2015 CLINICAL ANNUAL REPORT innovation &

patient-centered care

ANNUAL REPORT 2015

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 W 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 CLINICAL ANNUAL REPORT | 3 ANNUAL REPORT 2015

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 T 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

4 | ANNUAL REPORT 2015

table of co n t e n t s

Anesthesiology 6

Emergency Medicine 12

Family Medicine 20

Medicine 28

Obstetrics & Gynecology 58

Pathology 68

Pediatrics 76

Psychiatry 86

Radiology 92

Surgery 100

2015 CLINICAL ANNUAL REPORT | 5 innovation in anesthesiology

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

6 | DEPARTMENT OF ANESTHESIOLOGY DEPARTMENT OF ANESTHESIOLOGY: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: our Department in 2016, data will now be automatically uploaded into a national registry to allow comparison to The Year in Review 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 Betty-Ann Robustelli, MD operating room and the development of the structural Chair, Department of Anesthesia heart program, we have redesigned the cardiothoracic anesthesia coverage model to now include four fellowship- trained 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 t is with great pleasure that I write my first annual report undergoing open heart surgery, but they are also all board Ias Chairman of the Department of Anesthesiology. I certified in transthoracic echocardiography including began working for Stamford Anesthesiology in 2003 after the use of 3D echocardiography which has become the completing my residency at Mount Sinai Medical Center. standard of care for cardiac valve replacement surgery. The For the past two years, I have been the Associate Chair and structural heart program has successfully launched the also held the role of the Medical Director at the Tully Health transcatheter aortic valve replacement (TAVR) program Center. In October of this year, I took over for Dr. Theresa this year. It has allowed patients who are non-operative Bowling, who successfully led our department for the past candidates for valve replacement to successfully replace two years. Everyone at Stamford Anesthesiology greatly their valves percutaneously. The multidisciplinary procedure appreciates all of her hard work and dedication. Dr. Steven has strengthened our growing cardiac program and we are Finkel has been appointed the Associate Chairman as well happy to play such a large role. as the Medical Director of Tully. Dr. Finkel joined Stamford Anesthesia after completing his residency at Cornell in 2005. In February of last year, 30% of our Department became Both of us are excited for the future and look forward to the certified to perform a Focused Assessment Transthoracic growth and expansion of our Department into the new Echocardiogram exam (FATE). FATE is a non-invasive hospital opening in 2016. procedure that assesses cardiac function in the real time prior, during and after an anesthetic to assist in tailoring 2015 has been an exciting year for the Department of the anesthetic to a patient who is acutely unstable and Anesthesiology. The Department has continued to grow to when there is no time to have a complete cardiac exam by support the expanding and new service lines that Stamford a cardiologist. This has been shown to decrease mortality Hospital has been developing. We have recruited talented in certain patient populations compared to controls most new staff who have come to us from some of the finest notably in patients undergoing hip fracture repair surgery. institutions in the country. We have also trained our existing We have utilized this modality to avoid surgical delays. staff in progressive new techniques to improve outcomes especially for our sickest patients in order to continue to Our Department continues to offer unique anesthetic provide the safest anesthesia possible. solutions for complex medical problems even outside the operating room. This past year we started offering our The Department has also joined the Anesthesia Quality patients with fractured hips, who wanted to avoid surgery, Institute, AQI, a quality management program that was the option of a continuous peripheral nerve block to treat created by The American Society of Anesthesiology. pain. These patients require little to no narcotics and can thus AQI data will be useful for activities ranging from faculty avoid the negative side effects of narcotics such as delirium. education to outcomes measurement to emerging The program has been an enormous success with our elderly federal efforts to ensure performance improvement. patients and their families, who can now bring their loved With the approval of electronic medical records (EMR) for ones home in a few days and avoid surgery.

2015 CLINICAL ANNUAL REPORT | 7 DEPARTMENT OF ANESTHESIOLOGY: ANNUAL REPORT 2015

Our nerve block program continues to be recognized Figure 1: Overall Anesthesia Case Volume nationally and remains as the only Center of Excellence for regional anesthesia in the Northeast. Each month FY2015 CASES we teach a multidisciplinary course focusing not only on the technique of regional anesthesia and ultrasound Hospital Tully guided nerve blocks, but also on how to develop a successful acute pain management service. This year we October-14 774 1010 taught physicians from various places across the county, including New Mexico and the University of Alabama. The November-14 740 889 (Stamford) Advocate highlighted our progressive regional anesthesia program in a front-page article on September 10, December-14 789 1051 promoting our “almost pain-free” surgical approach. As you can see in Figure 4, our block program is continuing to grow January-15 700 884 and thrive, and we expect this trend to continue. We have also seen an increase in patient and surgeon satisfaction February-15 648 804 with acute post-op pain management due to this program.

In response to the growing need for anesthesia services March-15 780 1010 outside the operating room in locations like the Cardiac Catheterization Lab, CT Scan/MRI, VIR, and Endoscopy, the April-15 722 972 Department now offers anesthesia services 40 hours a week in these locations. May-15 724 917

SCOPE OF CLINICAL SERVICES June-15 787 940 The Department of Anesthesia provides services July-15 727 908 throughout Stamford Hospital. In addition to supporting basic surgical needs, the Department is an integral part August-15 779 855 of obstetrical and maternity cases in Labor and Delivery, Endoscopy, Interventional Radiology, MRI and CT scan September-15 782 873 studies, the Cardiac Catherization Lab, EP Studies and the Emergency Room. Each day we staff 22 locations with 22 Total 8,952 11,113 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.

8 | DEPARTMENT OF ANESTHESIOLOGY DEPARTMENT OF ANESTHESIOLOGY: ANNUAL REPORT 2015

Figure 2 highlights our surgical case volume by campus. As shown in Figure 3, Stamford Anesthesiology delivered anesthetics to 98% of the total 2,298 Labor and Delivery Figure 2: Surgical Case Volume by Campus cases for FY15. Figure 3: Obstetrical Volume – Stamford Hospital FY2015 CASES

Total Labor Emerg. Planned Cardiac OB OR NORA ENDO Deliveries w/ Anesthetic Epidural C-Section C/S Main Hospital October-14 187 108 19 60 October-14 4 187 497 34 52 November-14 198 111 28 59 November-14 9 198 444 37 52

December-14 6 211 476 36 60 December-14 211 105 34 72 January-15 7 186 408 46 53 January-15 186 108 27 51 February-15 5 156 394 36 57

March-15 6 195 473 46 60 February-15 156 88 16 52 April-15 8 156 453 50 55 March-15 195 112 20 63 May-15 6 194 432 38 54

June-15 7 171 509 43 57 April-15 156 82 20 54 July-15 8 180 442 51 46 May-15 194 105 25 64 August-15 3 221 445 36 74

September-15 12 220 448 43 59 June-15 171 96 20 55 Total 81 2,275 5,421 496 679 July-15 180 102 26 52

Tully August-15 221 130 31 60 October-14 – – 447 – 563 September-15 220 120 26 74 November-14 – – 410 – 479

December-14 – – 492 – 559 Total 2,275 1,267 292 716 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 CLINICAL ANNUAL REPORT | 9 DEPARTMENT OF ANESTHESIOLOGY: ANNUAL REPORT 2015

Our Nerve Block program continues to grow each year, as more surgeons and patients are pleased with the as is shown in Figure 4. In FY14, Stamford Anesthesiology outcomes. Our regional program has expanded to provide provided 1,961 blocks, compared to the 2,537 blocks benefits to every surgical specialty and we are excited to in FY15, and we expect this number to continue to rise share this with the Hospital community.

Figure 4: Nerve Block Growth

Single Shot Blocks FY2014 FY2015 CPT code Description # 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 Old Tap Code

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 New SS Tap Codes 64488 Transversus Abdominis Plane, Bilateral w/US N/A 245 1,562 1,860

Continuous Infusion 2014 Productivity (Aug to Dec) 2015 Productivity (Jan to Sept) CPT code Description # of Procedures # of Procedures Cervical or Thoracic, Indwelling Cath, 62318 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 Continuous Tap Codes 64489 TAP Bilateral by Continuous Infusions, w/ US 0 88 399 677

10 | DEPARTMENT OF ANESTHESIOLOGY DEPARTMENT OF ANESTHESIOLOGY: ANNUAL REPORT 2015

MEDICAL STAFF • Shahid Rafiq, MD • Betty Ann Robustelli, MD New Staff: • Nousheh Saidi, MD The Department of Anesthesiology welcomed the • Brian Sullivan, MD following physicians and CRNAs in 2015: • Benjamin Unger, MD • Ewelina Gibek, CRNA • Shiry Weisberg, MD • Elyse Goldblum, MD • Thomas Wong, MD • Maria Mazzeo, MD Hospital Committees: • Donna Nunno, CRNA • Elizabeth Rozen, MD • Credentialing Committee — Theresa Bowling, MD, Chair and Steven Finkel, MD • Jeffrey Sheehan, CRNA • Trauma Committee — Brian Sullivan, MD and • Andrew Sosa, MD Tara Doherty, DO • Brian Tevlin, MD • Pharmacy & Therapeutics Committee — Rodrigo Active Staff: Mendes, CRNA • Resuscitation Committee — Theresa Bowling, MD • Theresa Bowling, MD • Culture of Safety Committee — Benjamin Unger, MD • Kirsten Butkovsky, CRNA • Quality & Safety Committee — Shahid Rafiq, MD • Jen Hwei-Cheng, CRNA • OR Committee — Theresa Bowling, MD • Amy Crane, MD • Total Joint and Spine Committee — Vlad Frenk, MD • Joseph D’Agosto, MD • Peer Review Committee — Betty Ann Robustelli, MD, Chair • Margot Denham, MD • Kaili Dilts, MD Publications and Lectures: • Tara Doherty, DO • Vlad Frenk, MD — “Multimodality Perioperative Analgesia • Steven Finkel, MD with Paravertebral Nerve Block and Gabapentin Reduces Narcotic Use and Hospital Length of Stay in Mastectomy • Jay Freilich, MD Patients” Poster Presentation at the San Antonio Breast • Vlad Frenk, MD Cancer Symposium. • Ronald Giannotto, MD • Vlad Frenk, MD — “Multimodal Pain Management • Juliet Jackson, MD Protocol Reduces Opioid Use and Shortens Length of Stay After Major Breast Surgery” Presented to the • Eric Jankelovits, MD American Society of Regional Anesthesia. • Jeffrey Klein, MD • Vlad Frenk, MD — “Paravertebral Catheters Reduce • Alla Koorn, MD Post-Breast Surgery Use and Hospital Length of Stay” • Richard Libutti, CRNA Published in Anesthesiology News. • Adnan Malik, MD • Vlad Frenk, MD — “Basic Focused Assessed Transthoracic Echocardiography (FATE) Course” Lecture at Hospital for • Sergio Manimbo, MD Special Surgery (HSS). • Rodrigo Mendes, CRNA • Richard Morgulis, MD • Yevgeniy Printsev, MD

2015 CLINICAL ANNUAL REPORT | 11 innovation in e m e r g e n c y m e d i c i n e

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

12 | DEPARTMENT OF EMERGENCY MEDICINE DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: Stamford Hospital has one of the best door-to-balloon times in the NewYork-Presbyterian Healthcare System, The Year in Review 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 Andrew Jenis, MD, FACEP multidisciplinary team created to investigate ways to Director & Interim Chair, improve patient outcomes in this patient population, Department of Emergency Medicine 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 he Department of Emergency Medicine (ED) is might be suffering the effects of an acute stroke. It is charged with maintaining the well-being of the well-known that time is of the essence when dealing with T Stamford community when the community has this debilitating illness, and the Department is working nowhere else to turn. In 2015, the staff of the Department diligently to ensure the best possible outcomes for the evaluated and treated patients during more than 76,000 people of this community. acute care visits (Figure 1). With an overall admission rate Overall Departmental volume for FY15 decreased by of 20 percent — representing more than 50 percent of all less than 1%. Volume decreased at the Immediate Hospital admissions — the Emergency Department truly is Care Center (ICC) by .5%, and volume at the main the front door of the Hospital. ED decreased by 1.2% as compared to FY14. However, We have built on last year’s successes with the medical our volumes dropped far less than are being reported staff remaining well-satisfied with the service that we nationally, with an 8 – 10% decrease in ED volume provide to their patients. 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 CLINICAL ANNUAL REPORT | 13 DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 2015

SCOPE OF CLINICAL SERVICES ED and fast track length of stay. This change allows the Department to function more efficiently. We continue to Emergency Medicine Physicians (EMP) is a physician- refine our teletracking capabilities and investigate ways owned group that provides physician staffing of the to further streamline processes, so that we continually Emergency Department. Founded in 1992, the group’s improve on the work that has already been done. sole mission is “To Care for Patients.” EMP has staffing agreements with more than 70 hospitals nationally and MEDICAL STAFF 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. Suzy Shukovsky, MD Implementation of the “Physician First” staffing model Assistant Director is one example. In this model of care delivery, a board- certified 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 Alexandr Rafailov, MD 30 minutes. Stamford Hospital was recently recognized as Director, Quality Assurance 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. Douglas Gallo, MD Over the past year, Department members have EMS Director 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. Samuel Maryles, MD, FACEP Clinical Operations Director 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

14 | DEPARTMENT OF EMERGENCY MEDICINE DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 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 DEPARTMENTAL SAFETY AND QUALITY • Kim Zeh, MD Members of the Stamford Hospital Department of Emergency Medicine play key roles in ensuring and Part-time Physicians furthering the safety and quality of care we deliver.

• Carol Allen, MD Assistant Medical Director Suzy Shukovsky, MD, is • Maria Brea, MD, FACEP responsible for day-to-day operations of the Immediate Care Center (ICC) and works with nursing leadership on • Antonio Dajer, MD ways to improve care delivery. Through her collaboration • Jason Fischel, MD with the ICC staff, she has worked to improve the • Jose Mejia, MD efficiency of the Department, and is focusing her efforts on mechanisms to improve the overall patient experience • Adora Ozumba, MD at the ICC. • Kathy Park, MD, FACEP As Chair of the ED Quality Review Committee, Alex Rafailov, • Shivani Patel, DO MD, oversees all quality-related reviews conducted by • Sue Schemel, MD the Department. Partnering with nursing leadership, he revises and improves various departmental policies to Figure 2: CT Utilization per 100 Volume

2015 CLINICAL ANNUAL REPORT | 15 DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 2015 ensure that we deliver the highest possible quality of care. community-based EMS services to ensure the highest In addition, Dr. Rafailov reports to EMP monthly to ensure quality of training and medical oversight of crews that the clinicians are abiding by all clinical policies set by responding to those in need. As the Department the company. As the following data from the Emergency transitions to the new hospital and considers application Department Benchmark Alliance demonstrates (Figure 2), to be an ACS-accredited Level 1 Trauma Center, Dr. Gallo’s the Department is performing better than the national leadership will help to make the transition as seamless average for its cohort when it comes to CT utilization, as possible. and will continue to curtail unnecessary testing when evidence-based practice allows it. One of the main goals in the Emergency Department is to provide care in a timely manner. Through the “Physician As the EMS Medical Director for the Hospital, Douglas First” staffing model, a board-certified emergency Gallo, MD is responsible for working with various 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.)

16 | DEPARTMENT OF EMERGENCY MEDICINE DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 2015 serving as the first point of contact for patients arriving at The success of our physician in triage process is reflected the ED. As a result, the Department’s door-to-provider time in stable treat and release times, despite an increase in the has been reduced to below the national benchmark of 30 discharge from triage volume (Figure 5). minutes from patient arrival (Figure 3). The rates of patients who leave the ED without treatment Treat-and-release times for discharged patients remain continue to be significantly better than the national relatively static, and are comparable to hospitals of benchmark of 3%. There has been a slight increase in the Stamford’s size and acuity. Changes have recently been percentage at the ICC and changes to the practice model implemented, which we are confident will improve this have been made to correct this issue (Figure 6). metric in the months ahead (Figure 4).

Figure 5: Volume of Patients Discharged From Triage

Figure 6: Left Without Being Seen (%)

2015 CLINICAL ANNUAL REPORT | 17 DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 2015

Patient satisfaction scores have shown dramatic Outcomes improvement in the ICC. Emergency department scores have decreased, we have made operational changes that Providing excellent care to our patients is the basis for we expect will take it ends in 2016 (Figure 7). everything we do in the Department. We continually monitor and strive to outperform ED-specific national DEPARTMENTAL EDUCATION AND benchmarks. As can be seen in Figures 8 and 9, we continue to excel in our door-to-balloon times for patients TEACHING ACTIVITIES who are suffering from an acute myocardial infarction. We have been able to achieve this by developing a process As work on the new Stamford Hospital Emergency that is both easy to follow and reproduce, without regard Department advances, we are working to ensure that to external variables. We have brought this same approach patients receive the best possible care even before they to the management of patients with an acute ischemic arrive at the ED. To this end, the Department provides stroke, such that our performance for door-to-tPa time medical oversight of the Stamford EMS system as well as illustrates success with this approach. volunteer EMS providers in the surrounding area. Nationally, an acceptable Left Without Being Seen rate is The Department also serves as a teaching center for approximately 3%. Despite having seen minor increases in Quinnipiac and Bridgeport University physician assistant our rate during times of high ED utilization (we averaged students, as well as for both Internal Medicine and Family 146 patients per day in September in a Department Practice residents. Additionally, we also have medical designed for half that number of visits), we continue to students from Columbia rotating through the Department perform far below the national average with regard to as a part of their educational experience. Recently we were this measure. We have achieved superior results by the contacted by Fairfield University to have their students implementation of the Physician First process, in which rotate through our Department as well, and Sacred Heart we have a physician in the triage area to evaluate all University physician assistant students will be rotating walk-in arrivals within minutes of their presentation to through the ED in 2017. the Department.

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

18 | DEPARTMENT OF EMERGENCY MEDICINE DEPARTMENT OF EMERGENCY MEDICINE: ANNUAL REPORT 2015

Figure 8: Door-to-Balloon

Figure 9: TPA Within 4.5 Hours

2015 CLINICAL ANNUAL REPORT | 19 innovation in 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.

20 | DEPARTMENT OF FAMILY MEDICINE DEPARTMENT OF FAMILY MEDICINE: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: The top DRGs for admissions by Department members in 2015 were: The Year in Review • 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 • Renal failure 015 was a big year for physicians in general, and • Cellulitis for family physicians in particular. Medicare’s • Syncope 2sustainable growth rate formula was finally repealed by Congress thus removing the annual threat of major cuts for Medicare reimbursements for physicians. There SCOPE OF CLINICAL SERVICES is still work to be done to ensure fair compensation for The members of the Department of Family Medicine the valuable work primary care physicians do for their continue to provide a wide range of essential health increasingly complicated patients, but this is a step in services to the Stamford community and Stamford the right direction. The other monumental development Hospital and serve in a variety of roles including: for physicians this year was the roll out of ICD-10. So far, • School health physician it appears that office EMRs were up to the challenge and most physicians had a seemingly smooth transition. • Palliative care The next few months will be telling as we see whether • Geriatrics and nursing home practice reimbursements will be affected by the new system. • Public health director Members of the Department of Family Medicine • Medical IT continued to have an enormous impact on the health and • Indigent care well-being of their individual patients and the Stamford community in general. The unique and special relationship • Hospitalists of the Family Physician with his or her patient continues • Integrative medicine to be one of the most important and meaningful of all human relationships. Family physicians strive daily to limit • Medical missions abroad the intrusions and obstructions that threaten to impact the • Graduate medical education care they give to and for their patients. • Graduate nursing education

Members of the Department of Family Medicine admitted The geographic area served is from North Stamford to 535 patients in fiscal year 2015. This was a 3% increase the South End, from New Canaan to the West Side. The from FY14. Of these patients, 452 were adults, 10 were patients cared for include newborns, children, teens, children and 73 were newborns. 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

2015 CLINICAL ANNUAL REPORT | 21 DEPARTMENT OF FAMILY MEDICINE: ANNUAL REPORT 2015 the Hospital while others use the increasingly popular Milestones hospitalist service for their inpatients. The following Department members celebrated Stamford Hospital is fortunate to have one of the three milestone anniversaries as members of Stamford Family Medicine residency programs in Connecticut. At Hospital’s Medical Staff: this time, 16 of the 30 current members of the Department of Family Medicine have come from this residency • Sadna Alaigh, MD — 20 years program. With the country in the midst of an increasing • Joseph Connelly, MD — 30 years shortage of primary care physicians, the value of the Family Medicine Residency Program as a “feeder” of primary care New Staff physicians into the community continues to increase. This is an important factor in insulating the Hospital and The Department of Family Medicine welcomed the community from the serious quality and cost problems following physicians in 2014 – 15: seen in areas with a dearth of primary care physicians. • Anna Jamrozik, MD, Stamford Health Integrated Practices (SHIP) MEDICAL STAFF • Kamilah Rose, MD, Stamford Health Integrated Practices (SHIP)

These physicians bring the total Department membership to 31. Henry Yoon, MD Associate Chair • 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 Honors and Recognition Member at-Large to Department Executive Committee • 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.

• 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. Kathleen Nurena, MD Member at-Large to • Dr. Joshua Herbert was selected as Chair of the Medical Executive Committee Medical Staff.

• High Ridge Family Practice (Dr. Alan Falkoff) was designated as a High Performance Practice by the Medical University of South Carolina.

22 | DEPARTMENT OF FAMILY MEDICINE DEPARTMENT OF FAMILY MEDICINE: ANNUAL REPORT 2015

• Dr. Joseph Feuerstein was selected as the winner of the • Quality Assurance Committee (SHIP) – Dr. Clarke Latimer Fairfield County Business Journal Excellence In Medical Research Award. • Utilization Management Committee — Dr. Joseph Connelly • Dr. Rod Acosta was appointed President of Stamford Health Integrated Practices (SHIP). DEPARTMENTAL EDUCATION AND Hospital Committee Participation TEACHING ACTIVITIES • Continuing Medical Education Committee — The Family Medicine Residency Program had another Drs. Joseph Connelly, Henry Yoon successful year in 2015. For the fourteenth straight year, the program filled completely in the match with excellent • Credentials Committee — Drs. Joshua Herbert, candidates. The additions to the residency staff include: Henry Yoon, Jack DiTeodoro • Jacky Chen, MD

• Graduate Medical Education Committee — • Patrick Khalaf, MD Drs. Joseph Connelly, Henry Yoon • Durvi Patel, MD • Information Technology Leadership Council — Dr. Henry Yoon • Krupa Patel, MD

• Infection Control Committee — Dr. Clarke Latimer • Alyssa Sader, MD

• Internal Medicine/Family Medicine Performance Five physicians graduated from the residency program in Improvement Committee — Drs. Henry Yoon (co-chair), 2015 and all satisfactorily passed the American Board of Anne Brewer Family Medicine certification exam. Additionally:

• Medical Executive Committee — Drs. Joshua Herbert Dr. Lawrence Liebowitz was re-appointed Clinical Assistant (Chair), Rod Acosta (Outgoing Chair), Joseph Connelly, Professor of Medicine at NYMC. Kathleen Nurena Dr. Alan Falkoff had faculty appointments at NYU, • Medical Ethics Committee — Drs. Joseph Connelly, Columbia, Sacred Heart, Pace University and Anne Brewer Quinnipiac University.

• Ancillary Provider Committee — Dr. Clarke Latimer had faculty appointments at UCONN Dr. Jack DiTeodoro (Chair) 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 Dr. Joseph Feuerstein has a faculty appointment at Columbia University. • Pediatric Peer Review Committee — Dr. Kathleen Nurena Dr. Katie Takayasu has a faculty appointment at • Perinatal Infectious Disease Committee — Columbia University. Dr. Anne Brewer Dr. Joseph Connelly has a faculty appointment at • Pharmacy and Therapeutics Committee — Columbia University. Dr. Shanthi Devaraj Dr. Kathleen Nurena organized a medical grand rounds • Planetree Committee (SHIP) — Dr. Lawrence Liebowitz presentation on the association between domestic • Primary Care Committee (SHIP) — violence and animal abuse. Dr. Lawrence Liebowitz Dr. Joseph Feuerstein lectured about Integrative Medicine • Primary Care Integration Steering Committee — in the Stamford Hospital Mini-Medical School and at Grand Dr. Henry Yoon Rounds at Silver Hill Hospital.

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DEPARTMENTAL RESEARCH AND COMMUNITY OUTREACH SCHOLARLY ACTIVITIES Dr. Anne Brewer went to the Dominican Republic in January High Ridge Family Medicine participated in various for a medical mission trip, her seventh to this country. research projects in primary care with PPRNet. Dr. Henry Yoon served as School Medical Advisor to the Dr. Kathleen Nurena prepared a poster on interdisciplinary Stamford Board of Education as well as to the Stamford education of state agencies. Department of Public Health.

Dr. Joseph Connelly co-authored a chapter for the most Dr. Marc Brodsky coordinated the Athletes and the Arts recent edition of Rakel’s Textbook of Family Medicine. program at Chelsea Piers Connecticut.

Dr. Joseph Feuerstein published an article in Current Dr. Henry Yoon served on the board of directors for Smith Nutrition and Food Sciences entitled “Teaching a House and the Shelter for the Homeless. Lifestyle Modification Program to a Cohort of Local MDs to Treat Obesity and Hyperlipidemia and Hypertension.” Dr. Henry Yoon was Coordinator of Stamford Hospital’s Mini-Medical School. Three Family Medicine residents submitted articles and/or questions to the Core Content Review of Family Medicine. Dr. Joseph Connelly served on the board of directors for Optimus Health Care. Dr. Shakiella Howell presented a poster on the Optimus Integrative Medicine Clinic at a national conference on Dr. Lawrence Liebowitz served as Director of Health of the care for the underinsured. Town of Redding.

