Spring 2016
Mark Schmeltz, DO At the Helm of Beacon Home Care PHYSICIAN QUARTERLY
A COVER STORY: Docs Mohs Micrographic Bundled At the Helm Who Surgery for Payment of Beacon Really Non-melanoma Primer 3 Home Care 6 Rock 8 Skin Cancer 12
TABLE OF CONTENTS
A Bundled Payment Primer EDITORIAL BOARD 3 Ken Elek, MD, Faculty, 6 At the Helm of Memorial Family Medicine Residency Program Beacon Home Care Scott Eshowsky, MD, Chief Medical Docs Who Really Rock Information Officer, Beacon Health System 8 Beacon Bulletin Shelly Harkins, MD, Chief Medical 10 Officer, Beacon Health System 11 Continuing Medical Education Vince Henderson, MD, President, Welcome, New Docs Beacon Medical Group Genevieve Lankowicz, MD, CPE, Vice President, 12 Dermatology Update: Medical Staff Affairs, Elkhart General Hospital Mohs Micrographic Surgery for Non-melanoma Skin Cancer Dale Patterson, MD, Director, Memorial Family Medicine Residency Program Advanced Cancer Treatments Cheryl Wibbens, MD, Vice President, Medical 13 at Elkhart General Hospital: Staff Affairs, Memorial Hospital HDR Brachytherapy and Radioembolization Schwartz Rounds Foster Healing 14 Among Physicians, Nurses & Physician Support Staff 15 CMS Observes Local Collaboration Quarterly to Learn Best Practices is published by Beacon Health System to connect and educate physicians Elkhart General on the Road to 16 Trauma Center Accreditation and health care professionals in support of clinical integration, graceful 17 Elkhart General Surgery patient transitions and improved Center Opens quality and safety. 18 Medical Milestone for Memorial Hospital: First Hospital in Region Contact Us to Implant MRI-Compatible Do you have a story idea? Contact us at Cardioverter Defibrillator [email protected] or call 574.647.3234. 19 Case Study: Delayed Delivery of a Twin Pregnancy for 76 Days A Bundled Payment Primer By Shelly Harkins, MD, Chief Medical Offi cer, Beacon Health System
Shelly Harkins, MD
I’ve received several questions about the issue of Beacon hospitals have been receiving lump sum bundled payments. What does it mean? How will DRG-based payments for years now, right? it affect physicians, specifi cally? I’ve outlined some So why the fl urry of activity and focus now? of my thoughts about where we stand in regard You’re right. We have become accustomed to single diagnosis- based payments from CMS for most of our hospitalized patients. to bundled payments at Beacon Health System And you’ve witnessed the host of changes within our hospitals over the last few years to ensure we are delivering high quality and and where we’re likely to be headed. containing cost. But the concept of bundled payments has now been expanded to cover services 90 days after discharge and there is To help untangle some of the acronyms, I’ve included a key of the now a risk of having to pay back CMS, or recoup, if we don’t meet terminology commonly used when talking about bundled payments value targets. So this is distinctly different and deserves new attention and reimbursement issues. and focus. ACA – Affordable Care Act BPCI – Bundled Payment Care Improvement Initiative Where did the idea come from CJR – Comprehensive Care for Joint Replacement bundle and why did we decide to participate? CMS – Centers for Medicare & Along with the Affordable Care Act in 2010, CMS developed a Medicaid Services Center of Innovation to develop creative models of reimbursement and test them out. The Bundled Payment Care Improvement Initiative, DRG – Diagnosis related group or BPCI, is one of those creative ideas. The premise is that hospitals would voluntarily participate by selecting any of 48 diagnoses they preferred and agreeing to take the recoupment risk to help CMS What is a bundled payment? determine effectiveness of this new model. Since there is also the A bundled payment is a single lump sum reimbursement for a bundle possibility of getting an additional payment from CMS for meeting or of service. It’s a method of reimbursement that drives quality and exceeding value targets, hospitals were incentivized to participate. cost effi ciency. It seeks higher quality at a lower cost. So rather than Beacon has proudly selected Stroke at both hospitals. And at Elkhart billing for every piece of a care episode separately as we do under General, we selected Total Joint Replacements as well. The selection fee-for-service models, we are reimbursed a predetermined amount of these diagnoses came with a great deal of discernment. It was based on a diagnosis. This incentivizes value over volume.
3 based on a variety of factors including sufficient volume, current or undergoing a Total Joint Replacement in the hospital) all the way state of processes, potential impact and resources available. While through 90 days post-discharge. If our BPCI patient’s care met all of we didn’t have to participate, Beacon intends to be instrumental in the quality metrics and target price, there is no recoupment. If we fall guiding the changes in our nation’s health care delivery system and under the targets, CMS pays us the difference. But if our cost of care to stay on the leading edge of innovation. And because delivering during the entire episode is above target, we have to recoup CMS value is our mission, we are proud to embrace the change. the difference. All the while, the physicians and post-acute facilities will still be billing for their services and under no risk themselves. Only the hospital is at risk under this model. But, obviously, we So I get that we selected Stroke and Joints at must have every post-acute facility and physician tightly partnered Elkhart General and only Stroke at Memorial. But and aligned with efforts to deliver high value through the 90+ days “episode of care” for these BPCI patients to succeed. Eventually, we I keep hearing we are going to be in the “Joints predict that all diagnoses and all payers will reimburse in a bundle- like manner. And naturally, all providers, including physicians, will be Bundle at Memorial.” What’s that about? at risk. Model 4, for example, requires any physician involved in the This is a great question! Right about the time we were submitting care of a patient during the “episode of care” be reimbursed directly our applications for participation and gearing up for the voluntary by the hospital receiving the bundled payment. We encourage you BPCI program, CMS announced that it would be mandating a to review the CMS website regarding BPCI reimbursement and share Comprehensive Care for Joint Replacement bundle (CJR) in 75 your own predictions with us. geographic areas around the country. This is noted by CMS to be distinctly different from the voluntary program. Considering it’s mandated, it is fairly obvious this is different, isn’t it? Joint This seems like a big risk for hospitals. How replacements are one of the most costly and most regionally variable prepared is Beacon for bundled payments? episodes in health care. So it was a likely target for even more aggressive action by CMS. Our region was selected and as of April We are moving in the right direction but recognize there is still 1, 2016, Memorial Hospital will be in the CJR bundle. The substance much work to do. This is relatively new for every health system in of the CJR bundle is essentially the same: to deliver high-quality the nation. There aren’t a lot of experts out there yet to guide us. care at a lower cost in a method that puts hospitals “at risk” for the Some of our physician leaders in the Stroke arena have developed value of care delivered during the hospital stay and 90 days post- care paths as an infrastructure for stroke patients and are working to discharge. The reimbursement scheme is the same as Model 2 of the implement them as quickly as possible. As you know, new workflows BPCI, as well. and new processes are not easy to hardwire. We are making strides through accountability in our associates and building awareness in our physicians. For Joints, we are developing similar infrastructure How does the new method of reimbursement at Elkhart General and we will bring the lessons learned and the framework already established to Memorial Hospital as CJR goes really work? into the “at risk” phase there. The good news for physicians is that their reimbursement for professional services does not change. Beacon selected Model We also know the key to success under this bundled payment 2 of the four possible models. Under Model 2, Beacon hospitals model is to have a strong post-acute network of facilities eager bill for services after the inpatient chart is coded just as we have and ready to help drive out waste and provide higher efficiency always done. For our Stroke and Joint Replacement patients, the of care to our patients in those 90 days after discharge. And reimbursement will come in a single lump sum. Later, a “true-up” we know we must have all physicians aware of the impact they occurs. Medicare reviews each BPCI patient’s care starting from have on our success both in the inpatient setting and in the the initiating day (the day they were diagnosed with either Stroke ambulatory setting after discharge. We have proudly established
