eFocus, June 2014
  The ICD-10 Delay: UMMS ICD-10 Readiness Project Update
  Improving Care Through Readmission Reduction
  Paul Revere and the Global Budget
  Conundrums Continue; CRM Can Help
  Housekeeping Items
  Pharmacy Update
  Antibiograms 2014
  Upcoming Meetings and Events

The ICD-10 Delay: UMMS ICD-10 Readiness Project Update

On April 1, President Obama signed into law the Protecting Access to Medicare Act of 2014, which avoids cuts in physicians' Medicare rates and delays the implementation of ICD-10. Now, the federal government has announced that it will reset ICD-10 implementation for Oct. 1, 2015, the earliest date allowed by law.

Health care organizations nationwide, including all UMMS entities, were gearing up to switch from ICD-9 to ICD-10 on Oct. 1, 2014. In response to the current delay, the UMMS ICD-10 Implementation Work Group has already begun adjusting training plans and project timelines. The Work Group will focus resources to leverage what has been accomplished so far, and continue to implement the changes needed to migrate to ICD-10 in 2015. UMMS has decided to adjust the pace, but not stop progress.

It is critical that we not lose momentum on one of our key project successes: emphasizing the importance of more complete and precise clinical documentation with all providers. Every effort should be made to continue improving documentation standards and practices, as greater detail and accuracy has far-reaching benefits, regardless of the coding system in use.

ICD-9 and its successor, ICD-10, refer to the medical diagnostic and procedural classification for billing, statistical reporting and clinical research. It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases and is used by hospitals to code inpatient procedures and operations.

Continue to look for updates on the pending implementation from ICD-10 project leaders in your local communications channels.

Improving Care Through Readmission Reduction

Readmissions are a big concern for patients and are sometimes medically avoidable. The most carefully worded discharge instructions may not be understood by the patient/family at discharge, despite review with the hospital nursing staff. Unfortunately, discharge day is probably one of the most difficult (high stress) days for patient education and retention of new information (including specific dietary recommendations or fluid restrictions). It is not the best time for detailed question and answer discussions.

Since some of these patients are at risk of being lost to follow up during this transitional time, a nurse case manager will be contacting a number of the recently hospitalized patients concerning their understanding of their discharge instructions and management of their diseases, including whether they have filled the Rx they were given and soliciting any other questions they might have.

The patient is directed to contact your office and be seen in the time frequency that was directed by the hospital attending at the time of discharge. Please alert your staff that these recently hospitalized patients will be calling for these appointments and then make arrangements to get them in as directed rather than having them wait for the next available appointment.

Dr. Jeffrey Zale
Physician Advisor

Paul Revere and the Global Budget

If this were the 1700's, you probably would have heard Paul Revere riding through town on his horse shouting "The Global Budget is coming, The Global Budget is coming" for the past few months. It's now here.

According to the Maryland Hospital Association, 92% of total hospital revenues in Maryland are now governed by global budgets. So, what does that mean? To hospitals like UM Upper Chesapeake Health, it means that revenues are subject to an annual cap. Any overage is associated with a penalty. Furthermore, some potential revenues are withheld and placed in a central pool, divvied out as rewards for specific achievements, such as cost efficiency, process excellence (ACE-Inhibitors with CHF, Aspirin with MI, etc.), demonstrated outcomes, prevention of harm (DVT's, surgical-site infections, medication errors, falls with injury, etc.) and patient satisfaction.

What does this mean for physicians in general? The clear message from the insurers, the government and the public in general is this - "You cost too much and we want transparency in fees and quality metrics." It means that the costs of tests and treatments that we order need to be part of our thought processes and probably part of the discussion with our patients. It means relying more on clinical assessment and rational conversation with our patients; relying less on potentially unnecessary testing and consultorama*. It also means embracing data feedback to help demonstrate or drive improvement. How do you know that you provide cost effective, high quality care without some measurements of performance?

