

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 University Medical Center, is a principal operator of our TAVR procedures. A legend in the field of Interventional Cardiology, Dr. Colombo made groundbreaking contributions to coronary stenting, peripheral vascular interventions, and structural heart disease treatment. His 1995 landmark study regarding new technologies in coronary stenting changed the future of minimally invasive treatments for heart disease. He remains actively involved in the research and development of emerging Interventional Cardiology technologies. The Interventional Cardiologists and support staff provide around clock coverage for the acutely ill patient. They have achieved 96% door-to-balloon times for all eligible ST elevation myocardial infarction patients admitted to the Hospital in 2015. The procedures offered include advanced imaging and coronary interventions and hemodynamic support using percutaneous left ventricular assist devices. Stamford Hospital is the first in Connecticut to offer sophisticated hemodynamic monitoring for patients with severe congestive heart failure by implanting the Cardiomems® in the pulmonary arteries. Dr. Jeffery Green and Dr. Edward Portnay successfully performed all procedures. Under the leadership of Dr. Chris Choi, we received a gold medal award in heart failure care from the American Heart Association “Get With The Guidelines” program in 2014 – 2015. The Electrophysiology (EP) program provides pacemaker and implantable defibrillators, resynchronization devices for heart failure and ablations for both supraventricular and ventricular tachycardia. In 2013, Dr. Sandhya Dhruvakumar, former Director of the Electrophysiology Laboratory at University of Medicine and Dentistry of New Jersey, joined our Cardiology Division as Director of Electrophysiology. An excellent teacher, Dr. Dhruvakumar specializes in complex procedures such as atrial fibrillation ablation. In 2014, Dr. Dhruvakumar and her team designed and constructed an integrated electrophysiology operative suite with the most advanced equipment currently available. Our physician expertise and state-of-the-art technology allow Stamford Hospital to offer the breadth of new and leading-edge procedures such as: cryoablation; hybrid ablations for atrial fibrillation; subcutaneous implantable defibrillators; injectable heart monitors; and left atrial appendage closure devices. Quality initiatives, a focus on excellent outcomes and patient-centered care remain at the core of the program. Under her leadership, the Electrophysiology program has grown 300% in volume. Our EP specialists, Drs. Michael Pittaro and Joseph Tiano, bring 3 4 | DEPAR TM ENT O F ME D I C I N E

to Stamford Hospital their expertise in device implantations and ablation procedures. In addition, Dr. John Novella, who received his advanced EP training at Yale and New Haven Hospital, joined our Medical Staff in August 2014. The Division provides an educational program combining clinical discussions and exemplary, formal didactic presentations from Hospital-based cardiologists and many distinguished guest speakers, including Dr. Cynthia Taub from Montefiore Medical Center, Dr. Sharon Reimold from Texas University of Southwestern Medical Center and Drs. Paul Ridker and Leonard Lilly from Harvard Medical School in Boston. The Cardiology Division works closely with the physicians in Cardiac Surgery, Dr. Michael Coady, Chief, and Dr. William Feng, to optimize patient care across a spectrum of conditions. Dr. Steven Horowitz, Emeritus Cardiology Chief, took on the role of Medical Director, Planetree and Cardiac Care Management, and started a Preventive Cardiology Service. He is a nationally known expert in integrative medicine and cardiology. The Cardiac Rehabilitation Program has received national certification and acclaim under the leadership of Dr. Murray Low, past president of the American Association of Cardiovascular & Pulmonary Rehabilitation, and Dr. Edward Schuster, Medical Director. The Program incorporates contemporary concepts of wellness, fitness and lifestyle modification for the benefit of patients with known coronary artery disease and those patients who have undergone open heart surgery. Additionally, the Program includes both intensive ECG monitoring and lifetime wellness maintenance. Dr. Thomas Nero, Interventional Cardiologist, worked with the City of Stamford and many Stamford Hospital staff to lead a hugely successful “Hands for Life” campaign, educating more than 10,000 students and area residents in the resuscitation of cardiac arrest victims. Chief of Cardiac Surgery Dr. Michael Coady and Chief of Cardiology Dr. David Hsi co-chaired the Fourth Annual Cardiovascular Symposium in Stamford. They were grateful to Timothy Hansen, Chief Physician Assistant for Cardiac Surgery, for his role as the program coordinator, and keynote speaker Steve Ryan, the former President and COO of NHL Enterprise, for his special visit. Additional thanks to all speaking faculty members including Dr. Nicola Corvaja (Structural Heart Disease), Dr. Sandhya Dhruvakumar (EP Cardiology), Dr. Jeffrey Green (Non-Invasive Cardiology)

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 and Dr. Edward Portnay (Interventional Cardiology) for their time for and commitment to the program.

dermatopathologist, has been an outstanding addition to Stamford Hospital and the medical community.

Finally, the HVI warmly welcomed a new Director, Eilish Hourihan, in 2015. She brings in-depth expertise and experience in management to the Cardiology service line.

As a specialty, Dermatology focuses on skin cancer prevention and public education about the perils of sunbathing; to this end, individual Department members participate in various community forums and events.

DERMATOLOGY

ENDOCRINOLOGY Noel I. Robin, MD Chair, Department of Medicine Ellen S. Naidorf, MD Director of Dermatology

Active Staff: • Mary E. Arden-Cordone, MD • Maria Asnis, MD • Anna C. Freitag, MD

Active Staff:

• Melissa Goldstein, MD • Mary M. Kane-Brock, MD

• Severine Chavel, MD

• Bismruta Misra, MD

• Stephanie Dietz, MD

• Antonio Pantaleo, MD

• Rhett Drugge, MD

• Leonard Vinnick, MD

• Robin Evans, MD • Rena Fortier, MD • Samuel Gettler, MD • Omar Ibrahimi, MD • Steven Kolenik, MD • Sharon Littzi, MD • Fern Mayer, MD • Debra Pruzan-Clain, MD • Donald Savitz, MD

Provisional Active Staff: • Rebecca Hall, MD As acknowledged in last year’s Annual Report, in 2013, the Department gained Omar Ibrahimi, MD, who has a specialty in Mohs micrographic surgery. Members of the Department run the Dermatology outpatient clinic at Washington Boulevard and consult at the Hospital. Our Dermatologists also supervise and teach medical residents and rotating medical students, as well as lecture within the Hospital and community. The Department acknowledges the skill, kindness and resourcefulness of Dr. Elgida Volpicelli who, as a

The field of Endocrinology continues to see significant growth in the understanding of the pathophysiology of disease processes, and in earlier and more accurate disease detection. There also has been continued application of newer pharmacologics and technical skills to address endocrinologic dysfunction. Type 2 Diabetes remains the most prevalent disease seen by endocrinologists, a result of prevailing patterns of diet and lifestyle. Balanced glycemic control that matches the physiologic needs of the individual diabetic patient remains the mainstay of diabetes management, with new insulin preparations currently available. In addition, today there are various other categories of pharmacologics that can play a role in diabetes management. All of these treatment options are available at Stamford Hospital and are tailored to the unique needs of each patient. The optimal management of the diabetic patient underscores the indispensable necessity of interdisciplinary and collaborative medical practice. Notwithstanding the nine available categories (including insulin) of drugs to manage diabetes, nowhere in clinical practice is personalized medicine more applicable. The pathophysiology of diabetes is exquisitely elegant, but the needs of each patient must be individually addressed so that the blood glucose response is congruent with the therapeutic goal. Essential to effective management must be patient enfranchisement in a healthy lifestyle. 2015 CL INICA L A NNUAL R E POR T | 35

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 On the education front, Endocrinology sessions for colleagues, house staff and students take place throughout the year through inpatient teaching rounds, The Academic Half Day, student tutorial and preceptorship sessions, Endocrinology Tumor Board and Medical Grand Rounds, including the Summer Syllabus. In addition, residents spend one-on-one time with Certified Diabetes Educators (CDEs) at the Stamford Hospital Diabetes Education Center, an American Diabetes Association (ADA)-recognized center for diabetes education. Endocrinology support through consultation and clinical involvement takes place on all Hospital units, and a regularly scheduled and dedicated outpatient clinic is staffed by the Department.

thorough assessment, sound educational curriculum, diabetes support management planning and follow-up with behavioral outcome measurement. Our Diabetes Education Program is designed to offer outpatient individual instructional sessions, as well as group self-management classes. The sessions begin with an individual assessment to develop a plan of care. Classes are offered on different days and at different times, and staffing schedules are flexed, when necessary, to meet participant needs.

Fairfield County Diabetes and Endocrinology has dedicated endocrinologists and is part of the Stamford Health Integrated Practices (SHIP) network. The practice is led by Medical Director Dr. Bismruta Misra with Drs. Maria Asnis and Melissa Goldstein as attending endocrinologists. The practice is now located in a new facility at 292 Long Ridge Road in Stamford, Connecticut.

Instructional methods include demonstrations, return demonstrations, audiovisual presentations and interactive sessions. There is adequate time during each session for questions and answers. Our teaching approach is interactive; patient- and family-centered and supports the evolution of problem solving skills. Hearing-impaired patients are offered sign language interpretive services, and TDD devices are available. We have the availability of the AT&T Language line, in which instructors engage interpreters by speakerphone for the many different languages spoken in the service area. There is no cost to the patient for these interpretive services.

Diabetes Education Program at Stamford Hospital

Follow-up & Ongoing Support

Diabetes Education Programs apply for American Diabetes Association (ADA) Education Recognition voluntarily. We first acquired this Education Program Recognition from the ADA in 2001 and currently had maintained our program recognition through 2015. Our application to the ADA for Education Program Recognition extension through 2019 was submitted and accepted.

Follow-up is considered an integral part of the educational experience for the individual with diabetes. Behavioral goals are formed during the instruction sessions and are evaluated and/or modified. Follow-up may also occur in person, or on the telephone as needed. The participants in the Diabetes Education Program will be seen on an as-needed basis post-instruction. Phone contact is always encouraged to solve self-management problems that may arise. Diabetes Self-Management Support Planning (DSMSP) is provided in collaboration with the participant as well as to be communicated with other healthcare providers involved in the patient’s care. The referring primary care physician and/or specialist are notified for an urgent health issue needing to be resolved and on overall education program progress.

The application process is rigorous with participant data collection and interpretation. Diabetes Education Program Recognition is also the process through which programs that meet the National Standards for Diabetes Self-Management Training (DSMT) are formally identified for their performance and quality. The ADA Education Recognition Program actually has grown to become the leading quality assurance mechanism for all diabetes self-management education programs across the country. To that point, Medicare will cover diabetes education sessions for their beneficiaries only if provided through an ADA-accredited diabetes education program. Programs that do receive this recognition are viewed as having met the criteria for having a staff of knowledgeable health professionals (Registered Nurses and Registered Dieticians) who can provide state-of-the-art diabetes education. Currently all educators at the Diabetes and Endocrine Center are Certified Diabetes Educators. A multidisciplinary, interactive and proactive approach to diabetes education has been created to include a 3 6 | DEPAR TM ENT O F ME D I C I N E

Currently our staff includes: • Debra Milne, BSN, RN, CDE Director, Ambulatory Nursing and Diabetes Education • Sangeeta Ahuja, MS, RD, CDE • Lois Duke, MS, RD, CDE • Jill Ely, APRN, CDE • Barbara Nadolny, RN, BSN, CDE — Lead RN, CDE • Ann Rupp, RN, BSN, CDE

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 Diabetes Ed Visits FY15

Active Staff: Actual Visits

Budgeted Visits

% Growth Over FY14

2,646

2,175

22%

Diabetes Education Visits

• Neeraj Anand, MD • Henry Grafton Beecher, MD • Robert Dettmer, MD • Sarah Kahn, MD

Community Outreach Over the past year, the community outreach activities for the Hospital in this area included the following: • Demonstrated ongoing support of health fairs and Speakers Bureau. • Served as the title sponsor of the American Diabetes Association’s “Change The Future, Celebrate the Harvest” Event last November. • Served as the presenting sponsor of the Juvenile Diabetes Research Foundation’s Walk to Cure Diabetes in September. CDEs participated in: • Half-day academic session for residents related to delivering comprehensive diabetes care • Quarterly educational Nursing Diabetes Awareness sessions for GEMS and nursing staff. Additionally Barbara Nadolny, BSN, RN, CDE, serves as the legislative point person for the Connecticut Alliance of Diabetes Educators (CADE) and is actively involved in the State of Connecticut Department of Public Health coalition, where the goal is to achieve reimbursement from Connecticut Medicaid for Diabetes Education services.

GASTROENTEROLOGY

Stuart Waldstreicher, MD Director of Gastroenterology Assistant Clinical Professor of Medicine, Columbia University College of Physicians and Surgeons

• Darlene Negbenebor, MD • William Pintauro, MD • Neil Schamberg, MD • Amy Smithline, MD The Department of Gastroenterology continues to diversify the services it offers to patients and the healthcare community. Over the past year our Division performed 6,850 endoscopic procedures at both the Hospital and Tully Health Center. In addition, under the direction of Dr. Amy Smithline, we are currently providing esophageal motility and impedance studies along with 24-hour pH monitoring. This has enhanced our ability to evaluate and treat patients with problematic gastroesophageal reflux and esophageal motility disorders. We are currently working with our Colorectal Surgery colleagues in coordinating a new service dealing with pelvic floor physiology dysfunction. This includes high-resolution anorectal manometry and pudendal nerve-testing methodologies used for evaluation of function and coordination of anal sphincter and pelvic floor muscles. Our Division recently acquired the Fuse® endoscopic system with its new technology designed to enhance colorectal polyp detection. We have also incorporated the Provation dictation system to provide improved documentation for our endoscopic reports. The Endoscopy Center at the Tully Health Center recently received designation as an American Society of Gastrointestinal Endoscopy Center of Excellence. We are appreciative for all of the support of our colleagues and administration that allows us to provide state-of-the-art care for our patients and community.

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D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 GERIATRICS

Allison B. Ostroff, MD Director of Geriatric Medicine

Active Staff: • Rodrigo Acosta, MD • Anne Brewer, MD • Doreen Chimblo, APRN • Tzivia Moreen, MD • Santi Neuberger, MD • Meghan Newman, APRN • Noel Robin, MD • Monika Tello, APRN With our ever-expanding aging population, Geriatrics has emerged as one of the most important fields of medicine. Stamford Hospital has acknowledged the need for expertise in the field with the creation a Department of Geriatric Medicine in 2015, and the appointment of its Director, Dr. Allison Ostroff. As part of the neuro-sciences initiative for the Hospital we have been working toward better identifying and managing patients with cognitive impairment/dementia in the inpatient medical wards. A task force committee was formed in July 2014 and has been meeting monthly to achieve this purpose. This committee has included representation from nursing, nursing education, discharge planning, case management, Planetree and pastoral care, as well as the departments of Psychiatry, Neurology and Internal Medicine. The nursing staff for 3 South, the float pool, Physical Therapy and Occupational Therapy will be trained in the administration of a screening tool, the Mini-Cog, to be performed on each patient at the time of admission. If that patient’s results are consistent with an impairment, that patient will be given a purple bracelet to wear.

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We have partnered with the Alzheimer’s Association in training a dedicated group of volunteers who will work one-on-one with this patient population. The Alzheimer’s Association has also provided us with tool kits containing everything from information for family and caregivers to a deck of cards and coloring pads to provide stimulation to this patient population. Upon discharge, there will be a recommendation for follow-up with Dr. Ostroff for a comprehensive geriatrics assessment and memory evaluation in addition to their normal follow-up with their primary care physician. The nurses and ancillary staff were surveyed on their comfort in caring for the cognitively impaired patient population prior to the pilot and will be surveyed after the pilot is completed in February 2016. If we find the pilot to be successful and well-received, we plan to expand our work throughout the organization. The State of Connecticut instituted a new law mandating that all Hospital employees, both clinical and non-clinical, receive education on the signs and symptoms of dementia, beginning October 1, 2015. Our education subcommittee has worked with several other state hospitals to discuss these new recommendations and has submitted Healthstream presentations for both clinical and non-clinical staff. We have submitted a new delirium policy for the Hospital, presently under review, which outlines an identification and management process of delirium for the nursing staff and the treating physicians. As part of our pilot initiative, the nurses will also receive training in a delirium screening tool, (Confusion Assessment Method or CAM), which they will utilize if there is a noticeable change in a patient’s mental status. If the patient screens positive for delirium, the attending physician will be notified and the diagnosis will be added to the patient’s chart. Only 17% of delirium cases are currently identified in hospitals nationwide and early identification will help both patient and hospital outcomes. We have also created new patient education materials on delirium to better educate families to the condition and to manage their expectations. The Division of Geriatric Medicine has also partnered with Cardiology, specifically with the TAVR team, and will be performing comprehensive memory assessments on each of the patients who are undergoing TAVR. We hope that this will help risk stratify patients and also identify patients with contraindications to the procedure. The role of Geriatrics will also be to better manage family expectations regarding length of stay, post-procedure delirium and memory after the procedure.

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 We have submitted a proposal to the Connecticut Alzheimer’s Association Annual Meeting in April 2016, for a presentation outlining our current work, and we anticipate hearing back sometime before the end of the year if our proposal was accepted.

• Mary Fedor, MD

We are hoping to expand the division of Geriatric Medicine soon so that we can provide the most comprehensive and fluid care to our patients and make transitions of care as seamless as possible. We greatly look forward to working with everyone in caring for our older population.

• Michael Marchese, MD

• Kakra Gyambibi, MD • Clive Johnson, DO • Chinenye Kalu, APRN • Santy Mathew, MD • Hiren Mody, MD • Girija Narayanaswamy, MD • Michele Nelson, APRN

HOSPITALIST MEDICINE

• Aye Omoruyi, PA • Chinyelu Oraedu, MD Maher Madhoun, MD Hospitalist Director Infectious Disease Specialist Assistant Clinical Professor, Columbia University College of Physicians & Surgeons Assistant Program Director for Inpatient Teaching, Internal Medicine Residency Program

• Kwen Ortega, MD • Miroslav Radulovic, MD • Praveen Reddy, MD • Rolando Santos, MD • Sona Shah, MD • Danielle Sry, PA • Christina Suh, MD • Phi Tran, DO • Jessica Troy, PA

Peter J. Tenicki, MD Assistant Director Instructor in Clinical Medicine, Columbia University College of Physicians and Surgeons

Active Staff: • Jennifer Bendl, DO • Iulian Benetato, MD • MaryAnne Bhojwani, MD • Sasha Cobotic, MD • Resul Dalipi, MD • Satish Deshpande, MD • Jenifer Drummond, MD • Joseph Elassal, MD • Betty Exume, PA • Christiana Famodimu, MD

• Marcos Valerio, MD Since July 2003, when the program of full-time hospitalbased physicians (Hospitalists) was formally inaugurated, Hospitalist Medicine has developed into a strong and relevant in-hospital presence of trained medical professionals who serve the institution and the medical community in a variety of ways. At Stamford Hospital, it has evolved to fulfill important institutional needs and to set a standard of care in the oversight of inpatients seen in our Hospital. Hospitalists have also meaningfully complemented the role of practicing physicians, as the need for seamless and effective care of their inpatients has grown. Notably, Stamford Hospital’s Hospitalist group treats approximately 90% of the Medicine inpatient census. Hospitalist Medicine remains the fastest-growing specialty in clinical practice. In FY15, our average length of stay was slightly above 4.6 days with an average of 20 new admissions per day, and an average daily census of 106 patients per day. The Hospitalists continue to have a preeminent role in resident education. This has been both a natural and an evolutionary trend in medical education, promulgated by changing requirements mandated by the Accreditation Council for Graduate Medical Education (ACGME), as well 2015 CL INICA L A NNUAL R E POR T | 39

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 as the reality of the intensive involvement of Hospitalists in the care of patients also managed by medical house staff. Hospitalists’ importance in resident education is underscored by the appointments of Drs. Maher Madhoun and Hiren Mody, as Assistant Program Directors in Inpatient Medicine for the Residency Program in Internal Medicine. The Hospitalist group also provides clinical education to Quinnipiac students for their Internal Medicine rotation. Hospitalists continue to play a leadership role in developing and implementing the Meditech inpatient EMR, improving accountability and collaboration between various Hospital departments (particularly among the Medical Staff and Emergency Department). In conjunction with Neurology, Hospitalists play a major role in neurologic care at Stamford Hospital. The entire division is an active participant in the Stroke Program, recertified by the Joint Commission in 2015. The Hospitalist team is available around the clock to expedite the treatment of patients with stroke, working collaboratively with Neurology. With an aging population, limitations on medical residents’ hours and increased daily physician responsibilities, mid-level providers are delivering care not only in the outpatient setting but also in the Hospital. Currently, we have six full-time and per diem mid-level providers. Mid-levels are improving quality and safety with qualityimprovement projects by sitting on various committees in the Hospital and by using evidence-based best practice protocols. In addition, by informing patients and patients’ families about what is to happen and future treatment steps to take, patient satisfaction for our Division has increased and avoidable readmissions reduced. Physicians can delegate care to mid-level providers, within their

Figure 1: Hospitalist Patient Population Information for FY15

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scope of practice, which frees up physicians for more complex cases. Mid-levels are a crucial part of our Division and are accessible to answer nurses’ questions, complete histories and physicals, aid in ED throughput times, assist in minor procedures, respond to emergencies, complete discharge summaries, facilitate discharges earlier in the day and provide other care when needed. Members of the Hospitalist Medicine group continue to serve on many Hospital committees, including ED Leadership Throughput Committee; Pharmacy and Therapeutics Committee; Graduate Medical Education Committee; IT Leadership Committee; Clinical Competence Committee Meeting for Internal Medicine; Infection Control Committee; Patient Satisfaction Committee; Medicine Peer Review; Medical Executive Committee; Core Measures Work Group; Infection Prevention; and Patient Safety and Quality Committee. Figures 1 and 2 show Stamford Hospital’s Hospitalist patient population and payor mix. The top 10 admitting diagnoses include: 1. Unspecified chest pain 2. Pneumonia, organism unspecified 3. Syncope & collapse 4. Atrial fibrillation 5. Acute respiratory failure 6. Hemorrhage of gastrointestinal tract, unspecified 7. Urinary tract infection, site not specified 8. Cerebral artery occlusion, unspecified with cerebral infarction 9. Congestive heart failure 10. Unspecified septicemia

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 Figure 2: FY15 Payor Mix

Figure 3 highlights our growth in patient volume since 2011. Figure 3: Volume Growth

Hospitalist Medicine’s goals for 2016 include continued growth and expansion in developing Hospital protocols and efficiency-related projects such as: length of stay reduction; SNF utilization; re-admissions from both home and SNFs; improved case-mix index and medical record documentation; improved early discharge metrics; improved PCP satisfaction; and improved ED throughput. Due to the climate of the new healthcare law, Hospitalists have been called on to participate in a bundle savings program and revenue-sharing with multiple entities during the patient’s continuum of care. Finally, we consistently strive to provide a higher level of patient care quality. Therefore, we aim to increase our Medicare core measure metrics by giving patients the best-possible care, exceeding their expectations and preventing readmissions. We have ongoing initiatives to increase patient satisfaction scores with regard to communication.

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D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 INFECTIOUS DISEASES

Michael Parry, MD Thomas Jay Bradsell Chair of Infectious Diseases, Stamford Hospital Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons

The Infectious Diseases Department is a Division of the Department of Medicine and provides multiple services to patients and clinicians. The Division is responsible for infection prevention and Hospital epidemiology, microbiology laboratory direction, Employee Health Service direction, the antibiotic stewardship program in conjunction with Pharmacy, the HIV program, clinical consult service, emergency management (for infectious diseases) and staff education at all levels. Scheduled and ad hoc educational programs are provided for students, residents, attending staff, nursing staff, other Hospital employees and the community. The Department is also actively involved in numerous medical staff and Hospital committees: Dr. Michael Parry (Infection Prevention, Chair, IT leadership and Emergency Management, Regs and Accreditation, P&T); Dr. Lynda Streett (Infection Prevention, Perinatal Infection, ICU); Dr. Asha Shah (Infection Prevention, Perinatal Infection). Dr. Streett recently completed certification in Wound Care Management and Dr. Shah is entering her final year in the Columbia University (Mailman School of Public Health) Master’s in Medical Epidemiology Program. Two part-time division members, Dr. Maher Madhoun (full-time Hospitalist) and Dr. Ralph Cipriani (full-time Internist), are also members of the Division and participate in committee and educational programs. The most active subspecialty areas of clinical work are hospital-acquired infections and HIV/AIDS. Ariana Horton, NP, Director of Outpatient HIV Services, coordinates HIV clinic services and the bimonthly adult immunology clinic. She expertly supervises the care for a client base of up to 100 individuals, working both at Optimus Healthcare and Stamford Hospital. The Department was again successful in its reapplication for three federal Ryan White Grants in support of the Infectious Disease Nurse Practitioner, the Adherence Nurse (Laura Howard, LPN), and the Nutritional Counselor (Britt Berger, RD). They provide dedicated service to our clients and make the Stamford Hospital HIV Program 4 2 | DEPAR TM ENT O F ME D I C I N E

a unique and highly acclaimed program in the state. Private practice outpatient referral diagnoses in addition to HIV infection, include tick-borne diseases, skin/soft tissue, wound and bone/joint infections, immunization services and travel medicine. Research activities, Hospital epidemiology, environmental infection control and antibiotic stewardship are ongoing. The Department, together with Environmental Services, continues to be involved in a multi-medical center environmental study to evaluate the effectiveness of terminal room cleaning in the prevention of hospitalacquired infections. The Department just concluded its participation in a multicenter study of intravenous zanamivir in patients hospitalized with severe influenza and, in conjunction with Dr. Peter Krause at Yale, we are participating in a study of exchange transfusion in severe babesiosis. The influenza vaccination program continues its preeminence as the largest such cooperative program in Connecticut. Together with the Stamford Department of Health, seasonal influenza vaccine was administered to over 8,000 individuals in FY15. A mandatory influenza vaccination (or written refusal) program for Hospital employees resulted in a 78% vaccination rate for employees last season. Infection prevention represents the most important departmental activity at Stamford Hospital. Infection Prevention Nurses Brenda Grant, Merima Sestovic and Paula Castellano-Flynn function out of the Department’s offices on the Terrace level of the Physicians’ Office Building. They perform critical roles in infection surveillance, outbreak investigation and control, education, policy development and regulatory compliance. Ms. Grant continues her appointment to the State of Connecticut HealthcareAssociated Infections Advisory Committee. She was also elected to a three-year term on the National Board of Directors of the Association for Professionals in Infection Control and Epidemiology (APIC). Ms. Sestovic has been involved in regional APIC activities. Dr. Parry is also a member of the Connecticut Department of Public Health (CT DPH) Committee on Reportable Diseases and CT DPH Advisory Committee on Infectious Diseases. The Department’s quality improvement initiatives are ongoing and showed good performance in several collaborative areas for FY15. The Department was an active participant in two collaborative projects in this regard: the PAICAP (Preventing Avoidable Infectious Complications by Adjusting Payment) study with Harvard Medical School; and the Sentinel Laboratory RSV and Influenza Surveillance Program through CDC. Infection prevention targets include

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 reduction in all device-related infections including hospital-wide central line-associated bacteremia (CLABSI), hospital-wide catheter associated urinary tract infections (CAUTI) and colon surgical infections (with surgery). Increasing demands for surveillance and public reporting have taxed our resources as 2015 saw an increase in monthly requirements for reporting for CLABSI and CAUTIs, C. diff cases and MRSA bacteremia from all Med-Surg units, Pediatrics, Rehab and the ICU. Urinary catheter utilization rates remain 50% lower than CDC benchmarks. Hand hygiene monitoring is an integral part of our hospitalacquired infection (HAI) reduction effort but it has been a challenge to reach the 95% target. Nevertheless, HAI rates for 2015 reached all all-time low, falling below 0.8% and surgical site infections below 0.6%.