4 Physician Quarterly | Spring 2016 a robust post-acute network of preferred skilled nursing facilities costly. But don’t wait to hear data to make changes. Physicians and we are working diligently to communicate to physicians know better than anyone in health care where there is waste in the how critical their support and efforts are as we navigate this system and where there is opportunity to deliver higher value. Please new culture. There will be some important decisions to make engage with us by providing ideas and asking questions. But most as we look at the true value delivered in our operating rooms, importantly, take a good look at opportunities you have within your our post-op fl oors and through the rehabilitation weeks. infl uence and control to drive the overall value of care delivered to your patients. What exactly do I need to consider as a I understand the drive to be more cost-effi cient. physician involved in the care of these patients But even if I want to change it’s going to be over a 90+-days episode of care? This is another great question. This is a “Power of the Pen” issue really diffi cult because of all the moving parts and (power of the key strike nowadays). Physicians drive the care of the “way it’s always been” syndrome. Changing every patient with orders. Every provider within the Beacon family has an impact. From the surgeon selecting his preferences for the OR could even hurt my own profi tability. How can we table, to the physical therapist providing the recommendations for tomorrow’s PT plan, every person is affecting value. From the family overcome that? doctor receiving a call from the patient’s daughter that mom doesn’t There is not a great answer to that. We don’t know how to make understand her meds, to the ER physician who is seeing mom later this easier or how to protect our physicians entirely. Model 2, in and that day because she couldn’t get in to her doctor’s offi ce, every of itself, protects physicians fi nancially and we purposely selected provider is delivering a level of value. Every order given or not given Model 2. We do have gain-sharing mechanisms supported and and every decision made regarding a patient’s care delivers a level encouraged by CMS and we’re working on developing contracts of value; labs, radiology exams, medications and rehabilitation right now with some of our surgeon groups who will be instrumental preferences all must be considered. in making Beacon successful. We want to do all we can to make this a win-win. But the reality is that none of us are immune to the The selection of vendors, the utilization of all equipment, hardware high drive to become a more cost-effi cient health care delivery and resources, all the way through the care delivered in your offi ces system. These CMS bundled payment trials are not likely going after discharge must all be evaluated. We must ensure high quality, away and more will likely come. So getting really good at working that we provide care with evidence of improving outcomes. Overall collaboratively to ensure we all succeed is ultimately the answer to cost for the entire episode of care along with targeted quality metrics the question. We are in the business of taking care of patients. That’s must be in line. We ask all physicians to stay abreast of the data two important tasks. First, is patients and a close second is business. Beacon receives on its standings in bundled payments. Be aware To provide care for generations of our northern Indiana community, of projected risk so that swift changes can be made where we may we must get this right — and right now! fall out of national best practice or where we may be especially
For more information, please visit:
Innovation.CMS.gov/initiatives/bundled-payments Innovation.CMS.gov/initiatives/cjr or, call:
Shelly Harkins, MD, Chief Medical Offi cer Beacon Health System 574 . 6 47. 72 4 5 Cheryl Wibbens, MD Vice President, Medical Staff Affairs Memorial Hospital of South Bend 574.647.6525
Genevieve Lankowicz, MD, CPE, Vice President, Medical Staff Affairs, Elkhart General Hospital 574.523.7994
5 At the Helm of BEACON
PHYSICIAN SPOTLIGHT PHYSICIAN Home Care
Physician Quarterly recently Melding Compliance services between the inpatient and outpatient environments, our patients are spoke with Mark Schmeltz, DO, and Coordination family medicine physician at going to benefi t through improved outcomes At the top of his agenda is to fi nd ways and decreased costs. And, ultimately, this Beacon Medical Group Bittersweet to remove barriers referring physicians benefi ts the health system as well.” Commons. In addition to tending to may experience in establishing home his busy family medicine practice, care services for their patients. As a busy The Future of Home Care Dr. Schmeltz has served as Medical family medicine physician himself, Dr. With the increasing number of Americans Director of Elkhart General Home Schmeltz can understand fellow physicians’ who will be age 65 or older within the Care since 2013. challenges of ordering home care services next 30 years or so, the home care industry for patients, particularly regulatory will likely play a pivotal role in the future of compliance for Medicare patients under health care. In late fall 2015, Dr. Schmeltz the face-to-face encounter rule. Medicaid assumed the role of Medical Director will follow suit with the same documentation “Home care is a lot more cost-effective for the entire Beacon Home Care requirement beginning July 1 this year. than hospital-based care,” Dr. Schmeltz division as Vince Henderson, MD, says. “As we have more patients becoming “I want my colleagues to know that I’m stepped down as Medical Director for homebound as they age, we expect that their ally, and that I can identify with each our services will be utilized more.” Memorial Home Care to fulfi ll his new offi ce when it comes to interacting with duties as President of Beacon Medical home care,” he explains. “I want to be their To help manage the potential increase Group. Beacon Home Care is the liaison and really help them to work through in home care patients — including many new name and unifying brand of the any logistics that may have been diffi cult in patients with chronic and complex medical former Elkhart General Home Care the past.” needs — Dr. Schmeltz expects the fi eld of and Memorial Home Care operations. telehealth to expand rapidly in the near Dr. Schmeltz is part of the electronic health future. record team pursuing a more streamlined ith his experience in helping approach for ordering home care, “We’re excited about the prospect of to lead efforts with Beacon’s particularly during the discharge process at bringing telehealth tools into the home care W electronic health record, his role the hospital. Improving such patient hand- arena,” he says. “Ideally, home monitoring as patient safety chair for Elkhart General offs and relaying patient statuses between options will help to get patients’ data to Hospital and his breadth of knowledge the discharging physician and the attending clinicians to help them make care decisions as a family medicine physician, Dr. Mark physician provides many benefi ts. before problems arise, to automatically Schmeltz is well-suited as the Medical trigger alerts via the EMR so the provider Director for Beacon Home Care. His “As we look at our population health and knows to reach out and contact the patient. experience will be invaluable as the home Accountable Care Organization goals, At very basic levels, this would include vitals care industry redefi nes itself in coming home care becomes a very important monitoring — blood pressure, heart rate, years as technology ramps up for telehealth bridge between that hospital stay and weight, for example. In a more expanded capabilities and a sharper focus on quality the outpatient follow-up,” Dr. Schmeltz role, it might include real-time, face-to-face through pay-for-performance standards explains. “So, wherever we can improve interaction using a tablet.” comes to the fore. communication as well as coordinate