Dr. Lawrence Liebowitz completed a two-year fellowship Drs. Joseph Feuerstein appeared on News 12 Connecticut in Integrative Medicine sponsored by the University to discuss integrative medicine and wellness. of Arizona. Dr. Robert Shapiro served as co-medical director of the Dr. Joseph Feuerstein presented a poster at the AmeriCares Stamford mobile van. International Congress on Integrative Medicine & Health Dr. Lawrence Liebowitz served as Camp Director for in Las Vegas on “The use of hypnosis and acupuncture in summer camps in Stamford, Ridgefield and Redding. the treatment of anxiety disorders — a case series.” Dr. Alan Falkoff continues coaching and playing for the Dr. Katherine Takayasu presented several lectures and Stamford Mets. Grand Rounds to attending physicians and residents at Stamford Hospital, Columbia University and New York Dr. Katherine Takayasu made several presentations Medical College. about chronic pelvic pain to physicians, as well as in the communities of Norwalk, Darien, Wilton, New Canaan Dr. Marc Brodsky is the principal investigator of a study and Stamford. based at the Wilton Y comparing a particular stretching exercise program to self-care for patients with back pain.

24 | DEPARTMENT OF FAMILY MEDICINE DEPARTMENT OF FAMILY MEDICINE: ANNUAL REPORT 2015

INTEGRATIVE MEDICINE Patients Overview The Center treats children, adolescents and adult patients. Most patients are referred for consultation by physicians The Center for Integrative Medicine & Wellness (CIMW) at and word of mouth. CIMW practitioners conduct over Stamford Hospital is comprised of a Hospital-based clinic 9,000 patent visits per year. that offers an integrative medicine consultation service. It is situated in the Tully Health Center. Practitioners

The Center’s model is a high-volume, outpatient, The CIMW employs three full-time board-certified Family sub-specialty medical clinic that provides the following Physicians who provide all treatments. The physicians integrative medicine services: oversee interdisciplinary aspects of care by conventional 1. Pain management and complementary practitioners, both Hospital- and community-based. Practitioners who share common 2. Nutrition and supplement consultation patients with the CIMW physicians are vetted to assure proper credentialing and are included in a monthly 3. Mind-body stress reduction meeting at the Center to discuss the care of mutual patients, improve communication among practitioners 4. Lifestyle medicine and optimize patient outcomes. Medicare and all private insurances are accepted, and visits are processed through insurance. In addition Services Offered to consultative care, the Center offers programs and The Center offers the following Integrative education to patients, Hospital employees and the Medicine programs: community. The Center also provides educational opportunities to medical practitioners. Pain Management — The pain management service accounts for the majority of patient visits and revenue for Philosophy the CIMW. Most patients with pain are seen for neck pain and associated symptoms to include headache. Other The philosophy of the CIMW is well-aligned with the conditions include low back pain, occupational- and Planetree philosophy that is based on the simple premise sports-related overuse injuries, osteoarthritis, neuropathy, that all care should be organized around the needs of fibromyalgia and autoimmune-related and cancer-related patients. CIMW focuses on its patients as people, how pain conditions. they live and what their personal goals may be, as well as how their lifestyle affects illnesses, injury and chronic Nutritional/Supplement Consultation — Weight loss medical conditions. is the most common condition that is treated in the nutritional consultation service. The weight loss plan is The CIMW treats the whole person — body, mind and made up of three components: a personalized diet, spirit — using a safe and evidence-based approach referral to a medical fitness program and behavioral customized for each individual. Working in collaboration strategies. Nutrition is an important aspect in the with the patients and their medical teams, CIMW offers treatment plan of all patients and includes attention to patient-centered care that blends conventional and metabolic syndrome, digestive symptoms, autoimmune complementary medicine tailored to achieve the patient’s and cancer-related conditions and attention deficit and personal needs and goals for health and wellness. hyperactivity disorders. Dr. Joseph Feuerstein collaborated with Stamford Health Integrated Practices (SHIP) physicians to offer his eating plan to patients and the community.

2015 CLINICAL ANNUAL REPORT | 25 DEPARTMENT OF FAMILY MEDICINE: ANNUAL REPORT 2015

Women’s Health — In addition to issues related Arizona distance learning and residential Fellowship in to reproductive health such as pelvic pain, fertility, Integrative Medicine curriculum, as well as a 300-hour childbearing, perimenopause and menopause, the CME acupuncture program. Fellows spend 50% time at Center complements standard care in the treatment of the CIMW and 50% time at Optimus, a Federally Qualified female patients with depression, heart disease risk factors, Health Care Center that is affiliated with Stamford Hospital arthritis and digestive issues. Dr. Katherine Takayasu led and primarily funded by U.S. Department of Health and a multidisciplinary biopsychosocial pelvic pain program Human Services. that included meetings with specialists, community presentations and presentations at national meetings to The CIMW receives no research funding. Center improve the quality of life of patients suffering with this physicians participate in quality improvement initiatives very challenging problem. and frequently present the findings in peer-reviewed publications and as abstracts at conferences. Presentations Stress Reduction — The CIMW provides patients with at national conferences have included data on a breast the tools to support lifestyle changes, such as Mindfulness pain program in collaboration with the Women’s Breast Meditation. The program also helps patients reduce Center and the effects on a dietary approach to reducing anxiety and pain through hypnosis and guided imagery. cardiac risk factors. The Athletes and the Arts Program — The Athletes and Financial Data the Arts Program was created by the CIMW in conjunction with specialists in Orthopedics and Sports Medicine to Philanthropic funding originally helped open the CIMW optimize performance in sport athletes and performing seven years ago, but the clinic is now self-sustaining. artists. The focus of the program is to prevent and treat Philanthropy continues to support the education of Center injuries, inform athletes and performers about optimal Fellows at University of Arizona and the acupuncture course. nutrition and hydration and reduce performance anxiety. There were over 9,300 patient visits during the year in Treatment methods may include lifestyle approaches the pain management, mind-body stress reduction and to include instruction in self-care acupressure and nutrition evidence-based services. stretching exercises, physician-administered acupuncture, Services at the CIMW are covered by most major medical trigger point injections, non-opioid pain medication insurance plans, including Medicare. recommendations, nutritional counseling, botanical and supplement consulting and physician-administered mind- Collaborations body stress-reduction therapies. A key strategy of the Center is to build relationships Education and Research within the Hospital system and community. The CIMW is engaged in the following collaborative process The clinical stories and patient care outcomes at the improvement programs: Center offer a rich resource for teaching Integrative Medicine Fellows at the CIMW as well as for learning 1. Breast pain with breast surgeons activities for medical students and medical residents. 2. Pelvic pain with gynecologists A full-time, two-year Integrative Medicine Fellowship 3. Cancer and pain with oncologists provides a unique clinical experience in evidence-based 4. Dietary approaches to reducing cardiac risk factors with complementary therapies in pain management, nutrition/ primary care physicians and specialist physicians supplement consultation and mind-body stress reduction 5. Concussion program with neurologists, with guided imagery and mindfulness meditation. Fellows neuropsychology and physical therapy are funded to complete the 1,000-hour University of 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

26 | DEPARTMENT OF FAMILY MEDICINE DEPARTMENT OF FAMILY MEDICINE: ANNUAL REPORT 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 CLINICAL ANNUAL REPORT | 27 innovation in m e d i c i n e

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.

28 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: up the Department of Medicine are detailed in their respective annual reports and presented under the Scope The Year in Review of Clinical Services.

The continued growth of the Department has resulted in Noel I. Robin, MD the largest number of physicians on its staff, in its history. There are a total of 254 medical practitioners representing Chair, Department of Medicine 16 primary care and specialty divisions. This has been the Professor of Clinical Medicine result of a concerted effort by Stamford Hospital to develop and Associate Dean at the Stamford Health System primary care centers in adjacent communities where patients historically might have related to other hospitals. Columbia University College of The growth of hospitalism has also contributed substantially Physicians and Surgeons 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 s a “department of departments,” the Department organization has been a catalyst to the advancement of of Medicine is involved in a wide range of clinical primary care. A parallel increase in the Ancillary Staff took A care, medical education and research. The place with 22 members now serving in that capacity. achievements of the individual departments that make (Figure 1)

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

Active Courtesy Affiliate Ancillary Provisional Provisional Provisional Specialty Staff Staff Staff Staff Active Affiliate Ancillary

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 Total 190 24 17 8 20 3 14

2015 CLINICAL ANNUAL REPORT | 29 DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

Admissions, by Diagnosis, to the Medical Service

Figure 2 demonstrates a modest increase in the number of A significant change in the attending physician care of inpatients from 5,710 (2013) to 5,855 (2014) to 5,860 (2015), inpatients was noted with increasing numbers of patients but with an overall slight decrease in the number of patient admitted to the hospitalist service: 5,013 (2013), 5,201 days from 32,068 (2013) to 32,418 (2014) to 31,688 (2015). (2014), 5,235 (2015), and decreasing numbers of patients The net effect was a decline in average length of stay from admitted by primary care physicians: 643 (2013), 593 5.62 (2013) to 5.54 (2014) to 5.41 (2015). The average length (2014), 553 (2015). of stay for observation patients remained relatively static: 1.44 (2013) to 1.36 (2014) to 1.40 (2015).

Figure 2: Inpatient/Observation Volume

FY15 FY14 FY13 Medical Specialty # 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 Total 5,860 31,688 5,855 32,418 5,710 32,068 ALOS 5.41 5.54 5.62

Medical Specialty # 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 0 0 0 0 1 1 Total 1,559 2,192 1,547 2,103 1,606 2,314 ALOS 1.4 1.36 1.44

Admissions, by Diagnosis, to the Medical Service — Comparison

Figure 3 represents inpatient admission numbers by remaining the most common DRG, now comprising 6.8% of descending order of rank, with septicemia or severe sepsis admission to the medical service.

30 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

Figure 3: Department of Medicine, Comparison of Most Common DRGs

% of % of % of DRG DRG Description FY15 IP Dc All FY14 IP Dc % of All FY13 IP Dc All FY12 IP Dc All Rank Inpts Rank Inpts Rank Inpts Rank Inpts Septicemia or severe sepsis w/o 871 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% Septicemia or severe sepsis 872 w/o MV 96+ hours w/o MCC 3 142 2.4% 8 105 1.8% 12 78 1.4% 25 50 1.0% Esophagitis; gastroent & misc 392 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% Alcohol/drug abuse or dependence 897 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% Kidney & urinary tract 690 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% Perc cardiovasc proc w/ 247 drug-eluting Stent w/o MCC 13 81 1.4% 16 84 1.4% 23 60 1.1% 18 58 1.2% Simple pneumonia & pleurisy 194 w/CC 14 75 1.3% 11 95 1.6% 8 114 2.0% 7 94 2.0% Cardiac arrhythmia & conduction 310 disorders w/o CC/MCC 15 74 1.3% 17 83 1.4% 13 77 1.3% 10 80 1.7% Simple pneumonia & pleurisy 193 w/MCC 16 71 1.2% 15 86 1.5% 22 62 1.1% 16 61 1.3% Intracranial hemorrhage or 65 cerebral infarction w/CC 17 70 1.2% 18 81 1.4% 16 73 1.3% 14 65 1.4% Kidney & urinary tract 689 infections w/MCC 18 69 1.2% 32 49 0.8% 33 49 0.9% 31 42 0.9% Misc disorders of 641 nutrition; metabolism; 19 67 1.1% 13 89 1.5% 14 76 1.3% 21 54 1.1% fluids/electrolytes w/o MCC 638 Diabetes w/CC 20 61 1.0% 30 52 0.9% 47 32 0.6% 36 38 0.8% Cardiac arrhythmia & 309 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% Poisoning & toxic effects of 918 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 Inpt ALOS 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 Obs ALOS 1.4 4.7 1.4 1.4 1.4

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SCOPE OF CLINICAL SERVICES Allergists in our community work closely with other subspecialists and general practitioners to provide ALLERGY AND IMMUNOLOGY 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 Paul S. Lindner, MD by having the allergist identify and treat the allergic triggers, Director, Allergy and Immunology which can often complicate a case of chronic sinusitis and nasal polyposis. Assistant Clinical Professor of Medicine, Columbia University College of Many of our allergists are involved in clinical research Physicians and Surgeons 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.

Active Staff: Allergists in the Department also diagnose and treat a • Denis A. Bouboulis, MD variety of primary and secondary immunodeficiencies. The most prevalent immune disorder treated is common • Ora Burstein, MD variable immunodeficiency (CVID) which responds • Leslie R. Coleman, MD well to Intravenous Immunoglobulin (IVIG) therapy. The • Mitchell R. Lester, MD newest form of gammaglobulin therapy is through the subcutaneous (SCIG) route. With SCIG, patients no longer Members of the Department of Allergy and Immunology need to spend time at an outpatient infusion center and with active full staff privileges include: Denis A. Bouboulis, can administer their own gammaglobulin therapy at MD; Ora Burstein, MD; Leslie R. Coleman, MD; Mitchell home. The latest developments in the treatment of allergic R. Lester, MD; and Paul S. Lindner, MD. The physicians in disorders are the newly approved therapies for hereditary the Department function in an outpatient setting and angioedema including purified human C1 esterase inhibitor also provide inpatient consultations, treating patients for (Berinert — for acute attacks, Cinryze for maintenance a variety of allergic and immunologic conditions. These prevention) and a reversible kallikrein inhibitor, Kalbitor include: allergic rhinitis; asthma; sinusitis; skin disorders such (ecallantide) for acute attacks. A newly approved selective as urticaria, contact dermatitis and eczema; food allergy; bradykinin B2 receptor antagonist, Firazyr (icatibant) has also stinging insect allergy; drug allergy; and immunodeficiency. been found useful in reversing acute angioedema attacks.

In this specialty, specific allergens causing an allergic Newer forms of immunotherapy are in current response are pinpointed through the use of various development. The first monoclonal anti-IgE antibody to techniques that include skin testing, patch testing, be released is Xolair (omalizumab), which has been shown in-vitro analysis of antigen-specific IgE, oral and parenteral to improve asthma control while decreasing the need for challenges. In addition to avoidance techniques and systemic and inhaled steroids. Xolair theoretically will also allergy/asthma medications, we offer a program of work for allergic rhinitis and food allergies by decreasing desensitization that helps patients develop immunologic total IgE on mast cells, however these additional indications tolerance to offending allergens. Desensitization can be are currently being evaluated. Xolair has just been provided for all major environmental allergens such as dust approved for treating severe chronic idiopathic urticaria. mites, molds, pollens and cat and dog dander. Individuals Studies looking at a variety of future immunotherapy can be desensitized for bees, hornets, wasps and yellow options include the use of T-cell peptides to stimulate jackets, antibiotics and other medications including a preferential TH1 vs TH2 response, the use of adjuvants penicillins, cephalosporins and chemotherapy agents. A such as lipopolysaccharide and DNA oligonucleotides, major push toward developing desensitization techniques and immunotherapy with bacterial DNA oligonucleotides for food allergens such as peanuts is underway in many containing an abundance of CPG motifs to enhance a TH1 academic centers due to the rising prevalence of food protective response. Other monoclonal antibodies on the induced anaphylaxis over the past two decades. horizon include anti-IL5 for hypereosinophilic syndromes and anti-IL4, anti-IL13 for asthma.

32 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

The Department of Allergy and Immunology has an active • John Fisher, MD role in the teaching program for medical students, interns • Glenn Gandelman, MD and residents at Stamford Hospital. Residents spend many weeks with our physicians in elective rotations. As • Jeffrey Green, MD part of their outpatient internal medicine experience, • Mark Heiman, MD interns spend an afternoon every other week with one • Steven F. Horowitz, MD, FACC of our private allergists in the community learning about the practice of outpatient medicine as well as increasing • Robert Jumper, MD their understanding of common allergic disorders seen • Robert Labarre, MD on a daily basis by the typical internist. The Department • David Lomnitz, MD provides lectures for Grand Rounds in Medicine as well as lunch conferences for Residents and Medical Students. This • David Lorenz, MD year, Dr. Mitchell Lester presented a talk about many of the • Wayne Miller, MD misconceptions and fallacies in the field of allergy as part of • Thomas Nero, MD the Medical Grand Rounds series in August. • John Novella, MD In the coming year, our Department looks forward • Maria Palvis, MD to providing excellent care in the field of Allergy and Immunology as clinicians and educators, and will continue • Michael Pittaro, MD to bring the latest developments in our specialty to the • Edward Schuster, MD greater Stamford Hospital community. • Joseph Tiano, MD CARDIOLOGY • Anja Wagner, 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 David H. Hsi, MD, FACC, FASE the Hospital. This has included state-of-the-art Cardiac Chief of Cardiology Catheterization and Electrophysiology Laboratories, Co-Director of the Heart & nuclear cardiology cameras and 3-D echocardiography, Vascular Institute, along with the opening of a hybrid operating room for Stamford Hospital 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 Active Staff: Hospital’s Interventional Cardiology and Cardiac Surgery teams. Interventional Cardiologists Dr. Antonio Colombo, • Samuel Brodsky, MD world-renowned expert in TAVR, and Dr. Nicola Corvaja, • Salvatore Carbonaro, MD Medical Director of the Structural Heart Disease Center • Joonun (Chris) Choi, MD and Valve Clinic, work closely with cardiac surgeons Dr. Michael Coady, Chief of Cardiac Surgery, and Dr. William • Antonio Colombo, MD Feng, both of whom have proven records of experience • Nicola Corvaja, MD and expertise in the surgical management of aortic valve • Evelyn Cusack, MD disease. TAVR improves the survival and quality of life of patients with severe aortic stenosis who would otherwise • Sandhya Dhruvakumar, MD have limited choices to treat this serious medical condition. • Gregory D’Onofrio, MD The Heart & Vascular Institute (HVI) is proud to announce • Susan Eysmann, MD that Dr. Antonio Colombo, Attending Cardiologist at Stamford Hospital and a Visiting Professor of Medicine • Kevin Ferrick, MD at NewYork-Presbyterian Healthcare System/Columbia

2015 CLINICAL ANNUAL REPORT | 33 DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

University Medical Center, is a principal operator of our to Stamford Hospital their expertise in device implantations TAVR procedures. A legend in the field of Interventional and ablation procedures. In addition, Dr. John Novella, who Cardiology, Dr. Colombo made groundbreaking received his advanced EP training at Yale and New Haven contributions to coronary stenting, peripheral vascular Hospital, joined our Medical Staff in August 2014. interventions, and structural heart disease treatment. His 1995 landmark study regarding new technologies in The Division provides an educational program combining coronary stenting changed the future of minimally invasive clinical discussions and exemplary, formal didactic treatments for heart disease. He remains actively involved in presentations from Hospital-based cardiologists and many the research and development of emerging Interventional distinguished guest speakers, including Dr. Cynthia Taub Cardiology technologies. from Montefiore Medical Center, Dr. Sharon Reimold from Texas University of Southwestern Medical Center and The Interventional Cardiologists and support staff provide Drs. Paul Ridker and Leonard Lilly from Harvard Medical around clock coverage for the acutely ill patient. They have School in Boston. achieved 96% door-to-balloon times for all eligible ST elevation myocardial infarction patients admitted to the The Cardiology Division works closely with the physicians Hospital in 2015. The procedures offered include advanced in Cardiac Surgery, Dr. Michael Coady, Chief, and imaging and coronary interventions and hemodynamic Dr. William Feng, to optimize patient care across a support using percutaneous left ventricular assist devices. spectrum of conditions.

Stamford Hospital is the first in Connecticut to offer Dr. Steven Horowitz, Emeritus Cardiology Chief, took on sophisticated hemodynamic monitoring for patients the role of Medical Director, Planetree and Cardiac Care with severe congestive heart failure by implanting the Management, and started a Preventive Cardiology Service. Cardiomems® in the pulmonary arteries. Dr. Jeffery He is a nationally known expert in integrative medicine Green and Dr. Edward Portnay successfully performed and cardiology. all procedures. The Cardiac Rehabilitation Program has received national Under the leadership of Dr. Chris Choi, we received a gold certification and acclaim under the leadership of medal award in heart failure care from the American Heart Dr. Murray Low, past president of the American Association Association “Get With The Guidelines” program in 2014 – 2015. of Cardiovascular & Pulmonary Rehabilitation, and Dr. Edward Schuster, Medical Director. The Program The Electrophysiology (EP) program provides pacemaker incorporates contemporary concepts of wellness, fitness and implantable defibrillators, resynchronization devices and lifestyle modification for the benefit of patients with for heart failure and ablations for both supraventricular and known coronary artery disease and those patients who ventricular tachycardia. In 2013, Dr. Sandhya Dhruvakumar, have undergone open heart surgery. Additionally, the former Director of the Electrophysiology Laboratory at Program includes both intensive ECG monitoring and University of Medicine and Dentistry of New Jersey, joined lifetime wellness maintenance. our Cardiology Division as Director of Electrophysiology. An excellent teacher, Dr. Dhruvakumar specializes in Dr. Thomas Nero, Interventional Cardiologist, worked with complex procedures such as atrial fibrillation ablation. the City of Stamford and many Stamford Hospital staff In 2014, Dr. Dhruvakumar and her team designed and to lead a hugely successful “Hands for Life” campaign, constructed an integrated electrophysiology operative suite educating more than 10,000 students and area residents in with the most advanced equipment currently available. Our the resuscitation of cardiac arrest victims. physician expertise and state-of-the-art technology Chief of Cardiac Surgery Dr. Michael Coady and Chief of allow Stamford Hospital to offer the breadth of new and Cardiology Dr. David Hsi co-chaired the Fourth Annual leading-edge procedures such as: cryoablation; hybrid Cardiovascular Symposium in Stamford. They were grateful ablations for atrial fibrillation; subcutaneous implantable to Timothy Hansen, Chief Physician Assistant for Cardiac defibrillators; injectable heart monitors; and left atrial Surgery, for his role as the program coordinator, and appendage closure devices. Quality initiatives, a focus on keynote speaker Steve Ryan, the former President and COO excellent outcomes and patient-centered care remain of NHL Enterprise, for his special visit. Additional thanks to at the core of the program. Under her leadership, the all speaking faculty members including Dr. Nicola Corvaja Electrophysiology program has grown 300% in volume. Our (Structural Heart Disease), Dr. Sandhya Dhruvakumar (EP EP specialists, Drs. Michael Pittaro and Joseph Tiano, bring Cardiology), Dr. Jeffrey Green (Non-Invasive Cardiology)

34 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 and Dr. Edward Portnay (Interventional Cardiology) for dermatopathologist, has been an outstanding addition to their time for and commitment to the program. Stamford Hospital and the medical community.