NEPHROLOGY

Eric Brown, MD Director of Nephrology Associate Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons

Active Staff: • Revekka Babayev, MD • Brenda Chan, MD • John Fitzgibbons, MD • William Hines, MD • Nazanine Khairkhah, MD • Francis Walsh, MD The Division of Nephrology continues to offer acute inpatient hemodialysis, acute inpatient peritoneal dialysis and continuous renal replacement therapy (CCRT). For the period January 1 to September 30, 2015, we performed 763 inpatient hemodialysis treatments, annualized to 1,017 procedures, which is an increase from last year. For the calendar year to date, there were a total of 41 days of CRRT performed with an annualized number of 55 days, a decrease from last year. Our glomerulonephritis practice remains active and has benefited immensely from the cooperation of Interventional Radiology (for biopsies), Stamford Pathology (which performs an immediate

assessment of the adequacy of the biopsy and sends the tissue to Columbia) and the world-class renal pathologists at Columbia University. The Stamford DaVita dialysis center currently has 190 in-center hemodialysis patients, six home hemodialysis patients (who use the NxStage machine) and 32 peritoneal dialysis patients. We have been designated a Five-Star Clinic by CMS (its top rating) and have won a Fistula First Award from the ESRD Network of New England. Our clinic serves the greater Stamford area with patients residing in towns stretching from Norwalk to Port Chester and South Salem. In a reversal of recent trends, the hemodialysis patient population has grown while the peritoneal dialysis population has leveled off. The principal modality for peritoneal dialysis is CCPD, which is cyclic dialysis done overnight. Daily home hemodialysis is an important modality due to the greater degree of rehabilitation that it affords as well as superior phosphate and blood pressure control. We continue to aggressively refer patients for renal transplant and retain affiliations with the programs at Columbia and Yale. DaVita continues to provide outpatient dialysis services and, since March, 2014, has been supplying inpatient hemodialysis and CRRT. They will soon be the supplying plasmapheresis services as well. The Division of Nephrology supports the teaching program of the Hospital. All members of the Division participate in clinical teaching, morning report, formal lectures and renal conferences. One member of the Division participates in third-year medical student preceptorship for four weeks each year and another supervises the Department of Medicine Journal Club, which is an important educational vehicle for the house staff. Journal Club teaches analytic reading, interpretative skills, statistical analysis and critical thinking. Additionally, one member is an active participant in the outpatient Medicine Clinic at Optimus and two physicians are active members of the Department of Medicine Clinical Competence Committee. We collaborate with the Department of Medicine in arranging outside nephrology speakers and last year hosted Drs. Andrew Bomback and Jai Radhakrishnan from Columbia as well as Dr. Peter Aronson from Yale. The Division continues to participate in clinical research. We are actively recruiting for the SONAR Study, an endothelin agonist to slow the progression of diabetic nephropathy, and are participating in the waning days of studies of an intravenous calcimimetic and a treatment for uremic pruritis. We are also looking to join trials of an external defibrillator for new dialysis patients and a new erythropoetic. 2015 CL INICA L A NNUAL R E POR T | 43

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 The exciting change in our practice has been the addition of Dr. Revekka Babayev, who has joined us after completing her residency and fellowship at Columbia. In addition to the Stamford practice, clinical services are performed by Drs. Fitzgibbons, Khairkhah and Walsh, whose dedication continues to expand the clinical and academic services that the Division provides.

NEUROLOGY

Louise D. Resor, MD Director of Neurology

Active Staff: • David Hahn, MD • Eric Kung, MD • Charisse Litchman, MD • Sarah Mulukutla, MD • Evangelos Xistris, MD The Department of Neurology includes Drs. Charisse Litchman, Eric Kung, Louise Resor and Evangelos Xistris. Drs. Litchman and Kung received certification in the management of headaches. Dr. Resor has completed training in electroencephalography. Their subspecialty expertise has served to improve the depth and breadth of neurologic care to our community. This year the Department welcomed two new physicians. Dr. Sarah Mulukutla, a recent graduate of the Yale Neurology Residency Program, joined the Hospital staff as a neuro-hospitalist. She is devoted to the care of hospitalized patients and is available around the clock to provide urgent assessment and intensive management of neurologic cases. Dr. David Hahn joined the Hospital’s Medical Staff in November. He completed a neurology residency at Yale and a stroke fellowship at Mount Sinai. His expertise in vascular neurology will enhance the care of stroke patients at Stamford.

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The members of the Neurology Department continue to staff the stroke program at Stamford Hospital. They are on call around the clock to respond to “stroke alerts.” Intravenous tPA is a clot-busting medicine aimed at improving stroke outcomes. It must be given within 4.5 hours of the onset of symptoms. Our stroke protocol is designed to provide rapid assessment of stroke patients in the Emergency Room and in the Hospital to ensure the medication is administered in a safe and timely manner. In September 2015, we received recertification by the Joint Commission, having already achieved Gold Award status from the American Heart Association’s “Get With The Guidelines” program. The addition of Dr. Hahn will undoubtedly only further improve our program. Dr. Eric Kung continues to supervise the neurologic care of brain-injured patients as he leads the concussion program, a multidisciplinary group of neurosurgeons, neurologists, orthopedists, neuropsychologists and speech, occupational and physical therapists. The neurologists supervise electrodiagnostic services at Stamford Hospital. In addition to routine outpatient EEG and evoked potential exams, 24-hour ambulatory EEG testing is available. In the Hospital, the Department provides prolonged video-EEG monitoring for the evaluation of undiagnosed episodes of altered consciousness and monitoring of critically ill ICU patients.

ONCOLOGY AND HEMATOLOGY

Paul Weinstein, MD Director of Oncology

Michael Bar, MD Director of Hematology

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 Active Staff: • Anne Angevine, MD • Salvatore Del Prete, MD • Anthony Gulati, MD • Steve Lo, MD • Isidore Tepler, MD The Divisions of Hematology and Oncology are composed of the seven physicians practicing as Hematology Oncology PC (HOA), administratively named Medical Oncology and Hematology (MOH), as part of the cancer service line within the Bennett Cancer Center (BCC). Skilled medical colleagues including Radiation Oncologists, cancer-oriented Surgeons, Pathologists, Diagnostic Radiologists and other medical staff of Stamford Hospital provide dedicated support. We are greatly aided by subspecialty Nurse Navigators Dominique Srdanovic (GU, Supervisor), Melissa Ronk (Thoracic) and Katharine Radziewicz (GI). We serve the needs of patients with oncologic and hematologic (both benign and malignant) disorders in the Hospital’s primary catchment area and, increasingly, secondary, tertiary and even more distant markets. We are very often involved in the care of the nearly 900 patients diagnosed with cancer in Stamford Hospital each year. More than 100 patients typically are seen daily, accounting for more than 20,000 visits to the Bennett Cancer Center annually. The Divisions’ clinical research program for both Oncology and Hematology remains robust, under the leadership of Salvatore Del Prete, MD, and supervisor Molly Daley. In 2014, 66 patients were newly enrolled into our studies, encompassing a wide variety of solid tumors and hematologic malignancies. Currently, there are 153 patients actively enrolled in 57 studies (21 still accruing patients) at the BCC and hundreds of patients are in long-term follow-up. At times we recommend outside consultation for patients needing research treatments that cannot be offered here. Examples of the importance of our activities include our participation in trials leading to the approval of imbruvica (Ibrutinib) for chronic lymphatic leukemia and ado-trastuzumab emtansine (Kadcyla) for Her-2 neu positive advanced breast cancer. The Genetic Counseling Program, directed by Isidore Tepler, MD and Paul Weinstein, MD, and supervised by Erin Ash, MS, CGC, is increasingly active, serving the needs of those affected with cancer, their families and healthy but concerned individuals. The Program has advised persons with, or worried about, their personal risk for breast and ovarian cancer (using the internationally accepted NCI Gail

Risk Assessment Tool and the Tyrer Cuzick Model), as well as increasing numbers of persons having or concerned about gastrointestinal cancers (in collaboration with the Gastrointestinal Cancer Family Tumor Registry) and other malignancies. To that end, multigene mutation panel assays are being used more frequently. In 2013, we counseled 270 new persons, and discovered high-risk genetic mutations in 15 of them, undoubtedly fulfilling the maxim that knowledge is power. Our Survivorship Program, championed by Drs. Angevine and Lo, and under the direction of Deanna Xistris, RN, MSN and Fran Becker, LCSW, is ready to accept persons completing their treatment for early-stage cancer. A summary of their therapy and recommendations for future follow-up is supplied to patients, their families and their physicians via a formal report with updates as appropriate. The Division of Hematology at the Bennett Cancer Center offers a comprehensive range of treatments for adult malignant blood diseases. During the first nine months of 2015, 731 unique patients with primary hematologic malignancies were seen and managed by the physicians at the BCC. Additionally, the benign hematology program remained equally robust, as the majority of new consultations for hematologic disorders were related to helping patients with benign abnormalities of their blood counts, metabolic disorders such as Gaucher’s disease, autoimmune diseases, bleeding disorders such as hemophilia and von Willebrand disease and disturbances of the coagulation system predisposing to thromboembolic disease, including those afflicting women with infertility or maternal-fetal issues related to hypercoagulability. There is also an active in-patient consultation service focused on providing guidance on the management of the frequent transient hematologic complications of acute illnesses. Dedicated full-time genetic counseling for inheritable disorders is available to all patients and their families. Hematologists at the BCC continue to work closely with two dedicated hematopathologists, who utilize the most sophisticated cytogenetic, molecular and immunologic tools available for state-of-the-art molecularly-defined pathology. These tools include: fluorescence-activated cell sorting (FACS) for the rapid diagnosis of malignant hematologic disorders; and qualitative and quantitative polymerase chain reaction (PCR) studies of both DNA and RNA, which have the ability to detect one malignant cell/1,000,000 cells and fluorescent in situ hybridization (FISH), a technology that provides information on multiple genetic abnormalities (“molecular signature”) critical to the treatment of acute and chronic leukemias, lymphomas 2015 CL INICA L A NNUAL R E POR T | 45

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 and multiple myeloma. During 2015, the Department increasingly adopted direct deep-sequencing technologies to help identify mutations amenable to targeted drug therapy. This technology has proven particularly useful in patients with poorly classified hematologic malignancies or advanced relapsed/refractory disease without available standard treatment options. Continued rapid adaptation of an increasingly broad menu of new assays are made in real time in order to both provide patients with the most precise diagnostic and monitoring tools and to allow patients to access the ever-increasing array of targeted agents available to patients with hematologic disorders.

PAIN AND PALLIATIVE CARE SERVICE

A burgeoning array of sophisticated therapies is available to patients and includes: traditional systemic chemotherapy; small molecule targeted therapies such as the recently approved and revolutionary Bruton kinase inhibitors and phosphatidylinositol 3-kinase inhibitors for low-grade non-Hodgkin’s lymphomas and chronic lymphocytic leukemia; traditional monoclonal antibodies as well as both radio-conjugated and toxin-conjugated monoclonal antibodies for malignant lymphoproliferative disorders and leukemias; epigenetic hypomethylating agents for myelodysplastic syndromes and acute myelogenous leukemia of the elderly; immune modulation therapy for lymphoproliferative disorders, plasma cell dyscrasias and aplastic anemia; enzyme replacement therapy for metabolic disorders such as Gaucher’s disease; complement inhibition therapy for rare disorders such as paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome; and recombinant factor replacement therapy for congenital and acquired bleeding disorders. Plasmapheresis, apheresis and exchange transfusions are available to both inpatients and outpatients.

The Pain and Palliative Care Service provides an extra layer of support for patients from all departments who face a serious or life-threatening illness. The services have undergone some major changes and transitions this year, as described below.

The Division of Hematology continues to have a robust clinical research program that allows patients to access some of the most exciting therapeutic developments in the management of a wide variety of malignant and benign hematologic disorders. The physicians of the Division of Hematology continue their long-standing membership in the Eastern Cooperative Oncology Group (ECOG). A total of 11 hematology research protocols were available in 2015, six of which were new protocols opened in this calendar year, and 40 patients are currently being actively followed. The corresponding totals for the similar nine month period in 2014 were nine, three and 31, respectively.

Anne Brewer, MD, MPH, FAAFP Medical Director of Palliative Care

The Service continues to provide both assistance in transitioning to hospice and ongoing symptom management for those who are enrolled in inpatient hospice. It is staffed by nurse practitioners with physician collaboration. Monika Tello, MS, ANPBC, ACHPN, joined us in November 2012, Doreen B. Chimblo, MS, APRN, FNPBC, joined us in December 2012, and Maria Rivera, APRN, joined us in February 2015. This transition has enabled the provision of a higher level of consultation for patients, including more immediate improvement in pain and symptoms. The ability to recover billable services from the NPs’ care, along with a conversion to an electronic billing process, has improved efficiency. Because of the national shortage of specialty-trained Palliative Care clinicians, a major focus has been improving the primary palliative care skills of frontline clinicians. Accomplishments in this regard include: • Weekly inclusion of Palliative Care in both ICU and IMCU teaching rounds • Participation in Internal Medicine and Surgical lecture series programs for residents • Participation in Grand Rounds-Pastoral Care Lecture Series for attendings and chaplains • Weekly precepting in Family Medicine Clinic, which facilitates discussions of primary Palliative Care • Participation in the Pastoral Care Advisory Committee

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D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 • Active planning and participation in the third annual “SHARE” curricula for house staff, an interdepartmentally sponsored program that gives residents an opportunity to learn about patient/physician relationships from cancer survivors This year the Pain and Palliative Care Service worked with the Bennett Cancer Center in the training of several social work interns. Through this innovative interdisciplinary and interdepartmental effort, we were joined this year by two master’s-level interns. It has been a true win-win to partner in their education while they are active participants in providing mental health services to our patients. The time they have been able to spend with patients and families has been instrumental in supporting those families along their grief pathways, and facilitates better communication between the families and everyone on the Palliative Care team.

PULMONARY, CRITICAL CARE AND SLEEP MEDICINE

Paul Sachs, MD Director of Pulmonary Medicine Associate Clinical Professor of Medicine, Columbia University College of Physicians and Surgeons

Active Staff: • Michael Bernstein, MD • Caroline Gulati, MD • John Kazianis, MD • James S. Krinsley, MD • Samit Malholtra, MD • Alex Ortega, MD • Dominic Roca, MD • Steven Thau, MD The Pulmonary Medicine section continued to report a high utilization of its varied services. Inpatient and ambulatory services remained active over the past year. Over 178,000 procedures/interventions were performed by Respiratory Therapy in 2015. The volume of ventilator days remains

very high. The average daily ventilator census was 6.0 ventilators in use per day. The Section remained committed to preventing ventilator-associated events (VAE), soft tissue injuries due to endotracheal tube pressures and self-extubations. Among the interventions are a ventilatorassociated event (VAE) committee, VAE prevention bundles, oral care protocols, specialized endotracheal tubes and probiotic use. The Pulmonary Medicine section continued to perform outpatient pulmonary services on both campuses. Tests performed at the Pulmonary Function Lab on the fourth floor of the Tully Health Center were predominantly pediatric cases, but the Lab was available to adult outpatients as well. Overall, the Department performed more than 4,800 pulmonary function tests (PFTs) at the Hospital campuses. The turnaround time for PFT interpretations was improved to less than four days. Arterial blood gas (ABG) utilization remained high. Three new ABG machines now communicate wirelessly with Meditech. Over 9,000 ABGs were analyzed in 2015. The Pulmonary Laboratory passed its on-site College of Pathologists laboratory inspection. The Lab successfully renewed its ABG Lab license after an on-site inspection by the Connecticut Department of Health. Alpha-1 Antitrypsin Deficiency screening is available to physicians at the time of PFT, in accordance with American Thoracic Society guidelines. The Respiratory Therapy Department remained committed to education. In October, in honor of Respiratory Care Week, the Department organized its Second Annual Stamford Hospital Respiratory Care Symposium. This was a CME/ CEU event attended by RTs and nurses from throughout Connecticut and was once again highly successful. Our RTs continued to supervise students from Norwalk Community College’s RT Program. Two new students rotated through the Intensive Care Unit and the Intermediate Care Unit every six weeks. This continues to generate energy and enthusiasm among our RT staff. It has also helped with Stamford Hospital’s recruitment of the finest of the new graduates and some RT students have enjoyed their experience so much that they have stayed on to work as volunteers at Stamford Hospital. The Department also participated in new nursing orientations. Twice monthly nurse educators and nurse managers scheduled one- to two-hour sessions for their staff to review respiratory procedures, policies and equipment with the Respiratory Therapist Supervisor or Clinical Coordinator. In addition, four staff members completed a COPD educator course. Two 2015 CL INICA L A NNUAL R E POR T | 47

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 of our therapists are certified as BLS/ACLS/PALS instructors. One of our therapists is now a neonatal ALS instructor. 100% of the respiratory therapists are ACLS certified. More than 65% of our therapists are now certified in Pediatric Advanced Life Support as well. Our Respiratory Therapists remain involved in multidisciplinary committees to improve care at Stamford Hospital including Skin Breakdown; Ventilator Associated Events; Resuscitation; Quiet at Night; Regulations and Accreditation; Misuse of Vials; Ethics; ID; Disaster Preparedness; Nursing Coordinating Council; and Self Staffing. Diane Major-Olivant, RRT, is the facilitator of the Pediatric Neonatal Committee, and RT is also an active participant in the monthly CCU committee meetings. The entire RT staff is proficient in utilizing high-flow nasal cannula therapy. This new technology has allowed patients to tolerate high concentrations of oxygen via nasal cannula at flow. High-flow rates of up to 60 LPM are tolerated because the delivered gas is humidified and heated to body temperature. They were useful in avoiding the need for bulky high-flow masks and, in some cases, intubations.

Department assisted by completing COPD worksheet/ education forms on over 80% of in-patients admitted with a diagnosis of COPD exacerbation. The Pulmonary Department, in conjunction with Thoracic Surgery and the Bennett Cancer Center, rolled out a new initiative to assist our patients and staff with tobacco cessation — Stamford Hospital’s “Commit to Quit” Program. We now have three Association for the Treatment of Tobacco Use and Dependence-certified counselors who are available to see our patients. To date, the program has had 75 patient visits. Carbon monoxide testing and spirometry screening are available for participants of the program, as needed. Stamford Hospital’s new tobacco Quit Line can be reached by dialing 276.QUIT (Ext. 7848) from any Hospital phone.

The outpatient Pulmonary Rehabilitation Program continued to thrive on the second floor of the Tully Health Center. To date, 930 participants have graduated from the program since its inception. The program remained busy, graduating about 40 patients every year, with anywhere from 6 – 12 participants in the program at any one time. The variety of patient diagnoses in the program has increased as well. Patients with COPD as well as those with pulmonary fibrosis, sarcoidosis, asthma and s/p lung transplantation continued to take advantage of this multidisciplinary program. Participants continued to praise the program, documenting improved quality of life and exercise capacity. Many continued to exercise in the Post-Rehab Fitness Program at the Tully Health & Fitness Institute, specifically designed for Pulmonary Rehab graduates.

The Interventional Pulmonary and Advanced Bronchoscopy service, led by Dr. Michael Bernstein, remained one of the most complete and busiest interventional programs in Fairfield County. It offers a wide array of interventional and advanced diagnostic bronchoscopy procedures, including endobronchial ultrasound, both convex and radial probe imaging, navigational bronchoscopy using the SuperDimension System, cryobiopsy/cryoablation and APC ablation. We also remained an approved site for Spiration endobronchial valve use for persistent air leaks and have successfully performed this procedure. We continued to perform a wide array of both diagnostic and therapeutic pleural procedures including PleurX catheters; ultrasoundguided thoracenteses; percutaneous and conventional chest tubes; and closed pleural biopsies. Our Interventional Pulmonary and Advanced Bronchoscopy team is a core part of the Hospital’s multidisciplinary Lung Cancer Program working with colleagues in Thoracic Surgery, Medical Oncology, Radiation Oncology, Pathology and Diagnostic Radiology, all of which participate in our bi-weekly lung cancer tumor boards.

The Pulmonary Rehabilitation team hosted its 11th COPD Day/Health Fair. This was a patient education program that was the first of its kind in the northeast when it was initially developed in 2005, and remains unique to this area. About 70 patients and family members from the greater Stamford area attended the event and the feedback was overwhelmingly positive.

The Pulmonary Division plays a key role in Stamford Hospital’s Lung Cancer Screening Program. Dr. Michael Bernstein serves as the Co-Clinical Director of the program along with Dr. Michael Ebright of Thoracic Surgery. Our multidisciplinary program is accredited by the American College of Radiology. We have screened nearly 500 patients since the program began and are expanding every month.

Pulmonary Rehab Coordinator Kathryn Sullivan, RRT, continued her new role as our COPD Patient Liaison. She met with patients admitted to the Hospital with a diagnosis of COPD exacerbation. She also assisted with coordinating Hospital discharge in an effort to provide continuity with outpatient care and to try to prevent unnecessary readmissions. The entire Respiratory

The Pulmonary Department remained active in providing CME opportunities for the Stamford community. The 32nd Annual Pulmonary Symposium was held in May in the Brace Auditorium. Dr Christian Becker of the Icahn School of Medicine at Mount Sinai, Division of Pulmonary, Critical Care and Sleep Medicine, spoke on the topic “Sepsis – A Journey through the Evidence Base.” This was followed

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D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 by a lively discussion of sepsis issues by a panel of experts that included Drs. Krinsley, Parry, Dwyer and Bhalla. This new format was well-received and will be considered for future Pulmonary Symposia. Pulmonary Grand Rounds was given in July by our newest Stamford pulmonologist, Dr. Alex Ortega. He spoke on “Asthma 2015: Where We’ve Been and Where We’re Going.” In addition, the Division gave numerous talks throughout the Stamford community about topics such as lung cancer screening, smoking cessation and sleep apnea. We are pleased with the quantity and the quality of services that the Pulmonary Division provided, but we are particularly proud of the individuals who make up our staff. They participated in other community events such as performing screening spirometries at the Women’s Expo, Healthy Heart Day, COPD Day, Employee Health Fair and at Chelsea Piers Connecticut. They walked in a Cystic Fibrosis fundraiser to raise money for CF care. The Pulmonary Rehab staff volunteered their time and skills to make ID badge holders that were then sold to pay for light hand weights to be presented to Pulmonary Rehab participants upon graduation. We were delighted that Dr. Caroline Gulati was the Medical Residents’ choice for the “Rookie of the Year” Award at the Department of Medicine graduation dinner. We were also extremely proud of Dr. Michael Bernstein, who received the 2015 Melvin Magida Award. This is an award given to a young Fairfield County physician who renders care and treatment with a genuine concern for his patients and their families, serves his community well and is respected by his colleagues.

CRITICAL CARE In FY15 there were 1,174 admissions to the Intensive Care Unit (ICU), seven fewer than in FY14. The median length of stay of patients admitted to the ICU, 1.7 days, was unchanged. Sixty-five patients were admitted to the ICU following cardiovascular surgery during this fiscal year, 19 fewer than in the previous year. The distribution of cases was: 49% “isolated” coronary artery bypass surgery; 28% “isolated” valvular surgery; 9% combined coronary artery bypass and valvular surgery; and 13% with other procedures (predominantly complicated aortic root repair, including repair of emergency ruptures). Notably, for the third year in a row (227 cases), hospital mortality was 0%.

• Active mobilization of the critically ill patient was the major initiative during the year. This required intensive involvement of Nursing, Respiratory Therapy and Physical Therapy, as well as physician and Pharmacy involvement to modify sedation practices and orders. The culture of the ICU regarding this issue has changed. Over the course of the year, patients undergoing mechanical ventilation have been routinely taken out of bed and several of them have walked around the ICU while undergoing mechanical ventilation via endotracheal tube. • Glucose control evolved, based on interpretation of medical literature. Two blood glucose targets were used, based on preadmission glycemic control, reflected by the HbA1c level. Rates of hypoglycemia were extremely low. • The multidisciplinary effort to manage severe alcohol withdrawal has been associated with a significant reduction in ICU and hospital length of stay of this difficult to treat population. In addition, the team’s success using the protocol was reflected by a 0% rate of patients who required intubation for respiratory failure after being admitted to the ICU. Historic annual rates for this metric ranged from 15% – 30%. • The multidisciplinary committee on infection control met regularly and monitored infection control practices and protocol adherence, especially relating to the prevention of ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI) and central line-associated bacteremia (CLAB). Foley catheter utilization rate remained at approximately 50% of the national standard and the rate of the sentinel infections remained low. In fact, there has been an 80% reduction in the overall rate of ICU-acquired infections regularly monitored by the nurse epidemiologists since 2008. During the year, Director of Critical Care Dr. James Krinsley delivered presentations relating to intensive glucose management of critically ill patients, based on the work completed at the Stamford Hospital ICU, at the 2014 Congress of the European Society of Intensive Care Medicine in Barcelona, Spain; the 2015 Congress of the Society of Critical Care Medicine in Phoenix, Arizona; the 2015 Congress on Advanced Technologies and Treatments of Diabetes in Paris, France; and the 2015 Congress of the International Society of Intensive Care and Emergency Medicine, in Brussels, Belgium.

The year was marked by revision and development of numerous multidisciplinary patient care protocols, as well as creation of several new ones. 2015 CL INICA L A NNUAL R E POR T | 49

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 In addition, the following manuscripts were published: Krinsley JS, Bruns D, Boyd J. The impact of monitoring frequency on the domains of glycemic control — a Monte Carlo Simulation. J Diab Sci Tech. 2015 9(2):1-9. Krinsley JS, Preiser JC. Time in blood glucose range 70-140 mg/dL > 80% is strongly associated with increased survival in critically ill non-diabetic patients. Crit Care 2015; 19:179. Wenerman J, Desaive T, Finfer S, Foubert L, Furnary A, Holzinger U, Hovorka R, Joseph J, Kosiborod M, Krinsley JS, Mesotten D, Nasraway S, Rooyackers O, Schulz M, Van Herpe T, Vigersky R, Preiser JC. Continuous glucose control in the ICU: Report of a 2013 round table meeting. Crit Care 2014; 18:226. Krinsley JS. Is glycemic control in the critically ill cost effective? Hosp Prac. 2014, 42(4):53-58. Krinsley JS. Glycemic control in the critically ill: What have we learned since NICE-SUGAR? Hosp Prac. 2015; 43(3):191-197. Finally, following the replacement of the local Institutional Review Board (IRB) by a centralized IRB, Quorum, a group of clinical investigations was initiated by Dr. James Krinsley with medical and surgical residents, for presentation at national and regional conferences. Specifically these included: • Diabetes is associated with increased dysglycemia and mortality in patients with sepsis. • The relationship of the severity of sepsis to insulin resistance and dysglycemia. • Time in BG range 70 – 140 mg/dL is associated with survival in non-diabetic medical ICU patients. • The impact of vital sign measurement frequency on APACHE II and IV severity scoring. • In an ICU with a high-intensity staffing model, is a nocturnal intensivist necessary? • Time in BG range 70 – 140 is associated with survival in non-diabetic critically ill patients admitted with trauma.