6 Physician Quarterly | Spring 2016 Improving patient safety is another with inpatient staff in these transitions of initiative Dr. Schmeltz is heading up for care. And should any issues arise, we’ll I want my Beacon Home Care. Specifi cally, he’s have the same vocabulary to pull from to developing training and will roll out resolve those.” colleagues to TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Working in tandem with patient safety is an know that I’m Safety. The program, developed by the emphasis on patient satisfaction with home Department of Defense Patient Safety care services (see “Beacon Home Care Program and the Agency for Healthcare by the Numbers” for recent Press Ganey their ally, and Research and Quality, it is an evidence- scores). Dr. Schmeltz fi nds great value in based program for improving patient care attending annual advisory board meetings that I can identify through collaboration, leadership and that include community members who are communication within health care teams. also Beacon Home Care patients or clients. with each offi ce TeamSTEPPS is used by industries across the country and aims to improve team “We try to maintain transparency and when it comes to performance and patient safety by teaching enhance community relations,” he explains. four skills: Leadership, Situation Monitoring, “We do our best to make sure we are Mutual Support and Communication. meeting the needs of the population we interacting with serve by listening to their feedback. It’s an “TeamSTEPPS is a patient safety tool for incredibly valuable tool that helps us keep home care. improving communication and facilitating our patients at the center of all that we do.” – Mark Schmeltz, DO team work among staff in clinical areas,” he explains. “The goal is better interactions
About Beacon Home Care
In January, Elkhart General Home Care and Memorial Home Care became Beacon Home Care. Under this regional brand approach, Beacon Home Care will continue providing comprehensive home care services to individuals in southwest Michigan and northern Indiana, including: • Compounding pharmacy services in Elkhart and South Bend • Home health aides • Home IV therapy • Home medical equipment Dr. Schmeltz inspects the plane prior to takeoff. • Medical social worker • Private nursing care • Respiratory therapy About Mark Schmeltz, DO • Skilled nursing care • Sleep therapy Dr. Schmeltz earned his medical degree from the Philadelphia College of Osteopathic Medicine in Beacon Home Care by the Numbers Philadelphia, Pennsylvania, and completed his family medicine residency at Saint Joseph Regional Medical Beacon Home Care continues to achieve top-tier patient Center in Mishawaka. Dr. Schmeltz is board-certifi ed in satisfaction scores as measured by Press Ganey. The home family medicine and osteopathic manipulative treatment. medical equipment division ended 2015 in the 93rd percentile He is a member of the American Osteopathic Association with an overall satisfaction score of 90.2 percent. The home and the American Academy of Family Physicians. health agency consistently scored above 90 percent overall in Dr. Schmeltz is also an Aviation & Federal Motor the Press Ganey survey, achieving its highest point in Q4 with Carrier Certifi ed Medical Examiner. a score of 93.3 percent; the year-end score was 91.7 percent.
An aviation enthusiast, Dr. Schmeltz fl ies single-engine planes out of the Goshen Municipal Airport as often as he can, usually once a month. He says his hobby is especially handy for making trips back to see family in his home state of Pennsylvania. BeaconHomeCare.org
7 Matthew Teters, MD
To a 12-year-old Matthew Teters, there were Dr. Riley, on the other hand, was Dr. Teters, in 2005. The weekend gigs at few things more valuable than a bicycle – carving a different path as someone who local bars and community events are a vast that is, except a guitar. As a sixth grader, he “hated every minute of the piano” but found departure from his day job. rode his bike to Davenport’s Pawn in Prague, his creative calling with the trombone. “I play the drums so I get to hit things. Oklahoma, and promptly traded in his bike “I played it so much at home that my I recommend the drums to anyone who has for his fi rst guitar. It was a seminal moment Dad would get tired of hearing it,” says the stress,” he joked. “It’s legal and it doesn’t hurt in his young life, marking the beginning of a Wisconsin native. anyone. There are no rules or regulations. world fi lled with music at the center. His gift for music blossomed in high No one’s telling you what to do. That’s the “I have a passion for playing music. I school while in California, where he was beauty of it.” was a musician long before I was a doctor,” drum major of his high school marching For Dr. Beatty, who joined Delusions says the family medicine physician at band, as well as a participant in the San of Granger 11 years ago on the keyboard, Beacon Medical Group Main Street. Jose Youth Symphony Orchestra. Yet, he the band offers a welcome distraction from Just how much music and medicine are reached a proverbial crossroads early in his the rigors of medicine and offers a needed connected is easy to see when considering college career: a choice to pursue music sense of camaraderie outside of work. some Beacon Health System physicians as a career as a music major, or to pursue “Being a physician is very intense. who possess a love and a talent for playing a science major with the idea of going to It’s 50 to 60 hours of work a week. Forty music. For several physicians – David Beatty, medical school. As enamored as he was appointments a day, a new person in MD; Jesse Hsieh, MD; John Katsaropoulos, with the trombone, he chose the course that front of you every 15 minutes – it’s a lot of MD, FACC; Raman Mitra, MD, PhD, FACC; felt most right – and he hasn’t looked back. responsibility,” Dr. Beatty acknowledges. Tim Morgan, MD; Robert Riley, MD; Dr. “I don’t have any regrets,” he affi rms. “But playing music is an excuse to get out Teters and many more at Beacon – music is “Being a professional musician would have and have fun. I have a ball.” part and parcel of who they are. been a different kind of life than I wanted For Dr. Hsieh, a member of Vyagra Falls to have.” Growing Up (which includes fellow band mate Dr. Mitra), Growing up in Pennsylvania, Dr. Mitra was A Welcome Distraction playing his electric guitar provides stress enthralled with the idea of becoming the While the adolescent and teen years permit relief and an outlet for creativity. next David Bowie. a lot of time for music, the same can’t “Sometimes, I’ll go down to my “Who doesn’t want to be a rock star? be said for years in medical school and basement, crank up the tube amp and just It’s just a cool thing to do. As fate would residency. The following years are then wail (on the guitar). It gets loud,” Dr. Hsieh have it, I don’t think America was ready for consumed by starting medical practice, admits. an Indian-American rock star.” marriage and family, leaving little if any time Dr. Mitra views music as an artistic After six months of practice, Dr. Mitra for other interests. expression that touches at the very core of was capable of playing the rock ’n’ roll Following a 16-year hiatus from the humanity. songs he was listening to in the 1970s from drums, Dr. Katsaropoulos “fell back in love “For patients to do well, you have to bands like Queen and The Rolling Stones, with it” after he bought a drum set in 2000. be in touch with your own humanity, feelings eventually forming rock-cover bands in high He then joined the Ricki Lake Effect (now and emotions. Because of my passion for school and college. called Phineas Gage), a band started by music, I am more in tune with myself, and as