Accountable Care Organizations (ACO's), Patient Centered Medical Home (PCMH), Bundle Payment Plans are all out to achieve the same data driven results: greater cost efficiency, better outcomes and improved patient satisfaction.

Organizations such as Mayo Clinic and Geisinger that have seen early successes in this environment have been able to adjust practice styles and innovate, taking advantage of close, synergistic relationships between the health systems and community physicians.

The good news is that we are in an area where the health system and community physicians already work well together. So what are the next steps?

  1. Data-driven strategic planning to address those patients at highest risk for complications
  2. Risk stratification for all patients
  3. Work together (health system/practices) to provide the right amount of support for optimal patient care
  4. Collect and feed back data that is clinically meaningful and useful for physicians/practitioners to help improve overall quality and efficiency
  5. Develop improved working relationships with insurers/third-party payers, especially in regard to data sharing
  6. Look constantly for ways to "trim the fat" in medicine (for example-choosing wisely recommendations)

And that's just for starters! These are certainly exciting times in medicine. We have a great opportunity to mold the outcomes over the next few years. Feel free to share your thoughts, concerns, radical ideas and innovations.

The fact is, in a busy practice, each of us see opportunities almost every day where we think "there's definitely a better way to do that!" Now's the time to act. The Global Budget is upon us!

*Consultorama: The act of requesting consultative help in the face of obvious diagnoses. Examples - Pulmonary consult for community acquired pneumonia. Nephrology consult for a creatinine of 1.5 in a dehydrated patient.

J. Kevin Lynch, M.D.
Senior Vice President
Medical Affairs

Conundrums Continue; CRM Can Help

If observation and inpatient care are both delivered under the hospital roof, how am I to know the difference? The quick answer is to check with your case manager but some general rules are listed below.

The patient should be placed in OBSERVATION STATUS if:

  1. The service something that could be delivered in the Infusion Center, Coumadin Clinic or other outpatient service.
  2. The service be given at home: nebulizer treatments for COPD/ asthma.
  3. Home nursing care provide the service but the patient does not have a safe discharge after being placed in the ER at present.
  4. Questionable GI bleed with stable H&H.
  5. Service that can be provided in a skilled nursing facility (SNF) - wound care, therapies, etc.
  6. Clinically stable patients admitted for cellulitis for IV antibiotic therapy (a service that can be provided in the infusion center, in a SNF or at home.)
  7. You want to "observe the patient overnight" for any reason.

Dr. Jeffrey Zale
Physician Advisor

Housekeeping Items

Reminders, updates, and more.

  • Physicians should wear their badges at all times. It has come to our attention that some physicians are not wearing them and are, in particular, asking other team members to gain them entry into the ICU.
  • Reminder: Please remember to signal the care team once new orders have been written in patient charts. If not, it can cause significant delays in care.

Pharmacy Update

Drug Shortage Updates
Current shortages include Metronidazole IV (new), Fosphenytoin IV (continued) and IV fluids (continued).

1. Metronidazole IV - new shortage:

  • Consider PO route when possible. Pharmacy will review IV-PO report daily and contact prescribers to switch to PO (same dose and frequency) if patients can tolerate PO. Bioavailibility of PO flagyl is excellent.
  • For the treatment of C Difficile, PO metronidazole is the preferred route of administration
  • For GI uses / intra-abdominal infections, if patient is NPO or cannot tolerate PO, consider the following alternatives:
    • 1st choice: Cefotetan 1 gm IV q12h
    • 2nd choice: Zosyn extended infusion 3.375gm IV q8h (require ID consult after 3 days if no positive culture)
    • 3rd choice: Primaxin 500mg IV q6h(require ID consult after 3 days if no positive culture)
  • Precribers may consult/contact ID physicians for recommendations.
  • We reserve IV flagyl for surgical prophylaxis per order set.