SLEEP MEDICINE 2015 was a busy year for Stamford Hospital’s Connecticut Center for Sleep Medicine (CCSM). We increased the number of patients being evaluated for sleep disorders and the number of home and in-center sleep studies

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performed, despite the numerous challenges presented by federal regulations and private insurance companies. We continued to meet the increased demands of our patients and referring physicians. The team of Dr. Dominic Roca, Dr. Steven Thau, Dr. Michael Bernstein, Dr. Caroline Gulati, Diana Bernal Messinger, APRN, Lance Dougherty, RN, RT, RSPGT, and now Dr. Alex Ortega and Karolyn Chang PA-C, continued to provide outstanding care for our sleep patients while decreasing the waiting time for doctor visits. Karishma Bellara, PA-C, continued to work for the Center remotely to be closer to her new young family. We were sorry to see Dr. John Kazianis decide to move on with his career and we wish him luck in his future endeavors. Our staffing enabled us to provide care for those in Stamford Hospital’s Bariatric Program in a timely fashion. In addition, Dr. Hossein Sadeghi is board-certified in Sleep Medicine and, as a part the CCSM, makes us poised to treat our potential pediatric population. Thanks to the efforts of Medical Director Dr. Dominic Roca, Program Coordinator Laura DeFelice and CCSM Director Robb Mercer, the program is a Stamford Hospital Center of Excellence. As confirmation of our commitment, the CCSM was accredited by the American Academy of Sleep Medicine as a sleep center to diagnose and treat all sleep disorders including but not limited to sleep apnea, insomnia, restless legs, narcolepsy, delayed/advanced sleep phase, jet lag and all other conditions that cause sleepiness or difficulty sleeping. In FY14 we performed over 1,000 sleep studies; 454 “incenter” studies and 615 home studies, making us one of the largest providers of home studies in Fairfield County and we are at a pace to exceed that during the next fiscal year. The CCSM was prepared for the changing landscape of sleep medicine including this expected demand for home sleep studies and that foresight was crucial to maintaining the CCSM in a position to satisfy federal as well as private insurance rules and regulations. Although the home sleep studies have a significantly lower sensitivity than a formal polysomnogram, they enabled patients who were previously unable to visit the CCSM due to medical problems or logistical issues to receive an evaluation for sleep apnea at home. The home studies also provided another tool to monitor sleep apnea patients currently on treatment. It was to the credit of Vera Budzinski, RPSGT, our certified technician and lead scorer, that there was a seamless process for the patients to pick up and learn how to apply the home study device.

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 New data continued to strengthen the link between sleep apnea and cardiovascular disease, atrial fibrillation, other rhythm disturbances, stroke, thromboembolic events, psychological disorders, cognitive deficits, diabetes and other metabolic disorders, which can not only lead to obesity but an increased risk of cancer as well. The literature also continued to demonstrate that treatment with CPAP reduces that risk. There is even more data suggesting that obstructive sleep apnea contributes to cognitive decline in many early or late dementia patients and CPAP can ameliorate those symptoms. Drs. Roca, Thau and Bernstein gave several lectures to community groups throughout Fairfield County to educate the public on this important health issue. Members of the CCSM staff also gave CPAP support lectures four times this year. These quarterly patient support meetings remained very popular in the community as they continued to fill the Brace Auditorium with interested patients and family members.

The technical aspects of the CCSM have always been outsourced and we have been with our current company Persante, formerly known as Sleep Care of New Jersey, for the past 4.5 years. They provided the CCSM flexibility in managing IT and Federal guideline challenges throughout the year. All of the technicians were supervised by lead sleep technicians and our board-certified sleep physicians, 24-hours-a-day.

CPAP remains the most effective treatment for obstructive sleep apnea. For some patients the adjustment period can be difficult and education has been shown to be the largest factor in improving patient adherence. To further facilitate the goal of CPAP compliance, the CCSM continued to offer the CPAP Management Program. This program was run by Laura DeFelice and Respiratory Therapist Annette Nieves. They both saw patients on a weekly basis and improved compliance with CPAP. Additionally, the two deserve special credit as they stepped in to fill the void for patients when one of the largest equipment and supplies providers for our patients went bankrupt. For those patients who ultimately could not tolerate CPAP or did not wish to continue with CPAP therapy, we helped them explore other options such as oral appliances, positional therapy devices and/or surgery. The FDA has approved “Inspire,” a hypoglossal nerve pulse generator, so there is now yet another option available to help our patients maintain compliance.

The Connecticut Center for Sleep Medicine remained one of the premier sleep centers in the tri-state area and will continue to provide state-of-the-art sleep medicine to the region.

Our 13th Annual Sleep Symposium featured Dr. Carolyn D’Ambrosio from Massachusetts General Hospital, an Assistant Professor in the Department of Pulmonary, Critical Care and Sleep Medicine, on the topic of endocrine manifestations of sleep apnea titled, “From Low T to High TSH.” The topic, which is very dear to our own Dr. Noel Robin, was new to many of the people who turned out for this presentation, which covered a frequently overlooked issue affecting hundreds of thousands of people. The questions from the audience demonstrated the need for more studies to be performed.

While sleep apnea was the most common diagnosis seen at our center, the CCSM also had significant experience in treating all childhood and adult sleep disorders such as restless legs, insomnia, narcolepsy and REM behavior disorders. We continued to investigate other tools, such as online programs that assisted in the management of insomnia, and we collaborated with the Center for Integrative Medicine and Wellness to help our patients achieve a more relaxed state without medication.

REHABILITATION MEDICINE

Edwin F. Richter, MD Director of Rehabilitation Medicine

The Division of Rehabilitation Medicine provides a variety of physical medicine and rehabilitation services for patients of the Stamford Health System. Services are provided on the Van Munching Rehabilitation Unit and in other areas of Stamford Hospital. Outpatient care is provided in the clinic, as well as the private offices of the physiatrists (doctors specializing in physical medicine and rehabilitation) of the Department. My colleagues include Drs. Joseph Annichiarico, Aris Barbadimos, Carolyn Casino, Andrew Illig, Stephen Massimi, Thirumoorthi Seshan, Daniel Southern, David Walshin, Jun Xu and Po Priscilla Xu.

2015 CL INICA L A NNUAL R E POR T | 51

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 Rehabilitation services at the Tully Health Center and at Chelsea Piers Connecticut have been in very high demand. These include physical therapy, occupational therapy, speech therapy and neuropsychology. The Survivorship Training and Rehabilitation (STAR) program, offered in conjunction with the Bennett Cancer Center, provides specialized rehabilitation services for survivors of cancer. Support groups for patients with history of amputation or history of stroke/brain injury have continued to provide valuable assistance to those patient populations. Additionally, patient educational activities continue including participation in National COPD Patient Education Day and World Asthma Day. The Rehabilitation Unit inpatient program continues to be utilized by patients coming from within the Hospital and from hospitals around the region. This has remained at a very high level. Feedback has been very positive with the Unit receiving a national award for patient satisfaction from the Press Ganey organization. We benchmark ourselves against comparable units around the region and across the nation, and are continuing to pursue opportunities for programmatic development. Being part of an expanding health system provides many valuable opportunities for collaboration with colleagues across other departments and programs. The facilities of Stamford Hospital and the expertise of the Medical Staff are particularly valuable resources for the Rehabilitation Unit. I remain very grateful for the outstanding work by members of the Department as well as our colleagues across the health system.

RHEUMATOLOGY

Tomas Vietorisz, MD Director of Rheumatology

Active Staff: • Erik Beger, MD • Hana Hulinksa, MD 5 2 | DEPAR TM ENT O F ME D I C I N E

• Sharon Karp, MD • Shikha Mehta, MD The Department of Rheumatology is currently comprised of five members: Drs. Tomas Vietorisz (Chairman), Sharon Karp, and Hana Hulinska, along with our two newest members, Drs. Shikha Mehta and Erik Beger. As Chair of the Department, Dr. Vietorisz continues to practice full-time as a member of Stamford Health Integrated Practices (SHIP). He received his medical degree from the Mount Sinai School of Medicine in 1988. After a residency in internal medicine at Boston University, he completed his fellowship in rheumatology at The Albert Einstein College of Medicine in 1994. He is board-certified in both internal medicine and rheumatology. Dr. Karp practices part-time as a member of Shoreline Medical Group, which has recently joined Westchester Health. She received her medical degree from Brown University School of Medicine. After completing her residency at Stamford Hospital, she went on to complete her fellowship in rheumatology at New York University. She is board-certified in both internal medicine and rheumatology Dr. Hulinska practices full-time rheumatology with private practice offices in both Stamford and Westport. She received her medical degree from the University of Connecticut School of Medicine. She completed her residency and rheumatology fellowship at North Shore University Hospital in Manhasset and Long Island Jewish Hospital, and she is board-certified in internal medicine and rheumatology Dr. Mehta, the youngest member of the Department, opened her full-time practice of rheumatology in January of this year. She joined the Hospital as a member of Stamford Health Integrated Practices (SHIP) and works in partnership with Dr. Vietorisz. Dr. Mehta received her medical degree from Maulana Azad College of Medicine in New Delhi, India in 2008. She completed her residency in internal medicine at Maimonides Medical Center in New York City in 2012 and went on to complete a fellowship in rheumatology at Westchester Medical Center in Valhalla in June 2014. She is board-certified in internal medicine and board-eligible in rheumatology. Dr. Beger received his medical degree in 1992 at the Georg-August University in Goettingen, Germany. He completed his residency in internal medicine at Boston University in 1998 and went on to complete a fellowship in rheumatology at Albert Einstein College of Medicine in 2000. Since then, he has served as attending rheumatologist

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 at a variety of hospitals including Nassau University Medical Center, Queens Hospital Center, Catholic Medical Center and Flushing Hospital Center. Most recently, he has been practicing as a member of Soundview Medical Associates in Norwalk. Dr. Beger joined Stamford Health Medical Group in September 2015 and is in practice with Drs. Vietorisz and Mehta. He is board-certified in both internal medicine and rheumatology. The Rheumatology Department is proud to announce that two of our members, Drs. Karp and Vietorisz were both selected as “Top Docs” in Connecticut magazine’s physician edition. Dr. Beger made this list as well in 2013 and 2014. In addition to providing rheumatological care in the private practice setting, physicians in the Department continue to provide indigent care for members of the community suffering with rheumatological illnesses through the Optimus Clinic system. The Rheumatology Clinic meets once a month and is staffed by the house officers of Stamford Hospital under the supervision of Drs. Vietorisz, Mehta and Beger. These physicians also provide indigent care to medical inpatients requiring more urgent rheumatological interventions. The field of rheumatology continues to be exciting and rapidly developing. The use of biologic therapies has now become firmly established as safe and effective and has greatly expanded the number of patients with rheumatic diseases who can be successfully treated. Biologic therapies currently approved for use include agents targeting TNF, IL-1, IL-6, T-cell receptor molecules CD-80/86, B-cell receptor CD-20 and IL-12/23. In addition, studies looking at biologic agents targeting IL-12, IL-23, IL-17 and CD-19 among others are currently in phase two and three, and show promise as potential future options in treatment of autoimmune disease. The use of kinase inhibitors has also become a reality in the treatment of rheumatic disease with the approval of Tofacitinib for use in patients with rheumatoid arthritis. However, the cost of these agents continues to be prohibitive for many patients, particularly the uninsured and underinsured. With the expiration of patent protection for biologic agents etanercept and infliximab rapidly approaching, the era of biosimilars is nearly upon us. How these agents are to be regulated, priced, and approved by the FDA are questions that are yet to be answered. Hopefully, these products will reduce the cost of these therapies and make these highly effective treatments available to a wider number of individuals.

HOSPITAL COMMITTEE PARTICIPATION In addition to the broad participation of members of various Departments and Divisions within the Department of Medicine (referred to in each department’s individual report), acknowledgment goes to Jeffrey Green, MD, who was elected by his peers to be the at-large Department of Medicine representative to Stamford Hospital’s Medical Executive Committee, a position he has held since January 1, 2011.

DEPARTMENTAL SAFETY AND QUALITY Under the leadership of Rohit Bhalla, MD, Vice President, Quality and Chief Quality Officer, the Department of Medicine actively participates in Stamford Hospital’s many safety and quality initiatives. The following are year-to-date statistics (as of September 27, 2014) for the measures in which the Department of Medicine is actively involved (numbers in parentheses represent the target values):

Clinical Effectiveness: VTE Prophylaxis — All Inpatients

97%

(98%)

Stroke Education

97%

(97%)

Surgical Prophylactic Antibiotics 99% (98%) Discontinued Within 24 Hours of Surgery End Early Elective Deliveries <39 Weeks 1.2% (Elective deliveries<39 Weeks Gestation)

(0.6%)

Outpatient Surgery Antibiotic Use Composite

100% (99%)

Acute Myocardial Infarction — Appropriate Care

97%

(99%)

Congestive Heart Failure — Appropriate Care

98%

(99%)

Pneumonia Appropriate Care

95%

(99%)

Surgical — SCIP — Appropriate Care

99%

(97%)

Venous Thromboembolism – Appropriate Care

95%

(97%)

Stroke – Appropriate Care

94%

(96%)

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D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 Hospital-Acquired Infections: Hand Hygiene

94%

(95%)

Central Line-Associated Bloodstream 0.71 (0.99) Infections (Med/Surg + ICU) per 1,000 line days Central Line-Associated Bloodstream Infections (Med/Surg + ICU Actual #)

6

(9)

Central Line-Associated Bloodstream Infections (NICU Actual #)

0

(1)

Catheter-Associated Urinary Tract 0.11 (0.11) Infections (ICU, CAUTI per 1,000 catheter days) Catheter-Associated Urinary Tract Infections (ICU, Actual # of CAUTIs)

8

(11)

All Surgical Site Infections (per 100 Surgical Cases)

0.74

(0.65)

All Surgical Site Infections (Actual # of SSI)

38

(47)

Colon Surgical Site Infections (Actual #, all classes)

4

(7)

MRSA (per 1,000 patient days)

0.04

VRE (per 1,000 patient days)

0.016 (0.028)

C. Difficile (per 1,000 patient days)

0.919 (0.920)

Resistant Infection Rate (MRSA, VRE, C. Diff per 1,000 patient days)

0.978 (0.991)

Columbia P & S students are assigned to our Department of Medicine in both the Inpatient Clinical Clerkship and in Primary Care Medicine, as well as in Family Medicine, Surgery, Obstetrics and Gynecology and Pediatrics. At any given time, there are as many as 24 Columbia students throughout all rotations. Stamford Hospital teaches the entire student body of Columbia P & S. Within the Department of Medicine, seven or eight thirdyear students are assigned to Inpatient Medicine and one or two to Primary Care/Ambulatory Medicine at any one time. The Department also regularly accommodates students who seek clinical electives at Stamford Hospital. Since Critical Care Medicine is not a dedicated rotation during the third year at Columbia, this is an especially attractive and vital elective experience we can offer. Other clinical electives include Cardiology, Pulmonary Medicine, Infectious Disease Medicine, Hematology and Oncology and a fourth-year subinternship in Internal Medicine and Emergency Medicine. Columbia P & S medical students consistently laud the quality of their educational experience at Stamford Hospital and the personalized, role model education they receive. The following physicians are recognized as preceptors for the 10 clinical clerkship sessions of the academic year: • Revekka Babayev, MD • Salvatore Carbonaro, MD

(0.04)

TEACHING ACTIVITIES Medical Student Education

• Joonun Choi, MD • Deena Ebright, MD • Melissa Goldstein, MD • Anthony Gulati, MD • William Hines, MD • Sarah Kahn, MD • Ted Listokin, MD • Shikha Mehta, MD • Wayne Miller, MD

Stamford Hospital’s affiliation with Columbia University College of Physicians and Surgeons (Columbia P & S) is now in its 18th year. Currently, 100 physicians at the Hospital hold faculty appointments in the Department of Medicine at Columbia:

• Bismruta Misra, MD

• Instructor in Clinical Medicine — 35

• Brianna Siegel, MD

• Assistant Clinical Professor of Medicine — 40

The Fourth Annual “Residents as Teachers Day,” jointly sponsored by Columbia P & S and Stamford Hospital, was held on September 17, 2015. The major presentation was given by Lisa Mellman, MD, Senior Associate Dean for Student Affairs and Clinical Professor of Psychiatry at

• Associate Clinical Professor of Medicine — 9 • Clinical Professor of Medicine — 2 • Professor of Clinical Medicine — 3 5 4 | DEPAR TM ENT O F ME D I C I N E

• Craig Olin, MD • Paul Sachs, MD • Asha Shah, MD

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 Columbia University College of Physicians and Surgeons. This was followed by additional presentations along with individual meetings with department chairs, clerkship site directors and Columbia P & S residency program directors. Additionally, the Department of Medicine provides a comprehensive course in the Foundations of Medicine; it is the first major experience in clinical medicine for medical students. This course is under the exemplary leadership of Dr. Neil Boside, with Drs. Peggy Geimer, Alfred Wolfsohn and Richard Sheinbaum ably serving as educators.

RESIDENCY PROGRAM IN INTERNAL MEDICINE Maria Maldonado, MD Program Director, Internal Medicine Residency Program Associate Chair, Department of Medicine Associate Clinical Professor of Medicine, Columbia University College of Physicians and Surgeons

Kirsten B. Hohmann, MD Associate Program Director, Internal Medicine Residency Program Medical Director of Ambulatory Practice, Optimus Healthcare Assistant Clinical Professor of Medicine, Columbia University College of Physicians and Surgeons

Stamford Hospital’s Residency Program in Internal Medicine has had a productive and fulfilling year. The program welcomes the addition of seven new categorical interns, Drs. Somera Chaudhry, Chao Guo, Kimberly Gupta, Melanie LaVoie, Jean Lee, Sadiya Thermidor, Madhuri Tirumandas and one preliminary intern, Dr. David Gedeon, who, upon completion of his PG-1 year here at Stamford Hospital, will go on to complete his residency in Diagnostic Radiology at UC Irvine-CA. We also acknowledge the achievements of recent graduates who have gone on to complete residencies, fellowships or start practices at respected institutions around the country. Notably, the Internal Medicine program has received over 2,000

applications for six categorical and two preliminary positions for the 2016 NRMP Match. The Clinical Competence Committee spends a great deal of time on curriculum development, program innovation and improvement and assessment of residents in addition to their other administrative and clinical responsibilities. They also teach residents in the ICU, Inpatient Medicine, Ambulatory Medicine and on elective rotations. Acknowledgment goes to Committee Chair Dr. Noel Robin, along with Drs. Kirsten Hohmann, David Hsi, James Krinsley, Dominic Roca, Maher Madhoun, Hiren Mody, Praveen Reddy and John Fitzgibbons along with Mary Dolan. In addition, the Program Evaluation Committee, charged with program assessment and improvement, is comprised of members of the Clinical Competence Committee, Drs. Michael Bernstein and Tzivia Moreen, and our two Chief Residents Morgan Kellogg and Marta Kokoszynska, who are also completing their third year of residency. Ambulatory education remains under the leadership of Dr. Kirsten Hohmann, Associate Program Director and Director of the Medical Clinic. The program’s success is due in large part to her deep commitment to ensuring a robust educational program at Stamford Hospital. The program continues its collaboration with the Residency Program in Family Medicine. Teams are composed of one junior resident (PG-1), one senior resident (PG-2 or PG-3) and one teaching Hospitalist attending. At any given time on the inpatient teaching service, there are three Medicine PG-1 residents, one PG-1 Family Medicine resident, three Medicine seniors and one Family Medicine senior. The Inpatient Teaching experience remains under the able leadership of Drs. Maher Madhoun and Hiren Mody, Co-Assistant Program Directors. Many Internal Medicine residents were among the presenters of nine posters at the Annual Connecticut Chapter Meeting Scientific Session of the American College of Physicians on October 30, 2015, and several of our residents are engaged in institutional quality improvement projects as well as research with Dr. James Krinsley, Director of the Intensive Care Unit. This was the fourth year of a bi-directional educational experience with the required neurology rotation for PG-2 residents at the renowned Neurologic Institute at Columbia University Medical Center. Under the supervision of Dr. Blair Ford, Associate Professor of Clinical Neurology, an authority on movement disorders and deep brain stimulation for Parkinson’s disease, residents receive education in multiple domains of neurologic experiences. In addition, under the aegis of Dr. Richard Marottoli, Associate Professor of Medicine in the Section of

2015 CL INICA L A NNUAL R E POR T | 55

D EPA R T M ENT O F M E DI C I N E : AN N UA L R E P OR T 2015 Geriatric Medicine at Yale University School of Medicine and Director of the Dorothy Adler Geriatric Assessment Center at Yale-New Haven Hospital, residents are taught geriatric assessment. The annual “Resident-As-Teacher” Workshop, led by Columbia P & S faculty, continued this past September with both resident and faculty development in the area of medical student assessment and evaluation. The thrust and goals of graduate medical education are evolving to ensure that residents are prepared to practice medicine in a rapidly evolving health care delivery system that underscores quality, efficiency and patient-centered care. The Accreditation Council on Graduate Medical Education now ensures that residents are meaningfully engaged in their institutions through the Clinical Learning Environment Review, which provides the opportunity to collaborate on best practices in ensuring that the mission of education is intertwined with the quality strategy and patient safety initiatives. Residents at Stamford Hospital are inculcated with strategies to evaluate systems and generate and evaluate solutions to challenges that arise in the delivery of healthcare. They are given multiple opportunities to work with Hospital leadership and interprofessional teams to improve the quality of patient care, and several sit on institutional committees such as Sepsis, ED Throughput and Information Technology. This collaboration helps residents develop the insight and skills needed to advocate for quality care as part of their training as well as practice in the present healthcare environment.

CONTINUING MEDICAL EDUCATION Reflective of its commitment to continuing medical education, Stamford Hospital was awarded an unprecedented six years of accreditation, with commendation, by the Committee on Continuing Medical Education (CME) of the Connecticut State Medical Society. The breadth of CME programs offered in 2015 illustrates this commitment: • Medical Grand Rounds — Weekly diverse, educational presentations, many emphasizing an integrative and multidisciplinary approach to care. Themes in 2015 included “Transitional Care and Care Management Initiatives,” “Treatment of Relapsing Multiple Sclerosis,” “Nutritional Assessment and Management” and Nephrology.

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• Comprehensive Clinical Case Conference — This monthly conference draws on the rich array of relevant clinical cases requiring multidisciplinary involvement. • Yale University Seminars in Geriatric Medicine — Four timely, topical presentations regarding the care of older adults. Themes this year included “Sleep-Wake Disturbances in Sedentary Older Persons with Mobility Limitations,” “Mistreatment of Older Adults” and “Agitation in the Older Adult.” The topic of “Dementia and Delirium” also gave Dr. Allison Ostroff the opportunity to formally deliver Medical Grand Rounds as the newly appointed Director of Geriatrics. • The 7th Annual Keith Landesman Memorial Lectureship — A lasting tribute to a beloved colleague and the values that defined his life. This year’s lecture was given by Dr. Terry Trow, Professor of Medicine at Yale Medical School, on pulmonary arterial hypertension. • The Annual William F. Buckley, Jr. Memorial Lecture — Given in memory of Mr. Buckley, whose gracious bequest allowed for the creation of an ongoing lectureship in Infectious Disease. • The 37th Annual William H. Resnik Memorial Lecture — This year’s speaker was Dr. Rudolph Leibel, Christopher J. Murphy Memorial, Professor of Diabetes Research and Professor of Pediatrics at Columbia University College of Physicians and Surgeons. • The 13th Annual Paul H. Dalgin Memorial Lectureship — Given in dedication to a special colleague, and as a lasting tribute to the ideals of medical education. This year’s lecturer was Dr. John P. Bilezikian, Professor of Medicine at Columbia University School of Physicians and Surgeons, who spoke on “Osteoporosis: Horizons of Therapy.” • Senior Resident Presentations — Seven senior resident presentations addressed a wide range of clinical topics. • Schwartz Rounds — Although in the domain of Stamford Hospital, these important, reflective and poignant teaching experiences, held every two months, are meaningful and inspirational to our Department. • The 11th Annual Sleep Medicine Symposium — Sponsored by the Connecticut Center for Sleep Medicine, under the leadership of Drs. Dominic Roca and Steven Thau. This year’s topic was “Low T to High TSH” and was presented by Dr. Carolyn M. D’Ambrosio.

D EPA R T M EN T O F M E DI C I N E : A N N UA L R E P OR T 2015 • The 33rd Annual Pulmonary, Critical Care and Sleep Medicine Symposium — Sponsored annually by the Department of Pulmonary Medicine to enlighten physicians on current issues in Pulmonary Medicine, their pathophysiologic mechanisms and their clinical management. Three presentations by staff were given this year by Drs. James Krinsley, Michael Parry, Kevin Dwyer and Rohit Bhalla on “A Journey Through Evidence-Based Literature” followed by a discussion given by Dr. Christian D. Becker. • The 22nd Annual Oncology Symposium —Sponsored by the Carl and Dorothy Bennett Cancer Center to provide physicians with the most current knowledge and understanding of cancer. This year’s theme was “Cancer Survivorship and Rehabilitation.” • Dedicated Summer Syllabus in Medicine — A comprehensive, 12-week compendium aimed at new house staff and medical students. • Medical Grand Rounds during the Summer Syllabus — 12 weekly sessions led by Department staff on clinical, medico-legal, and quality and safety topics. • Annual Medical Grand Rounds Lecture in Podiatry — The 2015 Speaker was Dr. Robert Fridman, who spoke on “A Practical Guide to Heel Pain.”

COMMUNITY OUTREACH As part of the Department’s commitment to promoting a healthier community through education, physician members participate in an array of forums and programs including the Mini Medical School, health fairs, lectures, symposia and awareness days focused on specific health conditions.

that Hospitalist Medicine continue to be represented in all components of medical education, and that community physicians feel a part of the clinical and intellectual stimulation that is part of their association with Stamford Hospital. An important corollary is the need to maintain and foster Stamford Hospital’s role as a major teaching campus. The Hospital has established a special relationship with Columbia University College of Physicians and Surgeons and is privileged to have the responsibility of educating so many future physicians. This privilege is cherished with pride, humility and unwavering commitment. The responsibilities of the Department of Medicine are large and are shared by many. No single individual or group of individuals can possibly perform all the clinical, service and educational responsibilities. This annual report gives formal recognition to those members who have generously given of their time, energy, and, above all, themselves. Our medical community is surely better as a result of their kindness and good deeds. They have enriched all and have made our community and profession all the better. We may be very fortunate as a community to have facilities and technology, present and future, of extraordinary design and sophisticated capability. Nothing, however, is more important than the worth of our staff. They deserve our highest respect and appreciation. Their beneficiaries and generosity must never be taken for granted. It is my deep hope that their generous and selfless contributions ennoble them and augment their pride and esteem in our beautiful profession. To those good physicians who exemplify these ideals, who continue to make ours a profession of meaning and worth — for their dedication, kindness, friendship and collegiality, the Department of Medicine extends its heartfelt gratitude.