Finally, the HVI warmly welcomed a new Director, Eilish As a specialty, Dermatology focuses on skin cancer Hourihan, in 2015. She brings in-depth expertise and prevention and public education about the perils of experience in management to the Cardiology service line. 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 Active Staff: Director of Dermatology • Mary E. Arden-Cordone, MD • Maria Asnis, MD • Anna C. Freitag, MD • Melissa Goldstein, MD Active Staff: • 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 The field of Endocrinology continues to see significant • Rena Fortier, MD growth in the understanding of the pathophysiology of • Samuel Gettler, MD disease processes, and in earlier and more accurate disease detection. There also has been continued application • Omar Ibrahimi, MD of newer pharmacologics and technical skills to address • Steven Kolenik, MD endocrinologic dysfunction. • Sharon Littzi, MD Type 2 Diabetes remains the most prevalent disease seen • Fern Mayer, MD by endocrinologists, a result of prevailing patterns of diet • Debra Pruzan-Clain, MD and lifestyle. Balanced glycemic control that matches the physiologic needs of the individual diabetic patient remains • Donald Savitz, MD the mainstay of diabetes management, with new insulin Provisional Active Staff: preparations currently available. In addition, today there are various other categories of pharmacologics that can play a • Rebecca Hall, MD role in diabetes management. All of these treatment options are available at Stamford Hospital and are tailored to the As acknowledged in last year’s Annual Report, in 2013, the unique needs of each patient. The optimal management Department gained Omar Ibrahimi, MD, who has a specialty of the diabetic patient underscores the indispensable in Mohs micrographic surgery. necessity of interdisciplinary and collaborative medical practice. Notwithstanding the nine available categories Members of the Department run the Dermatology (including insulin) of drugs to manage diabetes, nowhere in outpatient clinic at Washington Boulevard and consult at clinical practice is personalized medicine more applicable. the Hospital. Our Dermatologists also supervise and teach The pathophysiology of diabetes is exquisitely elegant, but medical residents and rotating medical students, as well as the needs of each patient must be individually addressed lecture within the Hospital and community. so that the blood glucose response is congruent with the The Department acknowledges the skill, kindness therapeutic goal. Essential to effective management must and resourcefulness of Dr. Elgida Volpicelli who, as a be patient enfranchisement in a healthy lifestyle. 2015 CLINICAL ANNUAL REPORT | 35 DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

On the education front, Endocrinology sessions for thorough assessment, sound educational curriculum, colleagues, house staff and students take place throughout diabetes support management planning and follow-up the year through inpatient teaching rounds, The Academic with behavioral outcome measurement. Our Diabetes Half Day, student tutorial and preceptorship sessions, Education Program is designed to offer outpatient individual Endocrinology Tumor Board and Medical Grand Rounds, instructional sessions, as well as group self-management including the Summer Syllabus. In addition, residents spend classes. The sessions begin with an individual assessment to one-on-one time with Certified Diabetes Educators (CDEs) develop a plan of care. Classes are offered on different days at the Stamford Hospital Diabetes Education Center, an and at different times, and staffing schedules are flexed, American Diabetes Association (ADA)-recognized center when necessary, to meet participant needs. for diabetes education. Endocrinology support through consultation and clinical involvement takes place on all Instructional methods include demonstrations, return Hospital units, and a regularly scheduled and dedicated demonstrations, audiovisual presentations and interactive outpatient clinic is staffed by the Department. sessions. There is adequate time during each session for questions and answers. Our teaching approach is interactive; Fairfield County Diabetes and Endocrinology has patient- and family-centered and supports the evolution of dedicated endocrinologists and is part of the Stamford problem solving skills. Hearing-impaired patients are offered Health Integrated Practices (SHIP) network. The practice is sign language interpretive services, and TDD devices are led by Medical Director Dr. Bismruta Misra with Drs. Maria available. We have the availability of the AT&T Language line, Asnis and Melissa Goldstein as attending endocrinologists. in which instructors engage interpreters by speakerphone The practice is now located in a new facility at 292 Long for the many different languages spoken in the service area. Ridge Road in Stamford, Connecticut. 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 Follow-up is considered an integral part of the educational Association (ADA) Education Recognition voluntarily. We experience for the individual with diabetes. Behavioral first acquired this Education Program Recognition from the goals are formed during the instruction sessions and are ADA in 2001 and currently had maintained our program evaluated and/or modified. Follow-up may also occur in recognition through 2015. Our application to the ADA for person, or on the telephone as needed. The participants Education Program Recognition extension through 2019 in the Diabetes Education Program will be seen on an was submitted and accepted. as-needed basis post-instruction. Phone contact is always encouraged to solve self-management problems that The application process is rigorous with participant may arise. Diabetes Self-Management Support Planning data collection and interpretation. Diabetes Education (DSMSP) is provided in collaboration with the participant Program Recognition is also the process through which as well as to be communicated with other healthcare programs that meet the National Standards for Diabetes providers involved in the patient’s care. The referring Self-Management Training (DSMT) are formally identified primary care physician and/or specialist are notified for an for their performance and quality. urgent health issue needing to be resolved and on overall The ADA Education Recognition Program actually has education program progress. grown to become the leading quality assurance mechanism Currently our staff includes: for all diabetes self-management education programs across the country. To that point, Medicare will cover • Debra Milne, BSN, RN, CDE diabetes education sessions for their beneficiaries only if Director, Ambulatory Nursing and Diabetes Education provided through an ADA-accredited diabetes education • Sangeeta Ahuja, MS, RD, CDE program. Programs that do receive this recognition are viewed as having met the criteria for having a staff of • Lois Duke, MS, RD, CDE knowledgeable health professionals (Registered Nurses • Jill Ely, APRN, CDE and Registered Dieticians) who can provide state-of-the-art • Barbara Nadolny, RN, BSN, CDE — Lead RN, CDE diabetes education. Currently all educators at the Diabetes and Endocrine Center are Certified Diabetes Educators. • Ann Rupp, RN, BSN, CDE A multidisciplinary, interactive and proactive approach to diabetes education has been created to include a

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Diabetes Ed Visits Active Staff:

Actual Budgeted % Growth • Neeraj Anand, MD FY15 Visits Visits Over FY14 • Henry Grafton Beecher, MD Diabetes Education Visits 2,646 2,175 22% • Robert Dettmer, MD • Sarah Kahn, MD Community Outreach • Darlene Negbenebor, MD Over the past year, the community outreach activities for • William Pintauro, MD the Hospital in this area included the following: • Neil Schamberg, MD • Demonstrated ongoing support of health fairs and • Amy Smithline, MD Speakers Bureau. The Department of Gastroenterology continues to diversify • Served as the title sponsor of the American Diabetes the services it offers to patients and the healthcare Association’s “Change The Future, Celebrate the Harvest” community. Over the past year our Division performed Event last November. 6,850 endoscopic procedures at both the Hospital and • Served as the presenting sponsor of the Juvenile Tully Health Center. In addition, under the direction of Dr. Diabetes Research Foundation’s Walk to Cure Diabetes Amy Smithline, we are currently providing esophageal in September. motility and impedance studies along with 24-hour pH monitoring. This has enhanced our ability to evaluate and CDEs participated in: treat patients with problematic gastroesophageal reflux and esophageal motility disorders. • Half-day academic session for residents related to delivering comprehensive diabetes care We are currently working with our Colorectal Surgery colleagues in coordinating a new service dealing with • Quarterly educational Nursing Diabetes Awareness pelvic floor physiology dysfunction. This includes sessions for GEMS and nursing staff. high-resolution anorectal manometry and pudendal Additionally Barbara Nadolny, BSN, RN, CDE, serves as nerve-testing methodologies used for evaluation of the legislative point person for the Connecticut Alliance function and coordination of anal sphincter and pelvic of Diabetes Educators (CADE) and is actively involved in floor muscles. the State of Connecticut Department of Public Health Our Division recently acquired the Fuse® endoscopic coalition, where the goal is to achieve reimbursement from system with its new technology designed to enhance Connecticut Medicaid for Diabetes Education services. colorectal polyp detection. We have also incorporated the Provation dictation system to provide improved GASTROENTEROLOGY documentation for our endoscopic reports.

The Endoscopy Center at the Tully Health Center recently received designation as an American Society of Stuart Waldstreicher, MD Gastrointestinal Endoscopy Center of Excellence. We are Director of Gastroenterology appreciative for all of the support of our colleagues and administration that allows us to provide state-of-the-art Assistant Clinical Professor of Medicine, Columbia care for our patients and community. University College of Physicians and Surgeons

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GERIATRICS 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 Allison B. Ostroff, MD to this patient population. Upon discharge, there will Director of Geriatric Medicine 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 Active Staff: surveyed after the pilot is completed in February 2016. If we find the pilot to be successful and well-received, we plan to • Rodrigo Acosta, MD expand our work throughout the organization. • Anne Brewer, MD The State of Connecticut instituted a new law • Doreen Chimblo, APRN mandating that all Hospital employees, both clinical and non-clinical, receive education on the signs and • Tzivia Moreen, MD symptoms of dementia, beginning October 1, 2015. Our • Santi Neuberger, MD education subcommittee has worked with several other • Meghan Newman, APRN state hospitals to discuss these new recommendations and has submitted Healthstream presentations for both • Noel Robin, MD clinical and non-clinical staff. • Monika Tello, APRN We have submitted a new delirium policy for the Hospital, With our ever-expanding aging population, Geriatrics has presently under review, which outlines an identification emerged as one of the most important fields of medicine. and management process of delirium for the nursing staff Stamford Hospital has acknowledged the need for expertise and the treating physicians. As part of our pilot initiative, in the field with the creation a Department of Geriatric the nurses will also receive training in a delirium screening Medicine in 2015, and the appointment of its Director, tool, (Confusion Assessment Method or CAM), which they Dr. Allison Ostroff. will utilize if there is a noticeable change in a patient’s mental status. If the patient screens positive for delirium, the As part of the neuro-sciences initiative for the Hospital attending physician will be notified and the diagnosis will we have been working toward better identifying and be added to the patient’s chart. Only 17% of delirium cases managing patients with cognitive impairment/dementia are currently identified in hospitals nationwide and early in the inpatient medical wards. A task force committee identification will help both patient and hospital outcomes. was formed in July 2014 and has been meeting monthly We have also created new patient education materials on to achieve this purpose. This committee has included delirium to better educate families to the condition and to representation from nursing, nursing education, discharge manage their expectations. planning, case management, Planetree and pastoral care, as well as the departments of Psychiatry, Neurology and The Division of Geriatric Medicine has also partnered with Internal Medicine. The nursing staff for 3 South, the float Cardiology, specifically with the TAVR team, and will be pool, Physical Therapy and Occupational Therapy will performing comprehensive memory assessments on each be trained in the administration of a screening tool, the of the patients who are undergoing TAVR. We hope that this Mini-Cog, to be performed on each patient at the time of will help risk stratify patients and also identify patients with admission. If that patient’s results are consistent with an contraindications to the procedure. The role of Geriatrics impairment, that patient will be given a purple bracelet will also be to better manage family expectations regarding to wear. length of stay, post-procedure delirium and memory after the procedure.

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We have submitted a proposal to the Connecticut • Mary Fedor, MD Alzheimer’s Association Annual Meeting in April 2016, for a • Kakra Gyambibi, MD presentation outlining our current work, and we anticipate hearing back sometime before the end of the year if our • Clive Johnson, DO proposal was accepted. • Chinenye Kalu, APRN We are hoping to expand the division of Geriatric Medicine • Michael Marchese, MD soon so that we can provide the most comprehensive and • Santy Mathew, MD fluid care to our patients and make transitions of care as • Hiren Mody, MD seamless as possible. We greatly look forward to working with everyone in caring for our older population. • Girija Narayanaswamy, MD • Michele Nelson, APRN HOSPITALIST MEDICINE • Aye Omoruyi, PA • Chinyelu Oraedu, MD Maher Madhoun, MD • Kwen Ortega, MD Hospitalist Director • Miroslav Radulovic, MD Infectious Disease Specialist • Praveen Reddy, MD Assistant Clinical Professor, Columbia University College of • Rolando Santos, MD Physicians & Surgeons • Sona Shah, MD Assistant Program Director for Inpatient Teaching, Internal • Danielle Sry, PA Medicine Residency Program • Christina Suh, MD • Phi Tran, DO • Jessica Troy, PA • Marcos Valerio, MD Peter J. Tenicki, MD Assistant Director Since July 2003, when the program of full-time hospital- Instructor in Clinical Medicine, based physicians (Hospitalists) was formally inaugurated, Columbia University College of Hospitalist Medicine has developed into a strong Physicians and Surgeons 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 Active Staff: Hospital. Hospitalists have also meaningfully complemented the role of practicing physicians, as the need for seamless • Jennifer Bendl, DO and effective care of their inpatients has grown. Notably, • Iulian Benetato, MD Stamford Hospital’s Hospitalist group treats approximately • MaryAnne Bhojwani, MD 90% of the Medicine inpatient census. Hospitalist Medicine remains the fastest-growing specialty in clinical practice. • Sasha Cobotic, MD In FY15, our average length of stay was slightly above 4.6 • Resul Dalipi, MD days with an average of 20 new admissions per day, and an • Satish Deshpande, MD average daily census of 106 patients per day. • Jenifer Drummond, MD The Hospitalists continue to have a preeminent role in • Joseph Elassal, MD resident education. This has been both a natural and an evolutionary trend in medical education, promulgated by • Betty Exume, PA changing requirements mandated by the Accreditation • Christiana Famodimu, MD Council for Graduate Medical Education (ACGME), as well

2015 CLINICAL ANNUAL REPORT | 39 DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 as the reality of the intensive involvement of Hospitalists scope of practice, which frees up physicians for more in the care of patients also managed by medical house complex cases. Mid-levels are a crucial part of our Division staff. Hospitalists’ importance in resident education is and are accessible to answer nurses’ questions, complete underscored by the appointments of Drs. Maher Madhoun histories and physicals, aid in ED throughput times, assist and Hiren Mody, as Assistant Program Directors in Inpatient in minor procedures, respond to emergencies, complete Medicine for the Residency Program in Internal Medicine. discharge summaries, facilitate discharges earlier in the day The Hospitalist group also provides clinical education to and provide other care when needed. Quinnipiac students for their Internal Medicine rotation. Members of the Hospitalist Medicine group continue Hospitalists continue to play a leadership role in developing to serve on many Hospital committees, including ED and implementing the Meditech inpatient EMR, improving Leadership Throughput Committee; Pharmacy and accountability and collaboration between various Hospital Therapeutics Committee; Graduate Medical Education departments (particularly among the Medical Staff and Committee; IT Leadership Committee; Clinical Competence Emergency Department). Committee Meeting for Internal Medicine; Infection Control Committee; Patient Satisfaction Committee; Medicine Peer In conjunction with Neurology, Hospitalists play a major Review; Medical Executive Committee; Core Measures Work role in neurologic care at Stamford Hospital. The entire Group; Infection Prevention; and Patient Safety and division is an active participant in the Stroke Program, Quality Committee. recertified by the Joint Commission in 2015. The Hospitalist team is available around the clock to expedite the Figures 1 and 2 show Stamford Hospital’s Hospitalist treatment of patients with stroke, working collaboratively patient population and payor mix. The top 10 admitting with Neurology. diagnoses include:

With an aging population, limitations on medical residents’ 1. Unspecified chest pain hours and increased daily physician responsibilities, 2. Pneumonia, organism unspecified mid-level providers are delivering care not only in the 3. Syncope & collapse outpatient setting but also in the Hospital. Currently, we have six full-time and per diem mid-level providers. 4. Atrial fibrillation Mid-levels are improving quality and safety with quality- 5. Acute respiratory failure improvement projects by sitting on various committees 6. Hemorrhage of gastrointestinal tract, unspecified in the Hospital and by using evidence-based best practice protocols. In addition, by informing patients and patients’ 7. Urinary tract infection, site not specified families about what is to happen and future treatment 8. Cerebral artery occlusion, unspecified with steps to take, patient satisfaction for our Division has cerebral infarction increased and avoidable readmissions reduced. Physicians 9. Congestive heart failure can delegate care to mid-level providers, within their 10. Unspecified septicemia

Figure 1: Hospitalist Patient Population Information for FY15

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Figure 2: FY15 Payor Mix

Figure 3 highlights our growth in patient volume Hospitalist Medicine’s goals for 2016 include continued since 2011. growth and expansion in developing Hospital protocols and efficiency-related projects such as: length of stay Figure 3: Volume Growth 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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INFECTIOUS DISEASES 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 Michael Parry, MD and travel medicine. Thomas Jay Bradsell Chair of Infectious Diseases, Research activities, Hospital epidemiology, environmental Stamford Hospital infection control and antibiotic stewardship are ongoing. Professor of Clinical Medicine, The Department, together with Environmental Services, Columbia University College of continues to be involved in a multi-medical center Physicians and Surgeons environmental study to evaluate the effectiveness of terminal room cleaning in the prevention of hospital- acquired infections. The Department just concluded its participation in a multicenter study of intravenous The Infectious Diseases Department is a Division of the zanamivir in patients hospitalized with severe influenza Department of Medicine and provides multiple services and, in conjunction with Dr. Peter Krause at Yale, we are to patients and clinicians. The Division is responsible participating in a study of exchange transfusion in for infection prevention and Hospital epidemiology, severe babesiosis. microbiology laboratory direction, Employee Health Service The influenza vaccination program continues its direction, the antibiotic stewardship program in conjunction preeminence as the largest such cooperative program in with Pharmacy, the HIV program, clinical consult service, Connecticut. Together with the Stamford Department of emergency management (for infectious diseases) and staff Health, seasonal influenza vaccine was administered to over education at all levels. Scheduled and ad hoc educational 8,000 individuals in FY15. A mandatory influenza vaccination programs are provided for students, residents, attending (or written refusal) program for Hospital employees resulted staff, nursing staff, other Hospital employees and the in a 78% vaccination rate for employees last season. community. The Department is also actively involved in numerous medical staff and Hospital committees: Infection prevention represents the most important Dr. Michael Parry (Infection Prevention, Chair, IT leadership departmental activity at Stamford Hospital. Infection and Emergency Management, Regs and Accreditation, Prevention Nurses Brenda Grant, Merima Sestovic and Paula P&T); Dr. Lynda Streett (Infection Prevention, Perinatal Castellano-Flynn function out of the Department’s offices Infection, ICU); Dr. Asha Shah (Infection Prevention, Perinatal on the Terrace level of the Physicians’ Office Building. They Infection). Dr. Streett recently completed certification in perform critical roles in infection surveillance, outbreak Wound Care Management and Dr. Shah is entering her final investigation and control, education, policy development year in the Columbia University (Mailman School of Public and regulatory compliance. Ms. Grant continues her Health) Master’s in Medical Epidemiology Program. Two appointment to the State of Connecticut Healthcare- part-time division members, Dr. Maher Madhoun (full-time Associated Infections Advisory Committee. She was also Hospitalist) and Dr. Ralph Cipriani (full-time Internist), are also elected to a three-year term on the National Board of members of the Division and participate in committee and Directors of the Association for Professionals in Infection educational programs. Control and Epidemiology (APIC). Ms. Sestovic has been involved in regional APIC activities. Dr. Parry is also a member The most active subspecialty areas of clinical work are of the Connecticut Department of Public Health (CT DPH) hospital-acquired infections and HIV/AIDS. Ariana Horton, Committee on Reportable Diseases and CT DPH Advisory NP, Director of Outpatient HIV Services, coordinates HIV Committee on Infectious Diseases. clinic services and the bimonthly adult immunology clinic. She expertly supervises the care for a client base of up to The Department’s quality improvement initiatives are 100 individuals, working both at Optimus Healthcare and ongoing and showed good performance in several Stamford Hospital. The Department was again successful collaborative areas for FY15. The Department was an active in its reapplication for three federal Ryan White Grants in participant in two collaborative projects in this regard: the support of the Infectious Disease Nurse Practitioner, the PAICAP (Preventing Avoidable Infectious Complications by Adherence Nurse (Laura Howard, LPN), and the Nutritional Adjusting Payment) study with Harvard Medical School; Counselor (Britt Berger, RD). They provide dedicated service and the Sentinel Laboratory RSV and Influenza Surveillance to our clients and make the Stamford Hospital HIV Program Program through CDC. Infection prevention targets include

42 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 reduction in all device-related infections including assessment of the adequacy of the biopsy and sends the hospital-wide central line-associated bacteremia (CLABSI), tissue to Columbia) and the world-class renal pathologists at hospital-wide catheter associated urinary tract infections Columbia University. (CAUTI) and colon surgical infections (with surgery). Increasing demands for surveillance and public reporting The Stamford DaVita dialysis center currently has 190 have taxed our resources as 2015 saw an increase in in-center hemodialysis patients, six home hemodialysis monthly requirements for reporting for CLABSI and CAUTIs, patients (who use the NxStage machine) and 32 peritoneal C. diff cases and MRSA bacteremia from all Med-Surg units, dialysis patients. We have been designated a Five-Star Pediatrics, Rehab and the ICU. Urinary catheter utilization Clinic by CMS (its top rating) and have won a Fistula First rates remain 50% lower than CDC benchmarks. Hand Award from the ESRD Network of New England. Our clinic hygiene monitoring is an integral part of our hospital- serves the greater Stamford area with patients residing in acquired infection (HAI) reduction effort but it has been a towns stretching from Norwalk to Port Chester and South challenge to reach the 95% target. Nevertheless, HAI rates Salem. In a reversal of recent trends, the hemodialysis for 2015 reached all all-time low, falling below 0.8% and patient population has grown while the peritoneal dialysis surgical site infections below 0.6%. population has leveled off. The principal modality for peritoneal dialysis is CCPD, which is cyclic dialysis done NEPHROLOGY 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 Eric Brown, MD Columbia and Yale. Director of Nephrology DaVita continues to provide outpatient dialysis services Associate Professor of Clinical Medicine, Columbia and, since March, 2014, has been supplying inpatient University College of hemodialysis and CRRT. They will soon be the supplying Physicians and Surgeons plasmapheresis services as well.

The Division of Nephrology supports the teaching program of the Hospital. All members of the Division participate in Active Staff: clinical teaching, morning report, formal lectures and renal conferences. One member of the Division participates in • Revekka Babayev, MD third-year medical student preceptorship for four weeks • Brenda Chan, MD each year and another supervises the Department of Medicine Journal Club, which is an important educational • John Fitzgibbons, MD vehicle for the house staff. Journal Club teaches analytic • William Hines, MD reading, interpretative skills, statistical analysis and critical • Nazanine Khairkhah, MD thinking. Additionally, one member is an active participant in the outpatient Medicine Clinic at Optimus and two • Francis Walsh, MD physicians are active members of the Department of The Division of Nephrology continues to offer acute Medicine Clinical Competence Committee. We collaborate inpatient hemodialysis, acute inpatient peritoneal dialysis with the Department of Medicine in arranging outside and continuous renal replacement therapy (CCRT). For the nephrology speakers and last year hosted Drs. Andrew period January 1 to September 30, 2015, we performed Bomback and Jai Radhakrishnan from Columbia as well as 763 inpatient hemodialysis treatments, annualized to Dr. Peter Aronson from Yale. 1,017 procedures, which is an increase from last year. For The Division continues to participate in clinical research. We the calendar year to date, there were a total of 41 days of are actively recruiting for the SONAR Study, an endothelin CRRT performed with an annualized number of 55 days, a agonist to slow the progression of diabetic nephropathy, decrease from last year. Our glomerulonephritis practice and are participating in the waning days of studies of an remains active and has benefited immensely from the intravenous calcimimetic and a treatment for uremic pruritis. cooperation of Interventional Radiology (for biopsies), We are also looking to join trials of an external defibrillator Stamford Pathology (which performs an immediate for new dialysis patients and a new erythropoetic.

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The exciting change in our practice has been the addition The members of the Neurology Department continue of Dr. Revekka Babayev, who has joined us after completing to staff the stroke program at Stamford Hospital. They her residency and fellowship at Columbia. In addition to are on call around the clock to respond to “stroke alerts.” the Stamford practice, clinical services are performed by Intravenous tPA is a clot-busting medicine aimed at Drs. Fitzgibbons, Khairkhah and Walsh, whose dedication improving stroke outcomes. It must be given within 4.5 continues to expand the clinical and academic services that hours of the onset of symptoms. Our stroke protocol is the Division provides. designed to provide rapid assessment of stroke patients in the Emergency Room and in the Hospital to ensure the NEUROLOGY 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. Louise D. Resor, MD Dr. Eric Kung continues to supervise the neurologic care of Director of Neurology 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 Active Staff: Stamford Hospital. In addition to routine outpatient EEG and evoked potential exams, 24-hour ambulatory EEG • David Hahn, MD testing is available. In the Hospital, the Department provides • Eric Kung, MD prolonged video-EEG monitoring for the evaluation of • Charisse Litchman, MD undiagnosed episodes of altered consciousness and monitoring of critically ill ICU patients. • Sarah Mulukutla, MD • Evangelos Xistris, MD ONCOLOGY AND HEMATOLOGY 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 Paul Weinstein, MD expertise has served to improve the depth and breadth of Director of Oncology 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 Michael Bar, MD residency at Yale and a stroke fellowship at Mount Sinai. Director of Hematology His expertise in vascular neurology will enhance the care of stroke patients at Stamford.

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Active Staff: Risk Assessment Tool and the Tyrer Cuzick Model), as well as increasing numbers of persons having or concerned • Anne Angevine, MD about gastrointestinal cancers (in collaboration with the • Salvatore Del Prete, MD Gastrointestinal Cancer Family Tumor Registry) and other malignancies. To that end, multigene mutation panel assays • Anthony Gulati, MD are being used more frequently. In 2013, we counseled 270 • Steve Lo, MD new persons, and discovered high-risk genetic mutations • Isidore Tepler, MD in 15 of them, undoubtedly fulfilling the maxim that knowledge is power. The Divisions of Hematology and Oncology are composed of the seven physicians practicing as Hematology Oncology Our Survivorship Program, championed by Drs. Angevine PC (HOA), administratively named Medical Oncology and and Lo, and under the direction of Deanna Xistris, RN, Hematology (MOH), as part of the cancer service line within MSN and Fran Becker, LCSW, is ready to accept persons the Bennett Cancer Center (BCC). Skilled medical colleagues completing their treatment for early-stage cancer. A including Radiation Oncologists, cancer-oriented Surgeons, summary of their therapy and recommendations for future Pathologists, Diagnostic Radiologists and other medical staff follow-up is supplied to patients, their families and their of Stamford Hospital provide dedicated support. We are physicians via a formal report with updates as appropriate. greatly aided by subspecialty Nurse Navigators Dominique The Division of Hematology at the Bennett Cancer Center Srdanovic (GU, Supervisor), Melissa Ronk (Thoracic) and offers a comprehensive range of treatments for adult Katharine Radziewicz (GI). We serve the needs of patients malignant blood diseases. During the first nine months with oncologic and hematologic (both benign and of 2015, 731 unique patients with primary hematologic malignant) disorders in the Hospital’s primary catchment malignancies were seen and managed by the physicians area and, increasingly, secondary, tertiary and even more at the BCC. Additionally, the benign hematology distant markets. We are very often involved in the care of program remained equally robust, as the majority of new the nearly 900 patients diagnosed with cancer in Stamford consultations for hematologic disorders were related Hospital each year. More than 100 patients typically are seen to helping patients with benign abnormalities of their daily, accounting for more than 20,000 visits to the Bennett blood counts, metabolic disorders such as Gaucher’s Cancer Center annually. disease, autoimmune diseases, bleeding disorders such as The Divisions’ clinical research program for both Oncology hemophilia and von Willebrand disease and disturbances of and Hematology remains robust, under the leadership the coagulation system predisposing to thromboembolic of Salvatore Del Prete, MD, and supervisor Molly Daley. In disease, including those afflicting women with infertility or 2014, 66 patients were newly enrolled into our studies, maternal-fetal issues related to hypercoagulability. There encompassing a wide variety of solid tumors and is also an active in-patient consultation service focused on hematologic malignancies. Currently, there are 153 patients providing guidance on the management of the frequent actively enrolled in 57 studies (21 still accruing patients) transient hematologic complications of acute illnesses. at the BCC and hundreds of patients are in long-term Dedicated full-time genetic counseling for inheritable follow-up. At times we recommend outside consultation disorders is available to all patients and their families. for patients needing research treatments that cannot be Hematologists at the BCC continue to work closely with offered here. Examples of the importance of our activities two dedicated hematopathologists, who utilize the most include our participation in trials leading to the approval of sophisticated cytogenetic, molecular and immunologic imbruvica (Ibrutinib) for chronic lymphatic leukemia and tools available for state-of-the-art molecularly-defined ado-trastuzumab emtansine (Kadcyla) for Her-2 neu positive pathology. These tools include: fluorescence-activated advanced breast cancer. cell sorting (FACS) for the rapid diagnosis of malignant The Genetic Counseling Program, directed by Isidore hematologic disorders; and qualitative and quantitative Tepler, MD and Paul Weinstein, MD, and supervised by Erin polymerase chain reaction (PCR) studies of both DNA Ash, MS, CGC, is increasingly active, serving the needs of and RNA, which have the ability to detect one malignant those affected with cancer, their families and healthy but cell/1,000,000 cells and fluorescent in situ hybridization concerned individuals. The Program has advised persons (FISH), a technology that provides information on multiple with, or worried about, their personal risk for breast and genetic abnormalities (“molecular signature”) critical to the ovarian cancer (using the internationally accepted NCI Gail treatment of acute and chronic leukemias, lymphomas

2015 CLINICAL ANNUAL REPORT | 45 DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 and multiple myeloma. During 2015, the Department PAIN AND PALLIATIVE CARE SERVICE 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 Anne Brewer, MD, MPH, FAAFP standard treatment options. Continued rapid adaptation of an increasingly broad menu of new assays are made in real Medical Director of Palliative Care 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.