8 Physician Quarterly | Spring 2016 Jesse Hsieh, MD Tim Morgan, MD Raman Mitra, PhD, FACC MD, David Beatty, MD David Beatty, MD Riley, Robert John Katsaropoulos, FACC MD,
a result, I am more in tune with my patients discipline of practice. This all helps in other David Beatty, MD and I empathize with them better – and endeavors in life,” he affi rms. OSMC that’s a good thing for physicians.” Band: Delusions of Granger As a family medicine physician for For the Love of It Music can do more than help a person more than 30 years, Dr. Riley loves the Jesse Hsieh, MD become a better physician. Dr. Morgan everyday work of building relationships The South Bend Clinic with his patients, a phenomenon similar to credits the choir at Albion College in Bands: Vyagra Falls and Jesse connecting with a musical audience. Michigan for bringing together he and his Ryan Project Physicians freely admit performing eventual wife, Sandra Morgan, MD, a on stage elicits such a rush that they keep pediatrician with Beacon Medical Group John Katsaropoulos, MD, FACC coming back for more. Pediatrics Bristol Street. Beacon Medical Group “It’s infectious and intoxicating. I get a Now, as fi rst tenor in the Trinity United Advanced Cardiovascular feeling of what it is to be a rock star,” says Methodist Men’s Quartet, Dr. Morgan Specialists South Bend Dr. Teters. performs several times a year at his church in Band: Phineas Gage Elkhart as well as at community events. Medicine and Music “I just love singing,” he says. “I feel Raman Mitra, MD, PhD, FACC The qualities it takes to be a good musician sense of achievement when I can add to a Beacon Medical Group – discipline, focus, hard work, knowledge person’s worship experience.” Advanced Cardiovascular and training – also apply to being a good Just as these physicians were born to Specialists South Bend physician, explains Dr. Mitra. help heal people, it seems that they were Band: Vyagra Falls “In some ways, learning a new musical also born to share their gift of music. skill or technique is akin to performing a “Playing the trombone,” says Dr. Riley, Tim Morgan, MD complex heart procedure,” he says. “will always be a great part of my life.” River Oaks OB/GYN “Just like with medicine,” adds Dr. Teters, When Dr. Teters thinks back to when he Group: Trinity United “music has complex formulas – it involves exchanged his bike for the guitar, he has no Methodist Men’s Quartet math and there’s plenty of problem solving second thoughts. that occurs. Just as I try to fi nd a solution for “I envisioned a world where I could do Robert Riley, MD someone’s health problem, so too there’s the both – play music and practice medicine – Beacon Medical Group need to resolve tension in a song.” and I am getting to live out that dream.” E. Blair Warner Dr. Beatty goes so far as to credit music Bands: Beacon Innovators, for changing the trajectory of his academic Terry and the Heartbeats life. As a third grader, he was a “C student and LaPorte County at best.” But after beginning violin lessons the Symphony Orchestra next year, he became the best student in the fourth grade. Matthew Teters, MD “Learning music helped me to focus, Beacon Medical Group Main Street better organize my thoughts and develop the Band: Phineas Gage
9 Andreas J. Deymann, Maliha Iqbal, MD, BEST WISHES MD, was named a hospitalist at Pediatric Intensive Care Memorial Hospital, Elkhart General Medical Director for recently earned the Hospital Memorial Children’s distinguished designation President Retires Hospital. Dr. Deymann of Senior Fellow of Greg Losasso, the joined Memorial Hospital Medicine highly respected and Children’s Hospital through the Society talented president Critical Kids, a Beacon of Hospital Medicine. This is the highest of Elkhart General Medical Group affiliate, in October 2015. designation possible through the society. Hospital, retired in Dr. Deymann is board-certified in internal February after 40 years medicine, pediatrics and pediatric critical Ryan Sorrell, MD, in health care administration. He retires care. He is also a Fellow of the American was named Memorial from Beacon Health System with a long Academy of Pediatrics and a member Hospital’s Post- list of significant achievements. In 2011, of the Society of Critical Care Medicine Anesthesia Care his leadership was instrumental in (SCCM); he also serves as a member of the Unit’s “Hot Doc” bringing Memorial Hospital and Elkhart SCCM’s task force on pediatric sepsis. for the past year. He General together to create Beacon Health had the most patients System. Perhaps his most significant Scott Eshowsky, MD, with the optimum accomplishment was celebrated in has accepted the body temperature of 98.6 upon arrival January with the opening of the Elkhart position of Chief Medical into the PACU. Patients heal faster and General Surgery Center, the hospital’s Information Officer experience fewer complications when single, largest expansion in its history. His (CMIO) for Beacon the body temperature is 98.6 after leadership abilities, knowledge, passion Health System. He will surgery. Dr. Sorrell is an anesthesiologist and strength of character will be missed. maintain his family with Michiana Anesthesia Care. medicine practice at Beacon Medical Group Cindie McPhie was Main Street. promoted to Vice President of Operations NEWS YOU CAN USE To enhance a systemwide approach at Elkhart General toward informatics, Beacon executive New Beacon Website Hospital. She joined leadership approved the transition of the the hospital in 1995 Coming Soon program to a single CMIO. The program and most recently Beacon Health System will launch a previously consisted of a CMIO at Elkhart served as Executive new, more consumer-friendly website General Hospital (D. Thomas Mellin, MD), Director of Specialty Services and (BeaconHealthSystem.org) in late March. Memorial Hospital (Ken Elek, MD), and Exceptional Experience. In her Physicians and office staff will find helpful Beacon Medical Group (Dr. Eshowsky). links and medical staff information new role, Cindie will oversee 11 under “For Medical Professionals” at the Dr. Elek served as Memorial’s CMIO since departments, including radiology, top of the new page. The EGH.org and 2010 and was an integral part of launching outpatient oncology and pharmacy. QualityOfLife.org websites will redirect the use of computerized physician order users to the new Beacon website, until they entry at Memorial to advance the use of the are eventually removed. Cerner EMR system. Dr. Elek served on the ACHIEVEMENTS faculty at the Memorial Family Medicine Residency Program for many years prior to EGH Breast Care Center taking on the CMIO role, and has returned KUDOS to the faculty of that program. Certification Justin Chow, MD, a Dr. Tom Mellin, who served as CMIO The Elkhart General Breast Care Center hospitalist at Memorial for Elkhart General since 2012, retired was recognized as a Certified Quality Hospital, earned the January 1. He was instrumental in the Breast Center of Excellence™ for the sixth designation of Fellow implementation of Cerner at Elkhart year in a row. This distinguished honor of Hospital Medicine General; his vision of advancing patient represents a commitment by the Breast through the Society of care through technology still resonates Care Center to provide the highest level of Hospital Medicine. within Elkhart and across the system. quality breast health care in the area.