STRATEGY/FUTURE DIRECTION The continued vitality of medical practice in the greater Stamford community depends on consistent recruitment of newer generations of physicians to the staff of our Hospital — this revitalization is essential to the progress of our profession and our institution, and an effort to which the Department of Medicine remains committed. Stamford Hospital has been an integral part of the evolution of Hospitalist Medicine, which has freed primary care physicians to tend to their office-based patients and improved the efficiency of inpatient care. It is imperative

2015 CL INICA L A NNUAL R E POR T | 57

i nn ov a t io n i n

obstetrics & gynecology

Our exceptional Obstetrics care earned Stamford Hospital a Women’s Choice Award in 2015.

5 8 | DE PA R TM ENT O F O B S T E T R I C S & G Y N E CO LO G Y

D EPA R T M EN T O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2 015 A MESSAGE FROM THE CHAIR:

• Under the leadership of Kathy LiVolsi, Stamford Hospital received the Women’s Choice Award in Obstetrics for 2015.

The Year in Review

• Additionally, the collaboration among multidisciplinary team members continues to be an asset to our program, particularly in terms of achievements related to patient safety. The Department’s commitment to quality and patient-centered care resonates with patients and this is evidenced in our increasing volume of births and strong patient satisfaction scores.

Carol Fucigna, MD Interim Chair, Department of Obstetrics and Gynecology

I am proud to serve as Interim Chair of this Department and look forward to continued growth in the Women’s Health service line over the next fiscal year.

T

he Hugh K. Miller, MD, Department of Obstetrics & Gynecology works in collaboration with our obstetricians and gynecologists and strives to provide the highest level of quality care to patients in our community by offering the most up-to-date diagnostic testing and novel treatment modalities in a safe and nurturing atmosphere. The Department is proud to share its accomplishments and highlight the areas in which we continue to work to assure that we are setting the highest standards for providing excellent patient care. This was a productive year for the Department:

SCOPE OF CLINICAL ACTIVITIES The Department is pleased to report volume growth in Obstetrics, Gynecology and Gynecologic Oncology (with data provided in Figures 1 – 7). In addition, our global quality program continued to achieve results, demonstrating a Departmental focus on quality and value. All Department members continue their commitment to put patients first, and patient feedback affirms the success of these efforts. The following charts and graphs illustrate clinical productivity and volume for fiscal year 2015.

• Obstetric volume at Stamford Hospital increased by 3% over 2014, while the national birth rate saw 1% growth, its first increase since 2008. Figure 1: Obstetrical Service Volume — Total Deliveries

Deliveries (Number of Births at TSH) Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

July

Aug

Sept

Total

FY12

2,157

FY13

2,285

FY14

167

196

170

198

168

181

177

188

211

233

202

195

2,228

FY15

205

203

212

182

163

201

165

209

174

188

225

237

2,364

Budget

190

190

190

190

190

190

190

190

190

190

190

190

2,280

Variance

15

13

22

-8

-27

11

-25

19

-16

-2

35

47

84

2015 CL INICA L A NNUAL R E POR T | 59

D EPA R T M ENT O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2015 Figure 2: 2015 Maternal Child Health Scorecard Maternal Child Health Scorecard FY 2015 Indicator

Threshold

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

YTD

JC-PC-1 Elective <39 wks*

LF & JC 5%

0/27 0%

0/35 0%

0/28 0%

0/22* 0%

1/20 5%

0/20 0%

0/21 0%

0/15 0%

0/9 0%

1/21 4.8%

1/27 3.7%

0/17 0%

1%

JC-PC 2- NSTV

Ntl 26.3%

26/77 34%

28/75 37%

23/47 49%

32/67 48%

16/60 26%

18/70 26%

22/57 39%

26/67 38%

24/65 37%

23/61 37%

28/85 33%

31/74 41%

37%

JC-PC 3Ante. Steroids

Ntl 81.8%

1/1 100%

5/5 100%

2/2 100%

6/6 100%

3/3 100%

4/4 100%

10/10 100%

3/3 100%

6/6 100%

7/7 100%

2/2 100%

1/1 100%

100%

JC-PC 4- Neo BS Inf.

Ntl 0.9%

0/207

0/203

0/212

0/182

0/163

0/201

0/165

0/209

0/174

1/189

0/225

0/237

0.04%

JC-PC 5- Excl. BF

Ntl 50.8%

14/33 41.2%

17/38 44.7%

13/41 31.7%

10/32 31.2%

15/31 48%

9/36 25%

13/34 38.2%

13/34 38.2%

9/37 24.3%

11/32 34%

19/40 47.5%

14/38 36.8%

37%

Skin to Skin Within 30 Minutes of Del.

NSI 90%

19/20 95%

19/20 95%

18/20 90%

16/20 80%

18/20 90%

19/20 95%

18/20 90%

16/20 80%

18/20 90%

20/20 100%

20/20 100%

17/20 85%

91%

BF - Attempt/ Latch 1 Hour

NSI 80%

15/20 75%

15/20 75%

12/20 60%

11/20 55%

16/20 80%

16/20 80%

15/20 75%

13/20 65%

16/20 80%

14/20 70%

13/20 65%

11/20 55%

70%

DVT Prophylaxis for C/B

LF 80%

19/20 95%

19/22 86%

19/22 86%

9/10 90%

9/10 90%

10/10 100%

9/10 90%

10/10 100%

9/9 100%

8/11 72%

8/11 72%

7/11 64%

87%

DTRs on Mag. Sulfate

PI 95% Q

Episiotomy

LF <12%

18/104 17%

17/84 20%

17/80 21%

18/97 19%

11/79 14%

20/94 21%

11/89 12%

19/85 22%

18/89 20%

16/110 15%

24/92 26%

15/97 15%

18%

NB Bilirubin Screening

LF 80%

48/48 100%

48/48 100%

48/48 100%

48/48 100%

47/48 98%

48/48 100%

48/48 100%

47/48 98%

48/48 100%

48/48 100%

48/48 100%

48/48 100%

99.9%

Oxytocin Protocol Compliance

PI DPH 100%

2/5 40%

40%

BMV L&D

PI 90%

89

91

92.9

93.3

92.4

92.1

90

91.5

90

89.5

89.6

90

90.9

Falls with Injury

NDNQI

0

0

0

0

0

0

0

0

0

0

0

0

0

Falls

NSI

1 PD

0

0

0

0

1 LD

0

0

1 LD

1 MB 1 LD

1 LD

0

6

Pedi PIV Infiltrates

NDNQI

1

1

0

1

1

1

1

1

1

1

0

0

9

NICU CLABSI

NDNQI Q

<37 wk adm temp on NICU adm

PI 75%

4/8 50%

9/10 90%

15/15 100%

16/18 89%

13/14 93%

12/14 86%

13/15 87%

7/11 63%

13/18 72%

12/15 80%

9/10 90%

11/13 85%

82%

<1500 gm temp on NICU adm > 96F (36C)

VON 25%tile

1/1 100%

2/2 100%

2/2 100%

1/1 100%

2/2 100%

2/2 100%

3/3 100%

No Cases

3/3 100%

1/2 50%

2/2 100%

1/1 100%

95%

192/194 99%

37/63 59%

0

155/156 99%

0

6 0 | DEPAR TM ENT O F O B S T E T R I C S & GY N E CO LO GY

0

0

0%

D EPA R T M EN T O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2 015 Figure 3: 2015 Deliveries Vaginal & Cesarean

We are cognizant of the constantly evolving medical landscape and remain poised to change quickly to meet regulatory requirements as well as implement cutting-edge technologies. The Department is comprised of many members across several disciplines. This multidisciplinary approach to patient care and our commitment to continually strive to improve that care position us well for the future. Included below are some of the highlights of the Department’s activities in 2015: • In Obstetrics, we enjoyed a 3% growth in the number of babies from 2014 to 2015 (from 2,288 to 2,364), while nationally, the birth rated increased by 1% for the first time since 2008.

• The Minimally Invasive Surgery/Robotics Program is now in its seventh year, and recently received a three-year reaccreditation as a Center of Excellence for Minimally Invasive Gynecologic Surgery. Gary Besser, MD, and Stephen Gallousis, MD, are Co-Directors of Minimally Invasive Gynecologic Surgery. • Our MIG numbers continue to be affected by the loss of uterine power morcellation in hysterectomy and myomectomy (April 17, 2014). Stamford Hospital has proactively prohibited the use of the morcellator in all gynecologic cases and we are constantly re-evaluating the literature on morcellation. • 367 inpatients were admitted to the Gynecologic Service in FY15, up from 318 in FY14. This represents a 16% increase in overall GYN volume.

2015 CL INICA L A NNUAL R E POR T | 61

D EPA R T M ENT O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2015 • The Gynecologic Oncology program led by Elena Ratner, MD, and comprised of three Gynecologic Oncologic surgeons, grew by 55% from 2014 to 2015. • Setul Pardanani, MD, joined Stamford Hospital in December as our new Director of Ambulatory Care Services & Associate Residency Program Director. • Planetree tenets continued to be integrated into daily patient care operations. • The Department published a quarterly newsletter highlighting clinical and programmatic updates for the system including information on our residency program and recognition of physicians.

Figure 4: 2015 Gynecological Service Volume

6 2 | DEPAR TM ENT O F O B S T E T R I C S & GY N E CO LO GY

The Department’s gynecologic procedure numbers continue to be robust, however, we continue to be impacted by the ban on morcellation. The FDA ban on intraabdominal morcellation in April 2014 led to a decrease in minimally invasive procedures. The Gynecologic Oncology program experienced a 55% growth in surgical volume in 2015 (Figure 5). Our patients are cared for by three board-certified Gynecologic Oncologists: Drs. Elena Ratner, Karen Nishida, and Babak Litkouhi. Community physicians continue to support the program with an increase in referrals from all towns.

D EPA R T M EN T O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2 015 Figure 5: 2015 Gynecologic Oncology Service Volume

MEDICAL STAFF The Department is comprised of 14 full-time physicians, 41 voluntary attending physicians, 12 resident physicians, four nurse practitioners and one physician assistant.

Paul Bobby, MD Director, Perinatology Co-Director, OB Safety & Quality Committee Medical Student Clerkship Director At-Large member, Medical Executive Committee

Frances Ginsburg, MD Director, Reproductive Endocrinology & Infertility Residency Director

2015 CL INICA L A NNUAL R E POR T | 63

D EPA R T M ENT O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2015 MEDICAL STAFF

Setul Pardanani, MD Associate Residency Director

Tracy Shevell, MD Director, Perinatal Ultrasound

Gary Besser, MD Co-Director, GYN Minimally Invasive Surgery

Stephen Gallousis, MD Co-Director, GYN Minimally Invasive Surgery

Brian Hines, MD Director, Urogynecology & Pelvic Reconstructive Surgery

Janine Popot, MD Chair, Peer Review Committee

Donna Bowman, APRN Co-Director, OB Safety & Quality Committee Elena Ratner, MD Director, Gynecologic Oncology

Kathy LiVolsi, RN, MHA Clinical Operations Director, Maternal & Child Health Services Mary Henwood-Klotz Director, Women’s Health & Pediatric Service Line

6 4 | DEPAR TM ENT O F O B S T E T R I C S & GY N E CO LO GY

D EPA R T M EN T O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2 015 New Staff:

The recent graduate residents are:

• Babak Litkouhi, MD, Gynecology Oncology

• Maureen Burke, MD, Assistant Residency Program Director, SUNY Upstate Medical University, Syracuse

• Setul Pardanani, MD Director, Ambulatory Care & Associate Residency Program Director

Transitions: The following Department members resigned in 2014: • Mary Ellen Humes, MD • Adam Ofer, MD • Shefali Pathy, MD

DEPARTMENTAL EDUCATION AND TEACHING ACTIVITIES The Department serves as a clinical training site for a second- and third-year core clerkship in Obstetrics and Gynecology for medical students from Columbia University College of Physicians and Surgeons. The OB/GYN residency program received a three-year accreditation from the RRC/ACGME. The Maternal-Fetal Medicine Division is approved by the American Board of Genetic Counseling as a teaching site for senior genetic counseling students from Sarah Lawrence College. Additionally, the Department continues its relationship with Planned Parenthood of New England as a second- and third-year resident rotation site for outpatient practice. The Residency Program in Obstetrics and Gynecology is under the supervision of Director Frances Ginsburg, MD, and assisted by Setul Pardanani, MD. The program has a full complement of residents, which consists of three residents in each of the four years. The current first-year residents are: • Kelly Fellows, MD, University of Minnesota Medical School • Kiger Lau, MD, Tufts University School of Medicine • Jade Mas, MD, Florida International University

• Jennifer Cabral, MD, Faculty Position, Lincoln Hospital • Molly Findley, DO, Fellowship in Family Planning, Albert Einstein College of Medicine, The Department also provides an active program of Continuing Medical Education: • Faculty and Departmental Meeting • Multidisciplinary M&M Conference • Multidisciplinary OB/PEDS Conference • Grand Rounds • CoreCases for OB/GYN — Co-Developed by ACOG & CaseNetwork In addition, the Department sponsored the 21st Annual Morton A. Schiffer Day Resident Research Symposium on May 29, 2015.

DEPARTMENTAL RESEARCH AND SCHOLARLY ACTIVITIES Department members gave several presentations at regional meetings in the past year: • “Impact of a quality improvement initiative on the episiotomy rate at a community hospital,” Andrew C. Rausch, MD; Maureen Burke, MD; Donna Bowman, DNP, FNP-BC, RNC-OB; Paul Bobby, MD; Daryl Wieland, MD, MSMI. Annual State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Oral Presentation. • “A comparison of perioperative morbidity between transvaginal and supracervical hysterectomies in the setting of robotic-assisted sacrocolpopexies,” Oluwakemi Adegoke, MD; Brian Hines, MD; Katherine Sandhu, MD. Annual State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation.

2015 CL INICA L A NNUAL R E POR T | 65

D EPA R T M ENT O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2015 • “Transvaginal resection of sacrocolpopexy mesh to relieve pelvic pain,” Xibei Jia, MD; Oluwakemi Adegoke, MD; Brian J. Hines, MD; Katherine S. Sandhu, MD. Annual State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation. • “Intrahepatic cholestasis of pregnancy in Stamford,” Ana Pantel, MD. Annual State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation. • An observational study of paternal weight gain during pregnancy, Courtney Noonan, MD; Paul Bobby, MD. State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation. • “Effect of change in counseling regarding trial of labor after Cesarean amongst a clinic population at Stamford Hospital,” Elizabeth Rodriguez, MD. State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation. • “Safely decreasing the Cesarean section rate in a community hospital,” Paul Bobby, MD; Kezia Spence, MD; Andrew Rausch, MD; Donna Bowman, APRN, MSN, RNCOB. State of Connecticut Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation.

plan which includes continued expansion into the secondary market and growing our physician network. Our plans this year also include expanding our research program and providing annual simulation training for OB attendings, residents, L&D nurses, Family Medicine residents and medical students. Plans are also underway to initiate global OB simulation involving malignant hyperthermia and obstetrical codes. Continuing our strong commitment to safety and quality, we will continue to update our safety protocols to reflect best practices; implement mandatory attending documentation elements; create operative delivery bundles; and update clinical pathways and order sets. Finally, our Department attendings and residents are very involved in the pursuit of research and innovation. Current and future projects for research include: • Trial of Labor after Cesarean Delivery Before and After the Implementation of a Vaginal Birth After Cesarean Delivery Calculator in a Clinic Population at Stamford Hospital — Elizabeth Rodriguez, MD • Prevalence of Intrahepatic Cholestasis in Pregnancy in SW Connecticut — Ana Pantel, MD

Additionally, we would like to recognize some of our Department members for their recent journal publication:

• An Observational Study of Paternal Weight Gain during Pregnancy — Courtney Noonan, MD; Paul Bobby, MD

• “Impact of a Quality Improvement Initiative on the Episiotomy Rate at a Community Hospital,” Maureen Burke, MD; Donna Bowman, DNP, FNP-BC, RNC-OB; Paul Bobby, MD; Daryl Wieland, MD, MSMI. Journal of Reproductive Medicine.

• Has Use of Non-invasive Prenatal Testing Changed Practice in the Community Hospital Setting: A Restrospective Chart Review — Tracy Shevell, MD

STRATEGY/FUTURE DIRECTION

• Impact of a Quality Improvement Initiative on the Episiotomy Rate at a Community Hospital — Andrew C. Rausch, MD; Maureen Burke, MD; Donna Bowman, DNP, FNP-BC, RNC-OB; Paul Bobby, MD; Daryl Wieland, MD, MSMI

The Department’s goals for 2016 are focused and clear. With the new hospital opening in 2016 and the goals of a new service line to offer a full complement of Women’s Health services, this year we will focus on generating increases in obstetrical volume, gynecological oncology volume, robotics and referrals to our chronic pelvic pain program. In collaboration with Mary Henwood-Klotz, Service Line Director for Women’s Health, we will implement our growth strategy

6 6 | DEPAR TM ENT O F O B S T E T R I C S & GY N E CO LO GY

• Safely Decreasing the Primary Cesarean Section Rate in a Community Hospital — Kezia Spence, MD

• Resection of Vaginal Mesh and Recurrent Pelvic Organ Prolapse: A Retrospective Study — Xibei Jia, MD; Oluwakemi Adegoke- PGY 4; MD, Brian J. Hines, MD; Katherine S. Sandhu, MD

D EPA R T M EN T O F OB S T E T RI C S & G YN E COLOG Y: A N N UA L R E P OR T 2 015 • Retrospective Analysis of Transvaginal Hysterectomy vs. Supracervical Hysterectomy with Associated Sacrocolpopexy — Oluwakemi Adegoke, MD; Brian Hines, MD; Katherine Sandhu, MD • “Transvaginal Resection of Sacrocolpopexy Mesh to Relieve Pelvic Pain” — Xibei Jia, MD; Oluwakemi Adegoke, MD; Brian J. Hines, MD; Katherine S. Sandhu, MD

Safety Program • OB Simulation Drills: »» 80% of attendings completed (target 95%) »» 100% of residents completed (target 95%) • 100% eligible residents passed Electronic Fetal Heart Monitoring Exam

• Polycystic Ovarian Syndrome (PCOS): A Survey on Diagnosis & Treatment — Daniel Cibulsky, MD

• 100% eligible nursing staff passed Electronic Fetal Heart Monitoring Exam

• Retrospective Analysis of Toxicity, Treatment Delays and Recurrence-free Intervals for High-risk Endometrial Adenocarcinoma of the Uterus Treated with Chemotherapy vs. Combined Modality Therapy — Elena Ratner, MD

• Preeclampsia DTR compliance 91% (internal target 90%)

OUTCOMES IN THE DEPARTMENT OF OB/GYN Departmental Safety and Quality Led by Co-Directors Paul Bobby, MD, and Donna Bowman, APRN, the primary mission of the OB Safety and Quality Committee is to develop evidence-based protocols for delivering obstetrical care at the highest level of safety and quality. Compliance with these protocols, along with the Department’s collaborative, multidisciplinary approach to care, has produced favorable results on a variety of quality and safety measures.

Quality Metrics/Core Measures 2015 • Joint Commission (year-to-date FY15) »» Elective deliveries <39 weeks — 1% (Leapfrog & CMS benchmark <5%) »» Cesarean in NSTV (Nullip, Term Singleton, Vertex) 37% (no benchmark) -- Most are for labor arrests and NRFH. We are drilling down on these deliveries. • Antenatal steroid administration — 100% (no benchmark) • Exclusive Breastfeeding — 37% (no benchmark) • Leapfrog (publicly reported) »» Episiotomy 18% (benchmark <12%) »» DVT prophylaxis for Cesarean — 87% (benchmark 80%)

2015 CL INICA L A NNUAL R E POR T | 67

i nn ov a t io n i n

pat h o l o g y

Ongoing review of our daily workflow processes to ensure accurate test results and optimal turnaround time of patient results.

6 8 | DE PA R TM ENT O F PAT H O LO GY

D EPA R T M EN T O F PAT H O LO GY: A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Robert C. Babkowski, MD, MMM, FCAP Chair of Pathology and Laboratory Medical Director

I

n 2015, the Laboratory focused on enterprise growth and cost containment, and initiated an RFP process to identify a new, fully automated clinical chemistry system to further upgrade our capabilities. This decision is expected to be finalized and implemented in 2016.

We have experienced significant growth in surgical volume from outpatient referrals of dermatopathology, oral pathology and podiatric pathology — all due to clinical excellence of our Dermatopathologist, Dr. Elgida Volpicelli.

SCOPE OF CLINICAL ACTIVITIES Division of Clinical Chemistry We continue to review and enhance our daily workflow processes to ensure accurate test results and optimal turnaround time (TAT) of patient results. Our Siemens Work Cell instruments and automation line all include the most current software updates. In July, the Lab went live with the Nova pHOx analyzers for STAT testing for the Emergency Department (ED). This was part of a lean initiative to reduce TAT. The average TAT for BMPs have been reduced to 41 minutes from order to result.

The Lab served as a beta site for Roche/Ventana H600 automated histology singleslide stainer. Being one of four sites in the U.S. and Europe, it was exciting to see The Pathology team. this advanced technology. Over a four-week period, we parallel ran 60 slides per day and did a comparison study, which led to FDA approval of this new technology. In 2016, this instrument will replace our Symphony single-slide histology staining process. It eliminates using Xylene (a known carcinogen), is cheaper to operate, has improved coverslipping and produces “high-definition” histology slides to improve pathologist diagnostic accuracy.

The Lab will be bringing Hgb, Serum Proteins and Immunofixation Electrophoresis in-house. This will improve TAT, increase patient and physician satisfaction and decrease our reference testing costs.

Our team performed CAP inspection of Women & Infants Hospital of Rhode Island in June and a self-inspection in preparation for our own CAP inspection in 2016. The Lab continues to participate in the College of American Pathologists Laboratory Accreditation program, CAP Performance Improvement Programs in Surgical Pathology, Cytopathology, and, new in 2015, Dermatopathology.

Fourth Generation HIV testing will be added to our capabilities during the first quarter of FY16. We continue to offer vitamin D testing and Procalcitonin testing 24 hours a day, seven days a week. We also continue to test for HIV 1 and 2 with results reported out every 12 hours.

We are also in the final steps of our RFP process to evaluate analyzers and full lab automation. Siemens, Abbott, Beckman, Roche and Ortho Clinical will be presenting their solutions for our laboratory during the first quarter of FY16. Full lab automation will result in improved test TAT, and improved employee and physician satisfaction. It will also enable the Lab to reduce staffing. We expanded our allergy testing by adding tests to our immulite 2000 XPi analyzer including: Beta-2 Microglobulin, Anti-Thyroglobulin, Anti-TPO, Free and Total PSA. AmnioStat-FLM-PG Fetal Lung Maturity Test is no longer done in-house due to the discontinuation of the kit by the manufacturer. We are currently in the process of looking for an alternate method. In the interim, all FLM testing is being sent to Yale-New Haven Hospital’s Laboratory.

The Department remains focused on the cost efficiency of our reference testing, and we continue to review these tests with the intent of bringing more assays in-house as the criteria of order frequency and cost are met. 2015 CL INICA L A NNUAL R E POR T | 69

D EPA R T M ENT O F PAT H O LO GY: A N N UA L R E P OR T 2015 Division of Hematology, Coagulation and Urinalysis

from 8:00 a.m. to 2:00 p.m. Please call the Hematology department at ext. 7600 to make appointments.

Hematology/CBC Analysis

Stamford Hospital Coagulation Clinic

We acquired and implemented new Sysmex XN technology for both the Bennett Cancer Center (BCC) as well as the main laboratory. This technology upgrade to the BCC resulted in offering a six-part differential (as opposed to previous 3-part diff ), nRBC enumeration (previously not available) and Immature Granulocyte (IG) enumeration (also previously not available). For the main Hospital laboratory, this upgrade results in automatic repeat testing when questionable results arise (thus improving quality of results), decreased turn-around-time, a smaller footprint and reduced reagent consumption (and therefore decreased cost of operation). Having the same platforms at the BCC and main lab allow for a complete patient chart in Meditech, which means previous result history from either testing location is integrated into a uniform patient record. Coagulation The Lab eliminated Nanosphere molecular testing and Factor II and Factor V genetic testing is live on the Cepheid GeneXpert analyzer. We also implemented new fibrinogen reagents from Instrumentation Laboratory. This greatly reduces the effect of Direct Thrombin Inhibitors, which falsely decrease the fibrinogen value. Our new fibrinogen normal range is now assigned to all fibrinogen values. We acquired new Thromoboelastograph (TEG) analyzers to meet the needs of Cardiac Surgery to appropriately identify need for blood products. After an initial roll-out with Cardiac Surgery, TEG analysis will be extended for trauma and general surgical use. Urinalysis We acquired and implemented a new Arkray AU4050, which automates both dipstick and sediment analysis. Analyzer flags for pathogenic components including yeast, casts, crystals and flags for manual microscopic review for confirmation. Fertility Semen Analysis, Post-Vasectomy Semen Analysis and Sperm Wash procedures have been transitioned from the Chemistry section to the Hematology section, as these technologists have better competency to accurately perform such analyses. These tests will continue to be offered by appointment only, Monday through Friday,

7 0 | DEPAR TM ENT O F PAT H O LO G Y

The Lab continues to closely support the Coagulation Clinic, which is administered by Isabelle Millet, PharmD, PhD, and is under the medical directorship of Raymond Baer, MD. We perform the required correlation testing of Clinic devices as compared to Lab devices, and perform genetic testing for warfarin sensitivity. The Clinic accepts patients by physician referral only for those who wish to use it for anticoagulation initiation and/or maintenance of their anticoagulated patients.

Blood Bank The Blood Bank transitioned to the New York Blood Center (NYBC) services this year. The NYBC collects 2,000 blood product units per day and distributes to more than 20 million people in New York City, Long Island, Hudson Valley, NY, New Jersey, Connecticut and Pennsylvania. It has a web-based ordering system to expedite blood deliveries. The NYBC reference laboratories, under the direction of Connie Westhoff, utilize state-of- the-art methods in serological investigation and DNA blood group analysis to resolve complex cases, determine clinical significance and provide consultation for the selection of proper blood for transfusion. The NYBC also performs RHD Genotyping testing for cases where routine laboratory testing for RHD results in discordant or weaker than expected results for pregnant women, or potential transfusion recipients. This allows for fewer unnecessary injections of Rh immune globulin and increased availability of Rh-negative red blood cells. The Blood Bank continues to provide activated factor VII (Novo 7) and prothrombin complex (Kcentra) for treatment of patients with life-threatening bleeding. Both of these products require consultation and dose calculation by Blood Bank Director Dr. Raymond Baer. The Blood Bank maintains sufficient blood products for the cardiac and trauma services, and has protocols to provide blood products quickly. The Blood Bank Director also serves as consultant for difficult patient coagulation issues. The Transfusion Administration Record (TAR) computer module was implemented by the Nursing Department and Blood Bank. This allows for transfusion documentation to be directly entered in the computer, which increases transfusion safety.