A burgeoning array of sophisticated therapies is available to The Pain and Palliative Care Service provides an extra patients and includes: traditional systemic chemotherapy; layer of support for patients from all departments who small molecule targeted therapies such as the recently face a serious or life-threatening illness. The services have approved and revolutionary Bruton kinase inhibitors and undergone some major changes and transitions this year, phosphatidylinositol 3-kinase inhibitors for low-grade as described below. non-Hodgkin’s lymphomas and chronic lymphocytic leukemia; traditional monoclonal antibodies as well as The Service continues to provide both assistance in both radio-conjugated and toxin-conjugated monoclonal transitioning to hospice and ongoing symptom antibodies for malignant lymphoproliferative disorders management for those who are enrolled in inpatient and leukemias; epigenetic hypomethylating agents for hospice. It is staffed by nurse practitioners with physician myelodysplastic syndromes and acute myelogenous collaboration. Monika Tello, MS, ANPBC, ACHPN, joined us leukemia of the elderly; immune modulation therapy for in November 2012, Doreen B. Chimblo, MS, APRN, FNP- lymphoproliferative disorders, plasma cell dyscrasias and BC, joined us in December 2012, and Maria Rivera, APRN, aplastic anemia; enzyme replacement therapy for metabolic joined us in February 2015. This transition has enabled disorders such as Gaucher’s disease; complement inhibition the provision of a higher level of consultation for patients, therapy for rare disorders such as paroxysmal nocturnal including more immediate improvement in pain and hemoglobinuria and atypical hemolytic uremic syndrome; symptoms. The ability to recover billable services from the and recombinant factor replacement therapy for congenital NPs’ care, along with a conversion to an electronic billing and acquired bleeding disorders. Plasmapheresis, apheresis process, has improved efficiency. and exchange transfusions are available to both inpatients Because of the national shortage of specialty-trained and outpatients. Palliative Care clinicians, a major focus has been improving The Division of Hematology continues to have a robust the primary palliative care skills of frontline clinicians. clinical research program that allows patients to access Accomplishments in this regard include: some of the most exciting therapeutic developments in the management of a wide variety of malignant and benign • Weekly inclusion of Palliative Care in both ICU and IMCU hematologic disorders. The physicians of the Division of teaching rounds Hematology continue their long-standing membership in the Eastern Cooperative Oncology Group (ECOG). A total of • Participation in Internal Medicine and Surgical lecture 11 hematology research protocols were available in 2015, six series programs for residents of which were new protocols opened in this calendar year, • Participation in Grand Rounds-Pastoral Care Lecture and 40 patients are currently being actively followed. The Series for attendings and chaplains corresponding totals for the similar nine month period in • Weekly precepting in Family Medicine Clinic, which 2014 were nine, three and 31, respectively. facilitates discussions of primary Palliative Care • Participation in the Pastoral Care Advisory Committee

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• Active planning and participation in the third annual very high. The average daily ventilator census was 6.0 “SHARE” curricula for house staff, an interdepartmentally ventilators in use per day. The Section remained committed sponsored program that gives residents an opportunity to preventing ventilator-associated events (VAE), soft to learn about patient/physician relationships from tissue injuries due to endotracheal tube pressures and cancer survivors self-extubations. Among the interventions are a ventilator- associated event (VAE) committee, VAE prevention bundles, This year the Pain and Palliative Care Service worked with oral care protocols, specialized endotracheal tubes and the Bennett Cancer Center in the training of several social probiotic use. work interns. Through this innovative interdisciplinary and interdepartmental effort, we were joined this year by two The Pulmonary Medicine section continued to perform master’s-level interns. It has been a true win-win to partner outpatient pulmonary services on both campuses. Tests in their education while they are active participants in performed at the Pulmonary Function Lab on the fourth providing mental health services to our patients. The time floor of the Tully Health Center were predominantly they have been able to spend with patients and families pediatric cases, but the Lab was available to adult has been instrumental in supporting those families along outpatients as well. Overall, the Department performed their grief pathways, and facilitates better communication more than 4,800 pulmonary function tests (PFTs) at between the families and everyone on the Palliative the Hospital campuses. The turnaround time for PFT Care team. interpretations was improved to less than four days.

PULMONARY, CRITICAL CARE AND Arterial blood gas (ABG) utilization remained high. Three new ABG machines now communicate wirelessly with SLEEP MEDICINE Meditech. Over 9,000 ABGs were analyzed in 2015.

The Pulmonary Laboratory passed its on-site College of Pathologists laboratory inspection. The Lab successfully Paul Sachs, MD renewed its ABG Lab license after an on-site inspection Director of Pulmonary Medicine by the Connecticut Department of Health. Alpha-1 Antitrypsin Deficiency screening is available to physicians Associate Clinical Professor at the time of PFT, in accordance with American Thoracic of Medicine, Columbia University College of Society guidelines. Physicians and Surgeons 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/ Active Staff: CEU event attended by RTs and nurses from throughout Connecticut and was once again highly successful. • Michael Bernstein, MD • Caroline Gulati, MD Our RTs continued to supervise students from Norwalk Community College’s RT Program. Two new students • John Kazianis, MD rotated through the Intensive Care Unit and the • James S. Krinsley, MD Intermediate Care Unit every six weeks. This continues to • Samit Malholtra, MD generate energy and enthusiasm among our RT staff. It has also helped with Stamford Hospital’s recruitment of the • Alex Ortega, MD finest of the new graduates and some RT students have • Dominic Roca, MD enjoyed their experience so much that they have stayed on • Steven Thau, MD to work as volunteers at Stamford Hospital. The Department also participated in new nursing orientations. Twice monthly The Pulmonary Medicine section continued to report a high nurse educators and nurse managers scheduled one- to utilization of its varied services. Inpatient and ambulatory two-hour sessions for their staff to review respiratory services remained active over the past year. Over 178,000 procedures, policies and equipment with the Respiratory procedures/interventions were performed by Respiratory Therapist Supervisor or Clinical Coordinator. In addition, four Therapy in 2015. The volume of ventilator days remains staff members completed a COPD educator course. Two

2015 CLINICAL ANNUAL REPORT | 47 DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 of our therapists are certified as BLS/ACLS/PALS instructors. Department assisted by completing COPD worksheet/ One of our therapists is now a neonatal ALS instructor. education forms on over 80% of in-patients admitted 100% of the respiratory therapists are ACLS certified. More with a diagnosis of COPD exacerbation. than 65% of our therapists are now certified in Pediatric Advanced Life Support as well. Our Respiratory Therapists The Pulmonary Department, in conjunction with Thoracic remain involved in multidisciplinary committees to improve Surgery and the Bennett Cancer Center, rolled out a new care at Stamford Hospital including Skin Breakdown; initiative to assist our patients and staff with tobacco Ventilator Associated Events; Resuscitation; Quiet at Night; cessation — Stamford Hospital’s “Commit to Quit” Program. Regulations and Accreditation; Misuse of Vials; Ethics; ID; We now have three Association for the Treatment of Tobacco Disaster Preparedness; Nursing Coordinating Council; and Use and Dependence-certified counselors who are available Self Staffing. Diane Major-Olivant, RRT, is the facilitator of to see our patients. To date, the program has had 75 patient the Pediatric Neonatal Committee, and RT is also an active visits. Carbon monoxide testing and spirometry screening participant in the monthly CCU committee meetings. are available for participants of the program, as needed. Stamford Hospital’s new tobacco Quit Line can be reached The entire RT staff is proficient in utilizing high-flow nasal by dialing 276.QUIT (Ext. 7848) from any Hospital phone. cannula therapy. This new technology has allowed patients to tolerate high concentrations of oxygen via nasal cannula The Interventional Pulmonary and Advanced Bronchoscopy at flow. High-flow rates of up to 60 LPM are tolerated service, led by Dr. Michael Bernstein, remained one of because the delivered gas is humidified and heated to body the most complete and busiest interventional programs temperature. They were useful in avoiding the need for in Fairfield County. It offers a wide array of interventional bulky high-flow masks and, in some cases, intubations. and advanced diagnostic bronchoscopy procedures, including endobronchial ultrasound, both convex and The outpatient Pulmonary Rehabilitation Program radial probe imaging, navigational bronchoscopy using the continued to thrive on the second floor of the Tully Health SuperDimension System, cryobiopsy/cryoablation and APC Center. To date, 930 participants have graduated from the ablation. We also remained an approved site for Spiration program since its inception. The program remained busy, endobronchial valve use for persistent air leaks and have graduating about 40 patients every year, with anywhere successfully performed this procedure. We continued to from 6 – 12 participants in the program at any one time. The perform a wide array of both diagnostic and therapeutic variety of patient diagnoses in the program has increased pleural procedures including PleurX catheters; ultrasound- as well. Patients with COPD as well as those with pulmonary guided thoracenteses; percutaneous and conventional fibrosis, sarcoidosis, asthma and s/p lung transplantation chest tubes; and closed pleural biopsies. Our Interventional continued to take advantage of this multidisciplinary Pulmonary and Advanced Bronchoscopy team is a core program. Participants continued to praise the program, part of the Hospital’s multidisciplinary Lung Cancer Program documenting improved quality of life and exercise capacity. working with colleagues in Thoracic Surgery, Medical Many continued to exercise in the Post-Rehab Fitness Oncology, Radiation Oncology, Pathology and Diagnostic Program at the Tully Health & Fitness Institute, specifically Radiology, all of which participate in our bi-weekly lung designed for Pulmonary Rehab graduates. cancer tumor boards.

The Pulmonary Rehabilitation team hosted its 11th COPD The Pulmonary Division plays a key role in Stamford Day/Health Fair. This was a patient education program Hospital’s Lung Cancer Screening Program. Dr. Michael that was the first of its kind in the northeast when it was Bernstein serves as the Co-Clinical Director of the program initially developed in 2005, and remains unique to this area. along with Dr. Michael Ebright of Thoracic Surgery. Our About 70 patients and family members from the greater multidisciplinary program is accredited by the American Stamford area attended the event and the feedback was College of Radiology. We have screened nearly 500 patients overwhelmingly positive. since the program began and are expanding every month.

Pulmonary Rehab Coordinator Kathryn Sullivan, RRT, The Pulmonary Department remained active in providing continued her new role as our COPD Patient Liaison. CME opportunities for the Stamford community. The 32nd She met with patients admitted to the Hospital with a Annual Pulmonary Symposium was held in May in the diagnosis of COPD exacerbation. She also assisted with Brace Auditorium. Dr Christian Becker of the Icahn School coordinating Hospital discharge in an effort to provide of Medicine at Mount Sinai, Division of Pulmonary, Critical continuity with outpatient care and to try to prevent Care and Sleep Medicine, spoke on the topic “Sepsis – A unnecessary readmissions. The entire Respiratory Journey through the Evidence Base.” This was followed

48 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 by a lively discussion of sepsis issues by a panel of experts • Active mobilization of the critically ill patient was the that included Drs. Krinsley, Parry, Dwyer and Bhalla. This new major initiative during the year. This required intensive format was well-received and will be considered for future involvement of Nursing, Respiratory Therapy and Pulmonary Symposia. Pulmonary Grand Rounds was given Physical Therapy, as well as physician and Pharmacy in July by our newest Stamford pulmonologist, Dr. Alex involvement to modify sedation practices and orders. Ortega. He spoke on “Asthma 2015: Where We’ve Been and The culture of the ICU regarding this issue has changed. Where We’re Going.” In addition, the Division gave numerous Over the course of the year, patients undergoing talks throughout the Stamford community about topics mechanical ventilation have been routinely taken such as lung cancer screening, smoking cessation and out of bed and several of them have walked around sleep apnea. the ICU while undergoing mechanical ventilation via endotracheal tube. We are pleased with the quantity and the quality of services that the Pulmonary Division provided, but we • Glucose control evolved, based on interpretation of are particularly proud of the individuals who make up our medical literature. Two blood glucose targets were used, staff. They participated in other community events such as based on preadmission glycemic control, reflected by the performing screening spirometries at the Women’s Expo, HbA1c level. Rates of hypoglycemia were extremely low. Healthy Heart Day, COPD Day, Employee Health Fair and at Chelsea Piers Connecticut. They walked in a Cystic Fibrosis • The multidisciplinary effort to manage severe alcohol fundraiser to raise money for CF care. The Pulmonary Rehab withdrawal has been associated with a significant staff volunteered their time and skills to make ID badge reduction in ICU and hospital length of stay of this holders that were then sold to pay for light hand weights difficult to treat population. In addition, the team’s to be presented to Pulmonary Rehab participants upon success using the protocol was reflected by a 0% rate of graduation. We were delighted that Dr. Caroline Gulati was patients who required intubation for respiratory failure the Medical Residents’ choice for the “Rookie of the Year” after being admitted to the ICU. Historic annual rates for Award at the Department of Medicine graduation dinner. this metric ranged from 15% – 30%. We were also extremely proud of Dr. Michael Bernstein, • The multidisciplinary committee on infection control who received the 2015 Melvin Magida Award. This is an met regularly and monitored infection control practices award given to a young Fairfield County physician who and protocol adherence, especially relating to the renders care and treatment with a genuine concern for his prevention of ventilator-associated pneumonia (VAP), patients and their families, serves his community well and is catheter-associated urinary tract infections (CAUTI) and respected by his colleagues. central line-associated bacteremia (CLAB). Foley catheter utilization rate remained at approximately 50% of the CRITICAL CARE national standard and the rate of the sentinel infections remained low. In fact, there has been an 80% reduction In FY15 there were 1,174 admissions to the Intensive in the overall rate of ICU-acquired infections regularly Care Unit (ICU), seven fewer than in FY14. The median monitored by the nurse epidemiologists since 2008. length of stay of patients admitted to the ICU, 1.7 days, was unchanged. During the year, Director of Critical Care Dr. James Krinsley delivered presentations relating to intensive glucose Sixty-five patients were admitted to the ICU following management of critically ill patients, based on the work cardiovascular surgery during this fiscal year, 19 fewer than completed at the Stamford Hospital ICU, at the 2014 in the previous year. The distribution of cases was: 49% Congress of the European Society of Intensive Care “isolated” coronary artery bypass surgery; 28% “isolated” Medicine in Barcelona, Spain; the 2015 Congress of the valvular surgery; 9% combined coronary artery bypass Society of Critical Care Medicine in Phoenix, Arizona; the and valvular surgery; and 13% with other procedures 2015 Congress on Advanced Technologies and Treatments (predominantly complicated aortic root repair, including of Diabetes in Paris, France; and the 2015 Congress of the repair of emergency ruptures). Notably, for the third year in a International Society of Intensive Care and Emergency row (227 cases), hospital mortality was 0%. 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.

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In addition, the following manuscripts were published: performed, despite the numerous challenges presented by federal regulations and private insurance companies. We Krinsley JS, Bruns D, Boyd J. The impact of monitoring continued to meet the increased demands of our patients frequency on the domains of glycemic control — a Monte and referring physicians. The team of Dr. Dominic Roca, Carlo Simulation. J Diab Sci Tech. 2015 9(2):1-9. Dr. Steven Thau, Dr. Michael Bernstein, Dr. Caroline Gulati, Krinsley JS, Preiser JC. Time in blood glucose range 70-140 Diana Bernal Messinger, APRN, Lance Dougherty, RN, RT, mg/dL > 80% is strongly associated with increased survival RSPGT, and now Dr. Alex Ortega and Karolyn Chang PA-C, in critically ill non-diabetic patients. Crit Care 2015; 19:179. continued to provide outstanding care for our sleep patients while decreasing the waiting time for doctor visits. Karishma Wenerman J, Desaive T, Finfer S, Foubert L, Furnary A, Bellara, PA-C, continued to work for the Center remotely to Holzinger U, Hovorka R, Joseph J, Kosiborod M, Krinsley JS, be closer to her new young family. We were sorry to see Mesotten D, Nasraway S, Rooyackers O, Schulz M, Van Herpe Dr. John Kazianis decide to move on with his career and we T, Vigersky R, Preiser JC. Continuous glucose control in wish him luck in his future endeavors. the ICU: Report of a 2013 round table meeting. Crit Care 2014; 18:226. Our staffing enabled us to provide care for those in Stamford Hospital’s Bariatric Program in a timely fashion. In addition, Krinsley JS. Is glycemic control in the critically ill cost Dr. Hossein Sadeghi is board-certified in Sleep Medicine and, effective?Hosp Prac. 2014, 42(4):53-58. as a part the CCSM, makes us poised to treat our potential pediatric population. Krinsley JS. Glycemic control in the critically ill: What have we learned since NICE-SUGAR? Hosp Prac. 2015; Thanks to the efforts of Medical Director Dr. Dominic 43(3):191-197. Roca, Program Coordinator Laura DeFelice and CCSM Director Robb Mercer, the program is a Stamford Hospital Finally, following the replacement of the local Institutional Center of Excellence. As confirmation of our commitment, Review Board (IRB) by a centralized IRB, Quorum, a group of the CCSM was accredited by the American Academy of clinical investigations was initiated by Dr. James Krinsley with Sleep Medicine as a sleep center to diagnose and treat all medical and surgical residents, for presentation at national sleep disorders including but not limited to sleep apnea, and regional conferences. Specifically these included: insomnia, restless legs, narcolepsy, delayed/advanced sleep • Diabetes is associated with increased dysglycemia and phase, jet lag and all other conditions that cause sleepiness mortality in patients with sepsis. or difficulty sleeping.

• The relationship of the severity of sepsis to insulin In FY14 we performed over 1,000 sleep studies; 454 “in- resistance and dysglycemia. center” studies and 615 home studies, making us one of the largest providers of home studies in Fairfield County • Time in BG range 70 – 140 mg/dL is associated with and we are at a pace to exceed that during the next fiscal survival in non-diabetic medical ICU patients. year. The CCSM was prepared for the changing landscape of sleep medicine including this expected demand for • The impact of vital sign measurement frequency on home sleep studies and that foresight was crucial to APACHE II and IV severity scoring. maintaining the CCSM in a position to satisfy federal as well as private insurance rules and regulations. Although the • In an ICU with a high-intensity staffing model, is a home sleep studies have a significantly lower sensitivity nocturnal intensivist necessary? than a formal polysomnogram, they enabled patients who • Time in BG range 70 – 140 is associated with survival in were previously unable to visit the CCSM due to medical non-diabetic critically ill patients admitted with trauma. problems or logistical issues to receive an evaluation for sleep apnea at home. The home studies also provided SLEEP MEDICINE another tool to monitor sleep apnea patients currently on treatment. It was to the credit of Vera Budzinski, RPSGT, 2015 was a busy year for Stamford Hospital’s Connecticut our certified technician and lead scorer, that there was a Center for Sleep Medicine (CCSM). We increased the seamless process for the patients to pick up and learn how number of patients being evaluated for sleep disorders to apply the home study device. and the number of home and in-center sleep studies

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New data continued to strengthen the link between sleep The technical aspects of the CCSM have always been apnea and cardiovascular disease, atrial fibrillation, other outsourced and we have been with our current company rhythm disturbances, stroke, thromboembolic events, Persante, formerly known as Sleep Care of New Jersey, for psychological disorders, cognitive deficits, diabetes and the past 4.5 years. They provided the CCSM flexibility in other metabolic disorders, which can not only lead to managing IT and Federal guideline challenges throughout obesity but an increased risk of cancer as well. The literature the year. All of the technicians were supervised by lead also continued to demonstrate that treatment with CPAP sleep technicians and our board-certified sleep physicians, reduces that risk. There is even more data suggesting that 24-hours-a-day. obstructive sleep apnea contributes to cognitive decline in many early or late dementia patients and CPAP can While sleep apnea was the most common diagnosis seen ameliorate those symptoms. Drs. Roca, Thau and Bernstein at our center, the CCSM also had significant experience gave several lectures to community groups throughout in treating all childhood and adult sleep disorders such Fairfield County to educate the public on this important as restless legs, insomnia, narcolepsy and REM behavior health issue. Members of the CCSM staff also gave CPAP disorders. We continued to investigate other tools, such support lectures four times this year. These quarterly patient as online programs that assisted in the management support meetings remained very popular in the community of insomnia, and we collaborated with the Center for as they continued to fill the Brace Auditorium with Integrative Medicine and Wellness to help our patients interested patients and family members. achieve a more relaxed state without medication.

CPAP remains the most effective treatment for obstructive The Connecticut Center for Sleep Medicine remained one sleep apnea. For some patients the adjustment period can of the premier sleep centers in the tri-state area and will be difficult and education has been shown to be the largest continue to provide state-of-the-art sleep medicine to factor in improving patient adherence. To further facilitate the region. the goal of CPAP compliance, the CCSM continued to offer the CPAP Management Program. This program was run by REHABILITATION MEDICINE 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 Edwin F. Richter, MD patients went bankrupt. For those patients who ultimately could not tolerate CPAP or did not wish to continue with Director of Rehabilitation Medicine 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 Division of Rehabilitation Medicine provides a variety Our 13th Annual Sleep Symposium featured Dr. Carolyn of physical medicine and rehabilitation services for patients D’Ambrosio from Massachusetts General Hospital, an of the Stamford Health System. Services are provided Assistant Professor in the Department of Pulmonary, on the Van Munching Rehabilitation Unit and in other Critical Care and Sleep Medicine, on the topic of endocrine areas of Stamford Hospital. Outpatient care is provided in manifestations of sleep apnea titled, “From Low T to High the clinic, as well as the private offices of the physiatrists TSH.” The topic, which is very dear to our own Dr. Noel Robin, (doctors specializing in physical medicine and rehabilitation) was new to many of the people who turned out for this of the Department. My colleagues include Drs. Joseph presentation, which covered a frequently overlooked issue Annichiarico, Aris Barbadimos, Carolyn Casino, Andrew Illig, affecting hundreds of thousands of people. The questions Stephen Massimi, Thirumoorthi Seshan, Daniel Southern, from the audience demonstrated the need for more studies David Walshin, Jun Xu and Po Priscilla Xu. to be performed.

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Rehabilitation services at the Tully Health Center and at • Sharon Karp, MD Chelsea Piers Connecticut have been in very high demand. • Shikha Mehta, MD These include physical therapy, occupational therapy, speech therapy and neuropsychology. The Survivorship The Department of Rheumatology is currently comprised of Training and Rehabilitation (STAR) program, offered in five members: Drs. Tomas Vietorisz (Chairman), Sharon Karp, conjunction with the Bennett Cancer Center, provides and Hana Hulinska, along with our two newest members, specialized rehabilitation services for survivors of cancer. Drs. Shikha Mehta and Erik Beger. Support groups for patients with history of amputation or history of stroke/brain injury have continued to As Chair of the Department, Dr. Vietorisz continues provide valuable assistance to those patient populations. to practice full-time as a member of Stamford Health Additionally, patient educational activities continue Integrated Practices (SHIP). He received his medical degree including participation in National COPD Patient Education from the Mount Sinai School of Medicine in 1988. After Day and World Asthma Day. a residency in internal medicine at Boston University, he completed his fellowship in rheumatology at The Albert The Rehabilitation Unit inpatient program continues to be Einstein College of Medicine in 1994. He is board-certified in utilized by patients coming from within the Hospital and both internal medicine and rheumatology. from hospitals around the region. This has remained at a very high level. Feedback has been very positive with the Dr. Karp practices part-time as a member of Shoreline Unit receiving a national award for patient satisfaction from Medical Group, which has recently joined Westchester the Press Ganey organization. We benchmark ourselves Health. She received her medical degree from Brown against comparable units around the region and across University School of Medicine. After completing her the nation, and are continuing to pursue opportunities for residency at Stamford Hospital, she went on to complete programmatic development. her fellowship in rheumatology at New York University. She is board-certified in both internal medicine and rheumatology Being part of an expanding health system provides many valuable opportunities for collaboration with colleagues Dr. Hulinska practices full-time rheumatology with private across other departments and programs. The facilities of practice offices in both Stamford and Westport. She received Stamford Hospital and the expertise of the Medical Staff are her medical degree from the University of Connecticut particularly valuable resources for the Rehabilitation Unit. School of Medicine. She completed her residency and rheumatology fellowship at North Shore University Hospital I remain very grateful for the outstanding work by members in Manhasset and Long Island Jewish Hospital, and she is of the Department as well as our colleagues across the board-certified in internal medicine and rheumatology health system. Dr. Mehta, the youngest member of the Department, RHEUMATOLOGY 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 Tomas Vietorisz, MD York City in 2012 and went on to complete a fellowship in Director of Rheumatology 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 Active Staff: completed his residency in internal medicine at Boston University in 1998 and went on to complete a fellowship • Erik Beger, MD in rheumatology at Albert Einstein College of Medicine in • Hana Hulinksa, MD 2000. Since then, he has served as attending rheumatologist

52 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015 at a variety of hospitals including Nassau University HOSPITAL COMMITTEE PARTICIPATION Medical Center, Queens Hospital Center, Catholic Medical Center and Flushing Hospital Center. Most recently, he In addition to the broad participation of members of has been practicing as a member of Soundview Medical various Departments and Divisions within the Department Associates in Norwalk. Dr. Beger joined Stamford Health of Medicine (referred to in each department’s individual Medical Group in September 2015 and is in practice with report), acknowledgment goes to Jeffrey Green, MD, Drs. Vietorisz and Mehta. He is board-certified in both who was elected by his peers to be the at-large internal medicine and rheumatology. Department of Medicine representative to Stamford Hospital’s Medical Executive Committee, a position he has The Rheumatology Department is proud to announce that held since January 1, 2011. two of our members, Drs. Karp and Vietorisz were both selected as “Top Docs” in Connecticut magazine’s physician DEPARTMENTAL SAFETY AND QUALITY edition. Dr. Beger made this list as well in 2013 and 2014. Under the leadership of Rohit Bhalla, MD, Vice President, In addition to providing rheumatological care in the Quality and Chief Quality Officer, the Department of private practice setting, physicians in the Department Medicine actively participates in Stamford Hospital’s many continue to provide indigent care for members of the safety and quality initiatives. The following are year-to-date community suffering with rheumatological illnesses statistics (as of September 27, 2014) for the measures in through the Optimus Clinic system. The Rheumatology which the Department of Medicine is actively involved Clinic meets once a month and is staffed by the house (numbers in parentheses represent the target values): officers of Stamford Hospital under the supervision of Drs. Vietorisz, Mehta and Beger. These physicians also Clinical Effectiveness: provide indigent care to medical inpatients requiring more urgent rheumatological interventions. VTE Prophylaxis — All Inpatients 97% (98%)

The field of rheumatology continues to be exciting and Stroke Education 97% (97%) rapidly developing. The use of biologic therapies has now become firmly established as safe and effective and has Surgical Prophylactic Antibiotics 99% (98%) greatly expanded the number of patients with rheumatic Discontinued Within 24 Hours of diseases who can be successfully treated. Biologic therapies Surgery End currently approved for use include agents targeting TNF, Early Elective Deliveries <39 Weeks 1.2% (0.6%) IL-1, IL-6, T-cell receptor molecules CD-80/86, B-cell receptor (Elective deliveries<39 Weeks Gestation) 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 Outpatient Surgery Antibiotic 100% (99%) are currently in phase two and three, and show promise Use Composite as potential future options in treatment of autoimmune disease. The use of kinase inhibitors has also become a Acute Myocardial Infarction — 97% (99%) reality in the treatment of rheumatic disease with the Appropriate Care approval of Tofacitinib for use in patients with rheumatoid Congestive Heart Failure — 98% (99%) arthritis. However, the cost of these agents continues to be Appropriate Care prohibitive for many patients, particularly the uninsured and underinsured. With the expiration of patent protection Pneumonia Appropriate Care 95% (99%) for biologic agents etanercept and infliximab rapidly approaching, the era of biosimilars is nearly upon us. How Surgical — SCIP — Appropriate Care 99% (97%) these agents are to be regulated, priced, and approved Venous Thromboembolism – 95% (97%) by the FDA are questions that are yet to be answered. Appropriate Care Hopefully, these products will reduce the cost of these therapies and make these highly effective treatments Stroke – Appropriate Care 94% (96%) available to a wider number of individuals.