10 Physician Quarterly | Spring 2016 CONTINUING MEDICAL EDUCATION Memorial Hospital of South Bend Hospital Auditorium (unless otherwise noted) , continued 12:10 to 1:10 p.m. Lunch available at 11:30 a.m. Registration is not required. Call 574.647.7381 with questions. The Elkhart General Breast Care Center is not only familiar with existing standards of care, but is also focused March 30 May 11 on implementing the latest medical Arif Nazir, MD, CMD, FACP Thomas J. Reid III, MD, PhD, FACP technology for the advancement of breast CMO, Signature HealthCare, Medical Director, Memorial Regional health. The National Quality Measures Louisville, Kentucky Cancer Center for Breast Centers Program™ annually evaluates breast care centers around Selecting the Best Post-Acute Familial Cancer Syndromes: the country based on the quality of care. Setting: Role of Discharge What Every Primary Care Elkhart General Breast Care Center fi rst Teams in Care Continuum Physician Needs to Know received the certifi cation in 2010. April 13 May 25 National Recognition for Aisha Shareef, MD Stephen Mitros, MD Bariatric Program Director of Neurology and Stroke Mitros Orthopaedics Elkhart General Bariatric and Metabolic Program, Memorial Hospital Institute was named a Metabolic and Implementation of a Non- Bariatric Surgery Accredited Center by Update in Stroke Management Opioid Pain Program for Total the American Society of Metabolic and Joint Arthroplasty Bariatric Surgeons and the American April 27 College of Surgeons. The Institute, Douglas Smucker, MD led by bariatric surgeons Eric Knapp, Director, Hospice and Palliative DO, and Luis Benavente, MD, has long Medicine, Cincinnati, Ohio been recognized as a regional leader in bariatric surgery and weight loss services. Palliative Care in a Community In fact, it is the only accredited bariatric Hospital: Supporting Critically surgery center in the region. Ill Patients and Their Families The national designation is based on the Institute’s quality of care, surgical cases, outcomes and other standards following a rigorous, voluntary evaluation in April that included a site visit from an independent surgeon who reviewed the program standards as well as policies BEACON HEALTH SYSTEM and procedures. Welcomes New Docs Elkhart General Recognized (October – December 2015) for Patient Safety In February, the Indiana Hospital DIAGNOSTIC RADIOLOGY PEDIATRIC CRITICAL CARE Association (IHA) announced that Irfan Ahmad, MD Andreas Deymann, MD Elkhart General Hospital was among Jack Markiewicz, MD PEDIATRIC NEUROLOGY just 12 member hospitals named to the Krishna Pillai, MD Women’s Choice Award America’s Best Susan Conrad, MD Smari Thordarson, MD Hospitals for Patient Safety list. PEDIATRICS FAMILY MEDICINE According to the IHA, the evidence-based Puja Whitlow, MD designation includes hospitals that have Carol Mann, MD URGENT CARE “exceptional performance in limiting EmmaLeigh Smith, MD Wendell Garcia, MD a wide range of hospital-associated GENERAL SURGERY Carol Mann, MD infections and complications from Emily Mitchell, DO surgery and medical treatment. HOSPITAL MEDICINE Sameer Khalid, MD Jose Luis Lopez, MD (Neurohospitalist)
11 Fellowship-trained dermatologic surgeon Luiz Pantalena, MD, PhD, and dermatology nurse practitioner Jill Maddox, RN, MSN, FNP-BC, offer DERMATOLOGY UPDATE: Mohs micrographic surgery as well as general and cosmetic dermatology at Mohs Micrographic Surgery for Beacon Medical Group Ireland Road. Non-melanoma Skin Cancer
Submitted by Luiz Pantalena, MD, PhD Beacon Medical Group Ireland Road
Non-melanoma skin cancers, including basal cell and squamous cell addition, by removing the least amount of tissue, this form of “skin- carcinomas, are the most commonly diagnosed cancers in the adult sparing surgery” offers superior cosmetic results. population . One in fi ve Americans will develop skin cancer in the course of a lifetime, and between 40 and 50 percent of Americans While Mohs micrographic surgery can be performed by any who live to age 65 will have either a basal cell or a squamous cell dermatologist, it is an advanced technique that is best performed carcinoma at least once. Each year, in the U.S. alone, over 5.4 million by a highly trained and experienced surgeon. Fellowship-trained cases are treated. dermatologic surgeons have taken a one-year specialized course of training, including training on “reconstruction.” This way, the Basal cell carcinomas are rarely fatal, but can be highly disfi guring if dermatologic surgeon can properly and precisely repair the skin and allowed to grow. Even so, as many as 3,000 deaths from advanced underlying tissue to eliminate or minimize scarring. basal cell carcinoma occur annually in the U.S. Approximately 8,000 to 10,000 people die of squamous cell carcinomas each year, and The types of cancer most likely to warrant this treatment are located organ transplant patients are up to 250 times more likely to develop in cosmetically sensitive areas or functionally critical areas around these skin cancers. the eyes, nose, lips, scalp, fi ngers or toes. In addition, regardless of location, tumors that are large, aggressive, growing rapidly, have Diagnosis of skin cancers relies on primary care physicians and ill-defi ned edges or are recurrent are best treated with Mohs. Finally, dermatologists performing skin checks and skin biopsies of suspicious transplant patients with non-melanoma skin cancers are best treated lesions. Once the diagnosis of a skin cancer is made, treatment can with Mohs, as these cancers can behave very aggressively in an take many forms, including scraping and burning, freezing, radiation immunosuppressed background. and routine excision. However, while these remedies may be fi ne for many cancers, not all treatments are equal. The gold standard for treatment of non-melanoma skin cancer is called Mohs micrographic For more information regarding Mohs surgery, and it is now being offered at the Beacon Medical Group micrographic surgery or to make a general Ireland Road Specialties. dermatology referral, please contact Beacon Mohs micrographic surgery offers the highest potential cure rate — Medical Group Ireland Road Specialties at 99 percent — for non-melanoma skin cancer. With Mohs micrographic surgery, the dermatologic surgeon uses both the scalpel and the 574.647.DERM (3376). microscope to confi dently achieve successful tumor clearance. In
12 PhysicianPhysician Quarterly Quarterly | |Vol. Spring I, Issue 2016 I ADVANCED CANCER TREATMENTS Implemented at Elkhart General Hospital