D EPA R T M EN T O F PAT H O LO GY: A N N UA L R E P OR T 2015 We continue to review and update policies with the Nursing Department. Blood transfusion audits are reviewed and documented at the Transfusion Committee and recorded by Nursing for National Patient Safety Goals. In order to reduce data and clinical entry errors, the Blood Bank is in the process of interfacing the automated analyzer (Tango) with the Meditech computer. Due to the collaborative efforts of the Blood Bank, Transfusion Committee and clinical departments, Stamford Hospital continues to have one of the lowest crossmatch-to-transfusion ratios in the state. The Blood Bank continues to monitor transfusion practices, resulting in decreased utilization of blood and blood products throughout the Hospital.

Division of Microbiology Our PCR platform (Cepheid) continues to grow. We now do PCR for Enterovirus in CSF, Nasal MRSA, Nasal MRSA/ MSSA, C. difficile (including the virulent NAP1 strain), Influenza A, B and H1N1 and our newest addition, Mycobacteria tuberculosis complex and gene mutations associated with Rifampin resistance. This assay will enable us to determine whether a sample that is acid fast smear positive is M. tuberculosis or not, thus expediting patient care. All of these assays provide real-time testing, improving TAT of results so that our patients can be treated as quickly as possible. The Lab uses the Hologic Panther system for amplified RNA detection for chlamydia and gonorrhea testing, and HPV. The E6 and E7 genes of high-risk HPV genotypes are known oncogenes. Fourteen HPV genotypes are considered pathogenic or high-risk for cervical disease. Multiple studies have linked genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68 to disease progression. Women with a persistent infection with one of these types have an increased risk for developing severe dysplasia or cervical carcinoma. We have expanded our capability to identify respiratory pathogens with the introduction of the BioFire Microarray, an automated in-vitro diagnostic system that utilizes nested multiplex PCR and high-resolution melting analysis to detect and identify multiple nucleic acid targets from clinical specimens. The assay is capable of identifying 20 of the most common viruses and bacteria associated with infectious respiratory diseases. BioFire testing is now available 24/7/365 with an approval/order by Infectious Disease physicians. TAT for this assay is one hour.

Working with our Infectious Diseases physicians, we continue to perform 100% daily clinical follow-up on all positive blood cultures. We generate drug:bug mismatch alerts that allow for the early detection of inappropriate drug selection, and we monitor BC growth 24/7 to enable early notification of positive results to the clinicians. We also monitor monthly endotoxin and bacteria levels in Hospital water and dialysis effluent, and review instrument sterilizer performance on an ongoing basis hospital-wide. In 2015, we implemented the Bruker Maldi-Tof to improve our capability for microorganism identification. This mass spectrometry instrumentation enables us to perform same-day identification of most organisms, drastically reducing our TAT. The Lab also implemented Allere-i isothermic PCR for rapid molecular detection of influenza. This new platform is more accurate, faster and less expensive than GeneExpert. We were the first hospital in Connecticut to employ this new technology.

Division of Point-of-Care Testing The Point-of-Care section upgraded fingerstick glucose devices in 2014. In May 2014, 56 new glucose meters were introduced to 31 sites across the organization and over 700 users were trained on this new equipment. The move was necessitated by an FDA edict to eliminate the prior device’s maltose interference issue. The manufacturer redesigned the meters to allow for improved cleaning procedures as well. The new meters have been well-received by staff and the transition has been relatively seamless. The Stamford Hospital Public Wellness division added two additional Cholestech devices to its roster to support larger community health screenings. This device provides rapid lipid profiles and results can be shared with patients quickly. A registered nurse is thereby able to use the results from these screenings to suggest diet and lifestyle changes, as well as to provide referrals for follow-up care.

Anatomic Pathology Laboratory Molecular Pathology Testing at Stamford Hospital GYN We utilize the Hologic Panther for HPV testing. This automated PCR DNA-detection method identifies 14 high-risk HPV types and specifically identifies the most oncogenic types, HPV 16 and HPV 18.

2015 CL INICA L A NNUAL R E POR T | 71

D EPA R T M ENT O F PAT H O LO GY: A N N UA L R E P OR T 2015 Coagulation The Lab utilizes the Cepheid GeneXpert platform to detect Factor II and Factor V abnormalities. Bladder Cancer For the detection of bladder cancer (urothelial neoplasia), Fluorescent In Situ Hybridization interpretation of the UroVysion test is performed by Bo Xu, MD, PhD. We have successfully implemented reflex UroVysion testing on those urine cytology specimens where determination of urothelial neoplasia is difficult and where the additional molecular testing can better identify a neoplastic process. Thyroid, Colon & Lung Cancer Dr. Xu also evaluates EGFR, KRAS, BRAF, ROS, ALK and PDL1 mutations in lung, colon and thyroid cancers. We continue to evaluate colon cancers for mismatch repair proteins (MMRP) using IHC with reflex positives to full-sequence analysis (microsatellite instability evaluation) in order to identify patients with Lynch syndrome (hereditary non-polyposis cancer). We also continue to augment thyroid FNA cytology evaluation with molecular pathology testing. We promote a collaborative process to our referring endocrinologists and radiologists whereby indeterminate/suspicious category thyroid FNA biopsy specimens are evaluated with molecular testing for various KRAS, NRAS and BRAF mutations. This process allows for judicious and cost-effective molecular testing. With cooperation from our Colorectal Surgeons and Medical Oncologists, we established that all Stage II and III colorectal cancer tumors will be evaluated for Recurrence Score using Oncotype Colon RX assay. This independent variable, when combined with T stage and MMRP status, allows for optimal patient selection for adjuvant chemotherapy and benefit of Oxyplatin (at Stage III CRC). Leukemia/Lymphoma In conjunction with Neogenomics Laboratories, we continue to offer our clinicians an array of ancillary testing, the equivalent of which would be offered at any large academic institution or specialty cancer hospital. All hematopathology cases are evaluated by either Dr. Raymond Baer or Dr. Tal Oren, both board-certified Hematopathologists. In close collaboration with the treating Hematologists and/or Oncologists, Drs. Baer and Oren select the most appropriate battery of ancillary tests to supplement conventional morphologic evaluation. Ongoing advances in molecular diagnostics enabled us to bring these advancements to Stamford Hospital. FISH 7 2 | DEPAR TM ENT O F PAT H O LO G Y

panels for myelodysplastic syndrome have been expanded to better capture the growing number of abnormalities that were recently incorporated into the revised IPSS scoring system. FISH panels for acute myeloid leukemia have also been expanded to reflect the growing number of distinct subtypes recognized in the latest World Health Organization classification schema. FISH panels for multiple myeloma can now be performed by enriching plasma cells, thereby improving the sensitivity of this assay to identify prognostically significant abnormalities in the neoplastic plasma cells. In response to National Comprehensive Cancer Network (NCCN) guidelines recommending that molecular BCR-ABL testing be reported on the International Scale (IS), we can provide qualitative BCR-ABL testing on the IS, making long-term follow-up more consistent and bringing us in line with the recent NCCN guideline changes. The Lab also provides next-generation sequencing to identify a variety of common molecular alterations in hematologic malignancies. This technique holds the promise of bringing “personalized medicine” to our patients by enabling oncologists to better understand the exact biologic underpinnings of a given patient’s malignancy. We continue to provide the professional interpretation for many of these tests, which allows us to better integrate all of the available data and generate a single, cohesive, comprehensive final diagnostic report for our clinicians. We feel that this approach not only improves patient care and but is also of significant value to our clinical colleagues. Melanoma We continue to offer BRAF testing for metastatic melanoma. BRAF mutation positive melanoma patients derive significant benefit from this new medication. Melanoma FISH testing is also available through Neogenomics Laboratories for those lesions that fall under the provisional category of “MELTUMP” (melanocytic tumor of unknown malignant potential) or borderline lesions such as is the case with Atypical Spitz tumors. Dr. Elgida Volpicelli coordinates the ordering of this test and correlates results with the morphology of these difficult melanocytic lesions in order to predict behavior.

Division of Cytology We continue our “push-cart service” with microscope and staining equipment placed on a mobile cart. We provide on-site immediate assessment for deep-organ CT-guided

D EPA R T M EN T O F PAT H O LO GY: A N N UA L R E P OR T 2015 biopsies, ultrasound-guided transbronchial biopsies of the lungs and mediastinum performed in the Operating Room and endoscopic ultrasound-guided fine needle aspirations (FNA) of the pancreas/stomach/duodenum performed in the special procedure room. We work closely with Interventional Radiologists, Pulmonologists, Thoracic Surgeons and Gastroenterologists to make sure diagnostic material is obtained and appropriate triage of each specimen takes place. We now have five years of experience with the Celient cell block technology for creation of cell blocks from cytology material. This technology enables us to create superior, concentrated samples from body fluids and FNA specimens for subsequent immunohistochemical testing to classify malignancies. The direct patient benefit is that we can “do more with less.” In our community we are fortunate to have a number of Endocrinologists who are also skilled ultrasonographers and perform ultrasound-guided FNAs in their office. Thyroid lesions which are difficult to sample and require Interventional Radiology with immediate cytopathology assessment are performed at Stamford Hospital. Our skilled Interventional Radiologists work hand-in-hand with our Cytopathologists in sampling difficult lesions. Due to the Hospital’s growing expertise, we have seen a significant amount of thyroid pathology, more than most academic medical centers. Stamford Hospital is the only institution in Connecticut with two MD Anderson fellowship-trained Cytopathologists (Dr. Babkowski and Dr. Xu). At this point, we handle the majority of thyroid FNA cytology specimens in Fairfield County. 2015 was our first year of completely insourced gynecologic cytology. We hired three experienced Cytotechnologists and implemented Hologic computer-assisted screening. This has decreased our cost of gynecologic cytology and improved our result TAT.

The turnaround time for Surgical Pathology reports for 2015 remains at an average of 24 to 48 hours for 95% of reports.

MEDICAL STAFF

Raymond A. Baer, MD, FCAP Director of Clinical Pathology and Transfusion Services

Tal Oren, MD, PhD, FCAP Director of Hematopathology

Augusto H. Podesta, MD, FCAP Director of Surgical Pathology

Division of Surgical Pathology The Division of Anatomic/Surgical Pathology and the Histology Laboratory at Stamford Hospital has remained very active with over 22,000 surgical specimens processed during the fiscal year. Our case complexity has also grown with increasing dermatology/melanoma, breast and thoracic pathology volumes.

Elgida Volpicelli, MD, FCAP Director of Dermatopathology

One of our three pathology assistants, Grace Valenzano, MHS, PA, serves as Anatomical Pathology Supervisor, and is responsible for overseeing the day-to-day operations of Anatomic and Cytopathology sections of the Lab. 2015 CL INICA L A NNUAL R E POR T | 73

D EPA R T M ENT O F PAT H O LO GY: A N N UA L R E P OR T 2015 Barbara Hazay Beam, MHS, PA (ASCP) Grace Valenzano, MHS, PA (ASCP) Bo Xu, MD, PhD, FCAP Director of Cytopathology and Molecular Pathology

Clinical Activity (FY2015)

7 4 | DEPAR TM ENT O F PAT H O LO G Y

Ramon Grant, MHS, PA (ASCP) Paula Sweeney, MT (ASCP), MHA Laboratory Administrative Director

D EPA R T M EN T O F PAT H O LO GY: A N N UA L R E P OR T 2015 Departmental Physician Activities

• Continuing Medical Education Committee — Dr. Bo Xu

• Department members continue to actively participate in institutional tumor boards and conferences as follows:

• GI Tumor Steering Committee — Dr. Robert Babkowski

»» Weekly Breast Tumor Board — Dr. Robert Babkowski, Dr. Elgida Volpicelli »» Weekly Radiology-Pathology Breast Biopsy Correlation Conference — Dr. Robert Babkowski, Dr. Elgida Volpicelli »» Monthly GYN Oncology Tumor Board — Dr. Bo Xu »» Monthly Genito-Urinary Tumor Board — Dr. Bo Xu »» Bi-Weekly Chest Tumor Board — Dr. Augusto Podesta »» Monthly General Tumor Board — Dr. Augusto Podesta, Dr. Tal Oren »» Monthly Hematology Tumor Board — Dr. Tal Oren »» Monthly GI Tumor Conference — Dr. Augusto Podesta »» Quarterly Neuro-Oncology Conference — Dr. Robert Babkowski »» Quarterly Dermatology-Oncology Conference — Dr. Elgida Volpicelli »» Bi-Weekly Complex Surgical Case Conference — Dr. Robert Babkowski

• Graduate Medical Education Committee — Dr. Bo Xu • Infectious Disease Committee — Dr. Raymond Baer • Institutional Review Board — Dr. Bo Xu • Lung Cancer Steering Committee — Dr. Robert Babkowski • Medical Executive Committee — Dr. Robert Babkowski. • Medical Executive Committee — Dr. Robert Babkowski • Patient Safety & Quality Committee — Dr. Robert Babkowski

Laboratory Outreach The Lab expanded our in-office phlebotomy service to Glenville Medical Group in Greenwich. We also established relationships with several Urgent Care Centers, including those on: Frost Road in Waterbury, Chase Street in Waterbury and East Main Street in Stratford. Additionally we completed interfaces to Practice Fusion (Dr. Mayzlor); Athena (Pulmonary Associates, Gastroenterology Associates and Stamford Gastroenterology); Healthtronics (Drs. Nurzia and Santarosa); and Lab Soft (Dr. Goldberg).

Hospital Committee Participation Department members participate in various Hospital committees, including: • Transfusion Committee — Dr. Raymond Baer • Breast Center Steering Committee — Dr. Robert Babkowski • Cancer Coordinating Committee — Dr. Robert Babkowski

2015 CL INICA L A NNUAL R E POR T | 75

i nn ov a t io n i n

p e d i at r i c s

Well-positioned as the destination of choice in lower Fairfield County for patient-centered, compassionate children’s care of the highest caliber.

7 6 | DE PA R TM ENT O F P E D I AT R I C S

D EPA R T M EN T O F P E DI AT RI C S : A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Gerald B. Rakos, MD, FAAP Chair, Department of Pediatrics Director, Division of Neonatology

T

he Department of Pediatrics at Stamford Hospital is on the threshold of a new era thanks to the landmark gift of $20 million from the Steven & Alexandra Cohen Foundation establishing the Cohen Children’s Institute. This past year, much time was spent planning for the opening of the area’s first true Pediatric Emergency Department. This coming year will be focused on operationalizing the ED while finishing the design and development phase for the new in-patient Pediatric unit. These two new areas when combined with the existing Goldstein Neonatal Intensive Care Unit and the Cohen Children’s Specialty Center, will allow the Cohen Children’s Institute to establish itself as the destination of choice in lower Fairfield County for patient-centered, compassionate children’s care of the highest caliber. PediNEWS, the Department’s newsletter, completed its first year of publication to very positive reviews. Its objective is to provide area pediatricians and family medicine practitioners, including those in our secondary and extended markets, a comprehensive picture of the Department’s various programs and offerings. Further efforts to enhance communication and dissemination of information include a new Pediatrics intranet page and phone optimization via a new dedicated phone line (203.276.PEDI) that is answered every business day. Kids’ FANS (Fitness and Nutrition Services) programs have grown nicely under the direction of Ilaria St. Florian, MS, RD, and continue their important work in preventing childhood obesity. Programs are running in 24 sites including schools, daycare centers and community centers in both Stamford and Norwalk. Most importantly, data is beginning to show a decline in the prevalence of childhood obesity across the nation.

The Department continues to operate the Medical Home Initiative of Southwest Connecticut, a program that has received grant funding from the Department of Public Health since 2005. We are in year two of a three-year grant, ensuring that children and youth with special healthcare needs from Greenwich through Bridgeport have their complex care well-coordinated. With construction of the new hospital nearing completion, next year promises to be both busy and exciting as we prepare to open the new Cohen Children’s Emergency Department and begin to build our new inpatient facility, the Cohen Children’s Unit.

SCOPE OF CLINICAL SERVICES Cardiology Pediatric Cardiology at Stamford Hospital has been a well-utilized area of subspecialty care over the past year, providing both inpatient and outpatient evaluations and treatment to referring physicians and the community. There are three full-time pediatric cardiologists on staff. Drs. Allison Levey, Michael Monaco and Michael Snyder all hold academic appointments at Columbia University with admitting privileges at Morgan Stanley Children’s Hospital of New York, enabling the local delivery of academic-based subspecialty care. Hospital-based cardiology imaging and testing has continued to be active. Figure 1 details the pediatric and neonatal echocardiograms, non-invasive studies and pediatric stress tests performed over the course of the year. Both ECGs and echocardiograms are now available for rapid review on line, facilitating timely reporting. Figure 1: Diagnostic Pediatric Cardiology Volume 2014

2015

Change

Echocardiograms

259

254

-2%

Electrocardiograms

514

418

-18.7%

24 Hour ECGs

44

43

-2.3%

Pediatric Stress Tests

30

24

-20%

Fetal Echocardiograms

195

213

+8.5%

2015 CL INICA L A NNUAL R E POR T | 77

D EPA R T M ENT O F P E DI AT RI C S : AN N UA L R E P OR T 2015 Fetal imaging continues to be an important component of our service. Working in close collaboration with the Division of Maternal-Fetal Medicine and community obstetrical practices, we have doubled our scheduled hours, and performed a significantly increased number of fetal consultations and echocardiographic studies over the past year. All fetal studies are now integrated with the hospital EMR. Finalized reports are available for review by OB staff and referring physicians shortly after the studies have been completed. All three physicians are part of the Cohen Children’s Specialty Center.

Cohen Children’s Specialty Center The Steven & Alexandra Cohen Children’s Specialty Center at the Tully Health Center continues its vital role as a center of highly specialized outpatient pediatric care for our region. In total, there are 29 providers in 18 specialties with more growth anticipated in the coming year. Figure 2 showcases the year-over-year growth in volume since 2009. Figure 2: Cohen Children’s Specialty Center Volume

General Pediatrics The staff is fully engaged in the planning of the new Cohen Children’s Unit while they continue to care for sick children in our existing unit. This past year saw a slight decrease in the number of admissions to the Pediatric Unit (Figure 4). Figure 4: Inpatient Pediatrics — Discharges 2014

2015

Change

Inpatient

398

377

-5.3%

Observation

53

57

+7.5 %

Total

451

434

-3.8%

Medical Home Initiative Dr. Madhu Mathur of the Department of Pediatrics directs the Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs – Southwest. The program received a new three-year grant from the State of Connecticut’s Department of Public Health last year thus ensuring that this initiative, which began in 2005, will continue. Emphasis this past year was on care coordination for un- and under-insured children with highly complex special healthcare needs (Figure 5). Figure 5: Connecticut Medical Home Initiative for Children and Youth with Special Healthcare Needs — Southwest 2014

2015

Change

Gastroenterology

Patients Served for Special Healthcare Needs

2,000

934

-53.3%

During the past year, the Division of Pediatric Gastroenterology has continued to support the pediatric inpatient service, NICU and Emergency Department, as well as provide specialty care to patients of the area’s primary care pediatricians and Family Medicine physicians. Drs. Mark Glassman and Sarah Lusman remain part of the Cohen Children’s Specialty Center.

Patients Served With High Complexity Needs

455

466

+ 2.4%

We anticipate that the Division of Pediatric Gastroenterology will experience continued growth as we provide care to the children throughout southwestern Connecticut (Figure 3). Figure 3. Tully Health Center Cohen Children’s Specialty Center Gastroenterology Patient Visits

7 8 | DEPAR TM ENT O F P E D I AT R I C S

2014

2015

Change

742

681

-7.3%

Neonatology Consistent with our high tech-high touch philosophy, another initiative that began this year under the leadership of Dr. Jennifer Bragg was our infant massage program. The NICU received a grant from the March of Dimes to implement this program for all infants born preterm (<37 weeks gestation) at Stamford Hospital. Infant massage has been shown to have many benefits in preterm infants, including reduced stress behaviors, improved growth and earlier discharge home. Our intent in starting this program was to not only improve the neurodevelopmental outcomes of our NICU graduates,

D EPA R T M EN T O F P E DI AT RI C S : A N N UA L R E P OR T 2015 but also further empower our families to play an integral role in the care of their child. This grant enabled one neonatologist and two NICU nurses to undergo a four-day certification training this past spring. The program was implemented over the summer and is growing rapidly. The NICU Infant Clinical Evaluation (NICE) Program, also directed by Dr. Jennifer Bragg, has been growing in leaps and bounds. This past year Kimberly Neely, RN, a highly experienced NICU nurse, joined Dr. Bragg in evaluating babies at the Cohen Children’s Specialty Center. In addition to Stamford Hospital NICU graduates, the program saw an increase in referrals from other area NICUs and private pediatric practices. There were 48 visits over the fiscal year and, as a result, the program has expanded and now sees patients twice a month. This coming year, materials are being developed to distribute to families that provide anticipatory guidance about expected developmental milestones, possible hurdles to expect and additional resources they can use. As the infant massage program grows, we hope to incorporate it into the NICE Program. Both the newborn service and NICU saw growth over the past year as shown in Figures 6 and 7. Figure 6: Stamford Hospital Newborn Service

Births

2014

2015

Change

2,348

2,426

+3.2%

Figure 7: Neonatal Intensive Care Unit

Admissions

2014

2015

Change

277

308

+11.2%

Figure 8: The Pediatric Pulmonary Function Laboratory at the Tully Health Center 2014

2015

Change

Spirometry

58

240

+414%

Plethysmography

355

353

- 0.6 %

Diffusion Capacity

6

12

+ 200%

Bronchodilator Evaluations

155

175

+12.9%

Pulmonary Exercise Testing

39

68

+74%

Sweat Tests

62

68

+9.7%

Neurology Drs. Murray Engel and Robert Fryer along with Margot Laedlein, APRN, and the non-clinical staff at Fairfield County Pediatric Neurology, have continued our mission to be the regional center for Pediatric Neurology care. Our referral base remains quite broad, drawing from Westchester and from both lower and upper Fairfield County. While currently located at the Cohen Children’s Specialty Center in shared space, planning is underway for dedicated space, which will allow further expansion of the practice. Planning has also begun to add another Child Neurologist to the group over the next year. Drs. Engel and Fryer continue their involvement at Concussion Center at Chelsea Piers Connecticut. The Division maintains a strong academic affiliation with NewYork-Presbyterian at both the Cornell and Columbia campuses. Our EEG volume is shown in Figure 9. Figure 9: Pediatric Neurology EEG Volume

Pulmonology Pediatric Pulmonology at Stamford Hospital continues to provide inpatient and outpatient consultations, RSV prophylaxis treatment and cystic fibrosis care. Pediatric sleep evaluation and management is also available at Stamford Hospital’s Sleep Center. Pediatric pulmonary function tests and exercise pulmonary function evaluations increased significantly over the past year (Figure 8). Dr. Hossein Sadeghi holds an academic appointment at Columbia University as its Director of the Pediatric Cystic Fibrosis program.

2014

2015

Change

EEGs

187

174

-7%

Long-term EEGs

57

70

+22.8%

2015 CL INICA L A NNUAL R E POR T | 79

D EPA R T M ENT O F P E DI AT RI C S : AN N UA L R E P OR T 2015 MEDICAL STAFF

Michael Snyder, MD

Letitia Borras, MD

Director, Division of Cardiology

Co-Director, Hospitalist Medicine

Murray Engel, MD

Shahrzad Mohammadi, MD

Director, Division of Child Neurology

Co-Director, Hospitalist Medicine

Mark Glassman, MD

Madhu Mathur, MD, MPH

Director, Division of Gastroenterology

Director, Medical Home Initiative

Hossein Sadeghi, MD Director, Division of Pulmonology

8 0 | DEPAR TM ENT O F P E D I AT R I C S

D EPA R T M EN T O F P E DI AT RI C S : A N N UA L R E P OR T 2015 New Staff The Department of Pediatrics welcomed the following members this year: • Lauren Bader, MD (General Pediatrics) • Jennifer Gruen, MD (General Pediatrics) • Jeanine Freliech, MD (General Pediatrics) • Joseph Hufnagel, MD (General Pediatrics) • Christine Macken, MD (General Pediatrics) • Nicholas Matarazzo, MD (General Pediatrics) • Marc Mishkin, MD (General Pediatrics) • Michael Schessel, MD (General Pediatrics) • Lawrence Zemel, MD (Rheumatology)

Transitions The following members resigned this year: • Hariram Ganesh, MD (General Pediatrics) • Amy Lief, MD (General Pediatrics)

Honors and Recognition Top Doctor Awards • Karen Beckman, MD — New York Metro Area and Fairfield County • Ora Burstein, MD — New York Metro Area and Fairfield County • Murray Engel, MD — New York Metro Area and Fairfield County • Robert Fryer, MD — New York Metro Area and Fairfield County • Mark Glassman, MD — New York Metro Area and Fairfield County • Jennifer Henkind, MD — Connecticut • Timothy Kenefick, MD — Connecticut • Rosemary Klenk , MD — New York Metro Area and Fairfield County • Arnold Korval, MD — New York Metro Area, Connecticut, and Fairfield County • Susan Lasky, DO — Connecticut • Allison Levey, MD — New York Metro Area and Fairfield County

• Alan Morelli, MD — New York Metro Area and Fairfield County • Gerald B. Rakos, MD — New York Metro Area and Fairfield County • Henry Rascoff, MD — New York Metro Area and Fairfield County • Hossein Sadeghi, MD — New York Metro Area and Fairfield County • Michael Snyder, MD — New York Metro Area and Fairfield County • Sanford Swidler, MD — Connecticut • George Tsimoyanis, MD — New York Metro Area and Fairfield County Sarah Lusman, MD, was appointed Director of the Fellowship Training Program in Pediatric Gastroenterology, Hepatology and Nutrition at Columbia. Susan Lasky, DO, joined the Ridgefield Public Schools Wellness Committee. Jeanne Marconi, MD, received the “Lifetime Achievement Award” by the Fairfield County Medical Society and a commendation award from Senator Richard Blumenthal. She was also appointed by the American Academy of Pediatrics to their Executive Advisory Board for the Committee on Coding and Nomenclature and named a review editor for the Coding Newsletter.

Grants • Madhu Mathur, MD, and Gerald B. Rakos, MD, received a three-year grant from the Connecticut Department of Public Health for the Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs — Southwest in the amount of $808,000. The program is in year two of three years. • Sarah Lusman, MD, received a grant from the Cystic Fibrosis Foundation entitled Developing Innovative GastroEnterology Specialty Training (DIGEST) in the amount of $30,000. The program is in year two of three years. • Jennifer Bragg, MD, received a grant from the March of Dimes for a study entitled “The impact of infant massage in the Neonatal Intensive Care Unit” in the amount of $5,000.