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Hospital-Acquired Infections: Columbia P & S students are assigned to our Department of Medicine in both the Inpatient Clinical Clerkship and Hand Hygiene 94% (95%) in Primary Care Medicine, as well as in Family Medicine, Surgery, Obstetrics and Gynecology and Pediatrics. At any Central Line-Associated Bloodstream 0.71 (0.99) given time, there are as many as 24 Columbia students Infections (Med/Surg + ICU) per throughout all rotations. Stamford Hospital teaches the 1,000 line days entire student body of Columbia P & S. Central Line-Associated Bloodstream 6 (9) Within the Department of Medicine, seven or eight third- Infections (Med/Surg + ICU Actual #) year students are assigned to Inpatient Medicine and one or Central Line-Associated Bloodstream 0 (1) two to Primary Care/Ambulatory Medicine at any one time. Infections (NICU Actual #) The Department also regularly accommodates students who seek clinical electives at Stamford Hospital. Since Catheter-Associated Urinary Tract 0.11 (0.11) Critical Care Medicine is not a dedicated rotation during the Infections (ICU, CAUTI per 1,000 third year at Columbia, this is an especially attractive and catheter days) vital elective experience we can offer. Other clinical electives include Cardiology, Pulmonary Medicine, Infectious Disease Catheter-Associated Urinary Tract 8 (11) Medicine, Hematology and Oncology and a fourth-year sub- Infections (ICU, Actual # of CAUTIs) internship in Internal Medicine and Emergency Medicine. All Surgical Site Infections 0.74 (0.65) Columbia P & S medical students consistently laud the (per 100 Surgical Cases) quality of their educational experience at Stamford Hospital and the personalized, role model education they receive. All Surgical Site Infections 38 (47) The following physicians are recognized as preceptors for (Actual # of SSI) the 10 clinical clerkship sessions of the academic year: Colon Surgical Site Infections 4 (7) • Revekka Babayev, MD (Actual #, all classes) • Salvatore Carbonaro, MD MRSA (per 1,000 patient days) 0.04 (0.04) • Joonun Choi, MD • Deena Ebright, MD VRE (per 1,000 patient days) 0.016 (0.028) • Melissa Goldstein, MD C. Difficile (per 1,000 patient days) 0.919 (0.920) • Anthony Gulati, MD Resistant Infection Rate (MRSA, VRE, 0.978 (0.991) • William Hines, MD C. Diff per 1,000 patient days) • Sarah Kahn, MD TEACHING ACTIVITIES • Ted Listokin, MD • Shikha Mehta, MD Medical Student Education • Wayne Miller, MD Stamford Hospital’s affiliation with Columbia University • Bismruta Misra, MD College of Physicians and Surgeons (Columbia P & S) • Craig Olin, MD is now in its 18th year. Currently, 100 physicians at the Hospital hold faculty appointments in the Department of • Paul Sachs, MD Medicine at Columbia: • Asha Shah, MD

• Instructor in Clinical Medicine — 35 • Brianna Siegel, MD • Assistant Clinical Professor of Medicine — 40 The Fourth Annual “Residents as Teachers Day,” jointly • Associate Clinical Professor of Medicine — 9 sponsored by Columbia P & S and Stamford Hospital, was held on September 17, 2015. The major presentation • Clinical Professor of Medicine — 2 was given by Lisa Mellman, MD, Senior Associate Dean • Professor of Clinical Medicine — 3 for Student Affairs and Clinical Professor of Psychiatry at

54 | DEPARTMENT OF MEDICINE DEPARTMENT OF MEDICINE: ANNUAL REPORT 2015

Columbia University College of Physicians and Surgeons. applications for six categorical and two preliminary positions This was followed by additional presentations along with for the 2016 NRMP Match. individual meetings with department chairs, clerkship site directors and Columbia P & S residency program directors. The Clinical Competence Committee spends a great deal of time on curriculum development, program innovation Additionally, the Department of Medicine provides a and improvement and assessment of residents in addition comprehensive course in the Foundations of Medicine; it is to their other administrative and clinical responsibilities. the first major experience in clinical medicine for medical They also teach residents in the ICU, Inpatient Medicine, students. This course is under the exemplary leadership of Ambulatory Medicine and on elective rotations. Dr. Neil Boside, with Drs. Peggy Geimer, Alfred Wolfsohn and Acknowledgment goes to Committee Chair Dr. Noel Robin, Richard Sheinbaum ably serving as educators. along with Drs. Kirsten Hohmann, David Hsi, James Krinsley, Dominic Roca, Maher Madhoun, Hiren Mody, Praveen Reddy RESIDENCY PROGRAM IN and John Fitzgibbons along with Mary Dolan. In addition, the Program Evaluation Committee, charged with program INTERNAL MEDICINE assessment and improvement, is comprised of members of the Clinical Competence Committee, Drs. Michael Bernstein Maria Maldonado, MD and Tzivia Moreen, and our two Chief Residents Morgan Program Director, Internal Medicine Kellogg and Marta Kokoszynska, who are also completing Residency Program their third year of residency. Associate Chair, Department Ambulatory education remains under the leadership of of Medicine Dr. Kirsten Hohmann, Associate Program Director and Associate Clinical Professor of Director of the Medical Clinic. The program’s success is due Medicine, Columbia University College of Physicians and Surgeons 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 Kirsten B. Hohmann, MD (PG-1), one senior resident (PG-2 or PG-3) and one teaching Associate Program Director, Hospitalist attending. At any given time on the inpatient Internal Medicine teaching service, there are three Medicine PG-1 residents, Residency Program one PG-1 Family Medicine resident, three Medicine seniors Medical Director of Ambulatory and one Family Medicine senior. The Inpatient Teaching Practice, Optimus Healthcare experience remains under the able leadership of Drs. Maher Assistant Clinical Professor of Madhoun and Hiren Mody, Co-Assistant Program Directors. Medicine, Columbia University College of Physicians and Surgeons Many Internal Medicine residents were among the presenters of nine posters at the Annual Connecticut Chapter Meeting Scientific Session of the American College Stamford Hospital’s Residency Program in Internal Medicine of Physicians on October 30, 2015, and several of our has had a productive and fulfilling year. residents are engaged in institutional quality improvement The program welcomes the addition of seven new projects as well as research with Dr. James Krinsley, Director categorical interns, Drs. Somera Chaudhry, Chao Guo, of the Intensive Care Unit. This was the fourth year of a Kimberly Gupta, Melanie LaVoie, Jean Lee, Sadiya Thermidor, bi-directional educational experience with the required Madhuri Tirumandas and one preliminary intern, Dr. David neurology rotation for PG-2 residents at the renowned Gedeon, who, upon completion of his PG-1 year here at Neurologic Institute at Columbia University Medical Center. Stamford Hospital, will go on to complete his residency in Under the supervision of Dr. Blair Ford, Associate Professor Diagnostic Radiology at UC Irvine-CA. We also acknowledge of Clinical Neurology, an authority on movement disorders the achievements of recent graduates who have gone and deep brain stimulation for Parkinson’s disease, residents on to complete residencies, fellowships or start practices receive education in multiple domains of neurologic at respected institutions around the country. Notably, experiences. In addition, under the aegis of Dr. Richard the Internal Medicine program has received over 2,000 Marottoli, Associate Professor of Medicine in the Section of

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Geriatric Medicine at Yale University School of Medicine and • Comprehensive Clinical Case Conference — This Director of the Dorothy Adler Geriatric Assessment Center monthly conference draws on the rich array of relevant at Yale-New Haven Hospital, residents are taught geriatric clinical cases requiring multidisciplinary involvement. assessment. The annual “Resident-As-Teacher” Workshop, led by Columbia P & S faculty, continued this past September • Yale University Seminars in Geriatric Medicine — Four with both resident and faculty development in the area of timely, topical presentations regarding the care of medical student assessment and evaluation. older adults. Themes this year included “Sleep-Wake Disturbances in Sedentary Older Persons with Mobility The thrust and goals of graduate medical education are Limitations,” “Mistreatment of Older Adults” and “Agitation evolving to ensure that residents are prepared to practice in the Older Adult.” The topic of “Dementia and Delirium” medicine in a rapidly evolving health care delivery system also gave Dr. Allison Ostroff the opportunity to formally that underscores quality, efficiency and patient-centered deliver Medical Grand Rounds as the newly appointed care. The Accreditation Council on Graduate Medical Director of Geriatrics. Education now ensures that residents are meaningfully engaged in their institutions through the Clinical Learning • The 7th Annual Keith Landesman Memorial Lectureship Environment Review, which provides the opportunity to — A lasting tribute to a beloved colleague and the collaborate on best practices in ensuring that the mission values that defined his life. This year’s lecture was given of education is intertwined with the quality strategy and by Dr. Terry Trow, Professor of Medicine at Yale Medical patient safety initiatives. Residents at Stamford Hospital are School, on pulmonary arterial hypertension. inculcated with strategies to evaluate systems and generate • The Annual William F. Buckley, Jr. Memorial Lecture and evaluate solutions to challenges that arise in the — Given in memory of Mr. Buckley, whose gracious delivery of healthcare. They are given multiple opportunities bequest allowed for the creation of an ongoing to work with Hospital leadership and interprofessional lectureship in Infectious Disease. teams to improve the quality of patient care, and several sit on institutional committees such as Sepsis, ED Throughput • The 37th Annual William H. Resnik Memorial Lecture — and Information Technology. This collaboration helps This year’s speaker was Dr. Rudolph Leibel, Christopher residents develop the insight and skills needed to advocate J. Murphy Memorial, Professor of Diabetes Research and for quality care as part of their training as well as practice in Professor of Pediatrics at Columbia University College of the present healthcare environment. Physicians and Surgeons.

• The 13th Annual Paul H. Dalgin Memorial Lectureship — CONTINUING MEDICAL EDUCATION Given in dedication to a special colleague, and as a lasting Reflective of its commitment to continuing medical tribute to the ideals of medical education. This year’s education, Stamford Hospital was awarded an lecturer was Dr. John P. Bilezikian, Professor of Medicine at unprecedented six years of accreditation, with Columbia University School of Physicians and Surgeons, commendation, by the Committee on Continuing Medical who spoke on “Osteoporosis: Horizons of Therapy.” Education (CME) of the Connecticut State Medical Society. • Senior Resident Presentations — Seven senior resident The breadth of CME programs offered in 2015 illustrates presentations addressed a wide range of clinical topics. this commitment: • Schwartz Rounds — Although in the domain of • Medical Grand Rounds — Weekly diverse, educational Stamford Hospital, these important, reflective and presentations, many emphasizing an integrative poignant teaching experiences, held every two months, and multidisciplinary approach to care. Themes in are meaningful and inspirational to our Department. 2015 included “Transitional Care and Care Management Initiatives,” “Treatment of Relapsing Multiple Sclerosis,” • The 11th Annual Sleep Medicine Symposium — “Nutritional Assessment and Management” Sponsored by the Connecticut Center for Sleep and Nephrology. 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.

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• The 33rd Annual Pulmonary, Critical Care and Sleep that Hospitalist Medicine continue to be represented Medicine Symposium — Sponsored annually by the in all components of medical education, and that Department of Pulmonary Medicine to enlighten community physicians feel a part of the clinical and physicians on current issues in Pulmonary Medicine, intellectual stimulation that is part of their association their pathophysiologic mechanisms and their clinical with Stamford Hospital. management. Three presentations by staff were given this year by Drs. James Krinsley, Michael Parry, Kevin An important corollary is the need to maintain and foster Dwyer and Rohit Bhalla on “A Journey Through Stamford Hospital’s role as a major teaching campus. Evidence-Based Literature” followed by a discussion The Hospital has established a special relationship with given by Dr. Christian D. Becker. Columbia University College of Physicians and Surgeons and is privileged to have the responsibility of educating so many • The 22nd Annual Oncology Symposium —Sponsored future physicians. This privilege is cherished with pride, by the Carl and Dorothy Bennett Cancer Center to humility and unwavering commitment. provide physicians with the most current knowledge and understanding of cancer. This year’s theme was The responsibilities of the Department of Medicine are “Cancer Survivorship and Rehabilitation.” large and are shared by many. No single individual or group of individuals can possibly perform all the clinical, service • Dedicated Summer Syllabus in Medicine — A and educational responsibilities. This annual report gives comprehensive, 12-week compendium aimed at new formal recognition to those members who have generously house staff and medical students. given of their time, energy, and, above all, themselves. Our medical community is surely better as a result of their • Medical Grand Rounds during the Summer Syllabus — kindness and good deeds. They have enriched all and have 12 weekly sessions led by Department staff on clinical, made our community and profession all the better. We medico-legal, and quality and safety topics. may be very fortunate as a community to have facilities • Annual Medical Grand Rounds Lecture in Podiatry — and technology, present and future, of extraordinary The 2015 Speaker was Dr. Robert Fridman, who spoke on design and sophisticated capability. Nothing, however, is “A Practical Guide to Heel Pain.” 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 COMMUNITY OUTREACH deep hope that their generous and selfless contributions As part of the Department’s commitment to promoting ennoble them and augment their pride and esteem in our a healthier community through education, physician beautiful profession. members participate in an array of forums and programs To those good physicians who exemplify these ideals, who including the Mini Medical School, health fairs, lectures, continue to make ours a profession of meaning and worth symposia and awareness days focused on specific — for their dedication, kindness, friendship and collegiality, health conditions. 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 CLINICAL ANNUAL REPORT | 57 innovation in obstetrics & gynecology

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

58 | DEPARTMENT OF OBSTETRICS & GYNECOLOGY DEPARTMENT OF OBSTETRICS & GYNECOLOGY: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: • Under the leadership of Kathy LiVolsi, Stamford Hospital received the Women’s Choice Award in Obstetrics The Year in Review for 2015.

• 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 Carol Fucigna, MD patient-centered care resonates with patients and this is Interim Chair, Department of evidenced in our increasing volume of births and strong Obstetrics and Gynecology patient satisfaction scores.

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. he Hugh K. Miller, MD, Department of Obstetrics & Gynecology works in collaboration with our SCOPE OF CLINICAL ACTIVITIES obstetricians and gynecologists and strives to T The Department is pleased to report volume growth provide the highest level of quality care to patients in our in Obstetrics, Gynecology and Gynecologic Oncology community by offering the most up-to-date diagnostic (with data provided in Figures 1 – 7). In addition, our testing and novel treatment modalities in a safe and global quality program continued to achieve results, nurturing atmosphere. The Department is proud to share demonstrating a Departmental focus on quality and value. its accomplishments and highlight the areas in which we All Department members continue their commitment to continue to work to assure that we are setting the highest put patients first, and patient feedback affirms the success standards for providing excellent patient care. of these efforts. This was a productive year for the Department: The following charts and graphs illustrate clinical • Obstetric volume at Stamford Hospital increased by 3% productivity and volume for fiscal year 2015. 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 CLINICAL ANNUAL REPORT | 59 DEPARTMENT OF OBSTETRICS & GYNECOLOGY: ANNUAL REPORT 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 LF & JC 0/27 0/35 0/28 0/22* 1/20 0/20 0/21 0/15 0/9 1/21 1/27 0/17 1% <39 wks* 5% 0% 0% 0% 0% 5% 0% 0% 0% 0% 4.8% 3.7% 0%

26/77 28/75 23/47 32/67 16/60 18/70 22/57 26/67 24/65 23/61 28/85 31/74 JC-PC 2- NSTV Ntl 26.3% 34% 37% 49% 48% 26% 26% 39% 38% 37% 37% 33% 41% 37%

JC-PC 3- 1/1 5/5 2/2 6/6 3/3 4/4 10/10 3/3 6/6 7/7 2/2 1/1 Ante. Steroids Ntl 81.8% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 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. 14/33 17/38 13/41 10/32 15/31 9/36 13/34 13/34 9/37 11/32 19/40 14/38 BF Ntl 50.8% 41.2% 44.7% 31.7% 31.2% 48% 25% 38.2% 38.2% 24.3% 34% 47.5% 36.8% 37% Skin to Skin Within 30 NSI 90% 19/20 19/20 18/20 16/20 18/20 19/20 18/20 16/20 18/20 20/20 20/20 17/20 91% Minutes of Del. 95% 95% 90% 80% 90% 95% 90% 80% 90% 100% 100% 85%

BF - Attempt/ 15/20 15/20 12/20 11/20 16/20 16/20 15/20 13/20 16/20 14/20 13/20 11/20 Latch 1 Hour NSI 80% 75% 75% 60% 55% 80% 80% 75% 65% 80% 70% 65% 55% 70% DVT Prophylaxis LF 80% 19/20 19/22 19/22 9/10 9/10 10/10 9/10 10/10 9/9 8/11 8/11 7/11 87% for C/B 95% 86% 86% 90% 90% 100% 90% 100% 100% 72% 72% 64% DTRs on 192/194 37/63 155/156 Mag. Sulfate PI 95% Q 99% 59% 99%

18/104 17/84 17/80 18/97 11/79 20/94 11/89 19/85 18/89 16/110 24/92 15/97 Episiotomy LF <12% 17% 20% 21% 19% 14% 21% 12% 22% 20% 15% 26% 15% 18% NB Bilirubin 48/48 48/48 48/48 48/48 47/48 48/48 48/48 47/48 48/48 48/48 48/48 48/48 Screening LF 80% 100% 100% 100% 100% 98% 100% 100% 98% 100% 100% 100% 100% 99.9% Oxytocin Protocol PI DPH 2/5 40% Compliance 100% 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 1 MB Falls NSI 1 PD 0 0 0 0 1 LD 0 0 1 LD 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 0 0 0 0 0%

<37 wk adm 4/8 9/10 15/15 16/18 13/14 12/14 13/15 7/11 13/18 12/15 9/10 11/13 temp on PI 75% 82% NICU adm 50% 90% 100% 89% 93% 86% 87% 63% 72% 80% 90% 85% <1500 gm temp on VON 1/1 2/2 2/2 1/1 2/2 2/2 3/3 No 3/3 1/2 2/2 1/1 NICU adm 25%tile 100% 100% 100% 100% 100% 100% 100% Cases 100% 50% 100% 100% 95% > 96F (36C)

60 | DEPARTMENT OF OBSTETRICS & GYNECOLOGY DEPARTMENT OF OBSTETRICS & GYNECOLOGY: ANNUAL REPORT 2015

Figure 3: 2015 Deliveries Vaginal & Cesarean

We are cognizant of the constantly evolving medical • The Minimally Invasive Surgery/Robotics Program is now landscape and remain poised to change quickly to in its seventh year, and recently received a three-year meet regulatory requirements as well as implement reaccreditation as a Center of Excellence for Minimally cutting-edge technologies. The Department is Invasive Gynecologic Surgery. Gary Besser, MD, and comprised of many members across several disciplines. Stephen Gallousis, MD, are Co-Directors of Minimally This multidisciplinary approach to patient care and our Invasive Gynecologic Surgery. commitment to continually strive to improve that care position us well for the future. • Our MIG numbers continue to be affected by the loss of uterine power morcellation in hysterectomy and Included below are some of the highlights of the myomectomy (April 17, 2014). Stamford Hospital has Department’s activities in 2015: proactively prohibited the use of the morcellator in all gynecologic cases and we are constantly re-evaluating • In Obstetrics, we enjoyed a 3% growth in the number the literature on morcellation. of babies from 2014 to 2015 (from 2,288 to 2,364), while nationally, the birth rated increased by 1% for the first • 367 inpatients were admitted to the Gynecologic Service time since 2008. in FY15, up from 318 in FY14. This represents a 16% increase in overall GYN volume.

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• The Gynecologic Oncology program led by Elena Ratner, The Department’s gynecologic procedure numbers MD, and comprised of three Gynecologic Oncologic continue to be robust, however, we continue to be surgeons, grew by 55% from 2014 to 2015. impacted by the ban on morcellation. The FDA ban on intraabdominal morcellation in April 2014 led to a • Setul Pardanani, MD, joined Stamford Hospital in decrease in minimally invasive procedures. December as our new Director of Ambulatory Care Services & Associate Residency Program Director. The Gynecologic Oncology program experienced a 55% growth in surgical volume in 2015 (Figure 5). Our • Planetree tenets continued to be integrated into daily patients are cared for by three board-certified Gynecologic patient care operations. Oncologists: Drs. Elena Ratner, Karen Nishida, and Babak • The Department published a quarterly newsletter Litkouhi. Community physicians continue to support the highlighting clinical and programmatic updates for the program with an increase in referrals from all towns. system including information on our residency program and recognition of physicians.

Figure 4: 2015 Gynecological Service Volume

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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 Frances Ginsburg, MD Co-Director, OB Safety & Director, Reproductive Quality Committee Endocrinology & Infertility Medical Student Clerkship Director Residency Director At-Large member, Medical Executive Committee

2015 CLINICAL ANNUAL REPORT | 63 DEPARTMENT OF OBSTETRICS & GYNECOLOGY: ANNUAL REPORT 2015

MEDICAL STAFF

Gary Besser, MD Setul Pardanani, MD Co-Director, GYN Minimally Associate Residency Director Invasive Surgery

Tracy Shevell, MD Stephen Gallousis, MD Director, Perinatal Ultrasound 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 Kathy LiVolsi, RN, MHA Director, Gynecologic Oncology Clinical Operations Director, Maternal & Child Health Services

Mary Henwood-Klotz Director, Women’s Health & Pediatric Service Line

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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 • Jennifer Cabral, MD, Faculty Position, Lincoln Hospital Program Director • Molly Findley, DO, Fellowship in Family Planning, Albert Transitions: Einstein College of Medicine, The following Department members resigned in 2014: The Department also provides an active program of Continuing Medical Education: • Mary Ellen Humes, MD • Faculty and Departmental Meeting • Adam Ofer, MD • Multidisciplinary M&M Conference • Shefali Pathy, MD • Multidisciplinary OB/PEDS Conference

DEPARTMENTAL EDUCATION AND • Grand Rounds TEACHING ACTIVITIES • CoreCases for OB/GYN — Co-Developed by ACOG The Department serves as a clinical training site for a & CaseNetwork second- and third-year core clerkship in Obstetrics and In addition, the Department sponsored the 21st Annual Gynecology for medical students from Columbia University Morton A. Schiffer Day Resident Research Symposium on College of Physicians and Surgeons. The OB/GYN residency May 29, 2015. 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 DEPARTMENTAL RESEARCH AND a teaching site for senior genetic counseling students from SCHOLARLY ACTIVITIES Sarah Lawrence College. Additionally, the Department continues its relationship with Planned Parenthood of New Department members gave several presentations at England as a second- and third-year resident rotation site regional meetings in the past year: for outpatient practice. • “Impact of a quality improvement initiative on the The Residency Program in Obstetrics and Gynecology is episiotomy rate at a community hospital,” Andrew C. under the supervision of Director Frances Ginsburg, MD, Rausch, MD; Maureen Burke, MD; Donna Bowman, DNP, and assisted by Setul Pardanani, MD. The program has a full FNP-BC, RNC-OB; Paul Bobby, MD; Daryl Wieland, MD, complement of residents, which consists of three residents MSMI. Annual State of Connecticut Resident Research in each of the four years. Day, Yale-New Haven Hospital. September 2015. Oral Presentation. The current first-year residents are: • “A comparison of perioperative morbidity between • Kelly Fellows, MD, University of Minnesota transvaginal and supracervical hysterectomies in Medical School the setting of robotic-assisted sacrocolpopexies,” Oluwakemi Adegoke, MD; Brian Hines, MD; Katherine • Kiger Lau, MD, Tufts University School of Medicine Sandhu, MD. Annual State of Connecticut Resident • Jade Mas, MD, Florida International University Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation.