HDR Brachytherapy Elkhart General Hospital is implementing the use of a new device for managing cervical cancer that greatly reduces treatment time, helping to prevent patients from developing pressure ulcers and other problems associated with extended time lying on one’s back, and reducing staff’s exposure to radiation. The standard of care for cervical cancer has been low-dose-rate brachytherapy, which required patients to lie still in their hospital beds for two days. A new device, the HDR Tandem and Ovoid, purchased in 2015, allows staff to perform the treatment with high-dose-rate brachytherapy, reducing treatment time to approximately 20 minutes. There is no radiation exposure to staff using the new procedure. The Tandem and Ovoid is inserted into the vagina in an operating room by the radiation oncologist and then stabilized with packing. The patient is then taken to the radiation oncology department for CT scans that are used for generating a 3D radiation therapy plan for treatment. This allows for a more accurate dose representation compared to previous plans done in 2D, and improves ability to protect critical normal structures. After the physician reviews the treatment plan, the patient is taken for the HDR treatment. The radiation therapist and physicist ensure that the catheters, which will carry the radioactive source into the device, are correctly attached. The physician oversees the entire procedure and treatment. After the treatment is completed, the device is removed and the patient is able to go home. The physician will usually want the patient to receive another two to fi ve treatments over the following weeks, at which time the whole procedure is repeated.
Radioembolization (Y-90) Radioembolization is a minimally invasive procedure that combines embolization and radiation therapy to treat liver cancer. Tiny glass or resin beads fi lled with the radioactive isotope yttrium Y-90 are placed inside the blood vessels that feed a tumor. This blocks the supply of blood to the cancer cells and delivers a high dose of radiation to the tumor while sparing normal tissue. It can help extend the lives of patients with inoperable tumors and improve their quality of life.
Elkhart General Hospital began performing Blood Vessels this procedure under the direction of Nazar Golewale, MD, in late 2014. Since August of Microspheres 2014, staff have performed nine total procedures in small vessels on six patients. This is a less invasive and less toxic treatment method to aggressively treat liver cancers with metastatic lesions. This treatment Nazar Golewale, MD option had not been offered locally in the past Interventional Radiology and now allows patients the advantage of being treated closer to home.
These procedures add more options to Beacon Health System’s robust cancer program to care for patients in our region. Both Elkhart General and Memorial offer HDR brachytherapy for treating other cancers, including breast cancer and Tumor Artery other gynecological cancers; Memorial uses the technique to treat prostate cancer. Vein Radioembolization is also available at Memorial for treating liver cancer.
13 Schwartz Rounds Foster Healing Among Physicians, Nurses & Support Staff
Schwartz Rounds panel members at Elkhart General include (L to R): Roger Hershberger, Cindie McPhie and Michelle Bache, MD.
y the end of the fi rst Schwartz Center Rounds® held at Elkhart Emergency medicine physician Michelle Bache, MD, Medical General Hospital in November, it’s fair to say there were very Director for the Schwartz Center Rounds at Elkhart General, believes Bfew dry eyes left in the crowd. But most of the 60 or so audience the Rounds are benefi cial for addressing the day-to-day stresses that members in the Patel Family Auditorium were not directly involved in can affect a provider on a personal level. caring for the patient being discussed by the four-member panel on “This program is unique in the sense that there isn’t another the dais. Universally, however, those physicians, nurses and support opportunity that provides a protected, dedicated time that all the staff in the room identifi ed with how the patient’s personal story members of a multidisciplinary caregiving team can come together touched each caregiver who spoke. In this supportive and cathartic to discuss these emotional, social and spiritual issues that surround setting, a singular truth emerged: Providing health care can have a patient care,” Dr. Bache explains. profound and emotional toll on caregivers. Amberly Burger, MD, Medical Director of Palliative Care Services The Creation of Schwartz Rounds and Chairperson of the Ethics Committee at Elkhart General Hospital, is a panel member for the Schwartz Center Rounds. Even in the In 1994, at age 40, Boston health care lawyer Ken Schwartz was program’s nascency, she believes the Rounds have already helped to diagnosed with lung cancer. Inspired by and deeply grateful for forge stronger bonds among team members and encourages other the compassion showed to him by his health care team during his physicians to attend future sessions. course of treatment, he founded the nonprofi t Schwartz Center for “I think any time we are able to ‘debrief’ or be in the moment Compassionate Healthcare just before he died in 1995. Based at improves our ability to be invested in the next patient,” says Dr. Massachusetts General Hospital, the Schwartz Center guides health Burger. “We often have multiple stressors placed on our shoulders: care institutions — now totaling over 300 hospitals and other facilities paperwork, insurance, politics, external confl icts at work beyond across the United States — in conducting multidisciplinary rounds that what it means to be present with patients. These rounds reset our focus solely on the emotional impact of caregiving. Sessions may mind and allow it to rest in a supportive way that helps to identify the focus on a particular patient case or a theme with broad appeal doctor as a person.” (“There’s not enough time to do the things I need to do,” for example.) Cindie McPhie, Vice President of Operations of Elkhart General Hospital, lobbied to bring Schwartz Rounds to the hospital after Learn More learning about them a few years ago, believing the program For more information about upcoming Schwartz Center could increase understanding and communication among hospital Rounds at Elkhart General Hospital or to suggest topics team members, reduce stress among staff as well as foster deeper or patient cases, contact Cindie McPhie at cmcphie@ connections with patients and their families. beaconhealthsystem.org or at 574.523.7895. “The fact that the Rounds are a safe and nonjudgmental forum is For more information about the Schwartz Center for extremely important,” says McPhie. “It’s not a medical review in any Compassionate Healthcare visit TheSchwartzCenter.org way. It’s simply a way to express the emotions that come out with or Facebook.com/TheSchwartzCenter. diffi cult patient-related situations.”