2015 CL INICA L A NNUAL R E POR T | 81

D EPA R T M ENT O F P E DI AT RI C S : AN N UA L R E P OR T 2015 DEPARTMENTAL SAFETY AND QUALITY The NICU’s Breast Milk Screening Program is an enhanced safety initiative with state-of-the-art technology (barcoding) to continually ensure proper disposition of patient breast milk. Stamford Hospital’s NICU has remained a member of the Vermont Oxford Neonatal Network since 1997. This year we joined the expanded database, which includes all admissions to the NICU, not just those whose birth weights are <1,500 grams. This allows us the opportunity to benchmark our outcomes of all infants admitted to the NICU with almost 1,000 NICUs worldwide. Over 175,000 Figure 10: Stamford Hospital NICU Outcomes in Top 25th Percentile 2012

2013

2014

Pneumothorax

Yes

Yes

Yes

Periventricular Leukomalacia

Yes

Yes

Yes

Chronic Lung Disease

Yes

Yes

Yes

Necrotizing Enterocolitis

Yes

Yes

No

Severe Intraventricular Hemorrhage

Yes

No

Yes

Severe Retinopathy of Prematurity

No

Yes

Yes

Late Infections

Yes

No

No

Mortality Excluding Early Deaths

Yes

No

No

Mortality

Yes

No

No

Death or Morbidity

Yes

Yes

Yes

8 2 | DE PA R TM ENT O F P E D I AT R I C S

infants are included in this database. Outcomes analysis is by the calendar year and the most recently available data is from 2014, which still reflects data only from very low birth weight infants (<1500 grams). Our goal is to be in the top 25th percentile for 10 major outcomes. Our results are shown in Figure 10.

Patient Satisfaction Patient satisfaction for the NICU continues to be high and is shown in Figure 11. Figure 12 outlines the Hospital performance for the Maternal Child Health. Figure 11: NICU Press Ganey Satisfaction FY15 Raw Score

Overall DB Percentile

AHA Region 2 Percentile

NICU Overall

91.0

79

81

NICU Nurses

94.4

93

99

NICU Physicians

93.1

97

99

D EPA R T M EN T O F P E DI AT RI C S : A N N UA L R E P OR T 2015 Quality Scorecard. Figure 12: Maternal Child Health Quality Scorecard Including Joint Commission’s Perinatal Care Core Measures which include: • JC-PC-1: Elective delivery • JC-PC-2: Cesarean section • JC-PC-3: Antenatal steroids • JC-PC-4: Healthcare-associated bloodstream infections in newborns • JC-PC-5: Exclusive breast milk feeding Maternal Child Health Scorecard FY 2015 Indicator

Threshold

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

YTD

JC-PC-1 Elective <39 wks*

LF & JC 5%

0/27 0%

0/35 0%

0/28 0%

0/22* 0%

1/20 5%

0/20 0%

0/21 0%

0/15 0%

0/9 0%

1/21 4.8%

1/27 3.7%

0/17 0%

1%

JC-PC 2- NSTV

Ntl 26.3%

26/77 34%

28/75 37%

23/47 49%

32/67 48%

16/60 26%

18/70 26%

22/57 39%

26/67 38%

24/65 37%

23/61 37%

28/85 33%

31/74 41%

37%

JC-PC 3Ante. Steroids

Ntl 81.8%

1/1 100%

5/5 100%

2/2 100%

6/6 100%

3/3 100%

4/4 100%

10/10 100%

3/3 100%

6/6 100%

7/7 100%

2/2 100%

1/1 100%

100%

JC-PC 4- Neo BS Inf.

Ntl 0.9%

0/207

0/203

0/212

0/182

0/163

0/201

0/165

0/209

0/174

1/189

0/225

0/237

0.04%

JC-PC 5- Excl. BF

Ntl 50.8%

14/33 41.2%

17/38 44.7%

13/41 31.7%

10/32 31.2%

15/31 48%

9/36 25%

13/34 38.2%

13/34 38.2%

9/37 24.3%

11/32 34%

19/40 47.5%

14/38 36.8%

37%

Skin to Skin Within 30 Minutes of Del.

NSI 90%

19/20 95%

19/20 95%

18/20 90%

16/20 80%

18/20 90%

19/20 95%

18/20 90%

16/20 80%

18/20 90%

20/20 100%

20/20 100%

17/20 85%

91%

BF - Attempt/ Latch 1 Hour

NSI 80%

15/20 75%

15/20 75%

12/20 60%

11/20 55%

16/20 80%

16/20 80%

15/20 75%

13/20 65%

16/20 80%

14/20 70%

13/20 65%

11/20 55%

70%

NB Bilirubin Screening

LF 80%

48/48 100%

48/48 100%

48/48 100%

48/48 100%

47/48 98%

48/48 100%

48/48 100%

47/48 98%

48/48 100%

48/48 100%

48/48 100%

48/48 100%

99.9%

Pedi PIV Infiltrates

NDNQI

1

1

0

1

1

1

1

1

1

1

0

0

9

NICU CLABSI

NDNQI Q

<37 wk adm temp on NICU adm

PI 75%

4/8 50%

9/10 90%

15/15 100%

16/18 89%

13/14 93%

12/14 86%

13/15 87%

7/11 63%

13/18 72%

12/15 80%

9/10 90%

11/13 85%

82%

<1500 gm temp on NICU adm > 96F (36C)

VON 25%tile

1/1 100%

2/2 100%

2/2 100%

1/1 100%

2/2 100%

2/2 100%

3/3 100%

No Cases

3/3 100%

1/2 50%

2/2 100%

1/1 100%

95%

0

0

0

0

0%

2015 CL INICA L A NNUAL R E POR T | 83

D EPA R T M ENT O F P E DI AT RI C S : AN N UA L R E P OR T 2015 DEPARTMENTAL EDUCATION AND TEACHING

DEPARTMENTAL RESEARCH AND SCHOLARLY ACTIVITIES

The Department continues to offer weekly continuing medical education conferences, which are regularly attended by many pediatricians, Family Medicine physicians and residents, nurse practitioners and school nurses. In addition to our staff, speakers come from academic medical centers such as Columbia University College of Physicians and Surgeons, the Albert Einstein College of Medicine, Icahn School of Medicine at Mount Sinai, Connecticut Children’s Medical Center and Blythedale Children’s Hospital, with a few additional experts coming from community and state agencies. This year, we are hoping to begin offering our Grand Rounds lectures via a webinar format for physicians who cannot get to the Hospital.

Papers

Family Medicine residents continue to rotate through Pediatrics. Columbia University College of Physicians and Surgeons medical students as well as Stamford Hospital OB/GYN residents rotate through the NICU. Formal educational and multidisciplinary rounds are held daily on the Pediatric Inpatient Unit. Teaching is also provided by Dr. Hossein Sadeghi to the Pediatric Pulmonary fellows at Children’s Hospital of NewYork-Presbyterian, Family Medicine residents and genetic counselors and Dietary Department students who participate in our Cystic Fibrosis program. All Pediatrics division directors hold teaching appointments at major academic medical centers.

Jennifer Bragg, MD Stroustrup A, Haimes H, Bragg JB, Gui Y, Andra SS, Kannan K, Gennings C. NICU-based phthalate exposure and neurodevelopment. Platform presentation at the 2015 International Society for Exposure Science meeting, Las Vegas, NV. Stroustrup A, Haimes H, Bragg JB, Andra SS, Kannan K, Gennings C. NICU-Based Phthalate Exposure and Neurodevelopmental Outcomes. Poster presentation at the 2015 Pediatric Academic Societies meeting, San Diego, CA. Stroustrup A, Hsu HH, Bragg JB, Svensson K, Guo Y, Kannan K, Wright RO. Environmental chemical exposure in the neonatal intensive care unit. Poster presentation at the 2014 International Society of Environmental Epidemiology annual meeting, Seattle, WA. Sara Shrager Lusman, MD co-authored an Entrustable Professional Activity Curriculum for fellows in pediatric gastroenterology.

Book Chapters Sara Shrager Lusman, MD Peritonitis. Hepatomegaly (with Sivan Kinberg). Asplenia and Hyposplenia (with Joseph Picoraro). The 5-Minute Pediatric Consult 7th edition. Wolters Kluwer Health - Lippincott Williams & Wilkins; 2015.

Presentations and Posters • Donna Bowman, DNP, FNP-BC, RNC-OB, Kathy LiVolsi, MHA, RNC; Paul Bobby, MD; Jennifer Cabral, MD; John Ciannella, MD; Beth Kelley, BSN, RNC-OB; Gerald Rakos, MD; Improvement in Preterm Infant Hypothermia by the Implementation of a Best Practice Bundle presented at International Society of Environmental Epidemiology. • A Stamford Hospital’s NICU poster that showcases our evidence-based nursing practice as well as our partnership with The Tiny Miracles Foundation was accepted by the Planetree Annual Conference.

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D EPA R T M EN T O F P E DI AT RI C S : A N N UA L R E P OR T 2015 COMMUNITY OUTREACH

STRATEGY/FUTURE DIRECTION

The Department was represented at many events and health fairs including:

This coming year promises to be memorable with the opening of the new Cohen Pediatric Emergency Department. We will also look to:

• The Fairfield County Women’s Expo • Health, Wellness & Sports Expo at Chelsea Piers • Community Health Fairs • Fairfield County Sports Commission • Stamford Restaurant Week • March of Dimes March for Babies • Early Childhood Fair School Readiness Council • Fall Harvest at Fairgate Farms • Stamford Childhood Obesity Prevention Task Force • Cystic Fibrosis Foundation’s Great Strides Walk • Stamford Public School Teacher Orientation

• Complete the design of the Cohen Children’s Unit with construction beginning in late 2016 or early 2017. • In collaboration with the Department of Emergency Medicine, recruit a Director of Pediatric Emergency Medicine in preparation for the opening of the new Pediatric Emergency Department. • Further recruit specialists for the Cohen Children’s Specialty Center, particularly in Pediatric Surgery. • Further develop a simulation testing program for all Hospital-based physicians and nurses. • Collaborate with the Stamford Health Department in the Connecticut Hospital Association’s Statewide Asthma Initiative. • Develop a NICU Parent Advisory Board. • Expand the NICU’s Infant Massage program. • Explore offering Grand Rounds via a web simulcast. • Continue efforts to recruit un- and under-insured children and youth with special healthcare needs for the Medical Home Initiative. • Continue philanthropic activities related to Pediatrics in the Healing Reimagined campaign. • Plan to replace aging cardio-respiratory monitoring equipment in the NICU and Pediatrics. • Explore research opportunities with the Vermont Oxford Neonatal Network. • Together with Physician Relations, continue visiting area practices to inform them of ongoing and planned Departmental programs and initiatives.

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p s y c h i at r y

We continue to reduce ED gridlock by holding four beds for emergency patients on the inpatient Psychiatric Unit.

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D EPA R T M EN T O F P S YC HI AT RY: A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Draupathi Nambudiri, MD, FAPA Chair, Department of Psychiatry

I

n the past year, the Department of Psychiatry has accomplished a great deal in its role as the major provider of patient-centered mental health assessment and treatment services for patients with acute and serious psychiatric disorders in the greater Stamford community. Specifically, we: • Maintained a high quality inpatient and consultation/ liaison service to meet the ever-increasing psychiatric care needs of our patients. • Met all requirements to maintain substantial grant funding through the Department of Mental Health and Addiction Services in the amount of $289,000 per year.

• Maintained the program that began in July 2004 to provide evening and weekend psychiatric house physician services in the ED to facilitate timely assessment of psychiatric patients. • Maintained a collaborative relationship with the Dorothy Bennett Behavioral Health Center at Optimus Health Care and Dubois Center in Stamford to provide continuity of high-quality psychiatric care to patients. The Department’s clinical services remained quite busy with significant activity. We continue to see large numbers of individuals from the community who present to the Hospital’s Emergency Department in need of psychiatric and substance abuse services. There was a 7% increase in inpatient volume in the Psychiatry Unit compared to the previous year and 13% increase compared to FY13 (5,072 days in FY15 compared to 4,728 in FY14 and 4,463 in FY13). The average length of stay increased from 6.4 days in FY13 to 8 days in FY14 and 9 days in FY15, reflecting the increased patient acuity and limited community residential resources for patients. Data on Department volume is presented in Figures 1 and 2 below. Figure 1: Psychiatric Inpatient Service (South-1) FY15

• Continued to reduce Emergency Department gridlock and improve clinical services through our emergency psychiatric hold program, providing four psychiatric ED hold beds located on the inpatient Psychiatric Unit. • Qualified for Connecticut Behavioral Health Partnership Bypass Program for Adult Inpatient Providers by reducing the average length of stay and the seven-day readmission rate to below the State averages.

The Psychiatry team. 2015 CL INICA L A NNUAL R E POR T | 87

D EPA R T M ENT O F P S YC HI AT RY: A N N UA L R E P OR T 2015 There was an 11% decrease in the Medical/Surgical and substance abuse consultations last year: 2,710 consults in FY15 compared with 3,056 consults in FY14. This probably is related to staff vacancies in the Department.

Upon discharge, patients receive a carefully constructed discharge plan and arrangements for aftercare. We invite involvement of a patient’s family or significant other (with patient permission) during this process.

Figure 2: Consultation/Liaison Services Volume

Consultation Liaison/Medical, Surgical and Emergency Department Consultation Services

ED Consults

Floor Consults

Substance Abuse Consults

Total # of Consults

Change from Last Year

FY12

1,486

1,188

93

2,767

+10%

FY13

1,541

1,984

126

3,651

+32%

FY14

1,501

1,533

22

3,056

-16%

FY15

1,554

1,156



2,710

-11%

SCOPE OF CLINICAL SERVICES

There is an ever-increasing demand for psychiatric evaluation services in the Emergency Department. Disorders such as delirium, behavioral difficulties associated with dementia, acute anxiety, panic, psychotic disorders, depressive states, alcohol and substance use disorders are but a few of the common difficulties which the Department is called upon to address with the medical/surgical inpatient population. The Psychiatry Consultation/Liaison service plays a vital role in the care of these patients.

MEDICAL STAFF

Inpatient Services The inpatient Psychiatric Unit at Stamford Hospital is the major provider of patient-centered mental health assessment and treatment services for patients with acute and serious psychiatric disorders in the greater Stamford community. The community has come to trust and rely upon the high quality of acute care with rapid assessment and stabilization delivered on the inpatient service. As the only community hospital-based inpatient psychiatric service between the New York-Connecticut border and Norwalk, Connecticut, this service provides a vital link in the mental health care of those who reside in lower Fairfield County. We maintain a high caliber of service on this unit while exploring how best to serve specialty populations in the area. The Department’s approach to mental health is multidisciplinary, and our care team is sensitive and compassionate to patients and their families. In addition to psychiatrists, psychiatry nurse practitioners and psychiatry physician assistants, nurses, and technicians, patients may also work with social workers, a substance abuse counselor, a case manager, an activity therapist and other support staff. Treatment is highly individualized to the unique needs of each patient. We offer dual-diagnosis behavioral health treatment services, group and individual behavioral therapy, medical psychiatry and psychopharmacological interventions. Pet therapy, music therapy, spirituality and relaxation groups are also available. 8 8 | DEPAR TM ENT O F P S YC H I AT RY

F. Carl Mueller, MD, FAPA Associate Chair

New Staff • Michael Adusei, MD • Dmitry Meyerovich, MD

Transitions • Simon Ovanessian, MD left the medical staff in March 2015 • Hale Perlmutter, PAC left the Ancillary staff in August 2015 • Sarah Bernier, APRN left the Ancillary staff in September 2015 • Farid Force, MD became Honorary Staff in September 2015

Hospital Committee Participation • Enenge A’Bodjedi, MD — Department Executive Committee, Outpatient Behavioral Health CQI Committee, Department Medical Peer Review Committee (Chair)

D EPA R T M EN T O F P S YC HI AT RY: A N N UA L R E P OR T 2015 • F. Carl Mueller, MD — Department Executive Committee, Medical Executive Committee • Draupathi Nambudiri, MD — Medical Executive Committee, Graduate Medical Education Committee, Department Executive Committee (Chair), Continuing Medical Education Committee, Inpatient Psychiatry CQI Committee, Hospital Falls Committee, Alcoholism Steering Committee, Patient Safety and Quality Committee, member Core Measures work group, Dementia Work Group • Rachit Patel, MD — Inpatient Psychiatry CQI Committee, Department Medical Peer Review Committee, Pharmacy and Therapeutic Committee

Seven-Day Readmission Rate Our seven day readmission rate remained steady at 4% in FY15 and FY14, a decrease from 5% in FY13.

Average Length of Stay (ALOS) Our inpatient unit staff has worked hard to reduce the average length of stay from 10.07 days in FY10 to 8 days in FY14 (Figure 3). In FY15 the ALOS increased to 9 days. This increase in ALOS is due to increased patient acuity and limited community residential resources for patients. Figure 3: Average Length of Stay (ALOS)

• Jeffrey Koffler, MD — Department Executive Committee • Gopal Upadhya, MD — Department Peer Review Committee, Department QIC (Chair)

DEPARTMENTAL SAFETY AND QUALITY Psychiatry Core Measures, HBIPS Psychiatry Core Measures target patient safety, quality of care and timely transmission of clinical information to next level of care. The Core Measure also includes compliance with screening all admissions to the inpatient Psychiatric Unit for alcohol and substance abuse using a special screening tool. At the beginning of the year our completion rate for the HBIPS was 92% and by mid-year we increased the compliance rate to 100%. Our overall compliance for the rest of the year was 94.7%. Since January 2015 the inpatient Psychiatric Unit has been participating in Tobacco Screening (TOB) Core Measures. For the year we are 100% compliant in screening patients for tobacco use and 95% compliant with ordering nicotine replacement therapy. Only about 75% of our patients currently accept the treatment.

Patient Satisfaction Patient satisfaction on the inpatient Psychiatric Unit is tracked by using a patient survey that is given to all patients who are discharged from the unit. The score range is from 1–5, with 1 being the lowest and 5 the highest. For FY15, the score was 4.36, which was higher than past years (4.32).

Thirty-Day Readmission Rate Our thirty-day readmission rates decreased from 14% in FY13 to 8% in FY14. The rate for FY15 was 10%.

AWARDS AND ACCOLADES • Justin Schechter, MD was reappointed by Governor Dannel Malloy and the Connecticut State Legislature, to serve another three years on the Psychiatric Security Review Board (PSRB). This board monitors the treatment, safety and security of those individuals found not guilty by reason of insanity. This is Dr. Schechter’s third consecutive term on the board. • Sejal Vyas, PhD received 2015 Best of Stamford Award in the Doctors category. • Christina Kunec, PsyD was appointed Director of Stamford Hospital’s Concussion Center in March 2015. • Justin Schechter, MD served as a Consultant for the Veterans Administration Compensation and Pension Division. 2015 CL INICA L A NNUAL R E POR T | 89

D EPA R T M ENT O F P S YC HI AT RY: A N N UA L R E P OR T 2015 DEPARTMENTAL EDUCATION AND TEACHING ACTIVITIES The Department’s academic activities continue to enhance the quality of care rendered to patients, as well as the educational experience provided to physician assistant students from Quinnipiac College and nursing students from local universities. Academic experiences with these students keep the Department vibrant and provide the opportunity to teach and continue to learn. Department members were involved in Grand Rounds presentations here at Stamford Hospital. This year’s Grand Rounds presentations included: TOPIC

LECTURER

HIPAA & Stamford Hospital Engagement

Stacey Spilka HIPAA Privacy Analyst & Team Leader for Release of Information Specialists

Transcranial Magnetic Stimulation

Joseph Deltito, MD Clinical Professor at NY Medical College & Senior Research Consultant at the Giafranco De Lisio Research Institute (Pisa, Italy)

Narcissism & Narcissistic Disorders

Richard Gallagher, MD Professor of Clinical Psychiatry and Behavioral Science, New York Medical College Faculty, Columbia University Psychoanalytic Institute

Practice Guidelines for Bipolar Disorder: What's Useful, What's Not & What's Missing

Joseph Goldberg, MD Clinical Professor of Psychiatry Icahn School of Medicine at Mount Sinai, New York, NY

ADHD: The Facts with an Emphasis in Psychiatry

Sejal Vyas, PhD Pediatric & Adult Neuropsychologist & Assistant Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai

An Evidence Based Approach to Concussion Management

Christina Kunec, PsyD Neuropsychologist Stamford Hospital

Decision Making Capacity

Christine Naungayan, MD CEO and Founder of Awakenings & Forensic Psychiatric Consultant

Duty to Warn: Duty to Protect. Tarasoff Law

Rachit Patel, MD Staff Psychiatrist Stamford Hospital

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In addition: • Simon Ovanessian, MD served as teaching faculty for the Osler Institute Psychiatry and Neurology Board preparation courses, and the Blue Tower Child Psychiatry Course, lecturing on topics such as addiction, substance abuse and psychiatric disorders. • Gopal Upadhya, MD received a Clinical Adjunct Assistant Professor degree at Quinnipiac University for his active participation in PA student education. • Justin Schechter, MD was reappointed as Assistant Clinical Professor of Psychiatry at Yale University School of Medicine.

DEPARTMENTAL RESEARCH AND SCHOLARLY ACTIVITIES Presentations Improved Treatment Acceptance and Adherence Following the Diagnosis of Multiple Malformations of Cortical Development in a Patient with Psychosis: Rachit Patel, MD, Kathleen Stuart, MSN, APRN, Draupathi Nambudiri, MD; APA Annual Meeting, May 2015. Poster session. S.K. Vyas, PhD. Everyone Reading Conference: Treating ADHD and Executive Functioning: The Facts – Part II March 3, 2015. S.K. Vyas, PhD. Everyone Reading Conference: Understanding ADHD: The Facts- Part I, March 3, 2015. S.K. Vyas, PhD. Grand Rounds held at the Stamford Hospital, Department of Psychiatry: ADHD: The Facts with an Emphasis in Psychiatry, February 12, 2015. S.K. Vyas, PhD. Attention-Deficit/Hyperactivity Disorder Grand Rounds held at the Stamford Hospital, Department of Pediatrics Stamford, CT, November 13, 2014. S.K. Vyas, PhD. “Understanding and Treating ADHD: What it is and how you can most effectively help your child.” Community Education held at Cognitive Behavioral Consultants of Westchester and Manhattan, White Plains, NY, October 20, 2014. S.K. Vyas, PhD. Treatment Implications for Executive Dysfunction Seminar for Psychologists, held at cognitive Behavioral Consultants of Westchester and Manhattan, White Plains, NY, September 14, 2014.

D EPA R T M EN T O F P S YC HI AT RY: A N N UA L R E P OR T 2015 Publication Christine Kunec, PsyD published two book chapters, references noted below: Kunec, C., Fedor, S., Collins, M. What constitutes a “failed” post-concussion test for athletes with baseline neurocognitive or balance tests? Quick Questions in Sport-Related Concussion. Edited by Valvovich, McLeod TC. Thorofare, NJ: Slack Incorporated. Hofbauer, M., Muller, B., Ward, J., Murawski, C., Wolf, M., Kunec, C., Collins, M., & Fu, F. Concussion in Sports Traumatology: Future Trends. In N. M. Doral & J. Karlsson (Eds.), Sports injuries: Prevention, diagnosis, treatment and rehabilitation. Springer Reference.

COMMUNITY OUTREACH Christina Kunec, PsyD gave a number of presentations and talks as part of the Concussion Center’s community outreach initiatives. She spoke at local YMCAs, SONO Ice House, Stamford Youth Foundation and Chelsea Piers Connecticut. Carl Mueller, MD was interviewed by The Connecticut Post about the impact of multiple snow storms on anxiety and depression during winter months. Draupathi Nambudiri, MD was one of the panelists for a United Way of Western Connecticut discussion on Behavioral Health issues in Stamford.

STRATEGY/FUTURE DIRECTION The Department’s focus in the next year and beyond is in the following areas:

Inpatient Services • Geriatric Psychiatry — Expanding geriatric psychiatry services will become increasingly important with the aging of “baby boomers.”

• Dual Diagnosis Treatment Services — As co-morbid psychiatric/substance abuse disorders continue to rise, the Unit will continue to adopt evidence-based practices in order to provide high-quality services for dually diagnosed patients. • Behavioral Health — The team actively participates in the Behavioral Health Work Group and will continue to lead projects to raise awareness and educate our communities about mental illness and impacts of alcohol and substance abuse. • Access to Care — Collaborate with community treatment providers to improve access to care for mentally ill substance abuse patients.

Consultation Liaison/Medical, Surgical and Emergency Department Consultation Services • Continued strengthening of the psychiatric house physician program to meet the growing demand for psychiatric evaluation of patients presenting to the ED after hours and on weekends. • Modification of the physical environment for psychiatric assessment in the ED to accommodate increasing demand and improve customer services and satisfaction. This will be accomplished when the new ED construction project is completed in the coming year. • Increased collaboration in the care of patients admitted to general hospital floors with co-morbid alcohol and substance abuse disorders. • Close collaboration with geriatric medicine to develop the dementia program at the Hospital. The Department of Psychiatry is committed to partnering with colleagues in all departments, and providing the finest psychiatric and behavioral healthcare services available.

• Medical Psychiatry Service — Assessment and treatment of co-morbid psychiatric/medical illnesses will have an increasingly pivotal role, particularly as we are the only community providers of these services in the area.

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r a d i o lo g y

Utilizing advanced technology and clinical expertise to care for more than 150,000 people each year.

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D EPA R T M EN T O F R ADI O LOGY: A N N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Brian Stainken, MD Chair and Medical Director, Department of Radiology

I

have been involved in Radiology since 1986, but have only been a part of Stamford Hospital for two short months. Eyes wide open and taking it all in — and what a sight it is. A magnificent glass tower in the background, grounded by a culture based on a Planetree. Hands-on and high-tech. What’s not to like about that? There is an advantage to being old and new. In the course of my 30 years in Radiology, everything has changed. I learned medicine when a wet reading was literal. I read wet x-ray films, wrote a note longhand in the chart and dictated a report that showed up in a few days. MR, CT, US, were in their infancy and IR, my chosen field, was just beginning. Fast forward to 2015, every single organ system, and every field of medicine has enjoyed significant advances as a direct result of advances in imaging and interventional medicine. It is not an exaggeration to say that Imaging and Interventional Radiology represent one of the top 11 most important medical advances of the last millennium. In fact, that’s what the editors of the New England Journal said in 2000 (Looking back on the millennium in medicine, New England J Med 342: 42-49, 2000). And, in this field, the pace of change has not slowed in the intervening 15 years. If anything, it has accelerated. Stamford has enjoyed, embraced and benefited from those changes and advancements. As the role of imaging and image-guided intervention has evolved, so have the models for delivery of care and that trend shows no sign of slowing. It’s all fast, automated and online. Three to five days to receive a hand-typed final report? How about three minutes! No one misses the time spent in front of those old smelly wet films talking about the meaning of the hazy shadow that might or might not be there. We do not miss that sense of uncertainty. What we do miss, and what we must work to improve, is the personal connection. It’s that desire to connect, to consult and

communicate that, in this newcomer’s opinion, separates Stamford’s staff from the pack. And it is where we need to catch up. We will push for new technology, because it is going to make our patients’ lives better by diagnosing earlier, treating less invasively and curing more often. But at the same time, we will focus equally on new ways of communicating, on supporting the effective delivery of information and enabling consultation and ongoing communication because that is what will take us to new heights. High-tech, hands-on. Computerized imaging made better by talking more. Makes sense to me. I would be remiss not to recognize and honor the hard work of one particular member of the Department who played a central role in building and supporting the Stamford Hospital Radiology Service over many years. Dr. Michael King, has served as Interim Chair for the past three years and as the primary Abdominal Imager at Stamford Hospital for 16 years. Besides being an indefatigable spirit, Mike is an extraordinarily talented physician who has served the institution and its patients well. We wish him the very best. In the following pages, you will have a chance to read about the remarkable group of people who make up the Radiology team. To an individual they represent the best in their class, people whom the Stamford Hospital community can be proud to call their own.