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• “Transvaginal resection of sacrocolpopexy mesh to plan which includes continued expansion into the relieve pelvic pain,” Xibei Jia, MD; Oluwakemi Adegoke, secondary market and growing our physician network. MD; Brian J. Hines, MD; Katherine S. Sandhu, MD. Annual State of Connecticut Resident Research Day, Yale-New Our plans this year also include expanding our research Haven Hospital. September 2015. Poster Presentation. program and providing annual simulation training for OB attendings, residents, L&D nurses, Family Medicine • “Intrahepatic cholestasis of pregnancy in Stamford,” residents and medical students. Plans are also underway Ana Pantel, MD. Annual State of Connecticut Resident to initiate global OB simulation involving malignant Research Day, Yale-New Haven Hospital. September hyperthermia and obstetrical codes. 2015. Poster Presentation. Continuing our strong commitment to safety and quality, • An observational study of paternal weight gain during we will continue to update our safety protocols to pregnancy, Courtney Noonan, MD; Paul Bobby, MD. reflect best practices; implement mandatory attending State of Connecticut Resident Research Day, Yale-New documentation elements; create operative delivery Haven Hospital. September 2015. Poster Presentation. bundles; and update clinical pathways and order sets. Finally, our Department attendings and residents are very • “Effect of change in counseling regarding trial of labor involved in the pursuit of research and innovation. after Cesarean amongst a clinic population at Stamford Hospital,” Elizabeth Rodriguez, MD. State of Connecticut Current and future projects for research include: Resident Research Day, Yale-New Haven Hospital. September 2015. Poster Presentation. • Trial of Labor after Cesarean Delivery Before and After the Implementation of a Vaginal Birth After Cesarean • “Safely decreasing the Cesarean section rate in a Delivery Calculator in a Clinic Population at Stamford community hospital,” Paul Bobby, MD; Kezia Spence, MD; Hospital — Elizabeth Rodriguez, MD Andrew Rausch, MD; Donna Bowman, APRN, MSN, RNC- OB. State of Connecticut Resident Research Day, Yale-New • Prevalence of Intrahepatic Cholestasis in Pregnancy in Haven Hospital. September 2015. Poster Presentation. SW Connecticut — Ana Pantel, MD

Additionally, we would like to recognize some of our • An Observational Study of Paternal Weight Gain during Department members for their recent journal publication: Pregnancy — Courtney Noonan, MD; Paul Bobby, MD

• “Impact of a Quality Improvement Initiative on the • Has Use of Non-invasive Prenatal Testing Changed Episiotomy Rate at a Community Hospital,” Maureen Practice in the Community Hospital Setting: A Burke, MD; Donna Bowman, DNP, FNP-BC, RNC-OB; Restrospective Chart Review — Tracy Shevell, MD Paul Bobby, MD; Daryl Wieland, MD, MSMI. Journal of • Safely Decreasing the Primary Cesarean Section Rate in a Reproductive Medicine. Community Hospital — Kezia Spence, MD STRATEGY/FUTURE DIRECTION • Impact of a Quality Improvement Initiative on the Episiotomy Rate at a Community Hospital — Andrew C. The Department’s goals for 2016 are focused and clear. Rausch, MD; Maureen Burke, MD; Donna Bowman, With the new hospital opening in 2016 and the goals DNP, FNP-BC, RNC-OB; Paul Bobby, MD; Daryl Wieland, of a new service line to offer a full complement of MD, MSMI Women’s Health services, this year we will focus on generating increases in obstetrical volume, • Resection of Vaginal Mesh and Recurrent Pelvic Organ gynecological oncology volume, robotics and referrals Prolapse: A Retrospective Study — Xibei Jia, MD; to our chronic pelvic pain program. In collaboration Oluwakemi Adegoke- PGY 4; MD, Brian J. Hines, MD; with Mary Henwood-Klotz, Service Line Director for Katherine S. Sandhu, MD Women’s Health, we will implement our growth strategy

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• Retrospective Analysis of Transvaginal Hysterectomy Safety Program vs. Supracervical Hysterectomy with Associated Sacrocolpopexy — Oluwakemi Adegoke, MD; Brian • OB Simulation Drills: Hines, MD; Katherine Sandhu, MD »» 80% of attendings completed (target 95%) »» 100% of residents completed (target 95%) • “Transvaginal Resection of Sacrocolpopexy Mesh to Relieve Pelvic Pain” — Xibei Jia, MD; Oluwakemi Adegoke, • 100% eligible residents passed Electronic Fetal Heart MD; Brian J. Hines, MD; Katherine S. Sandhu, MD Monitoring Exam

• Polycystic Ovarian Syndrome (PCOS): A Survey on • 100% eligible nursing staff passed Electronic Fetal Heart Diagnosis & Treatment — Daniel Cibulsky, MD Monitoring Exam

• Retrospective Analysis of Toxicity, Treatment Delays • Preeclampsia DTR compliance 91% (internal target 90%) and Recurrence-free Intervals for High-risk Endometrial Adenocarcinoma of the Uterus Treated with Chemotherapy vs. Combined Modality Therapy — Elena Ratner, MD

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%)

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

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A MESSAGE FROM THE CHAIR: We have experienced significant growth in surgical volume from outpatient referrals of dermatopathology, The Year in Review oral pathology and podiatric pathology — all due to clinical excellence of our Dermatopathologist, Dr. Elgida Volpicelli.

Robert C. Babkowski, MD, SCOPE OF CLINICAL ACTIVITIES MMM, FCAP Division of Clinical Chemistry Chair of Pathology and Laboratory We continue to review and enhance our daily workflow Medical Director 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. n 2015, the Laboratory focused on enterprise growth and cost containment, and initiated an RFP process In July, the Lab went live with the Nova pHOx analyzers for to identify a new, fully automated clinical chemistry STAT testing for the Emergency Department (ED). This was I part of a lean initiative to reduce TAT. The average TAT for system to further upgrade our capabilities. This decision is expected to be finalized and implemented in 2016. BMPs have been reduced to 41 minutes from order to result.

The Lab served The Lab will be bringing Hgb, Serum Proteins and as a beta site for Immunofixation Electrophoresis in-house. This will Roche/Ventana improve TAT, increase patient and physician satisfaction H600 automated and decrease our reference testing costs. histology single- We are also in the final steps of our RFP process to evaluate slide stainer. analyzers and full lab automation. Siemens, Abbott, Being one of Beckman, Roche and Ortho Clinical will be presenting their four sites in solutions for our laboratory during the first quarter of FY16. the U.S. and Full lab automation will result in improved test TAT, and Europe, it was improved employee and physician satisfaction. It will also exciting to see The Pathology team. enable the Lab to reduce staffing. this advanced technology. Over a four-week period, we parallel ran 60 We expanded our allergy testing by adding tests to our slides per day and did a comparison study, which led to immulite 2000 XPi analyzer including: Beta-2 Microglobulin, FDA approval of this new technology. Anti-Thyroglobulin, Anti-TPO, Free and Total PSA. In 2016, this instrument will replace our Symphony single-slide histology staining process. It eliminates AmnioStat-FLM-PG Fetal Lung Maturity Test is no longer using Xylene (a known carcinogen), is cheaper to done in-house due to the discontinuation of the kit by the operate, has improved coverslipping and produces manufacturer. We are currently in the process of looking “high-definition” histology slides to improve pathologist for an alternate method. In the interim, all FLM testing is diagnostic accuracy. being sent to Yale-New Haven Hospital’s Laboratory.

Our team performed CAP inspection of Women Fourth Generation HIV testing will be added to our & Infants Hospital of Rhode Island in June and a capabilities during the first quarter of FY16. We continue to self-inspection in preparation for our own CAP inspection offer vitamin D testing and Procalcitonin testing 24 hours in 2016. The Lab continues to participate in the College a day, seven days a week. We also continue to test for HIV 1 of American Pathologists Laboratory Accreditation and 2 with results reported out every 12 hours. program, CAP Performance Improvement Programs The Department remains focused on the cost efficiency in Surgical Pathology, Cytopathology, and, of our reference testing, and we continue to review these new in 2015, Dermatopathology. tests with the intent of bringing more assays in-house as the criteria of order frequency and cost are met.

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Division of Hematology, Coagulation from 8:00 a.m. to 2:00 p.m. Please call the Hematology and Urinalysis department at ext. 7600 to make appointments. Hematology/CBC Analysis Stamford Hospital Coagulation Clinic We acquired and implemented new Sysmex XN The Lab continues to closely support the Coagulation technology for both the Bennett Cancer Center (BCC) Clinic, which is administered by Isabelle Millet, PharmD, as well as the main laboratory. This technology upgrade PhD, and is under the medical directorship of Raymond to the BCC resulted in offering a six-part differential (as Baer, MD. We perform the required correlation testing of opposed to previous 3-part diff), nRBC enumeration Clinic devices as compared to Lab devices, and perform (previously not available) and Immature Granulocyte (IG) genetic testing for warfarin sensitivity. The Clinic accepts enumeration (also previously not available). For the main patients by physician referral only for those who wish to Hospital laboratory, this upgrade results in automatic use it for anticoagulation initiation and/or maintenance of repeat testing when questionable results arise (thus their anticoagulated patients. improving quality of results), decreased turn-around-time, a smaller footprint and reduced reagent consumption (and therefore decreased cost of operation). Having the same Blood Bank platforms at the BCC and main lab allow for a complete The Blood Bank transitioned to the New York Blood Center patient chart in Meditech, which means previous result (NYBC) services this year. The NYBC collects 2,000 blood history from either testing location is integrated into a product units per day and distributes to more than 20 uniform patient record. million people in New York City, Long Island, Hudson Valley, Coagulation NY, New Jersey, Connecticut and Pennsylvania. It has a web-based ordering system to expedite blood deliveries. The Lab eliminated Nanosphere molecular testing and The NYBC reference laboratories, under the direction Factor II and Factor V genetic testing is live on the Cepheid of Connie Westhoff, utilize state-of- the-art methods in GeneXpert analyzer. We also implemented new fibrinogen serological investigation and DNA blood group analysis reagents from Instrumentation Laboratory. This greatly to resolve complex cases, determine clinical significance reduces the effect of Direct Thrombin Inhibitors, which and provide consultation for the selection of proper blood falsely decrease the fibrinogen value. Our new fibrinogen for transfusion. The NYBC also performs RHD Genotyping normal range is now assigned to all fibrinogen values. testing for cases where routine laboratory testing for RHD We acquired new Thromoboelastograph (TEG) analyzers results in discordant or weaker than expected results for to meet the needs of Cardiac Surgery to appropriately pregnant women, or potential transfusion recipients. This identify need for blood products. After an initial roll-out allows for fewer unnecessary injections of Rh immune with Cardiac Surgery, TEG analysis will be extended for globulin and increased availability of Rh-negative red trauma and general surgical use. blood cells.

Urinalysis The Blood Bank continues to provide activated factor VII (Novo 7) and prothrombin complex (Kcentra) for treatment We acquired and implemented a new Arkray AU4050, of patients with life-threatening bleeding. Both of these which automates both dipstick and sediment analysis. products require consultation and dose calculation by Analyzer flags for pathogenic components including Blood Bank Director Dr. Raymond Baer. yeast, casts, crystals and flags for manual microscopic review for confirmation. The Blood Bank maintains sufficient blood products for the cardiac and trauma services, and has protocols to provide Fertility blood products quickly. The Blood Bank Director also Semen Analysis, Post-Vasectomy Semen Analysis and serves as consultant for difficult patient coagulation issues. Sperm Wash procedures have been transitioned from the Chemistry section to the Hematology section, as these The Transfusion Administration Record (TAR) computer technologists have better competency to accurately module was implemented by the Nursing Department perform such analyses. These tests will continue to be and Blood Bank. This allows for transfusion documentation offered by appointment only, Monday through Friday, to be directly entered in the computer, which increases transfusion safety.

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We continue to review and update policies with the Working with our Infectious Diseases physicians, we Nursing Department. Blood transfusion audits are continue to perform 100% daily clinical follow-up on all reviewed and documented at the Transfusion Committee positive blood cultures. We generate drug:bug mismatch and recorded by Nursing for National Patient Safety Goals. alerts that allow for the early detection of inappropriate drug selection, and we monitor BC growth 24/7 to enable In order to reduce data and clinical entry errors, the early notification of positive results to the clinicians. We Blood Bank is in the process of interfacing the automated also monitor monthly endotoxin and bacteria levels in analyzer (Tango) with the Meditech computer. Hospital water and dialysis effluent, and review instrument Due to the collaborative efforts of the Blood Bank, sterilizer performance on an ongoing basis hospital-wide. Transfusion Committee and clinical departments, In 2015, we implemented the Bruker Maldi-Tof to improve Stamford Hospital continues to have one of the lowest our capability for microorganism identification. This mass crossmatch-to-transfusion ratios in the state. The Blood spectrometry instrumentation enables us to perform Bank continues to monitor transfusion practices, resulting same-day identification of most organisms, drastically in decreased utilization of blood and blood products reducing our TAT. throughout the Hospital. The Lab also implemented Allere-i isothermic PCR for rapid Division of Microbiology molecular detection of influenza. This new platform is more accurate, faster and less expensive than GeneExpert. Our PCR platform (Cepheid) continues to grow. We now do We were the first hospital in Connecticut to employ this PCR for Enterovirus in CSF, Nasal MRSA, Nasal MRSA/ MSSA, new technology. C. difficile (including the virulent NAP1 strain), Influenza A, B and H1N1 and our newest addition, Mycobacteria Division of Point-of-Care Testing tuberculosis complex and gene mutations associated with Rifampin resistance. This assay will enable us to determine The Point-of-Care section upgraded fingerstick glucose whether a sample that is acid fast smear positive is M. devices in 2014. In May 2014, 56 new glucose meters were tuberculosis or not, thus expediting patient care. All of these introduced to 31 sites across the organization and over 700 assays provide real-time testing, improving TAT of results so users were trained on this new equipment. The move was that our patients can be treated as quickly as possible. necessitated by an FDA edict to eliminate the prior device’s maltose interference issue. The manufacturer redesigned The Lab uses the Hologic Panther system for amplified the meters to allow for improved cleaning procedures as RNA detection for chlamydia and gonorrhea testing, and well. The new meters have been well-received by staff and HPV. The E6 and E7 genes of high-risk HPV genotypes the transition has been relatively seamless. are known oncogenes. Fourteen HPV genotypes are considered pathogenic or high-risk for cervical disease. The Stamford Hospital Public Wellness division added Multiple studies have linked genotypes 16, 18, 31, 33, 35, two additional Cholestech devices to its roster to support 39, 45, 51, 52, 56, 58, 59, 66 and 68 to disease progression. larger community health screenings. This device provides Women with a persistent infection with one of these types rapid lipid profiles and results can be shared with patients have an increased risk for developing severe dysplasia or quickly. A registered nurse is thereby able to use the cervical carcinoma. results from these screenings to suggest diet and lifestyle changes, as well as to provide referrals for follow-up care. We have expanded our capability to identify respiratory pathogens with the introduction of the BioFire Microarray, Anatomic Pathology Laboratory an automated in-vitro diagnostic system that utilizes nested multiplex PCR and high-resolution melting analysis Molecular Pathology Testing at Stamford Hospital to detect and identify multiple nucleic acid targets from clinical specimens. The assay is capable of identifying 20 GYN of the most common viruses and bacteria associated We utilize the Hologic Panther for HPV testing. This with infectious respiratory diseases. BioFire testing is now automated PCR DNA-detection method identifies 14 available 24/7/365 with an approval/order by Infectious high-risk HPV types and specifically identifies the most Disease physicians. TAT for this assay is one hour. oncogenic types, HPV 16 and HPV 18.

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Coagulation panels for myelodysplastic syndrome have been expanded The Lab utilizes the Cepheid GeneXpert platform to detect to better capture the growing number of abnormalities Factor II and Factor V abnormalities. that were recently incorporated into the revised IPSS scoring system. FISH panels for acute myeloid leukemia Bladder Cancer have also been expanded to reflect the growing number For the detection of bladder cancer (urothelial neoplasia), of distinct subtypes recognized in the latest World Health Fluorescent In Situ Hybridization interpretation of the Organization classification schema. FISH panels for UroVysion test is performed by Bo Xu, MD, PhD. We have multiple myeloma can now be performed by enriching successfully implemented reflex UroVysion testing on plasma cells, thereby improving the sensitivity of this assay those urine cytology specimens where determination of to identify prognostically significant abnormalities in the urothelial neoplasia is difficult and where the additional neoplastic plasma cells. molecular testing can better identify a neoplastic process. In response to National Comprehensive Cancer Network Thyroid, Colon & Lung Cancer (NCCN) guidelines recommending that molecular BCR-ABL testing be reported on the International Scale Dr. Xu also evaluates EGFR, KRAS, BRAF, ROS, ALK and PDL1 (IS), we can provide qualitative BCR-ABL testing on the IS, mutations in lung, colon and thyroid cancers. We continue making long-term follow-up more consistent and bringing to evaluate colon cancers for mismatch repair proteins us in line with the recent NCCN guideline changes. (MMRP) using IHC with reflex positives to full-sequence analysis (microsatellite instability evaluation) in order to The Lab also provides next-generation sequencing to identify patients with Lynch syndrome (hereditary identify a variety of common molecular alterations in non-polyposis cancer). We also continue to augment hematologic malignancies. This technique holds the thyroid FNA cytology evaluation with molecular pathology promise of bringing “personalized medicine” to our patients testing. We promote a collaborative process to our by enabling oncologists to better understand the exact referring endocrinologists and radiologists whereby biologic underpinnings of a given patient’s malignancy. indeterminate/suspicious category thyroid FNA biopsy specimens are evaluated with molecular testing for various We continue to provide the professional interpretation for KRAS, NRAS and BRAF mutations. This process allows for many of these tests, which allows us to better integrate judicious and cost-effective molecular testing. all of the available data and generate a single, cohesive, comprehensive final diagnostic report for our clinicians. We With cooperation from our Colorectal Surgeons and feel that this approach not only improves patient care and Medical Oncologists, we established that all Stage II and III but is also of significant value to our clinical colleagues. colorectal cancer tumors will be evaluated for Recurrence Score using Oncotype Colon RX assay. This independent Melanoma variable, when combined with T stage and MMRP We continue to offer BRAF testing for metastatic melanoma. status, allows for optimal patient selection for adjuvant BRAF mutation positive melanoma patients derive chemotherapy and benefit of Oxyplatin (at Stage III CRC). significant benefit from this new medication.

Leukemia/Lymphoma Melanoma FISH testing is also available through In conjunction with Neogenomics Laboratories, we Neogenomics Laboratories for those lesions that fall under continue to offer our clinicians an array of ancillary the provisional category of “MELTUMP” (melanocytic testing, the equivalent of which would be offered at any tumor of unknown malignant potential) or borderline large academic institution or specialty cancer hospital. lesions such as is the case with Atypical Spitz tumors. All hematopathology cases are evaluated by either Dr. Elgida Volpicelli coordinates the ordering of this test Dr. Raymond Baer or Dr. Tal Oren, both board-certified and correlates results with the morphology of these Hematopathologists. In close collaboration with the difficult melanocytic lesions in order to predict behavior. treating Hematologists and/or Oncologists, Drs. Baer and Oren select the most appropriate battery of ancillary tests Division of Cytology to supplement conventional morphologic evaluation. We continue our “push-cart service” with microscope and Ongoing advances in molecular diagnostics enabled us staining equipment placed on a mobile cart. We provide to bring these advancements to Stamford Hospital. FISH on-site immediate assessment for deep-organ CT-guided

72 | DEPARTMENT OF PATHOLOGY DEPARTMENT OF PATHOLOGY: ANNUAL REPORT 2015 biopsies, ultrasound-guided transbronchial biopsies of The turnaround time for Surgical Pathology reports for 2015 the lungs and mediastinum performed in the Operating remains at an average of 24 to 48 hours for 95% of reports. Room and endoscopic ultrasound-guided fine needle aspirations (FNA) of the pancreas/stomach/duodenum MEDICAL STAFF 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. Raymond A. Baer, MD, FCAP We now have five years of experience with the Celient Director of Clinical Pathology and cell block technology for creation of cell blocks from Transfusion Services 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 Tal Oren, MD, PhD, FCAP assessment are performed at Stamford Hospital. Our skilled Director of Hematopathology 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. Augusto H. Podesta, MD, FCAP 2015 was our first year of completely insourced gynecologic Director of Surgical Pathology 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. 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 Elgida Volpicelli, MD, FCAP with increasing dermatology/melanoma, breast and Director of Dermatopathology thoracic pathology volumes.

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 CLINICAL ANNUAL REPORT | 73 DEPARTMENT OF PATHOLOGY: ANNUAL REPORT 2015

Barbara Hazay Beam, MHS, PA (ASCP)

Grace Valenzano, MHS, PA (ASCP)

Ramon Grant, MHS, PA (ASCP) Bo Xu, MD, PhD, FCAP Director of Cytopathology and Paula Sweeney, MT (ASCP), MHA Molecular Pathology Laboratory Administrative Director

Clinical Activity (FY2015)

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Departmental Physician Activities • Continuing Medical Education Committee — Dr. Bo Xu • Department members continue to actively participate in • GI Tumor Steering Committee — Dr. Robert Babkowski institutional tumor boards and conferences as follows: • Graduate Medical Education Committee — Dr. Bo Xu »» Weekly Breast Tumor Board — Dr. Robert Babkowski, Dr. Elgida Volpicelli • Infectious Disease Committee — Dr. Raymond Baer

»» Weekly Radiology-Pathology Breast Biopsy • Institutional Review Board — Dr. Bo Xu Correlation Conference — Dr. Robert Babkowski, Dr. Elgida Volpicelli • Lung Cancer Steering Committee — Dr. Robert Babkowski »» Monthly GYN Oncology Tumor Board — Dr. Bo Xu • Medical Executive Committee — Dr. Robert Babkowski. »» Monthly Genito-Urinary Tumor Board — Dr. Bo Xu • Medical Executive Committee — Dr. Robert Babkowski »» Bi-Weekly Chest Tumor Board — Dr. Augusto Podesta • Patient Safety & Quality Committee — »» Monthly General Tumor Board — Dr. Augusto Podesta, Dr. Robert Babkowski Dr. Tal Oren Laboratory Outreach »» Monthly Hematology Tumor Board — Dr. Tal Oren The Lab expanded our in-office phlebotomy service to »» Monthly GI Tumor Conference — Dr. Augusto Podesta Glenville Medical Group in Greenwich. We also established »» Quarterly Neuro-Oncology Conference — relationships with several Urgent Care Centers, including Dr. Robert Babkowski those on: Frost Road in Waterbury, Chase Street in Waterbury and East Main Street in Stratford. »» Quarterly Dermatology-Oncology Conference — Dr. Elgida Volpicelli Additionally we completed interfaces to Practice Fusion (Dr. Mayzlor); Athena (Pulmonary Associates, Gastroenterology »» Bi-Weekly Complex Surgical Case Conference — Associates and Stamford Gastroenterology); Healthtronics Dr. Robert Babkowski (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 CLINICAL ANNUAL REPORT | 75 innovation in 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.

76 | DEPARTMENT OF PEDIATRICS DEPARTMENT OF PEDIATRICS: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: The Department continues to operate the Medical Home Initiative of Southwest Connecticut, a program that has The Year in Review 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. Gerald B. Rakos, MD, FAAP With construction of the new hospital nearing completion, Chair, Department of Pediatrics next year promises to be both busy and exciting as we Director, Division of Neonatology 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 he Department of Pediatrics at Stamford Hospital is on the threshold of a new era thanks to the Cardiology Tlandmark gift of $20 million from the Steven & Alexandra Cohen Foundation establishing the Cohen Pediatric Cardiology at Stamford Hospital has been a Children’s Institute. This past year, much time was spent well-utilized area of subspecialty care over the past year, planning for the opening of the area’s first true Pediatric providing both inpatient and outpatient evaluations and Emergency Department. This coming year will be focused treatment to referring physicians and the community. on operationalizing the ED while finishing the design and There are three full-time pediatric cardiologists on staff. development phase for the new in-patient Pediatric unit. Drs. Allison Levey, Michael Monaco and Michael Snyder all hold academic appointments at Columbia University with These two new areas when combined with the existing admitting privileges at Morgan Stanley Children’s Hospital Goldstein Neonatal Intensive Care Unit and the Cohen of New York, enabling the local delivery of academic-based Children’s Specialty Center, will allow the Cohen Children’s subspecialty care. Institute to establish itself as the destination of choice in lower Fairfield County for patient-centered, compassionate Hospital-based cardiology imaging and testing has children’s care of the highest caliber. continued to be active. Figure 1 details the pediatric and neonatal echocardiograms, non-invasive studies and PediNEWS, the Department’s newsletter, completed pediatric stress tests performed over the course of the year. its first year of publication to very positive reviews. Its Both ECGs and echocardiograms are now available for objective is to provide area pediatricians and family rapid review on line, facilitating timely reporting. medicine practitioners, including those in our secondary and extended markets, a comprehensive picture of the Figure 1: Diagnostic Pediatric Cardiology Volume Department’s various programs and offerings. Further 2014 2015 Change efforts to enhance communication and dissemination of information include a new Pediatrics intranet page Echocardiograms 259 254 -2% and phone optimization via a new dedicated phone line Electrocardiograms 514 418 -18.7% (203.276.PEDI) that is answered every business day. 24 Hour ECGs 44 43 -2.3% Kids’ FANS (Fitness and Nutrition Services) programs have Pediatric Stress Tests 30 24 -20% grown nicely under the direction of Ilaria St. Florian, MS, RD, Fetal Echocardiograms 195 213 +8.5% 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.