2. Fosphenytoin IV - continued shortage:

  • Reason: temporary manufacturer recall due to glass particles in vials
  • Use phenytoin IV or change to PO phenytoin when possible (i.e. pts tolerate PO)
  • Cautions with phenytoin IV: use 0.22 micron filter, infuse via large vein when possible

3. IV fluids - continued shortage:
We continue to experience the shortages of all IV fluids. Pharmacy and IV therapy suggest the following:

  • Conserve IV bags as much as possible, consider:
    • Oral hydration (i.e. free water by mouth) when possible (i.e. patient is taking/tolerating PO)
    • Discontinue IV fluids as soon as possible when no longer clinically indicated
    • Minimize the use of KVO as much as possible. All KVO requires an order from prescriber
    • Restrict KVO usage for patients requiring frequent administration multiple IV meds (ie. 4 IV meds or more)
    • Use NS flush syringes to check patency and post administration of meds instead of hanging NS flush bags

** The most updated table of drug shortages is posted on the Intranet, under Pharmacy Department.

Antibiograms 2014

The Antibiogram 2014 is now available and will be distributed to all house staffs (paper and electronic copies). Copy of the antibiograms are placed in patients' charts and will be posted on the Intranet under Pharmacy Department. The purpose of the antibiogram is to guide prescribers in choosing the appropriate antibiotic(s) empirically for their patients before culture results are available. Studies have shown that incorrect choice(s) of antibiotics can be harmful to patients while inappropriate use of broad spectrum antibiotic(s) may lead to resistance and increased hospital costs. Antibiotics should be streamlined/de-escalated as soon as culture results/susceptibilities are available.

The new antibiogram 2014 has some information not previously included as below:


VRE= 17.5%
MRSA= 49.0%
ESBL= 7.5%
(E. coli, Klebsiella, Proteus)
VRE= 20.0%
MRSA= 49.0%
ESBL= 6.7%
(E. coli, Klebsiella, Proteus)


  1. About 50% of Staph aureus are MRSA
  2. About 60% of Enterococcus faecium are VRE
  3. About 50% of MRSA are resistant to Clindamycin
  4. About 95-100% of MRSA are susceptible to Bactrim (Trimethoprim/Sulfamethoxazole)
  5. Use Tobramycin for double coverage if suspecting Pseudomonas
  6. Unasyn (Ampicillin/Sulbactam) and Zosyn (Piperacillin/Tazobactam) have about 100% anaerobic coverage, therefore, it is unecessary to add Flagyl (Metronidazole) or Clindamycin for additional anaerobic coverage
  7. VRE in the stool is usually colonization
  8. Not all positive URINE cultures require antibiotics -need to obtain urinalysis
  9. The following dosing intervals are good for most infections:
    1. Ceftriaxone q24h dosing rather than q12h dosing (except meningitis, should use q12 dosing)
    2. Aztreonam q8h dosing rather than q6h dosing
    3. Clindamycin q8h dosing rather than q6h dosing

Upcoming Meetings and Events

Mark your calendars for important standing meetings and special events.

39th Annual Emergency Care Symposium
Friday, July 11 at the Richlin Ballroom, Edgewood, MD
Final speaker and presentation details are still being confirmed
Check-in is from 6-6:30pm and the program will begin at 6:30pm
Buffet dinner, including crabs, will follow the program

Registration required by 6/27 - please RSVP to Kim Thompson kthompson@uchs.org or 443-643-4206

Multidisciplinary Thoracic Conference
12 Noon, Every Monday
UM UCMC, KCC Streett Conference Room

Multidisciplinary Breast Conference
8 a.m., Every Tuesday
Radiology/Oncology Conference Room

Pharmacy &Therapeutics (P & T) Committee
7:30 a.m., Second Wednesday of each month
UM UCMC Maryland Room

Credentials Committee
7:30 - 9 a.m., Third Friday of each month

Medical Staff Leadership
8 - 9 a.m., Fourth Thursday of each month
UM UCMC, Fallston Room/UM HMH, MSCR


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