SCOPE OF CLINICAL SERVICES The Department performed 169,377 examinations this year, creating well over a million images. We create digital virtual images of humans using x-rays, gamma rays, beta rays, ultrasound energy and FM frequency radio waves. You see the finished products as Breast Tomosynthesis, Bone Densitometry, Computerized Tomography, General Radiography, Magnetic Resonance Imaging, Nuclear Medicine, Positron Emission Tomography and Ultrasound. In addition to diagnostics, image-guided procedural care is offered in Breast Imaging, Vascular and Interventional Radiology, Nuclear Medicine and Radiation Oncology. Stamford Hospital Radiology physicians complete five years of post-doctoral training as well as one to two years of fellowship training prior to obtaining subspecialty board certification in Body Imaging, Breast Imaging, Pediatric Imaging, Musculoskeletal Imaging, Neuro-Imaging, Nuclear Medicine, Vascular/Interventional Radiology and Radiation Oncology. 2015 CL INICA L A NNUAL R E POR T | 93

D EPA R T M ENT O F R ADI O LOGY: AN N UA L R E P OR T 2015 The Department is currently organized into three divisions. The largest is the General Diagnosis and Interventional Radiology group. These services are currently anchored by a group of six on-site specialized Radiologists as well as a network of 24 additional Radiologists who provide services from remote locations. General Diagnostics includes the subspecialty fields of Abdominal Imaging, Chest Imaging, Musculoskeletal Imaging, Neuroimaging, Nuclear Medicine and Interventional Radiology. We provide the full scope of services 24/7 with 100% final reports in the major disciplines of Radiology. The Breast Imaging Division is a nationally recognized leader in the delivery of comprehensive breast diagnostic care. Four fellowship-trained mammography experts provide comprehensive “one stop” services for more than 20,000 women cared for at the Women’s Breast Center at the Tully Health Center and Darien Imaging Center. Stamford Hospital was the first, and remains one of the only programs nationwide, to provide 3-D digital breast tomography for all screening mammography patients. This revolutionary tool uses a low-dose x-ray beam to literally see through tissues, find smaller cancers earlier and significantly reduce unnecessary imaging and intervention. Our personal experience, performing tens of thousands of tomosynthesis studies shows a cancer detection rate more than 50% greater than prior to tomosynthesis. With

Figure 1: Annual Trends by Location for FY15

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Connecticut having the highest incidence of breast cancer in the country, we are proud to provide this incredibly high level of accuracy to the women in our community. Radiation Oncology represents a cornerstone of Stamford Hospital’s comprehensive cancer program. Practicing from the Bennett Cancer Center and CyberKnife Center at the Tully Health Center, our two Radiation Oncologists offer state-of-the-art radiation therapy and stereotactic radiosurgery to approximately 400 new patients every year, mostly on an outpatient basis. This year, Stamford Hospital began offering high-dose rate (HDR) remote implant therapy for use primarily with gynecologic malignancies. This technology allows our patients to access all aspects of gynecologic radiation therapy at Stamford Hospital, thus eliminating the need for referrals to other institutions.

DEPARTMENTAL SAFETY AND QUALITY The radiological specialties span almost every aspect of in- and outpatient healthcare. We offer care to well over 150,000 people every year, and are involved in every organ system and disease state. We serve your patients as well as your practices, and many of us also maintain our own active clinical practices. The definition of quality in each of these domains is different but unified by a common goal of striving to deliver the best.

D EPA R T M EN T O F R ADI O LOGY: A N N UA L R E P OR T 2015 Radiation Safety

Accuracy

Radiology began in the 1930s in response to the growing recognition that x-rays could cause harm. Our roots as a specialty are invested in the protecting the patient. During training, Radiologists and Radiation Oncologists, Radiation Physicists and Technologists are all educated and certified in the physics of radiation and the science of radiation safety. There is growing interest from the public as well as regulators on the topic of radiation safety and medical applications. One such example is the Connecticut Hospital Association’s statewide Radiation Dose Management Collaborative committee on which Sarah Bull, our Radiation Safety Officer, Dr. David Gruen, Co-Director of the Women’s Breast Center, and Jory Vidulich Savino, Quality Imaging Manager, participate.

Making all the findings on an imaging study can be a daunting task. What was one to four images per patient in the era of plain film radiology is now easily 250 – 400 for a CT and up to 1,000 for many MRI examinations. We know that the average radiologist misses between two and 20% of the findings on based on second reviews. The more images, the more information, the higher the chance something will be missed. Importantly, and perhaps not as well understood, is that this error rate is roughly identical for colonoscopy and missed major diagnoses at autopsy. (Ulster Med J. 2012 Jan; 81(1): 3 – 9. Discrepancy and Error in Radiology: Concepts, Causes and Consequences Adrian Brady, Risteárd Ó Laoide, Peter McCarthy, and Ronan McDermott). We also know that we can impact our error rate through vigilance, education and, perhaps most importantly, communication. The fundamental importance of communicating up front about presentation, examination and suspected diagnosis, and as importantly, communicating when exam findings and clinical metrics are discrepant, cannot be overstated.

Two important radiation safety initiatives are the Image Gently (alliance for radiation safety in pediatric imaging — “child-sized” radiation) and Image Wisely (radiation safety in adult medical imaging) programs. At Stamford Hospital we are committed to: • Communicating openly with parents about imaging doses (“child-sized” imaging). • Putting patients’ safety, health and welfare first by optimizing imaging examinations to use only the radiation necessary to produce diagnostic quality images. • Conveying the principles of the Image Gently and Image Wisely programs to the Imaging team in order to ensure that our facility optimizes its use of radiation when imaging patients. • Communicating optimal patient imaging strategies to referring physicians, and having Radiologists available for consultation. • Routinely reviewing imaging protocols to ensure that the least radiation exposure or dose necessary to acquire a diagnostic quality image is used for each examination.

In the Radiology Department we track accuracy in a variety of ways. When we hear about a possible error in a report, we review the study independently and assess whether the missed finding was obvious or not. We also assess in the context of the clinical significance of the miss for the patient. In addition, the same system is used to randomly select approximately 5% of the studies we read which are randomly submitted for reinterpretation. Discrepancies are tracked by physician and also submitted to a national registry where normalized data is provided. Led by Dr. Howard Liu, our departmental Peer Review Committee reviews this data and reports to the administration quarterly. We also have an internal conference to review cases with teaching value.

Timeliness A report that is not available when decisions must be made has no value. We are proud to note that our reporting turnaround time is on average 20 minutes or less for a STAT request, less than 27 minutes for an urgent request and less than four hours for routine requests (Figure 2).

2015 CL INICA L A NNUAL R E POR T | 95

D EPA R T M ENT O F R ADI O LOGY: AN N UA L R E P OR T 2015 Figure 2: TAT (2015 Average Turn Around Time by Modality in Minutes) Month

ED

Inpatient

Outpatient

Jan

32

282

573

Feb

36

203

586

Mar

45

363

535

Apr

34

298

603

May

77

287

634

Jun

33

451

767

Jul

41

271

788

Aug

66

157

534

Sep

35

215

535

Physician Satisfaction In 2015, we completed our biennial Radiology Medical Staff Survey. The response rate increased significantly (32%) compared with the 2013 survey. All metrics trended up since the 2013 survey with 10 of the 13 categories increasing significantly. The key metrics associated with physician satisfaction, the percent satisfied or very satisfied and the percentage improvement compared with 2013 are:

2015

2013

Accuracy 89% 28% Consistency 79%

24%

Patient Satisfaction

Specialized 80%

26%

The Breast Imaging Division enjoys high satisfaction rates every month. This is driven by a nationally recognized best practice wherein patients receive the best imaging combined with a well-designed process and instant results. We all stand to learn from the success of this program and we continue to do so.

Accessible 88% 26%

In 2015, overall, our patients rated their satisfaction on a 100-point scale between 90 and 97% (Press Ganey and customer feedback survey data is shown in Figure 3). Figure 3: 2015 Breast Imaging Press Ganey Data

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Responsive 88%

19%

Certification Quality programs meet certification standards and pass site visits. There are multiple organizations involved in assessing quality and program certification. The Stamford Radiology practices are accredited by The Joint

D EPA R T M EN T O F R ADI O LOGY: A N N UA L R E P OR T 2015 Commission and the imaging modalities of CT, MRI and Ultrasound and Breast Imaging are also accredited by the American College of Radiology (ACR). Nuclear Medicine is accredited by ICANL. We have been inspected by the Nuclear Regulatory Commission (NRC), ACR, State of Connecticut and Mammography Quality Standards Act (MQSA), all with excellent results.

HONORS AND RECOGNITION • Dr. Gruen was inducted as a Fellow of the American College of Radiology. This honor is awarded to fewer than 10% of Radiologists in recognition of their service to the field.

Awards • The Breast Center received reaccreditation from the National Accreditation Program for Breast Centers, and was cited for numerous “best practices.” The program was the first in the nation to have received accreditation from the National Accreditation Program for Breast Centers and one of the first to have received it three times. • The Women’s Breast Center was again designated a Breast Center of Excellence by the American College of Radiology, one of only a handful in the state to receive this coveted designation. • The Center again received the Women’s Choice Award as an America’s Best Breast Center.

Conferences • Drs. Frank Masino and Sean Dowling organize and help chair more than 150 conferences annually. • Diagnostic Radiologists and Interventional Radiologists participate and present imaging studies at the following weekly multispecialty tumor boards: Breast, Gastrointestinal, Lung, Neuro-Oncology, Gynecology, Hematology and Genito-Urinary. • Diagnostic Radiologists present imaging studies at Trauma Conference. • Outreach: Community education is promoted through a robust outreach program, which involves physicians. The physicians and staff at the Bennett Cancer Center work collaboratively with the City of Stamford Department of Health, American Cancer Society and other physicians on the medical staff to provide community outreach.

Research/Scholarly Activity Brian Stainken, MD, “Trauma Management” Chapter 15 Handbook of Interventional Radiologic Procedures 5th Edition Lippincott Williams & Wilkins (in press). Gruen D, MD, Pass A, MD, Bishop J, “Management of Breast Masses in Women 25 and younger: A multi-year retrospective evaluation.” (Submitted for review).

• The Breast Center became a participant in the National Quality Metrics Program for Breast Centers, one of only a few in the state.

Departmental Education and Teaching Activities • Harvey Hecht, MD, an Associate Clinical Professor in the Department of Radiology at Columbia Presbyterian Hospital, continues to lecture and teach medical students and Radiology residents at monthly conferences.

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D EPA R T M ENT O F R ADI O LOGY: AN N UA L R E P OR T 2015 DIVISIONS

GENERAL DIAGNOSTIC AND INTERVENTIONAL:

• Brian Stainken, MD, FACR, FSIR, FCIRSE * (new) CAQ Interventional Radiology »» Fellowship: Vascular & Interventional Radiology, UCLA »» Joined the department in August as Chairman. »» Executive Committee of the Stamford Hospital Medical Staff »» Executive Council, The Society of Interventional Radiology (SIR)

Abdominal Imaging

Musculoskeletal Radiology

• Michael King, MD* »» Fellowship: Body Imaging Columbia Presbyterian, New York »» Trauma Committee

• Elizabeth Gaary, MD* »» Fellowship: MSK/MRI Radiology, Cornell University, Hospital for Special Surgery

* Denotes Stamford Hospital practice site. Note that all Radiology staff are certified by the American Board of Radiology. Additional American Board Added Qualification Certifications, CAQs, are as noted below. Committee Activity is noted in italics.

• Gregory Lee, MD* »» Fellowship: Breast and Body Imaging NewYork-Presbyterian Hospital-Weill Cornell Medical College • Patricia Barnes, MD »» Fellowship: University of Texas, MD Anderson Hospital • Mary Grebenc, MD »» Fellowship: National Naval Medical Center • Leslie Jacobson, MD »» Fellowship: Henry Ford Hospital

Vascular and Interventional • Bryan Lazzara, MD* CAQ Interventional Radiology »» Fellowship: Vascular & Interventional Radiology, Columbia University Medical Center • Josef Noga, MD* CAQ Interventional Radiology »» Fellowship: Vascular & Interventional Radiology, Columbia University Medical Center

• Michael A. Mahlon, DO »» Fellowship: Musculoskeletal Radiology, Penn State University • Anthony J. Minotti, MD »» Fellowship: Body Imaging, Metro Health Medical Center

Neuroradiology • Howard Liu, MD* CAQ Neuroradiology »» Fellowship: Neuroradiology, Yale University School of Medicine »» Chair, Radiology Peer Review • Bryan Lazzara, MD* CAQ Neuroradiology »» Fellowship: Neuroradiology, Northwestern University • Lorraine M. Ash, DO CAQ Neuroradiology »» Fellowship: Neuroradiology, University of Michigan • Tony Y. Maung, MD »» Fellowship: Neuroradiology, Harbor UCLA Medical Center • John R. Wohlwend, MD »» Fellowship: Neuroradiology, Northwestern University Program/McGaw Medical Center

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D EPA R T M EN T O F R ADI O LOGY: A N N UA L R E P OR T 2015 Nuclear Medicine • Harvey Hecht, MD* »» American Board of Nuclear Medicine • Josef Noga, MD* • Anthony J. Minotti, MD »» CAQ Nuclear Radiology

Pediatric Imaging • Terry L. Levin, MD* CAQ Pediatric Radiology »» Fellowship: Pediatric Radiology, Columbia Presbyterian Hospital

• Valencia King, MD* (new) »» Fellowship: Breast Imaging, Memorial Sloan Kettering Cancer Center »» Joined the Breast Imaging group in September after serving on the faculty at Memorial Sloan Kettering Cancer Center. • Allyson Parnes, MD * (new) »» Fellowship: Breast Imaging, Columbia University »» Joined the breast imaging team in December 2014 after completing a women’s imaging fellowship. »» Stamford Hospital Orientation Buddy

RADIATION ONCOLOGY

• Mark J. Halsted, MD CAQ Pediatric Radiology »» Fellowship: Pediatric Radiology, Cincinnati Children’s Hospital; Pediatric Neuroradiology, Cincinnati Children’s Hospital

• Frank A. Masino, MD* »» Medical Director of Cancer Services »» Director of Radiation Oncology »» Board Certification: Therapeutic Radiology »» Fellowship: Radiation Oncology, Yale »» Chair, Stamford Hospital Cancer Committee

• Chris J. Schettino, MD CAQ Pediatric Radiology »» Fellowship: Pediatric Radiology, Miami Children’s Hospital

• Sean W. Dowling, MD* »» Radiation Oncologist »» Board Certifications: Radiation Oncology and Internal Medicine »» Fellowship: Radiation Oncology, Yale »» Stamford Hospital Radiation Safety Committee

BREAST IMAGING/BREAST CARE: • David Gruen, MD, MBA, FACR* »» Director, Women’s Imaging »» Co-Director, Women’s Breast Center »» Fellowship: Oncologic Imaging, Memorial Sloan Kettering Cancer Center »» Chairman, Stamford Hospital Credentials Committee Vice President, Radiology Society of Connecticut »» Councilor, CT Chapter, American College of Radiology »» American College of Radiology National Breast Commission on Economics, »» Connecticut Hospital Association Commission on Radiation Safety • William Caragol, MD* • Lily Kernagis, MD* »» Fellowship: Breast Imaging, University of Pennsylvania

2015 CL INICA L A NNUAL R E POR T | 99

i nn ov a t io n i n

surgery

Using the latest robotic technology to advance our surgical capabilities and deliver a broad spectrum of procedures, from minimally invasive to complex, multi-quadrant surgeries.

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D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 A MESSAGE FROM THE CHAIR: The Year in Review

Michael D. Stone, MD Chair, Department of Surgery

E

very day as we arrive at Stamford Hospital, we can see progress toward completion of the new hospital building, a spectacular reminder of our bright future. This sense is further enhanced when we take visitors on tours of the interior of the new facility, which is beginning to look like the advanced medical center we will move into in September 2016. Many visiting surgeons, including some who thought the new center would never be built, have been impressed by, and have expressed a desire to be a part of, the future at Stamford. They marvel at the extraordinary technology that will be housed in our trauma center, specialized orthopedic and neurosurgical operating rooms and a hybrid operating room that allows us to provide synchronous, multidisciplinary approaches to patients who require complex procedures. The new ORs will have the most up-to-date equipment possible in a rapidly changing technologic environment. As we unveil our new surgical robot, we will have the most advanced capability in Fairfield and Westchester counties, allowing us to do procedures not previously possible in the abdomen, pelvis and chest. We have been in the vanguard in our geographic region in the application of three dimensional visual, navigational and guidance systems for pulmonary, neurosurgical, orthopedic and gastrointestinal surgery, and will continue to lead the way through thoughtful acquisition of new technologies. Stamford Hospital will be the safest place to have surgery in the area. Construction details such as antimicrobial copper-impregnated touch surfaces will contribute to our ongoing and successful efforts to reduce surgical infections (see Figure 2). The most important “touch surface” is the patient. It is that personal touch that our staff provides every day that will lead to our continuing success. We fully expect that patients and physicians will come to Stamford Hospital to see and experience the new facility. Those patients, their neighbors and friends will come back to our facility again because of

the extraordinary people who provide superb care every day. High-quality surgical care requires attention to detail from every staff member, some of whom never touch the patient physically, but their work product does. The patient experience is made up of interactions with Admitting, Patient Registration, Transportation and Environmental Services as well as Radiology, Laboratory Services, Nursing, Residents and Physicians. During patient satisfaction rounds with our clinical nurse manager over the last several weeks, I have heard almost universal appreciation for the high quality of care from all, but most importantly for the caring from all. While these rounds have been reassuring, the word “almost” reminds us that we can and will do better. Every day we look to find new approaches to improve the patient experience, whether it is remodeling the ambulatory surgery waiting area or providing the resident staff with business card “bookmarks” complete with the resident’s picture so their patients will remember them. We already are seeing the value of our efforts. Our surgical volume has increased approximately 6% for each of the last two years, as shown in Figure 1. More importantly, our patient satisfaction scores have reached new highs at both the Tully and Main Hospital perioperative areas. We understand that the success of the new hospital will depend on continuing to create changes that maintain this trajectory. This year we have added new staff in Orthopedics, Pediatric Orthopedics, Hand Surgery, Pediatric Plastic Surgery, Podiatry and Vascular Surgery. Our focus, as we look to the future, is to maximize our capabilities in minimally invasive and natural orifice/endoscopic surgery in all areas. Our goal and commitment is to provide surgical care that is equal to our spectacular new facility and recognized as the safest in Connecticut. Figure 1: Department of Surgery: 2015 by the Numbers Divisions/Sections:

19

Staff: (active, courtesy, honorary and provisional)

159

Residents:

17

Physician Assistants & Nurse Practitioners:

19

OR Procedures: Total Cases: Tully: Main OR: Endoscopy:

19,125 6,655 5,678 6,792

6.6% increase 6.1% increase 9.4% increase 4.9% increase

2015 CL INICA L A NNUA L R E POR T | 101

D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 SCOPE OF CLINICAL SERVICES MEDICAL STAFF The following is an overview of the Department’s divisions and active staff.

GENERAL SURGERY Active Staff: • James Bonheur, MD • Neeta Chaudhary, MD • Marissa DeFreese, MD • Xiang Do (Eric) Dong, MD

guided exercise programs within the Tully Health Center’s Health & Fitness Institute, nutritional support from an experienced team of nutritionists and dieticians, a variety of services provided by Stamford’s Integrative Medicine practices and of course Bariatric Surgery. Our goal is for patients to learn the importance of healthy living and overall wellness. CSWL surgeons, members of the section of Bariatric Surgery, perform all bariatric procedures, including laparoscopic gastric bypass, sleeve gastrectomies and gastric banding. Physicians are developing new capabilities in upper gastrointestinal endoscopic procedures to extend the armamentarium of weight-loss procedures.

BREAST SURGERY

• Kevin Dwyer, MD

Division Leadership

• Kevin Miller, MD • Harold Neyra, DO • Joey Papa, MD • Michael Stone, MD

Helen A. Pass, MD

The Division of General Surgery continues to expand its expertise in surgical care with particular emphasis on high-quality minimally invasive surgery. We have excellent outcomes and high patient satisfaction. Members of the Department are highly skilled in minimally invasive approaches to hernia repair, endocrine surgery and bariatric surgery.

Director of Breast Surgery

Active Staff:

BARIATRIC SURGERY

• Jennifer Bishop, MD

Section Leadership

• Zandra Cheng, MD • Mandy Greenburg, MD

James Bonheur, MD Medical Director

Active Staff: • Harold Neyra, DO The Center for Surgical Weight Loss (CSWL) engages patients in a comprehensive program designed to achieve medical and physical wellness. It combines 1 0 2 | D EPA R TM ENT O F S U R G E RY

The Section of Breast Surgery was very active over the past year. Our program underwent its third site visit by the National Accreditation Program for Breast Centers (NAPBC) in March. We received unconditional accreditation, with no citations on any of the 27 criteria. In addition, five of our practices were identified by the NAPBC as best practices, an unprecedented evaluation. We also were granted the 2015 Women’s Choice Award: America’s Best Breast Centers based on quality metrics (NAPBC Accreditation and Breast Imaging Center of Excellence Status) and patient satisfaction scores. A significant emphasis was placed on patient education. A new patient information binder included not only customizable relevant medical information, but also a comprehensive list of our capabilities to enhance navigation. The patient experience was mapped in an effort

D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 to identify areas for improvement. Similarly, a navigation team was created to better transition patients from diagnosis to surgery and then to their care at the Bennett Cancer Center. Once again, extensive community outreach programs were held. Dr. Bishop was appointed to the Education Committee of the American Society of Breast Surgeons as well as the Operating Room Product Committee of Stamford Hospital. She remains a member of the Executive Council of the Connecticut Chapter of the American College of Surgeons (ACS). Dr. Pass became a member of the Executive Committee of the Commission on Cancer. She remains a Governor of the ACS; a Member of the Committee on Applicants of the Connecticut Chapter of the ACS; Chairman of the Bylaws Committee of The American Society of Breast Surgeons; a Member of the American College of Surgeons Committee on Surgical Volunteerism and Humanitarian Awards; and a Member of the International Committee of the National Accreditation Program for Breast Centers (NAPBC). Members of the Section presented numerous national, regional, and community lectures on breast health and care over the course of the year.

Presentations • “Maximizing Your Patient’s Physical and Emotional Recovery through the Star Program,” invited panelist Carl and Dorothy Bennett Cancer Center Annual Oncology Symposium, Stamford Hospital, Stamford CT, October 16, 2014. • “Breast Cancer in Men and Women” invited lecture Stamford Senior Center, Stamford, CT, June 27, 2014. • “Optimal Breast Health” invited lecture Odyssey Reinsurance Group, Stamford, CT October 1, 2014. • “Breast Health and You” invited lecture YMCA, Darien, CT, October 8, 2014. • “Management of the Axilla in the Era of Z11 and MA20: A Surgeon’s Perspective” invited lecture Interdisciplinary Oncology Symposium William Beaumont Hospital, Troy, MI, October 17, 2014. • “What is New in Breast Wellness” invited lecture for NBS Sports Lunch and Learn Series, Stamford, CT, October 22, 2014.

• “The Role of Surgery in the Management of Ductal Carcinoma in Situ” invited lecture Clinical Congress of the American College of Surgeons, San Francisco, CA, October 30, 2014. • “Better Breast Health: New Technology and Treatments” keynote speaker Women’s Health Day, Rolling Hills Country Club, Wilton CT, November 7, 2014. • “Celebrate U” invited lecture YWCA, Darien, CT, January 14, 2015. • “The OncotypeDx Assay in the Contemporary Management of Breast Cancer” invited lecture Oncology Associates, New London, CT, April 16, 2015. • “Changing Practice Circumstances: Acquisitions, Alliances, and Your Autonomy — Leaving the Comfort of a Big Organization” invited seminar for the American Society of Breast Surgeons 16th Annual Conference, Orlando, FL, April 30, 2015. • “Top 10 Breast Papers of the Last 10 Years” invited lecture for the American Society of Breast Surgeons 16th Annual Conference, Orlando, FL, May 2, 2015.

Posters Cheng ZH, Frenk V, Bishop JD, Bowling T, Pass HA Mulitmodal Perioperative Analgesia with Paravertebral Nerve Block and Gabapentin Reduces Narcotic Use and Hospital Length of Stay in Mastectomy Patients. Poster Presentation for the San Antonio Breast Conference, December 9 – 13, 2014, San Antonio, Texas. Pass HA, Bishop JB, Babkowski R, Cheng ZH Quality Improvement in Mastectomy Processing: Routine Use of A Standardized Mastectomy Diagram by Surgeons Improves Accuracy and Timeliness Of Final Pathology Report. Poster Presentation for the Society of Surgical Oncology Annual Conference, March 25-28, 2015, Houston, Texas.

Papers Chafe S, Moughan J, McCormick B, Wong J, Pass H, Rabinovitch R, Arthur DW, Petersen I, White J, Vicini FA. Long-term Update of NRG Oncology/RTOG 0319: A Phase I/II Trial to Evaluate Three Dimensional Conformal Radiation Therapy (3D-CRT) Confined to the Region of the Lumpectomy Cavity For Stage I and II Breast Carcinoma. Submitted Int J Radiat Oncol.

• “Women’s Breast Health” invited lecture YMCA, New Canaan, CT, October 22, 2014.

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D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 CARDIOVASCULAR SURGERY

COLON AND RECTAL SURGERY

Division Leadership

Section Leadership

Charles E. Littlejohn, MD

Michael A. Coady, MD, MPH

Director of Colon and Rectal Surgery

Chief of Cardiovascular Surgery

Active Staff:

Active Staff:

• William C. Feng, MD

• Marilee Freitas, MD

Stamford Hospital offers patients a full spectrum of surgical procedures within the field of Cardiac Surgery, ranging from elective to immediate and life-saving. The surgical team continues to have outstanding clinical outcomes with a zero percent mortality rate during the past year.

• James McClane, MD

The Division continues to provide the Convergent Ablation Procedure for patients with long-standing atrial fibrillation, and actively participates with the Division of Cardiology in the new TAVR Program for aortic valve replacement. Unlike other institutions offering similar programs, Stamford Hospital’s surgical team is very focused on making each individual patient experience extraordinary. We have a full-time, dedicated patient navigator to coordinate care and guide patients through the process from pre-surgery through surgery and beyond. This Planetree approach to patient-centered care makes Stamford Hospital a very special place to practice medicine. Dr. Coady is completing an MBA degree program at the Massachusetts Institute of Technology. He is also a reviewer for Annals of Thoracic Surgery, Journal of Thoracic and Cardiovascular Surgery, Circulation and Aorta. Dr. Feng has a new manuscript accepted by the Annals of Thoracic Surgery. Feng W, Coady M. “Epicardial Tachosil patch repair of ventricular rupture in a 90-year-old following mitral valve replacement.” In press, Annals Thoracic Surg, 2015.

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• Shahzad Zafar, MD Dr. Charles Littlejohn was named President of the American Society of Colorectal Surgeons (ASCRS). This is a prestigious position in the world’s premier society of surgeons dedicated to the practice of colorectal surgery. Dr. Freitas has led the Division’s efforts in starting up an anal manometry program to provide better care for patients with pelvic floor problems. Dr. Zafar’s efforts have been in advancing robotic colonic surgery at Stamford Hospital. The Colorectal Surgery Division implemented the use of one of the first 3D laparoscopes in the state to enhance visualization in patients having minimally invasive colon and rectal surgery.