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Fetal imaging continues to be an important component General Pediatrics of our service. Working in close collaboration with the Division of Maternal-Fetal Medicine and community The staff is fully engaged in the planning of the new obstetrical practices, we have doubled our scheduled Cohen Children’s Unit while they continue to care for sick hours, and performed a significantly increased number children in our existing unit. This past year saw a slight of fetal consultations and echocardiographic studies over decrease in the number of admissions to the Pediatric the past year. All fetal studies are now integrated with the Unit (Figure 4). hospital EMR. Finalized reports are available for review by Figure 4: Inpatient Pediatrics — Discharges OB staff and referring physicians shortly after the studies have been completed. All three physicians are part of the 2014 2015 Change Cohen Children’s Specialty Center. Inpatient 398 377 -5.3% Cohen Children’s Specialty Center Observation 53 57 +7.5 % Total 451 434 -3.8% 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. Medical Home Initiative In total, there are 29 providers in 18 specialties with more Dr. Madhu Mathur of the Department of Pediatrics directs growth anticipated in the coming year. Figure 2 showcases the Connecticut Medical Home Initiative for Children and the year-over-year growth in volume since 2009. Youth with Special Health Care Needs – Southwest. The Figure 2: Cohen Children’s Specialty Center Volume 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 Patients Served With High 455 466 + 2.4% has continued to support the pediatric inpatient service, Complexity Needs 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 Neonatology Glassman and Sarah Lusman remain part of the Cohen Consistent with our high tech-high touch philosophy, Children’s Specialty Center. another initiative that began this year under the leadership of Dr. Jennifer Bragg was our infant massage program. We anticipate that the Division of Pediatric Gastroenterology The NICU received a grant from the March of Dimes to will experience continued growth as we provide care to the implement this program for all infants born preterm children throughout southwestern Connecticut (Figure 3). (<37 weeks gestation) at Stamford Hospital. Figure 3. Tully Health Center Infant massage has been shown to have many benefits Cohen Children’s Specialty Center 2014 2015 Change in preterm infants, including reduced stress behaviors, Gastroenterology Patient Visits 742 681 -7.3% improved growth and earlier discharge home. Our intent in starting this program was to not only improve the neurodevelopmental outcomes of our NICU graduates,

78 | DEPARTMENT OF PEDIATRICS DEPARTMENT OF PEDIATRICS: ANNUAL REPORT 2015 but also further empower our families to play an integral Figure 8: The Pediatric Pulmonary Function Laboratory at role in the care of their child. This grant enabled one the Tully Health Center neonatologist and two NICU nurses to undergo a four-day certification training this past spring. The program was 2014 2015 Change implemented over the summer and is growing rapidly. Spirometry 58 240 +414% The NICU Infant Clinical Evaluation (NICE) Program, also Plethysmography 355 353 - 0.6 % directed by Dr. Jennifer Bragg, has been growing in leaps Diffusion Capacity 6 12 + 200% and bounds. This past year Kimberly Neely, RN, a highly experienced NICU nurse, joined Dr. Bragg in evaluating Bronchodilator Evaluations 155 175 +12.9% babies at the Cohen Children’s Specialty Center. In addition Pulmonary Exercise Testing 39 68 +74% to Stamford Hospital NICU graduates, the program saw Sweat Tests 62 68 +9.7% 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 Neurology are being developed to distribute to families that provide anticipatory guidance about expected developmental Drs. Murray Engel and Robert Fryer along with Margot milestones, possible hurdles to expect and additional Laedlein, APRN, and the non-clinical staff at Fairfield resources they can use. As the infant massage program County Pediatric Neurology, have continued our mission grows, we hope to incorporate it into the NICE Program. to be the regional center for Pediatric Neurology care. Our referral base remains quite broad, drawing from Both the newborn service and NICU saw growth over the Westchester and from both lower and upper Fairfield past year as shown in Figures 6 and 7. County. While currently located at the Cohen Children’s Specialty Center in shared space, planning is underway Figure 6: Stamford Hospital Newborn Service for dedicated space, which will allow further expansion of the practice. Planning has also begun to add another Child 2014 2015 Change Neurologist to the group over the next year. Drs. Engel and Births 2,348 2,426 +3.2% Fryer continue their involvement at Concussion Center at Chelsea Piers Connecticut.

Figure 7: Neonatal Intensive Care Unit The Division maintains a strong academic affiliation with NewYork-Presbyterian at both the Cornell and Columbia 2014 2015 Change campuses. Our EEG volume is shown in Figure 9. Admissions 277 308 +11.2% Figure 9: Pediatric Neurology EEG Volume

Pulmonology 2014 2015 Change Pediatric Pulmonology at Stamford Hospital continues EEGs 187 174 -7% to provide inpatient and outpatient consultations, RSV Long-term EEGs 57 70 +22.8% 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.

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MEDICAL STAFF

Letitia Borras, MD Michael Snyder, MD Co-Director, Director, Division of Cardiology Hospitalist Medicine

Murray Engel, MD Shahrzad Mohammadi, MD Director, Division of Co-Director, Child Neurology Hospitalist Medicine

Mark Glassman, MD Madhu Mathur, MD, MPH Director, Division of Director, Medical Gastroenterology Home Initiative

Hossein Sadeghi, MD Director, Division of Pulmonology

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New Staff • Alan Morelli, MD — New York Metro Area and Fairfield County The Department of Pediatrics welcomed the following • Gerald B. Rakos, MD — New York Metro Area and members this year: Fairfield County • Lauren Bader, MD (General Pediatrics) • Henry Rascoff, MD — New York Metro Area and • Jennifer Gruen, MD (General Pediatrics) Fairfield County • Jeanine Freliech, MD (General Pediatrics) • Hossein Sadeghi, MD — New York Metro Area and • Joseph Hufnagel, MD (General Pediatrics) Fairfield County • Christine Macken, MD (General Pediatrics) • Michael Snyder, MD — New York Metro Area and Fairfield County • Nicholas Matarazzo, MD (General Pediatrics) • Sanford Swidler, MD — Connecticut • Marc Mishkin, MD (General Pediatrics) • George Tsimoyanis, MD — New York Metro Area and • Michael Schessel, MD (General Pediatrics) Fairfield County • Lawrence Zemel, MD (Rheumatology) Sarah Lusman, MD, was appointed Director of the Transitions Fellowship Training Program in Pediatric Gastroenterology, Hepatology and Nutrition at Columbia. The following members resigned this year: • Hariram Ganesh, MD (General Pediatrics) Susan Lasky, DO, joined the Ridgefield Public Schools Wellness Committee. • Amy Lief, MD (General Pediatrics) Jeanne Marconi, MD, received the “Lifetime Achievement Honors and Recognition Award” by the Fairfield County Medical Society and a commendation award from Senator Richard Blumenthal. Top Doctor Awards She was also appointed by the American Academy • Karen Beckman, MD — New York Metro Area and of Pediatrics to their Executive Advisory Board for the Fairfield County Committee on Coding and Nomenclature and named a • Ora Burstein, MD — New York Metro Area and review editor for the Coding Newsletter. Fairfield County Grants • Murray Engel, MD — New York Metro Area and Fairfield County • Madhu Mathur, MD, and Gerald B. Rakos, MD, received • Robert Fryer, MD — New York Metro Area and a three-year grant from the Connecticut Department Fairfield County of Public Health for the Connecticut Medical Home Initiative for Children and Youth with Special Health Care • Mark Glassman, MD — New York Metro Area and Needs — Southwest in the amount of $808,000. The Fairfield County program is in year two of three years. • Jennifer Henkind, MD — Connecticut • Sarah Lusman, MD, received a grant from the Cystic • Timothy Kenefick, MD — Connecticut Fibrosis Foundation entitled Developing Innovative • Rosemary Klenk , MD — New York Metro Area and GastroEnterology Specialty Training (DIGEST) in the Fairfield County amount of $30,000. The program is in year two of • Arnold Korval, MD — New York Metro Area, Connecticut, three years. and Fairfield County • Jennifer Bragg, MD, received a grant from the March of • Susan Lasky, DO — Connecticut Dimes for a study entitled “The impact of infant massage • Allison Levey, MD — New York Metro Area and in the Neonatal Intensive Care Unit” in the amount Fairfield County of $5,000.

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DEPARTMENTAL SAFETY AND QUALITY infants are included in this database. Outcomes analysis is by the calendar year and the most recently available data The NICU’s Breast Milk Screening Program is an enhanced is from 2014, which still reflects data only from very low safety initiative with state-of-the-art technology birth weight infants (<1500 grams). Our goal is to be in the (barcoding) to continually ensure proper disposition of top 25th percentile for 10 major outcomes. Our results are patient breast milk. shown in Figure 10. Stamford Hospital’s NICU has remained a member of Patient Satisfaction the Vermont Oxford Neonatal Network since 1997. This year we joined the expanded database, which includes Patient satisfaction for the NICU continues to be high all admissions to the NICU, not just those whose birth and is shown in Figure 11. Figure 12 outlines the weights are <1,500 grams. This allows us the opportunity Hospital performance for the Maternal Child Health. to benchmark our outcomes of all infants admitted to the NICU with almost 1,000 NICUs worldwide. Over 175,000 Figure 11: NICU Press Ganey Satisfaction FY15

Overall DB AHA Region Figure 10: Stamford Hospital NICU Outcomes in Raw Score Percentile 2 Percentile Top 25th Percentile NICU Overall 91.0 79 81

2012 2013 2014 NICU Nurses 94.4 93 99 Pneumothorax Yes Yes Yes NICU Physicians 93.1 97 99 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

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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 LF & JC 0/27 0/35 0/28 0/22* 1/20 0/20 0/21 0/15 0/9 1/21 1/27 0/17 1% <39 wks* 5% 0% 0% 0% 0% 5% 0% 0% 0% 0% 4.8% 3.7% 0%

26/77 28/75 23/47 32/67 16/60 18/70 22/57 26/67 24/65 23/61 28/85 31/74 JC-PC 2- NSTV Ntl 26.3% 34% 37% 49% 48% 26% 26% 39% 38% 37% 37% 33% 41% 37%

JC-PC 3- 1/1 5/5 2/2 6/6 3/3 4/4 10/10 3/3 6/6 7/7 2/2 1/1 Ante. Steroids Ntl 81.8% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 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. 14/33 17/38 13/41 10/32 15/31 9/36 13/34 13/34 9/37 11/32 19/40 14/38 BF Ntl 50.8% 41.2% 44.7% 31.7% 31.2% 48% 25% 38.2% 38.2% 24.3% 34% 47.5% 36.8% 37% Skin to Skin Within 30 NSI 90% 19/20 19/20 18/20 16/20 18/20 19/20 18/20 16/20 18/20 20/20 20/20 17/20 91% Minutes of Del. 95% 95% 90% 80% 90% 95% 90% 80% 90% 100% 100% 85%

BF - Attempt/ 15/20 15/20 12/20 11/20 16/20 16/20 15/20 13/20 16/20 14/20 13/20 11/20 Latch 1 Hour NSI 80% 75% 75% 60% 55% 80% 80% 75% 65% 80% 70% 65% 55% 70% NB Bilirubin 48/48 48/48 48/48 48/48 47/48 48/48 48/48 47/48 48/48 48/48 48/48 48/48 Screening LF 80% 100% 100% 100% 100% 98% 100% 100% 98% 100% 100% 100% 100% 99.9% Pedi PIV Infiltrates NDNQI 1 1 0 1 1 1 1 1 1 1 0 0 9

NICU CLABSI NDNQI Q 0 0 0 0 0%

<37 wk adm temp on PI 75% 4/8 9/10 15/15 16/18 13/14 12/14 13/15 7/11 13/18 12/15 9/10 11/13 82% NICU adm 50% 90% 100% 89% 93% 86% 87% 63% 72% 80% 90% 85% <1500 gm temp on VON 1/1 2/2 2/2 1/1 2/2 2/2 3/3 No 3/3 1/2 2/2 1/1 NICU adm 25%tile 100% 100% 100% 100% 100% 100% 100% Cases 100% 50% 100% 100% 95% > 96F (36C)

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DEPARTMENTAL EDUCATION DEPARTMENTAL RESEARCH AND AND TEACHING SCHOLARLY ACTIVITIES The Department continues to offer weekly continuing Papers medical education conferences, which are regularly attended by many pediatricians, Family Medicine Jennifer Bragg, MD physicians and residents, nurse practitioners and school Stroustrup A, Haimes H, Bragg JB, Gui Y, Andra SS, Kannan nurses. In addition to our staff, speakers come from K, Gennings C. NICU-based phthalate exposure and academic medical centers such as Columbia University neurodevelopment. Platform presentation at the 2015 College of Physicians and Surgeons, the Albert Einstein International Society for Exposure Science meeting, Las College of Medicine, Icahn School of Medicine at Vegas, NV. Mount Sinai, Connecticut Children’s Medical Center and Blythedale Children’s Hospital, with a few additional Stroustrup A, Haimes H, Bragg JB, Andra SS, Kannan experts coming from community and state agencies. This K, Gennings C. NICU-Based Phthalate Exposure and year, we are hoping to begin offering our Grand Rounds Neurodevelopmental Outcomes. Poster presentation at the lectures via a webinar format for physicians who cannot 2015 Pediatric Academic Societies meeting, San Diego, CA. get to the Hospital. Stroustrup A, Hsu HH, Bragg JB, Svensson K, Guo Y, Family Medicine residents continue to rotate through Kannan K, Wright RO. Environmental chemical exposure in Pediatrics. Columbia University College of Physicians and the neonatal intensive care unit. Poster presentation at the Surgeons medical students as well as Stamford Hospital 2014 International Society of Environmental Epidemiology OB/GYN residents rotate through the NICU. Formal annual meeting, Seattle, WA. educational and multidisciplinary rounds are held daily on the Pediatric Inpatient Unit. Teaching is also provided Sara Shrager Lusman, MD co-authored an by Dr. Hossein Sadeghi to the Pediatric Pulmonary fellows Entrustable Professional Activity Curriculum for fellows at Children’s Hospital of NewYork-Presbyterian, Family in pediatric gastroenterology. Medicine residents and genetic counselors and Dietary Department students who participate in our Cystic Fibrosis Book Chapters program. All Pediatrics division directors hold teaching Sara Shrager Lusman, MD appointments at major academic medical centers. 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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COMMUNITY OUTREACH STRATEGY/FUTURE DIRECTION The Department was represented at many events and This coming year promises to be memorable with health fairs including: the opening of the new Cohen Pediatric Emergency Department. We will also look to: • The Fairfield County Women’s Expo • Complete the design of the Cohen Children’s Unit with • Health, Wellness & Sports Expo at Chelsea Piers construction beginning in late 2016 or early 2017.

• Community Health Fairs • In collaboration with the Department of Emergency • Fairfield County Sports Commission Medicine, recruit a Director of Pediatric Emergency Medicine in preparation for the opening of the new • Stamford Restaurant Week Pediatric Emergency Department.

• March of Dimes March for Babies • Further recruit specialists for the Cohen Children’s Specialty Center, particularly in Pediatric Surgery. • Early Childhood Fair School Readiness Council • Further develop a simulation testing program for all • Fall Harvest at Fairgate Farms Hospital-based physicians and nurses.

• Stamford Childhood Obesity Prevention Task Force • Collaborate with the Stamford Health Department • Cystic Fibrosis Foundation’s Great Strides Walk in the Connecticut Hospital Association’s Statewide Asthma Initiative. • Stamford Public School Teacher Orientation • 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.

2015 CLINICAL ANNUAL REPORT | 85 innovation in p s yc h i at ry

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

86 | DEPARTMENT OF PSYCHIATRY DEPARTMENT OF PSYCHIATRY: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: • Maintained the program that began in July 2004 to provide evening and weekend psychiatric house The Year in Review 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 Draupathi Nambudiri, MD, FAPA Health Care and Dubois Center in Stamford to provide continuity of high-quality psychiatric care to patients. Chair, Department of Psychiatry 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 n the past year, the Department of Psychiatry has in inpatient volume in the Psychiatry Unit compared to accomplished a great deal in its role as the major the previous year and 13% increase compared to FY13 Iprovider of patient-centered mental health assessment (5,072 days in FY15 compared to 4,728 in FY14 and 4,463 in and treatment services for patients with acute and serious FY13). The average length of stay increased from 6.4 days psychiatric disorders in the greater Stamford community. in FY13 to 8 days in FY14 and 9 days in FY15, reflecting the Specifically, we: increased patient acuity and limited community residential resources for patients. • Maintained a high quality inpatient and consultation/ liaison service to meet the ever-increasing psychiatric Data on Department volume is presented in Figures 1 and care needs of our patients. 2 below.

• Met all requirements to maintain substantial grant Figure 1: Psychiatric Inpatient Service (South-1) FY15 funding through the Department of Mental Health and Addiction Services in the amount of $289,000 per year.

• 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.

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There was an 11% decrease in the Medical/Surgical and Upon discharge, patients receive a carefully constructed substance abuse consultations last year: 2,710 consults in discharge plan and arrangements for aftercare. We invite FY15 compared with 3,056 consults in FY14. This probably involvement of a patient’s family or significant other (with is related to staff vacancies in the Department. patient permission) during this process. Figure 2: Consultation/Liaison Services Volume Consultation Liaison/Medical, Surgical and Substance Change Emergency Department Consultation Services ED Floor Abuse Total # of from Last Consults Consults Consults Consults Year There is an ever-increasing demand for psychiatric evaluation services in the Emergency Department. FY12 1,486 1,188 93 2,767 +10% Disorders such as delirium, behavioral difficulties associated with dementia, acute anxiety, panic, psychotic FY13 1,541 1,984 126 3,651 +32% disorders, depressive states, alcohol and substance use disorders are but a few of the common difficulties which FY14 1,501 1,533 22 3,056 -16% the Department is called upon to address with the medical/surgical inpatient population. The Psychiatry FY15 1,554 1,156 — 2,710 -11% Consultation/Liaison service plays a vital role in the care of these patients. SCOPE OF CLINICAL SERVICES 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 F. Carl Mueller, MD, FAPA and serious psychiatric disorders in the greater Stamford community. The community has come to trust and rely Associate Chair 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 New Staff in the mental health care of those who reside in lower • Michael Adusei, MD Fairfield County. We maintain a high caliber of service on this unit while exploring how best to serve specialty • Dmitry Meyerovich, MD populations in the area. Transitions The Department’s approach to mental health is • Simon Ovanessian, MD left the medical staff in multidisciplinary, and our care team is sensitive and March 2015 compassionate to patients and their families. In addition to psychiatrists, psychiatry nurse practitioners and psychiatry • Hale Perlmutter, PAC left the Ancillary staff in physician assistants, nurses, and technicians, patients August 2015 may also work with social workers, a substance abuse • Sarah Bernier, APRN left the Ancillary staff in counselor, a case manager, an activity therapist and other September 2015 support staff. • Farid Force, MD became Honorary Staff in Treatment is highly individualized to the unique needs of September 2015 each patient. We offer dual-diagnosis behavioral health treatment services, group and individual behavioral Hospital Committee Participation therapy, medical psychiatry and psychopharmacological • Enenge A’Bodjedi, MD — Department Executive interventions. Pet therapy, music therapy, spirituality and Committee, Outpatient Behavioral Health CQI relaxation groups are also available. Committee, Department Medical Peer Review Committee (Chair) 88 | DEPARTMENT OF PSYCHIATRY DEPARTMENT OF PSYCHIATRY: ANNUAL REPORT 2015

• F. Carl Mueller, MD — Department Executive Committee, Seven-Day Readmission Rate Medical Executive Committee Our seven day readmission rate remained steady at 4% in • Draupathi Nambudiri, MD — Medical Executive FY15 and FY14, a decrease from 5% in FY13. Committee, Graduate Medical Education Committee, Department Executive Committee (Chair), Continuing Average Length of Stay (ALOS) Medical Education Committee, Inpatient Psychiatry Our inpatient unit staff has worked hard to reduce the CQI Committee, Hospital Falls Committee, Alcoholism average length of stay from 10.07 days in FY10 to 8 days in Steering Committee, Patient Safety and Quality FY14 (Figure 3). In FY15 the ALOS increased to 9 days. This Committee, member Core Measures work group, increase in ALOS is due to increased patient acuity and Dementia Work Group limited community residential resources for patients. • Rachit Patel, MD — Inpatient Psychiatry CQI Committee, Department Medical Peer Review Committee, Pharmacy Figure 3: Average Length of Stay (ALOS) and Therapeutic Committee • 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 AWARDS AND ACCOLADES for tobacco use and 95% compliant with ordering nicotine replacement therapy. Only about 75% of our patients • Justin Schechter, MD was reappointed by Governor currently accept the treatment. Dannel Malloy and the Connecticut State Legislature, to serve another three years on the Psychiatric Security Patient Satisfaction Review Board (PSRB). This board monitors the treatment, Patient satisfaction on the inpatient Psychiatric Unit safety and security of those individuals found not is tracked by using a patient survey that is given to all guilty by reason of insanity. This is Dr. Schechter’s third patients who are discharged from the unit. The score consecutive term on the board. range is from 1–5, with 1 being the lowest and 5 the • Sejal Vyas, PhD received 2015 Best of Stamford Award in highest. For FY15, the score was 4.36, which was higher the Doctors category. than past years (4.32). • Christina Kunec, PsyD was appointed Director of Thirty-Day Readmission Rate Stamford Hospital’s Concussion Center in March 2015. Our thirty-day readmission rates decreased from 14% in • Justin Schechter, MD served as a Consultant for the FY13 to 8% in FY14. The rate for FY15 was 10%. Veterans Administration Compensation and Pension Division.

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DEPARTMENTAL EDUCATION AND In addition: TEACHING ACTIVITIES • Simon Ovanessian, MD served as teaching faculty for the Osler Institute Psychiatry and Neurology Board The Department’s academic activities continue to enhance preparation courses, and the Blue Tower Child Psychiatry the quality of care rendered to patients, as well as the Course, lecturing on topics such as addiction, substance educational experience provided to physician assistant abuse and psychiatric disorders. students from Quinnipiac College and nursing students from local universities. Academic experiences with these • Gopal Upadhya, MD received a Clinical Adjunct Assistant students keep the Department vibrant and provide the Professor degree at Quinnipiac University for his active opportunity to teach and continue to learn. participation in PA student education. • Justin Schechter, MD was reappointed as Assistant Department members were involved in Grand Rounds Clinical Professor of Psychiatry at Yale University School presentations here at Stamford Hospital. of Medicine. This year’s Grand Rounds presentations included: DEPARTMENTAL RESEARCH AND TOPIC LECTURER SCHOLARLY ACTIVITIES HIPAA & Stamford Stacey Spilka Hospital Engagement HIPAA Privacy Analyst & Team Leader Presentations for Release of Information Specialists Improved Treatment Acceptance and Adherence Transcranial Magnetic Joseph Deltito, MD Following the Diagnosis of Multiple Malformations Stimulation Clinical Professor at NY Medical College of Cortical Development in a Patient with Psychosis: & Senior Research Consultant at the Giafranco De Lisio Research Institute Rachit Patel, MD, Kathleen Stuart, MSN, APRN, (Pisa, Italy) Draupathi Nambudiri, MD; APA Annual Meeting, May 2015. Poster session. Narcissism & Richard Gallagher, MD Narcissistic Disorders Professor of Clinical Psychiatry and S.K. Vyas, PhD. Everyone Reading Conference: Treating Behavioral Science, New York Medical ADHD and Executive Functioning: The Facts – Part II College Faculty, Columbia University Psychoanalytic Institute March 3, 2015.

Practice Guidelines for Joseph Goldberg, MD S.K. Vyas, PhD. Everyone Reading Conference: Bipolar Disorder: What's Clinical Professor of Psychiatry Icahn Understanding ADHD: The Facts- Part I, March 3, 2015. Useful, What's Not & School of Medicine at Mount Sinai, What's Missing New York, NY S.K. Vyas, PhD. Grand Rounds held at the Stamford Hospital, Department of Psychiatry: ADHD: The Facts with ADHD: The Facts with an Sejal Vyas, PhD Emphasis in Psychiatry Pediatric & Adult Neuropsychologist an Emphasis in Psychiatry, February 12, 2015. & Assistant Clinical Professor of Psychiatry, Icahn School of Medicine S.K. Vyas, PhD. Attention-Deficit/Hyperactivity Disorder at Mount Sinai Grand Rounds held at the Stamford Hospital, Department of Pediatrics Stamford, CT, November 13, 2014. An Evidence Based Christina Kunec, PsyD Approach to Neuropsychologist S.K. Vyas, PhD. “Understanding and Treating ADHD: Concussion Management Stamford Hospital What it is and how you can most effectively help your Decision Making Capacity Christine Naungayan, MD child.” Community Education held at Cognitive Behavioral CEO and Founder of Awakenings & Consultants of Westchester and Manhattan, White Plains, Forensic Psychiatric Consultant NY, October 20, 2014.

Duty to Warn: Duty to Rachit Patel, MD S.K. Vyas, PhD. Treatment Implications for Executive Protect. Tarasoff Law Staff Psychiatrist Dysfunction Seminar for Psychologists, held at cognitive Stamford Hospital Behavioral Consultants of Westchester and Manhattan, White Plains, NY, September 14, 2014.