14 Physician Quarterly | Spring 2016 BEST OF THE BEST
CMS Observes Radiology, Inc. and Elkhart Local Collaboration to General Hospital have worked together for the betterment of Learn Best Practices patients and the hospital, resulting When it comes to diagnostic and interventional radiology best practices, there are few in the in improved patient safety and country that perform better than Radiology, E A L T cost savings. Their best practices Inc. in partnership with Elkhart General H H N Hospital (Beacon Health System). S are now being considered for O Y
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B making its way onto the national B CE radar, but also potentially into Aff ordable Care Act’s Transforming hospitals and medical imaging rooms across the country. Clinical Practice Initiative. Radiology, Inc. and Elkhart General were given the distinct honor of being chosen by the The Goals of the American College of Radiology as a best practice site interviewed as part of the Transforming Clinical Practice Initiative, set forth by the Affordable Transforming Clinical Care Act. Practice Initiative The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation, by supporting clinician practices Support more than 140,000 physicians in their over the next four years in sharing, adapting and further developing their practice of transformation work. comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of Build the evidence, based on practice patient care and spend health care dollars more wisely. transformation, so that effective solutions Representatives from the Lewin Group, an entity that consults for Centers for can be scaled. Medicare and Medicaid Services, came to Elkhart General on Dec. 14, 2015, followed by a debriefi ng with CMS on Dec. 22. Elkhart General was Improve health outcomes for millions of one of four facilities in Indiana chosen by CMS for best practice review. Medicare, Medicaid and CHIP benefi ciaries and other patients. The accomplishments of Radiology, Inc.’s diagnostic and interventional radiologists were acknowledged in conjunction with Elkhart General, Reduce unnecessary hospitalizations for including: 5 million patients. • Applying value-added matrix • Implementing lean processes Sustain effi cient care delivery by reducing unnecessary testing and procedures. • Tracking population health metrics (breast cancer and lung cancer) Generate $1 to $4 billion in savings to the • Reducing radiation dosage federal government and commercial payers. • Reducing unnecessary testing Transition 75 percent of practices completing CMS leaders will use this information the program to participate in Alternative and data from other sites to develop Payment Models. processes/programs for utilization by more than 140,000 physicians nationwide. Samir Patel, MD “It is great for the diagnostic and Diagnostic Radiology interventional radiologists of Radiology, Inc. and Elkhart General Hospital to be recognized as a national leader in health care,” says board-certifi ed Diagnostic Radiologist Samir Patel, MD, of Radiology, Inc.
15 Going the Distance: Elkhart General on the Road to Trauma Center
Charles Peterson, MD, spearheads Elkhart General’s Accreditation journey to becoming a Level III Trauma Center.
There are no trauma centers between South thereby helping to quickly and effi ciently makes clear sense from the standpoint of Bend and Fort Wayne — a reality that is coordinate and mobilize resources and patient health to offer another option for changing thanks to Elkhart General Hospital manpower. outstanding trauma care in the region,” says and its effort to become the second trauma “Emergency room physicians, nurses Dr. Peterson. center in the region. and support personnel already do an Trauma Services at Elkhart General For more than 10 years, Memorial excellent job evaluating and treating trauma and Memorial are working closely together, Hospital — a Level II Trauma Center — has patients, but with the new Level III trauma evidenced by monthly meetings during shouldered much of the trauma caseload protocols in place, that makes the process which medical staffs review cases and work in the north central and northwestern half more effi cient,” says Dr. Peterson. to improve the coordination of care. of the state. But that has begun to change Level III accreditation requires all Memorial Hospital will continue to over the last year, with Elkhart General trauma doctors and nurses to be certifi ed in handle more extensive neurosurgical cases, gradually keeping more trauma cases Advanced Trauma Life Support. It’s a course specialized orthopedic surgical cases and as it seeks to become accredited by the that teaches how to assess a patient’s pediatric cases since the more stable cases American College of Surgeons as a Level condition, resuscitate and stabilize him can be handled at Elkhart General. III Trauma Center. or her, and determine if his or her needs exceed a facility’s capacity, as well as Raising the Bar Taking Priority covering how to arrange for a patient’s Elkhart General’s trauma program is greatly Elkhart General’s coordination, effi ciency interhospital transfer and assure that enhanced by the new Surgery Center, a and overall quality of its trauma care are optimum care is provided throughout the state-of-the-art facility complete with 10 “defi nitely improving,” says Trauma Services process. operating suites, a hybrid operating suite Medical Director Charles Peterson, MD. and a helistop. The program took a big step forward Gaining Momentum “When you take into account the new to become an accredited trauma center The momentum for becoming a trauma Surgery Center,” he says “the helistop and with the implementation of protocols late center naturally picked up steam when our rapidly improving trauma program, last year. Hospital-wide, departments are Memorial and Elkhart General formed Elkhart General is taking medicine to a alerted by an activation code (911 for Beacon Health System in 2012. higher level in our region.” severe trauma and 912 for less severe “Historically, Memorial Hospital has trauma) when a trauma case is coming in, been inundated with trauma cases, so it
TRAUMA CENTER NAME LOCATION ADULT PEDIATRIC DESIGNATION DESIGNATION A Level III Trauma Center Deaconess Hospital Evansville Level II is a hospital that provides Eskenazi Health Indianapolis Level I prompt assessment, resuscitation, IU Health Arnett Hospital Lafayette Level III emergency surgery, and IU Health Ball Memorial Hospital Muncie Level III stabilization and arranges IU Methodist Hospital Indianapolis Level I transfer to a higher level facility Riley Hospital for Children at IU Health Indianapolis Level I when necessary, maintains Lutheran Hospital of Indiana Fort Wayne Level II Level II continuous general surgery Memorial Hospital of South Bend South Bend Level II coverage, and has transfer Parkview Regional Medicine Center Fort Wayne Level II Level II agreements and standardized St. Mary’s Medical Center of Evansville Evansville Level II Level II treatment protocols to plan St. Vincent Indianapolis Hospital Indianapolis Level I for care of injured patients.
Source: Indiana State Department of Health
16 Physician Quarterly | Spring 2016 Elkhart General Hospital Surgery Center Opens A spacious family lounge where family 1 members can track a loved one’s progress via monitors and/or through text messages. A hybrid operating suite combines 2 imaging services and surgical procedures [1] in the same space.
A helistop on the roof speeds the 3 care of critically ill or injured patients in Elkhart County.