HAND SURGERY Section Leadership

John D. Dowdle, MD Director of Hand Surgery

D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 Active Staff:

OPHTHALMOLOGY

• Jeffrey Brooks, MD

Division Leadership

• Harold Gewirtz, MD • Haik Kavookjian, MD • Richard Magill, MD • Emily Slate, MD

Glenn E. Ostriker, MD

• Alfred Sofer, MD

Director of Ophthalmology

NEUROSURGERY Section Leadership Active Staff: • Robert J. Fucigna, MD Andrea Douglas, MD Chief of Neurosurgery

• Gregory Gallousis, MD • Joan Gewirtz, MD • Paul A. Goldberg, MD • Jacqueline J. Littzi, MD • Philip A. Piro, MD

Active Staff:

• Lauren Schneider, MD • Elizabeth Siderides, MD

• Richard Anderson, MD

• Esteban C. Vietorisz, MD

• Paul Apostolides, MD

• Eric L. Wasserman, MD

• Mark Camel, MD

• Richard B. Weber, MD

• Alain de Lotbiniere, MD

• James Wong, MD

• Amory Fiore, MD • Avinash Mohan, MD • Marc Otten, MD

ORAL AND MAXILLOFACIAL SURGERY Division Leadership

• C. Cory Rosenstein, MD • Scott Simon, MD Dr. Andrea Douglas has assumed leadership of the Division. We have continued to identify and recruit new surgeons with expertise in stereotactic neurosurgery, minimally invasive skull base surgery and cranial tumors. Dr. Marc Otten, who specializes in minimally invasive skull base surgery, joined the staff.

Robert M. Yudell, DDS, MD Director of Oral and Maxillofacial Surgery

Active Staff: • Donald Case, DMD • Clifford Evans, DMD • Christine Hamilton-Hall, MD, DMD 2015 CL INICA L A NNUA L R E POR T | 105

D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 ORTHOPEDIC SURGERY

• Craig D. Tifford, MD

Division Leadership

• Allen I. Troy, MD • Corrine VanBeek, MD • Avi Weiner, MD • Daniel Zelazny, MD Rudolph F. Taddonio, MD Director of Orthopedic Surgery

Active Staff: • Jeffrey Alwine, DO • David Aspirino, MD • Theodore A. Blaine, MD • Adam R. Brodsky, MD • Jeffrey J. Brooks, MD • Russell J. Cavallo, MD • Robert Cristofaro, MD • Joseph M. D’Amico, MD • Frank A. DiFazio, MD • John D. Dowdle, MD • Albert Dunn, DO

In 2015, the Division of Orthopedic Surgery continued to grow with the addition of surgeons from Westchester. These providers are participating in trauma call as well as performing elective surgery at Stamford Hospital. The Chelsea Piers Connecticut campus continues to grow and includes the Hospital’s newly established Concussion Center in addition to pain management and integrative medicine physicians. Construction is underway for Sports Rehabilitation services at the Chelsea Piers Connecticut campus. Both the Hip and Knee Replacement Programs and Spine Fusion Program achieved initial Certification in 2010, and recertification in 2013 without any deficiencies. The Spine Fusion Program was site visited in September 2015 and we await a final report with a highly favorable preliminary report. The Division seeks to lead the way in advancement in clinical practice and the adoption of additional technologies that will allow a more personalized approach to spinal deformity correction such as custom implants.

• Edward Feliciano, MD

OTOLARYNGOLOGY AND HEAD AND NECK SURGERY

• Alex Gitelman, MD

Division Leadership

• Andrew Grose, MD • Andrew L. Haas, MD • Peter W. Hughes, MD • Michael J. Kaplan, MD

Bruce H. Klenoff, MD

• Haik G. Kavookjian, MD

Director of Otolaryngology

• Adam Lazzarini, MD • Richard Magill, MD • John Nelson, MD • Charles Popkin, MD • Kevin D. Plancher, MD

Active Staff:

• Benjamin D. Roye, MD

• Steven A. Bramwit, MD

• David Roye, MD

• Jacquelyn M. Brewer, MD

• William T. Schmidt, MD

• Jason R. Klenoff, MD

• Krishn M. Sharma, MD

• Biana G. Lanson, MD

• Marc D. Silver, MD

• Michelle Marrinan, MD

• Emily Slate, MD

• Stephen J. Salzer, MD

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D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 The Division of Otolaryngology and Head and Neck Surgery has continued to increase the number of minimally invasive approaches to surgery and now have over 98% or our surgeries as outpatient surgery. Overall case volume has increased by 8% this year and the division volume at the Tully Health Center has increased by over 14%. We have continued to grow our balloon sinuplasty program and most of our sinus surgery is now done with image guidance for increased safety. We collaborate with our Neurosurgery and Thoracic Surgery colleagues for complex oncologic procedures including minimally invasive skull base surgery. We have optimized our sinus surgery anesthesia protocols and have worked with the pediatric team to improve the pediatric perioperative experience. Members of the Division have also been actively involved in the treatment of balance, hearing, taste and smell disorders. Additionally, Division members teach residents and medical students, provide lectures at the Hospital and to community groups, and are on the faculty of both Columbia and Yale medical schools.

PODIATRY Division Leadership

Jeremy A. Bier, DPM Director of Podiatry

Active Staff: • Rui DeMelo, DPM • Sarah Edgar, DPM • Marissa Girolamo, DPM • Ellen Golden, DPM • Jeffrey Gross, DPM

Members of the Division have had extensive recognition as outstanding practitioners in many distinguished lists such as Castle Connolly’s Top Doctors, New York Magazine, Connecticut magazine, Westchester WAG and other regional publications.

• Matthew Juriga, DPM

PLASTIC AND RECONSTRUCTIVE SURGERY

• Kelly Powers, DPM, MS

Division Leadership

• Mary Reilly, DPM

• Pedram Hendizadeh, DPM • Chris Kassaris, DPM • Francisco Lago, DPM

• Andrew Rice, DPM • David Rosenzweig, DPM • Steven Shindler, DPM Harold S. Gewirtz, MD

• Peter Siroka, DPM

Director of Plastic and Reconstructive Surgery

• Josephine Velasquez, DPM • Robert Weiss, DPM • Scott Weiss, DPM

Active Staff: • Chang Soo Kim, MD • Sandra L. Margoles, MD • Leif O. Nordberg, MD • David Passaretti, MD • Arthur R. Rosenstock, MD • Alfred Sofer, MD

Dr. Kelly Powers joined Associated Podiatrists in Fairfield and Greenwich. She was a resident in Podiatry at Boston University with a fellowship in Plastic Reconstruction at Georgetown University Medical Center. Drs. Robert and Scott Weiss have added a third associate, Dr. Matthew Juriga. Dr. Juriga was trained at the Beth Israel Deaconess Medical Center where the Podiatry Department works closely with vascular and medical physicians from the Joslin Diabetes Center to produce some of the highest rates of limb salvage in the country.

• Julie V. Vasile, MD 2015 CL INICA L A NNUA L R E POR T | 107

D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 Drs. Bier, Weiss and Juriga provide Podiatric Surgery Emergency Department call services at Stamford Hospital to ensure high-quality care to our patients with podiatric emergencies.

THORACIC SURGERY Division Leadership

SURGICAL ONCOLOGY Section Leadership

Michael Ebright, MD Section Chief, Thoracic Surgery

Xiang Da (Eric) Dong, MD Section Chief, Surgical Oncology

Active Staff: • William C. Feng, MD

Active Staff: • Michael D. Stone, MD The Section of Surgical Oncology provides rapid access to a complete range of surgical expertise in oncology care from highly experienced, fellowship-trained practitioners. Our experience in endocrine surgery, complex gastrointestinal cancers, hepatobiliary cancer, melanoma and other cutaneous malignancies is unmatched in the region. Members of the Section participate in several multidisciplinary conferences to ensure a complete approach to evaluation, diagnosis and therapeutics. We continue to incorporate minimally invasive surgery, including robotic surgery, in the care for our patients. Michael Stone, MD, (Department Chair and Surgical Oncology) co-authored three publications this year: Sissoko M, Josenia N, Uyeda , Stone M, Hartshorn, Roehrl M. A Rare Case of Primary Ampullary Squamous Cell Carcinoma and Review of the Literature. Gastrointestinal Cancer Research. 2014. Falcone T, Holick M, Pearce E, Devaiah A, Stein D, Jumaily J, Jalisi S, Grillone G, McAneny D, Stone M, Noordzij JP. Correlating Preoperative Vitamin D Status with Post Thyroidectomy Hypocalcemia. Endocrine Practice 10/20/14. Buch K, Qureshi M, Carpentier B, Cunningham D, Stone M, Jaffe C, Quinn M,Gonzalez C, LaVoye1 J, Hines N, Bloch B. Surveillance of Probably Benign(BI-RADS 3) Lesions in Mammography: What Is The Right Follow-Up Protocol? The Breast Journal 02/2015; 21(2). 1 0 8 | D EPA R TM ENT O F S U R G E RY

The Lung Cancer Screening Program continues to progress and is one of the largest and most successful in the area. Details include standardized readings, developing a patient database and working with the Department of Radiology in providing real-time results to patients and their doctors. A one-to-one smoking cessation program is now up and running. Dr. Ebright was appointed Editor of the International Thymic Malignancy Interest Group Newsletter. Additionally, he has given the following lectures: NewYork-Presbyterian Lung Cancer 2015: New Discoveries, New Directions CME Symposium, Weill Cornell Medical College, June 2015, Lymph Nodes 101: Diagnosis, Prognosis, Resection—What is the Data? Medical Grand Rounds, NewYork-Presbyterian/Lawrence Hospital, Bronxville, NY, June 2015, Beyond the Scan: Screening, Diagnosis, and Treatment of Early Stage Lung Cancer. In addition, the Section was represented at the following meetings: Zanbrakji M, Ebright MI. Management of unusual and difficult post-operative complications. Presented at the New York General Thoracic Club Spring Meeting, New York City, April 2015. Gesthalter Y, Berman J, Fernando HC, Ebright MI. Direct comparison of endobronchial ultrasound guided transbronchial needle aspiration and cervical mediastinoscopy for the diagnosis of suspected sarcoidosis. Presented at the CHEST Annual Meeting, October 2014.

D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 Dr. Ebright has two upcoming presentations at the Connecticut Chapter of the American College of Surgery Meeting and has published the following articles and book chapters: Hewes PD, Jachey KJ, Zhang X, Tripodis Y, Rosenkranz P, Ebright MI, McAneny D, Fernando HC, Litle VR. Evaluation of the Caprini model for venothromboembolism in esophagectomy patients. Annals of Thoracic Surgery. 2015; August 14 [Epub ahead of print]. Ebright MI. Seeing cancer in a new light. Journal of Thoracic and Cardiovascular Surgery. 2015; 150(1): 8-9. Stevenson EK, Sloan KA, Narsule CK, Kretschman DM, Sarita-Reyes CD, Steiling K, Ebright MI. Catamenial hemothorax in a patient with multiple sclerosis. Am J Respir Crit Care Med. 2014; 190(12): e69-70. Ebright MI, Krasna M. Overview of esophageal and proximal stomach malignancy. Adult Chest Surgery, 2nd Edition. Editors, David J. Sugarbaker et al. CK, Ebright MI, Fernando HC. Esophageal malignancy: palliative options and procedures. Adult Chest Surgery, 2nd Edition. Editors, David J. Sugarbaker et al.

TRAUMA SURGERY AND CRITICAL CARE Division Leadership

Kevin M. Dwyer, MD Director of Trauma and Critical Care

Active Staff:

The Trauma Center has three fellowship-trained Trauma and Critical Care surgeons, and is the regional leader for outreach, injury prevention, education and research. The Center had a site visit from the American College of Surgeons in November. In FY15, Stamford Hospital’s Emergency Department saw 9,714 patients for minor to severe traumatic injury. Of those, 1,144 patients were admitted to the Hospital. Additionally, the Immediate Care Center at the Tully Health Center saw 6,950 patients for a minor trauma injury. The Division hosted the Southwestern Connecticut Trauma Symposium for trauma professional staff in November 2014. This past year’s symposium included presentations on new ventilator modes, burns, blast injuries, EMS issues, reconstructive surgery after trauma and caregiver burnout. The Trauma Center is engaged in public and professional education. There is a dedicated referral and access line to Trauma Center resources. Prevention activities center on priorities based on local injury data. Examples of injury prevention activities include an Annual Trauma Fair, which focuses on distracted driving. The Trauma Center collaborates with national, regional and state programs, including the Trauma Quality Improvement Program (TQUIP). The Trauma Program Manager (TPM) participates in senior and family health fairs where information is provided on falls, helmet use, concussion and trauma safety in general. The TPM also participates in an ongoing Stamford Hospital Falls Prevention Program. The Hospital’s outreach programs include teaching at courses, the Annual Trauma Symposium, roundtable sessions provided for pre-hospital providers, an annual trauma fair, programs for local high school students interested in healthcare careers, participation in a large annual mock trauma disaster drill and presentations on substance abuse at local high schools.

UROLOGY

• Neeta Chaudhary, MD

Active Staff:

• Marissa DeFreese, MD

• Lori Dyer, MD

• Kevin Miller, MD

• Robert H. Lovegrove, MD

• Joey Papa, MD

• Michael J. Nurzia, MD

Stamford Hospital is a Level II Trauma Center designated by the Office of Emergency Medicine of the State of Connecticut and verified by the American College of Surgeons (ACS) to care for acutely injured trauma patients.

• Richard P. Santarosa, MD • Vincent J. Tumminello, MD • Paul F. Zelkovic, MD

2015 CL INICA L A NNUA L R E POR T | 109

D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 VASCULAR SURGERY

DEPARTMENT OF SURGERY

Division Leadership

New Staff

Timothy Manoni, MD

Richard Anderson, MD

Director of Vascular Surgery

Pediatric Neurosurgery

Active Staff: • Stephen M. Bauer, MD • Jonathan N. Bowman, MD • Paul J. Gagne, MD • Lee Goldstein, MD

David Asprinio, MD

• Taras V. Kucher, MD

Orthopedics

• Ben U. Marsan, MD • Bart Muhs, MD, PhD • Michael Sergi, MD Dr. Bart Muhs joined the Vascular Surgery Department at Stamford Hospital, bringing an extensive background and experience in the endovascular treatment of aortic disease. Dr. Muhs and colleagues performed lower Fairfield County’s first endovascular juxta-renal aneurysm repair using an individual patient customized aortic branch device at Stamford Hospital in 2015.

Matthew Juriga, DPM Podiatry

In addition to arterial disease, the Division also focuses on the management of venous disease, including large-vein thrombosis and venous hypertension. The Division staff has hosted quarterly vascular symposia in Greenwich, Norwalk, Fairfield, Waterbury and New Canaan this year.

Richard Magill, MD Hand & Orthopedic Surgery

1 1 0 | D EPA R TM ENT O F S U R G E RY

D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 Ancillary Staff • Stephanie E. Beierle, PA-C, Surgical Physician Assistant Bart Muhs, MD, PhD Vascular Surgery

Transitions The following staff members have departed from Stamford Hospital: • Neeta Chaudhary, MD, Trauma Surgery • Kimberly Curesky, DPM, Podiatry • Israel Franco, MD, Pediatric Urology • Bev Guo, MD, Hand Surgery • Marsel Huribal, MD, Vascular Surgery • Amira Mantoura, DPM, Podiatry

Kelly Powers, DPM

• George McGinniss, MD, Orthopedics

Podiatry

• Amy O’Callaghan, DMD, Dentistry • Christos Pappas, MD, Thoracic Surgery

Honors and Recognition • Dr. Kevin Dwyer was named Physician of the Quarter as voted by his peers. • Dr. Marilee Freitas was appointed Member of Program Committee for American Society of Colon and Rectal Surgeons. Emily Slate, MD Orthopedics and Hand Surgery

• Dr. Martin Lederman received the Humanitarian Award from Westchester County Doctors of Distinction. • Dr. Charles Littlejohn was elected president of American Society of Colon and Rectal Surgeons. • Dr. Marc Otten was named to New York Rising Stars — Super Doctors. • Dr. Joey Papa was appointed Director of Stamford Hospital’s Wound Care and Hyperbaric Center. She was also named a Fellow of the American College of Surgeons (FACS), Assistant Clinical Professor of Surgery.

Shahzad Zafar, MD Colorectal Surgery

• Dr. Josephine Velazquez received the 2015 Darien YWCA Woman of Distinction Award. • Dr. Shazad Zafar has played a leading role in the development of the Hospital’s robotic colorectal surgery program.

(Not Pictured)

• Charles Popkin, MD, Pediatric Orthopedics

2015 CL INICA L A NNUA L R E POR T | 111

D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 Stamford Hospital surgeons were listed among the Top Doctors in Fairfield County, New York or Connecticut in 2015. They are:

• Karen J. Nishida, MD

• Peter D. Angevine, MD

• Helen A. Pass, MD

• Paul J. Apostolides, MD

• David Passaretti, MD

• John Awad, MD

• Philip A. Piro, MD

• Stephen Bauer, MD

• Kevin Plancher, MD

• Steven A. Bramwit, MD

• William S. Potter, MD

• Mark H. Camel, MD

• Arthur R. Rosenstock, MD

• Michael A. Coady, MD

• Stephen J. Salzer, MD

• Robert Cristofaro, MD

• Richard P. Santarosa, MD

• Joseph M. D’Amico, MD

• Elizabeth Siderides, MD

• Alain de Lotbiniere, MD

• Peter Siroka, DPM

• Xiang D. Dong, MD

• Scott L. Simon, MD

• John D. Dowdle, MD

• Alfred Sofer, MD

• Kevin M. Dwyer, MD

• Joshua Sonett, MD

• Michael I. Ebright, MD

• Allen I. Troy, MD

• William C. Feng, MD

• Esteban C. Vietorisz, MD

• Amory J. Fiore, MD

• Eric L. Wasserman, MD

• Paul Gagne, MD

• Richard B. Weber, MD

• Harold S. Gewirtz, MD

• Daniel Zelazny, MD

• Michael J. Nurzia, MD • Glenn E. Ostriker, MD

• Joan T. Gewirtz, MD • Peter W. Hughes, MD

DEPARTMENTAL SAFETY AND QUALITY

• Haik G. Kavookjian MD

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The Department of Surgery has participated since 2012 and also participates in the Connecticut Surgical Quality Collaborative, a NSQIP subgroup. Entering data to compare our performance to others, and the opportunity to learn from our colleagues across the state and country are key components of the program.

• Bruce H. Klenoff, MD • Jason R. Klenoff, MD • Biana Lanson, MD • Charles E. Littlejohn, MD • Richard Magill, MD • Ben Marsan, MD • James McClane, MD • Guy M. McKhann II, MD • Martin Lederman, MD • Kevin D. Miller, MD • John Nelson, MD • Frederic A. Newman, MD

1 1 2 | D EPA R TM ENT O F S U R G E RY

Our first outcomes report showed that our mortality rate, adjusted for the severity of illness of our patients, put us in the top 10% nationally. Importantly, the report identified areas for improvement: reducing surgical site infections, especially in colorectal surgery and pulmonary complications across all subspecialties.

D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 Our efforts to develop a Culture of Safety are bearing fruit as evidenced by the reduction in our surgical site infections overall, and in colorectal surgery patients specifically (see Figure 2). We continue to review our outcomes through reports from the Infection Prevention and Control team and the National Healthcare Safety Network (NHSN, a subsection of the CDC) and through NSQIP. Figure 2: Stamford Hospital Colorectal Surgery Standardized Infection Ratio

Surgical Residency Program The Surgical Residency Program continues to attract bright students from much of the East Coast with over 500 applicants this past year. Our graduates leave with a deep and broad comprehension of surgical care and technique. Almost all go on to highly competitive fellowships in subspecialties. This year, our graduates went on to fellowships in colorectal surgery, minimally invasive surgery and trauma surgery at SUNY-Stonybrook, Lahey Clinic and the University of Kentucky, respectively. Our goal is to develop excellent clinical surgeons with a broad range of knowledge, including areas such as quality, safety and team approaches to healthcare delivery, the healthcare of the future. An absolute requirement of a complete education is the development of critical thinking skills through the intellectual stimulation of research, which is highly encouraged in the Department, as highlighted in Figure 3.

New Interns (PGY-1) • James Clarke, MD, Georgetown University School of Medicine • Diane Durgan, MD, St. George’s University Dr. Kevin Dwyer is leading a multi-disciplinary approach to reducing pulmonary complications through a multistep process based on a successful program at other sites across the nation. We have already seen improvements in this regard for the Department as a whole and for higher risk subspecialties.

• Hebroon Obaid, MD, St. George’s University • Kristin McCoy, MD, American University of the Caribbean School of Medicine • Marissa Novack, MD, Ross University School of Medicine

Current Residents

We are enhancing our methods of data collection, review and assessment, to better understand the costs of surgical care to improve our financial performance while maintaining quality and safety.

PGY 2

DEPARTMENTAL EDUCATION AND TEACHING ACTIVITIES

• XueWei Zhang, MD, Boston University School of Medicine

Student Education

• Kamal Addagatla, MD, State University of New York, Buffalo, School of Medicine and Biomedical Sciences

For eight years, Dr. Eric Dong has ably led our medical student clerkship program, including students from the Columbia University College of Physicians and Surgeons, Mercy Hospital and Quinnipiac University. We continue to get very high marks for teaching from some of the brightest students across the country. As Dr. Dong moves to a new position in Ohio, Dr. Marissa DeFreese will assume that role. She is working with Dr. Stone and the Dean’s Office at Columbia to introduce newer, more formalized approaches to the educational process, student and faculty assessment and outcomes.

• John Calhoun, MD, University of Central Florida College of Medicine • Elise McKenna, MD, New York Medical College PGY 3

• Basil Nwaoz, MD, Tufts University School of Medicine • Kostantinos Poulikidis, MD, New York Medical College PGY 4 • Christian Cain, MD, University of Illinois College of Medicine • Mohamad Zanbrakji, MD, Ross University School of Medicine • Kristina Ziegler, MD, University of Connecticut School of Medicine 2015 CL INICA L A NNUA L R E POR T | 113

D EPA R T M ENT O F S U RGE RY: AN NUA L R E P OR T 2015 PGY 5 • Debbie Bakes, MD, Tufts University School of Medicine • Elijah Min, MD, Ross University School of Medicine • Heather Player, MD, Weill Cornell Medical College

2015 Graduates and Positions Taken • Ryan Bendl, DO, Colon Rectal, State University of New York at Stony Brook • John Hwang, MD, Minimally Invasive Surgery, Lahey Clinic in Boston, MA • Katherine Petersen, MD, Surgical Critical Care, University of Kentucky

The Stamford Hospital resident team, John Calhoun, Heather Player and Kristina Ziegler, won First Place in the statewide “Top Gun” Surgical Technical Competition at the Connecticut ACS meeting.

Resident Awards 2014 • Research Award: Kamal Addagatla, MD • Patient Care Award: Christian Cain, MD • Teaching Award: Ryan Bendl, DO

Residency Program: Scholarly Activity Residents were highly visible as presenters at state and national conferences over the past year, including 13 presentations at The 2014 Connecticut Annual and Scientific Meeting (CT-ACS) — see Figure 3 below.

Figure 3: The 2014 Connecticut Annual and Scientific Meeting Presentations RESIDENT

ABSTRACT

John Hwang, MD*

The role of metabolic surgery in the treatment of type II diabetes.

John Calhoun, MD

Median arcuate ligament syndrome following gastric bypass.

Heather Player, MD

Synchronous breast cancers with differential responses to neoadjuvant chemotherapy.

Basil Nwaoz, MD

Congenital agenesis of the gall bladder.

Basil Nwaoz, MD

The application of latissimus dorsi flap for persistent air leak.

Kostantinos Poulikidis, MD*

Polycythemia in cardiac surgery patients as an indicator for antithrombin.

Kristina Ziegler, MD

Case report of a small bowl obstruction caused by anisakiosis.

Hebroon Obaid, MD*

Are swallow evaluations enough to prevent aspiration?

Ryan Bendl, DO

Outcomes in diverticulitis patients with intramural abscesses.

Mohamad Zanbrakji, MD

Endobronchial valves for the treatment of prolonged air leak.

Timothy Feeney, MD

Hemoperitoneum due to traumatic avulsion of a single leiomyoma.

Christian Cain, MD

Therapeutic hypothermia treatment in near-hanging.

Kamal Addagatla, MD#

Comparing the Risk Profiles of Intracranial Hemorrhage Seen on Initial Computerized Tomography Scans in Patients Who Fall on Warfarin versus other Antithrombotic Therapy.

*Best Paper Award

State winner Trauma Award

#

1 1 4 | D EPA R TM ENT O F S U R G E RY

D EPA R T M EN T O F S U RGE RY: AN N UA L R E P OR T 2015 Departmental Lectures/Visiting Professors

STRATEGY/FUTURE DIRECTION

• Karmel Lecture: “What’s New and Evidence-based in Pediatric Surgery” Brendan T. Campbell, MD Director, Pediatric Trauma and Injury Prevention Center; Connecticut Children’s Medical Center.

Technology, healthcare delivery and financing are changing rapidly. We heed the rejoinder from Satchel Paige “Don’t look back. Something might be gaining on you.” We will continue to bring that newest and most advanced care to the people of Fairfield County, but we will also remember to bring the most personal care. We are looking ahead toward, and with a plan to be, the future of surgical healthcare in Fairfield County.

Other Educational and Scholarly Activities Michael Stone, MD, (Department Chair and Surgical Oncology) co-authored three publications this year: Sissoko M, Josenia N, Uyeda , Stone M, Hartshorn, Roehrl M. A Rare Case of Primary Ampullary Squamous Cell Carcinoma and Review of the Literature. Gastrointestinal Cancer Research. 2014. Falcone T, Holick M, Pearce E, Devaiah A, Stein D, Jumaily J, Jalisi S, Grillone G, McAneny D, Stone M, Noordzij JP. Correlating Preoperative Vitamin D Status with Post Thyroidectomy Hypocalcemia. Endocrine Practice 10/20/14. Buch K, Qureshi M, Carpentier B, Cunningham D, Stone M, Jaffe C, Quinn M, Gonzalez C, LaVoye1 J, Hines N, Bloch B. Surveillance of Probably Benign(BI-RADS 3) Lesions in Mammography: What Is The Right Follow-Up Protocol? The Breast Journal 02/2015; 21(2). The Division of Trauma Surgery and Critical Care hosted the 2014 Annual Southwest Connecticut Trauma Symposium. The Department of Surgery hosted the 4th Annual Community Safety & Injury Prevention Fair.

2015 CL INICA L A NNUA L R E POR T | 115

the new stamford hospital and

integrated care pavilion OPENING 2016

Stamford Hospital 30 Shelburne Road PO Box 9317 Stamford, CT 06904-9317 Phone: 203.276.1000 StamfordHospital.org

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20 1 5 CLI NI C A L A N N UA L R E P O R T innovation & patient-centered care A NNUA L R E P O R T 2 0 1 5 W hen I assumed the position of Chair...

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