The pre/post surgery bays include sliding 4 glass doors for additional privacy for patients and families.
L to R: Pamela Goddard-Dunfee, Genevieve 5 Lankowicz, MD, Arthur J. Decio, Cindie McPhie, Lisa MacDonald, Karra Heggen, Elkhart Mayor Tim Neese, Phil Newbold and Kreg Gruber help cut the surgical gauze, officially opening the new Surgery Center on Jan. 6.
The Arthur J. Decio Pavilion was named 6 in honor of longtime prominent Elkhart philanthropist Art Decio. [2]
[3] [4]
[5] [6]
17 MEDICAL MILESTONE FOR MEMORIAL HOSPITAL First hospital in the region to implant cardioverter defi brillator
Raman Mitra, MD, PhD, FACC compatible for MRI scans Clinical Cardiac Electrophysiology
Memorial Hospital cardiologist Raman Mitra, MD, PhD, FACC, has once again led Memorial to another medical milestone in the region. Dr. Mitra inserted an implantable cardioverter defi brillator (ICD) that can be used during a full- body magnetic resonance imaging (MRI) scan, making Memorial Hospital the region’s fi rst to do so. Dr. Mitra, Medical Director of Beacon Medical Group Advanced Cardiovascular Institute South Bend, is proud Memorial Hospital continues to demonstrate itself as a medical leader in the region. “Patients at risk for sudden cardiac arrest have depended on ICDs to monitor their hearts, detect dangerous arrhythmias and deliver the lifesaving therapy,” says Dr. Mitra. Every year, more than 300,000 people are implanted with ICD systems to regulate their heartbeat, and studies estimate that 50 percent to 75 percent will need an MRI scan in their lifetime to help diagnose a variety of diseases. The strong magnetic forces applied during MRIs can potentially have a negative effect on both the device and leads, and are usually not recommended for pacemaker and ICD patients. But now with the medical breakthrough of MRI-compatible ICDs, people across the country who will be at risk for sudden cardiac arrest, including right here in Michiana, can have the assurance they can undergo an MRI, without fear the ICD will malfunction or fail, to deliver lifesaving shocks to correct lethal arrhythmias. ICDs help prevent sudden death in patients with known, sustained ventricular tachycardia or fi brillation. And when it comes to the treatment of arrhythmias, Dr. Mitra is cutting- edge. He is the fi rst and only cardiologist in the region and one of 20 cardiac electrophysiologists in the nation who does not use X-rays when conducting complex ablations (mapping and cauterizing abnormal electrical activity of the heart) for the treatment of arrhythmias. This allows the patient and staff to avoid any exposure to ionizing radiation. “To be able to perform ablations without the use of X-rays shows the expertise and ability of Dr. Mitra,” says Cheryl Wibbens, MD, Vice President of Medical Affairs at Memorial Hospital. Dr. Mitra has a history of being an innovative leader: In 2011, Dr. Mitra implanted the fi rst MRI-safe pacemaker in the region.
18 Physician Quarterly | Spring 2016 Delayed Interval Delivery of a Twin Pregnancy for 76 Days
The mother was a 29-year-old female G4 uterus). She received corticosteroids to Delaying delivery increases the risk P1112 with dichorionic diamniotic twin enhance fetal lung maturity at 23 weeks for maternal, fetal and neonatal gestation and a due date of late August. gestation. The patient was discharged six complications. An attempt to prolong the She presented to an outside hospital in days after the cerclage was placed. She pregnancy is not always successful and mid-April, at 222/7 weeks with symptoms of was monitored closely on an outpatient can result in complications such as serious preterm labor. Upon admission, her cervix basis by the team of Maternal Fetal maternal infection, a subsequent previable was dilated to 7 cm. Her membranes Medicine Specialists. infant or an extremely premature infant ruptured shortly after admission. One day who may suffer from long-term morbidity In early July, at 332/7 weeks she presented after admission, she delivered the fi rst related to prematurity. to Memorial Hospital in active labor. twin (Twin A), a male infant who passed She underwent a repeat cesarean section The optimal approach for the management away within several hours due to extreme 11 weeks (76 days) after delivery of the of these patients is not based on prematurity. The placenta of Twin A was fi r s t t w i n. randomized research trials but more so left in situ. on expert opinion. Most medical experts She delivered a male infant 4 pounds Following delivery of Twin A, the patient recommend the use of antibiotics, tocolysis 13 ounces with Apgars of 8 and 9 at one requested transfer to Memorial Hospital (medication to relax the uterus) and and 5 minutes respectively. The baby was for ongoing care under the supervision of placement of a cerclage. We believe that admitted to the NICU in good condition. Beacon Medical Group Maternal Fetal the best candidates for delayed interval The patient was discharged three days Medicine specialists. Upon admission to delivery are pregnancies with a multifetal after surgery. The baby remained in the Memorial, she was not in active labor gestation where one fetus delivers at NICU for two weeks. and Twin B was doing well. There were a previable gestational age (less than no signs of infection. A decision was Although a rare event, there are numerous 24 weeks) either as a result of cervical made to continue the pregnancy and case reports and case series in obstetrical insuffi ciency, preterm premature rupture of place the patient on hospital bed rest with literature on delayed interval delivery of membranes or spontaneous preterm labor in anticipation of Twin B reaching a viable multiple gestations. Multifetal pregnancies the absence of maternal or fetal infection. gestational age. are at greater risk for premature delivery either as a result of cervical insuffi ciency, On the second day in the hospital, she preterm premature rupture of membranes again showed no signs of infection or or spontaneous preterm labor. Frequently, labor. Her cervix was dilated to 3 cm. delivery of one fetus will result in all The patient was extensively counseled remaining fetuses delivering, but in rare with regard to the risks of pregnancy circumstances this is not the case. The continuation and was offered a cerclage longer the interval between delivery, (stitch to close the open cervix). She gave the greater the chances are for a good consent for the procedure. At the time of outcome in the surviving fetus. cerclage placement, the umbilical cord from the fi rst twin was ligated with an The ideal candidates for delayed interval absorbable suture as close to the placenta delivery are patients who deliver the fi rst as possible, allowing the remaining cord to fetus at a previable gestation. Patients retract inside the cervix. The cerclage was with maternal conditions such as severe performed without incident. preeclampsia or placental abruption are not appropriate candidates for such Mureena Turnquest Wells, MD For several days, following the cerclage management. Evidence of infection in Maternal Fetal Medicine placement, she was treated with antibiotics the retained fetus is a contraindication to and tocolysis (medication to relax the delayed interval delivery.
19 615 N. Michigan Street South Bend, Indiana 46601
MARCH 30, 2016