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Publication • Dual Diagnosis Treatment Services — As co-morbid psychiatric/substance abuse disorders continue to Christine Kunec, PsyD published two book chapters, rise, the Unit will continue to adopt evidence-based references noted below: practices in order to provide high-quality services for Kunec, C., Fedor, S., Collins, M. What constitutes a dually diagnosed patients. “failed” post-concussion test for athletes with baseline • Behavioral Health — The team actively participates in neurocognitive or balance tests? Quick Questions in the Behavioral Health Work Group and will continue Sport-Related Concussion. Edited by Valvovich, McLeod TC. to lead projects to raise awareness and educate our Thorofare, NJ: Slack Incorporated. communities about mental illness and impacts of Hofbauer, M., Muller, B., Ward, J., Murawski, C., Wolf, M., alcohol and substance abuse. Kunec, C., Collins, M., & Fu, F. Concussion in Sports • Access to Care — Collaborate with community Traumatology: Future Trends. In N. M. Doral & J. Karlsson treatment providers to improve access to care for (Eds.), Sports injuries: Prevention, diagnosis, treatment and mentally ill substance abuse patients. rehabilitation. Springer Reference. Consultation Liaison/Medical, Surgical and COMMUNITY OUTREACH Emergency Department Consultation Services Christina Kunec, PsyD gave a number of presentations • Continued strengthening of the psychiatric house and talks as part of the Concussion Center’s community physician program to meet the growing demand for outreach initiatives. She spoke at local YMCAs, SONO psychiatric evaluation of patients presenting to the ED Ice House, Stamford Youth Foundation and Chelsea after hours and on weekends. Piers Connecticut. • Modification of the physical environment for psychiatric Carl Mueller, MD was interviewed by The Connecticut assessment in the ED to accommodate increasing Post about the impact of multiple snow storms on anxiety demand and improve customer services and and depression during winter months. satisfaction. This will be accomplished when the new ED construction project is completed in the coming year. Draupathi Nambudiri, MD was one of the panelists for a United Way of Western Connecticut discussion on • Increased collaboration in the care of patients admitted Behavioral Health issues in Stamford. to general hospital floors with co-morbid alcohol and substance abuse disorders.

STRATEGY/FUTURE DIRECTION • Close collaboration with geriatric medicine to develop The Department’s focus in the next year and beyond is in the dementia program at the Hospital. the following areas: The Department of Psychiatry is committed to partnering with colleagues in all departments, and Inpatient Services providing the finest psychiatric and behavioral • Geriatric Psychiatry — Expanding geriatric psychiatry healthcare services available. services will become increasingly important with the aging of “baby boomers.”

• 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.

2015 CLINICAL ANNUAL REPORT | 91 innovation in 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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A MESSAGE FROM THE CHAIR: communicate that, in this newcomer’s opinion, separates Stamford’s staff from the pack. And it is where we need to The Year in Review 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 Brian Stainken, MD communicating, on supporting the effective delivery Chair and Medical Director, of information and enabling consultation and ongoing Department of Radiology 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 have been involved in Radiology since 1986, but work of one particular member of the Department who have only been a part of Stamford Hospital for two played a central role in building and supporting the Ishort months. Eyes wide open and taking it all in — Stamford Hospital Radiology Service over many years. and what a sight it is. A magnificent glass tower in the Dr. Michael King, has served as Interim Chair for the background, grounded by a culture based on a Planetree. past three years and as the primary Abdominal Imager Hands-on and high-tech. What’s not to like about that? at Stamford Hospital for 16 years. Besides being an indefatigable spirit, Mike is an extraordinarily talented There is an advantage to being old and new. In the course physician who has served the institution and its patients of my 30 years in Radiology, everything has changed. I well. We wish him the very best. learned medicine when a wet reading was literal. I read wet x-ray films, wrote a note longhand in the chart and dictated In the following pages, you will have a chance to read a report that showed up in a few days. MR, CT, US, were in about the remarkable group of people who make up their infancy and IR, my chosen field, was just beginning. the Radiology team. To an individual they represent the best in their class, people whom the Stamford Hospital Fast forward to 2015, every single organ system, and every community can be proud to call their own. field of medicine has enjoyed significant advances as a direct result of advances in imaging and interventional SCOPE OF CLINICAL SERVICES medicine. It is not an exaggeration to say that Imaging and Interventional Radiology represent one of the top 11 The Department performed 169,377 examinations this most important medical advances of the last millennium. year, creating well over a million images. We create digital In fact, that’s what the editors of the New England Journal virtual images of humans using x-rays, gamma rays, beta said in 2000 (Looking back on the millennium in medicine, rays, ultrasound energy and FM frequency radio waves. New England J Med 342: 42-49, 2000). And, in this field, the You see the finished products as Breast Tomosynthesis, pace of change has not slowed in the intervening 15 years. Bone Densitometry, Computerized Tomography, General If anything, it has accelerated. Radiography, Magnetic Resonance Imaging, Nuclear Medicine, Positron Emission Tomography and Ultrasound. Stamford has enjoyed, embraced and benefited from In addition to diagnostics, image-guided procedural care those changes and advancements. As the role of imaging is offered in Breast Imaging, Vascular and Interventional and image-guided intervention has evolved, so have the Radiology, Nuclear Medicine and Radiation Oncology. models for delivery of care and that trend shows no sign of slowing. It’s all fast, automated and online. Three to five Stamford Hospital Radiology physicians complete five days to receive a hand-typed final report? How about years of post-doctoral training as well as one to two years three minutes! No one misses the time spent in front of of fellowship training prior to obtaining subspecialty board those old smelly wet films talking about the meaning certification in Body Imaging, Breast Imaging, Pediatric of the hazy shadow that might or might not be there. Imaging, Musculoskeletal Imaging, Neuro-Imaging, We do not miss that sense of uncertainty. What we do Nuclear Medicine, Vascular/Interventional Radiology and miss, and what we must work to improve, is the personal Radiation Oncology. connection. It’s that desire to connect, to consult and

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The Department is currently organized into three divisions. Connecticut having the highest incidence of breast cancer The largest is the General Diagnosis and Interventional in the country, we are proud to provide this incredibly high Radiology group. These services are currently anchored by level of accuracy to the women in our community. a group of six on-site specialized Radiologists as well as a network of 24 additional Radiologists who provide services Radiation Oncology represents a cornerstone of Stamford from remote locations. General Diagnostics includes the Hospital’s comprehensive cancer program. Practicing subspecialty fields of Abdominal Imaging, Chest Imaging, from the Bennett Cancer Center and CyberKnife Center Musculoskeletal Imaging, Neuroimaging, Nuclear Medicine at the Tully Health Center, our two Radiation Oncologists and Interventional Radiology. We provide the full scope offer state-of-the-art radiation therapy and stereotactic of services 24/7 with 100% final reports in the major radiosurgery to approximately 400 new patients every year, disciplines of Radiology. mostly on an outpatient basis. This year, Stamford Hospital began offering high-dose rate (HDR) remote implant The Breast Imaging Division is a nationally recognized therapy for use primarily with gynecologic malignancies. leader in the delivery of comprehensive breast diagnostic This technology allows our patients to access all aspects of care. Four fellowship-trained mammography experts gynecologic radiation therapy at Stamford Hospital, thus provide comprehensive “one stop” services for more than eliminating the need for referrals to other institutions. 20,000 women cared for at the Women’s Breast Center at the Tully Health Center and Darien Imaging Center. DEPARTMENTAL SAFETY AND QUALITY Stamford Hospital was the first, and remains one of the only programs nationwide, to provide 3-D digital breast The radiological specialties span almost every aspect of tomography for all screening mammography patients. in- and outpatient healthcare. We offer care to well over This revolutionary tool uses a low-dose x-ray beam to 150,000 people every year, and are involved in every organ literally see through tissues, find smaller cancers earlier and system and disease state. We serve your patients as well significantly reduce unnecessary imaging and intervention. as your practices, and many of us also maintain our own Our personal experience, performing tens of thousands active clinical practices. The definition of quality in each of of tomosynthesis studies shows a cancer detection rate these domains is different but unified by a common goal more than 50% greater than prior to tomosynthesis. With of striving to deliver the best.

Figure 1: Annual Trends by Location for FY15

94 | DEPARTMENT OF RADIOLOGY Figure 1: Annual Trends by Location

DEPARTMENT OF RADIOLOGY: ANNUAL REPORT 2015

Radiation Safety Accuracy Radiology began in the 1930s in response to the growing Making all the findings on an imaging study can be a recognition that x-rays could cause harm. Our roots as daunting task. What was one to four images per patient a specialty are invested in the protecting the patient. in the era of plain film radiology is now easily 250 – 400 During training, Radiologists and Radiation Oncologists, for a CT and up to 1,000 for many MRI examinations. We Radiation Physicists and Technologists are all educated know that the average radiologist misses between two and certified in the physics of radiation and the science and 20% of the findings on based on second reviews. The of radiation safety. There is growing interest from the more images, the more information, the higher the chance public as well as regulators on the topic of radiation something will be missed. Importantly, and perhaps not as safety and medical applications. One such example is the well understood, is that this error rate is roughly identical Connecticut Hospital Association’s statewide Radiation for colonoscopy and missed major diagnoses at autopsy. Dose Management Collaborative committee on which (Ulster Med J. 2012 Jan; 81(1): 3 – 9. Discrepancy and Error in Sarah Bull, our Radiation Safety Officer, Dr. David Gruen, Radiology: Concepts, Causes and Consequences Adrian Brady, Co-Director of the Women’s Breast Center, and Jory Risteárd Ó Laoide, Peter McCarthy, and Ronan McDermott). Vidulich Savino, Quality Imaging Manager, participate. We also know that we can impact our error rate through vigilance, education and, perhaps most importantly, Two important radiation safety initiatives are the Image communication. The fundamental importance of Gently (alliance for radiation safety in pediatric imaging — communicating up front about presentation, examination “child-sized” radiation) and Image Wisely (radiation safety in and suspected diagnosis, and as importantly, communicating adult medical imaging) programs. At Stamford Hospital we when exam findings and clinical metrics are discrepant, are committed to: cannot be overstated.

• Communicating openly with parents about imaging In the Radiology Department we track accuracy in a doses (“child-sized” imaging). variety of ways. When we hear about a possible error in • Putting patients’ safety, health and welfare first by a report, we review the study independently and assess optimizing imaging examinations to use only the whether the missed finding was obvious or not. We also radiation necessary to produce diagnostic quality images. assess in the context of the clinical significance of the miss for the patient. In addition, the same system is used • Conveying the principles of the Image Gently and Image to randomly select approximately 5% of the studies we Wisely programs to the Imaging team in order to ensure read which are randomly submitted for reinterpretation. that our facility optimizes its use of radiation when Discrepancies are tracked by physician and also imaging patients. submitted to a national registry where normalized data • Communicating optimal patient imaging strategies to is provided. Led by Dr. Howard Liu, our departmental referring physicians, and having Radiologists available Peer Review Committee reviews this data and reports for consultation. to the administration quarterly. We also have an internal • Routinely reviewing imaging protocols to ensure conference to review cases with teaching value. that the least radiation exposure or dose necessary to acquire a diagnostic quality image is used for Timeliness each examination. 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).

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Figure 2: TAT (2015 Average Turn Around Time by Modality Physician Satisfaction in Minutes) In 2015, we completed our biennial Radiology Medical Month ED Inpatient Outpatient Staff Survey. The response rate increased significantly Jan 32 282 573 (32%) compared with the 2013 survey. All metrics trended Feb 36 203 586 up since the 2013 survey with 10 of the 13 categories Mar 45 363 535 increasing significantly. The key metrics associated with Apr 34 298 603 physician satisfaction, the percent satisfied or very satisfied and the percentage improvement compared with 2013 are: May 77 287 634 Jun 33 451 767 2015 2013 Jul 41 271 788 Accuracy 89% 28% Aug 66 157 534 Sep 35 215 535 Consistency 79% 24%

Patient Satisfaction Specialized 80% 26% The Breast Imaging Division enjoys high satisfaction rates Accessible 88% 26% every month. This is driven by a nationally recognized best practice wherein patients receive the best imaging Responsive 88% 19% combined with a well-designed process and instant results. We all stand to learn from the success of this Certification program and we continue to do so. Quality programs meet certification standards and pass In 2015, overall, our patients rated their satisfaction on a site visits. There are multiple organizations involved 100-point scale between 90 and 97% (Press Ganey and in assessing quality and program certification. The customer feedback survey data is shown in Figure 3). Stamford Radiology practices are accredited by The Joint

Figure 3: 2015 Breast Imaging Press Ganey Data

96 | DEPARTMENT OF RADIOLOGY DEPARTMENT OF RADIOLOGY: ANNUAL REPORT 2015

Commission and the imaging modalities of CT, MRI and Conferences Ultrasound and Breast Imaging are also accredited by the • Drs. Frank Masino and Sean Dowling organize and help American College of Radiology (ACR). Nuclear Medicine chair more than 150 conferences annually. is accredited by ICANL. We have been inspected by the Nuclear Regulatory Commission (NRC), ACR, State of • Diagnostic Radiologists and Interventional Radiologists Connecticut and Mammography Quality Standards Act participate and present imaging studies at the (MQSA), all with excellent results. following weekly multispecialty tumor boards: Breast, Gastrointestinal, Lung, Neuro-Oncology, Gynecology, HONORS AND RECOGNITION Hematology and Genito-Urinary.

• Dr. Gruen was inducted as a Fellow of the American • Diagnostic Radiologists present imaging studies at College of Radiology. This honor is awarded to fewer Trauma Conference. than 10% of Radiologists in recognition of their service to the field. • Outreach: Community education is promoted through a robust outreach program, which involves physicians. The Awards physicians and staff at the Bennett Cancer Center work collaboratively with the City of Stamford Department of • The Breast Center received reaccreditation from the Health, American Cancer Society and other physicians on National Accreditation Program for Breast Centers, and the medical staff to provide community outreach. was cited for numerous “best practices.” The program was the first in the nation to have received accreditation from Research/Scholarly Activity the National Accreditation Program for Breast Centers and one of the first to have received it three times. Brian Stainken, MD, “Trauma Management” Chapter 15 Handbook of Interventional Radiologic Procedures 5th • The Women’s Breast Center was again designated a Edition Lippincott Williams & Wilkins (in press). Breast Center of Excellence by the American College of Radiology, one of only a handful in the state to receive Gruen D, MD, Pass A, MD, Bishop J, “Management of this coveted designation. Breast Masses in Women 25 and younger: A multi-year retrospective evaluation.” (Submitted for review). • The Center again received the Women’s Choice Award as an America’s Best Breast Center.

• 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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DIVISIONS • Brian Stainken, MD, FACR, FSIR, FCIRSE * (new) CAQ Interventional Radiology * Denotes Stamford Hospital practice site. Note that all »» Fellowship: Vascular & Interventional Radiology staff are certified by the American Board of Radiology, UCLA Radiology. Additional American Board Added Qualification »» Joined the department in August as Chairman. Certifications, CAQs, are as noted below. Committee Activity »» Executive Committee of the Stamford Hospital is noted in italics. Medical Staff »» Executive Council, The Society of Interventional GENERAL DIAGNOSTIC AND INTERVENTIONAL: Radiology (SIR) Abdominal Imaging Musculoskeletal Radiology • Michael King, MD* • Elizabeth Gaary, MD* »» Fellowship: Body Imaging Columbia Presbyterian, »» Fellowship: MSK/MRI Radiology, Cornell University, New York Hospital for Special Surgery »» Trauma Committee • Michael A. Mahlon, DO • Gregory Lee, MD* »» Fellowship: Musculoskeletal Radiology, »» Fellowship: Breast and Body Imaging Penn State University NewYork-Presbyterian Hospital-Weill Cornell Medical College • Anthony J. Minotti, MD »» Fellowship: Body Imaging, Metro Health • Patricia Barnes, MD Medical Center »» Fellowship: University of Texas, MD Anderson Hospital Neuroradiology • Mary Grebenc, MD • Howard Liu, MD* »» Fellowship: National Naval Medical Center CAQ Neuroradiology »» Fellowship: Neuroradiology, • Leslie Jacobson, MD Yale University School of Medicine »» Fellowship: Henry Ford Hospital »» Chair, Radiology Peer Review

Vascular and Interventional • Bryan Lazzara, MD* CAQ Neuroradiology • Bryan Lazzara, MD* »» Fellowship: Neuroradiology, CAQ Interventional Radiology Northwestern University »» Fellowship: Vascular & Interventional Radiology, Columbia University Medical Center • Lorraine M. Ash, DO CAQ Neuroradiology • Josef Noga, MD* »» Fellowship: Neuroradiology, CAQ Interventional Radiology University of Michigan »» Fellowship: Vascular & Interventional Radiology, Columbia University Medical Center • 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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Nuclear Medicine • Valencia King, MD* (new) »» Fellowship: Breast Imaging, Memorial Sloan Kettering • Harvey Hecht, MD* Cancer Center »» American Board of Nuclear Medicine »» Joined the Breast Imaging group in September after • Josef Noga, MD* serving on the faculty at Memorial Sloan Kettering Cancer Center. • Anthony J. Minotti, MD »» CAQ Nuclear Radiology • Allyson Parnes, MD * (new) »» Fellowship: Breast Imaging, Columbia University Pediatric Imaging »» Joined the breast imaging team in December 2014 after completing a women’s imaging fellowship. • Terry L. Levin, MD* CAQ Pediatric Radiology »» Stamford Hospital Orientation Buddy »» Fellowship: Pediatric Radiology, Columbia Presbyterian Hospital RADIATION ONCOLOGY

• Mark J. Halsted, MD • Frank A. Masino, MD* CAQ Pediatric Radiology »» Medical Director of Cancer Services »» Fellowship: Pediatric Radiology, »» Director of Radiation Oncology Cincinnati Children’s Hospital; »» Board Certification: Therapeutic Radiology Pediatric Neuroradiology, Cincinnati »» Fellowship: Radiation Oncology, Yale Children’s Hospital »» Chair, Stamford Hospital Cancer Committee

• Chris J. Schettino, MD • Sean W. Dowling, MD* CAQ Pediatric Radiology »» Radiation Oncologist »» Fellowship: Pediatric Radiology, Miami »» Board Certifications: Radiation Oncology and Children’s Hospital Internal Medicine »» Fellowship: Radiation Oncology, Yale BREAST IMAGING/BREAST CARE: »» Stamford Hospital Radiation Safety Committee • 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 CLINICAL ANNUAL REPORT | 99 innovation in s u r g e ry

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.

100 | DEPARTMENT OF SURGERY DEPARTMENT OF SURGERY: ANNUAL REPORT 2015

A MESSAGE FROM THE CHAIR: the extraordinary people who provide superb care every day. High-quality surgical care requires attention to detail The Year in Review 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, Michael D. Stone, MD Residents and Physicians. Chair, Department of Surgery 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 very day as we arrive at Stamford Hospital, we can find new approaches to improve the patient experience, see progress toward completion of the new hospital whether it is remodeling the ambulatory surgery waiting Ebuilding, a spectacular reminder of our bright future. area or providing the resident staff with business card This sense is further enhanced when we take visitors on “bookmarks” complete with the resident’s picture so their tours of the interior of the new facility, which is beginning patients will remember them. to look like the advanced medical center we will move into in September 2016. Many visiting surgeons, including some We already are seeing the value of our efforts. Our surgical who thought the new center would never be built, have volume has increased approximately 6% for each of the been impressed by, and have expressed a desire to be a part last two years, as shown in Figure 1. More importantly, of, the future at Stamford. They marvel at the extraordinary our patient satisfaction scores have reached new highs at technology that will be housed in our trauma center, both the Tully and Main Hospital perioperative areas. We specialized orthopedic and neurosurgical operating rooms understand that the success of the new hospital will depend and a hybrid operating room that allows us to provide on continuing to create changes that maintain this trajectory. synchronous, multidisciplinary approaches to patients who This year we have added new staff in Orthopedics, require complex procedures. The new ORs will have the Pediatric Orthopedics, Hand Surgery, Pediatric Plastic most up-to-date equipment possible in a rapidly changing Surgery, Podiatry and Vascular Surgery. Our focus, as technologic environment. As we unveil our new surgical we look to the future, is to maximize our capabilities in robot, we will have the most advanced capability in Fairfield minimally invasive and natural orifice/endoscopic surgery and Westchester counties, allowing us to do procedures not in all areas. Our goal and commitment is to provide previously possible in the abdomen, pelvis and chest. We surgical care that is equal to our spectacular new facility have been in the vanguard in our geographic region in the and recognized as the safest in Connecticut. application of three dimensional visual, navigational and guidance systems for pulmonary, neurosurgical, orthopedic Figure 1: Department of Surgery: 2015 by the Numbers and gastrointestinal surgery, and will continue to lead the way through thoughtful acquisition of new technologies. Divisions/Sections: 19

Stamford Hospital will be the safest place to have surgery Staff: (active, courtesy, honorary and provisional) 159 in the area. Construction details such as antimicrobial Residents: 17 copper-impregnated touch surfaces will contribute to Physician Assistants & Nurse Practitioners: 19 our ongoing and successful efforts to reduce surgical infections (see Figure 2). OR Procedures: Total Cases: 19,125 6.6% increase The most important “touch surface” is the patient. It is that personal touch that our staff provides every day that will Tully: 6,655 6.1% increase lead to our continuing success. We fully expect that patients Main OR: 5,678 9.4% increase and physicians will come to Stamford Hospital to see and Endoscopy: 6,792 4.9% increase experience the new facility. Those patients, their neighbors and friends will come back to our facility again because of 2015 CLINICAL ANNUAL REPORT | 101 DEPARTMENT OF SURGERY: ANNUAL REPORT 2015

SCOPE OF CLINICAL SERVICES guided exercise programs within the Tully Health Center’s Health & Fitness Institute, nutritional support from MEDICAL STAFF an experienced team of nutritionists and dieticians, a variety of services provided by Stamford’s Integrative The following is an overview of the Department’s divisions Medicine practices and of course Bariatric Surgery. Our and active staff. goal is for patients to learn the importance of healthy GENERAL SURGERY living and overall wellness. CSWL surgeons, members of the section of Bariatric Surgery, perform all bariatric Active Staff: procedures, including laparoscopic gastric bypass, • James Bonheur, MD sleeve gastrectomies and gastric banding. Physicians are developing new capabilities in upper gastrointestinal • Neeta Chaudhary, MD endoscopic procedures to extend the armamentarium of • Marissa DeFreese, MD weight-loss procedures. • Xiang Do (Eric) Dong, MD BREAST SURGERY • Kevin Dwyer, MD • Kevin Miller, MD Division Leadership • Harold Neyra, DO • Joey Papa, MD • Michael Stone, MD

The Division of General Surgery continues to expand its Helen A. Pass, MD expertise in surgical care with particular emphasis on Director of Breast Surgery 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. Active Staff: BARIATRIC SURGERY • Jennifer Bishop, MD Section Leadership • Zandra Cheng, MD • Mandy Greenburg, MD

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) James Bonheur, MD in March. We received unconditional accreditation, with Medical Director 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. Active Staff: A significant emphasis was placed on patient education. • Harold Neyra, DO A new patient information binder included not only The Center for Surgical Weight Loss (CSWL) engages customizable relevant medical information, but also patients in a comprehensive program designed to a comprehensive list of our capabilities to enhance achieve medical and physical wellness. It combines navigation. The patient experience was mapped in an effort

102 | DEPARTMENT OF SURGERY DEPARTMENT OF SURGERY: ANNUAL REPORT 2015 to identify areas for improvement. Similarly, a navigation • “The Role of Surgery in the Management of Ductal team was created to better transition patients from Carcinoma in Situ” invited lecture Clinical Congress of diagnosis to surgery and then to their care at the Bennett the American College of Surgeons, San Francisco, CA, Cancer Center. Once again, extensive community outreach October 30, 2014. programs were held. • “Better Breast Health: New Technology and Treatments” Dr. Bishop was appointed to the Education Committee of the keynote speaker Women’s Health Day, Rolling Hills American Society of Breast Surgeons as well as the Operating Country Club, Wilton CT, November 7, 2014. Room Product Committee of Stamford Hospital. She remains • “Celebrate U” invited lecture YWCA, Darien, CT, a member of the Executive Council of the Connecticut January 14, 2015. Chapter of the American College of Surgeons (ACS). • “The OncotypeDx Assay in the Contemporary Dr. Pass became a member of the Executive Committee Management of Breast Cancer” invited lecture Oncology of the Commission on Cancer. She remains a Governor of Associates, New London, CT, April 16, 2015. the ACS; a Member of the Committee on Applicants of the • “Changing Practice Circumstances: Acquisitions, Connecticut Chapter of the ACS; Chairman of the Bylaws Alliances, and Your Autonomy — Leaving the Comfort Committee of The American Society of Breast Surgeons; a of a Big Organization” invited seminar for the American Member of the American College of Surgeons Committee Society of Breast Surgeons 16th Annual Conference, on Surgical Volunteerism and Humanitarian Awards; and Orlando, FL, April 30, 2015. a Member of the International Committee of the National • “Top 10 Breast Papers of the Last 10 Years” invited lecture Accreditation Program for Breast Centers (NAPBC). for the American Society of Breast Surgeons 16th Annual Members of the Section presented numerous national, Conference, Orlando, FL, May 2, 2015. regional, and community lectures on breast health and care Posters over the course of the year. Cheng ZH, Frenk V, Bishop JD, Bowling T, Pass HA Mulitmodal Presentations Perioperative Analgesia with Paravertebral Nerve Block and • “Maximizing Your Patient’s Physical and Emotional Gabapentin Reduces Narcotic Use and Hospital Length of Recovery through the Star Program,” invited panelist Stay in Mastectomy Patients. Poster Presentation for the Carl and Dorothy Bennett Cancer Center Annual San Antonio Breast Conference, December 9 – 13, 2014, Oncology Symposium, Stamford Hospital, Stamford CT, San Antonio, Texas. October 16, 2014. Pass HA, Bishop JB, Babkowski R, Cheng ZH Quality • “Breast Cancer in Men and Women” invited lecture Improvement in Mastectomy Processing: Routine Use of A Stamford Senior Center, Stamford, CT, June 27, 2014. Standardized Mastectomy Diagram by Surgeons Improves • “Optimal Breast Health” invited lecture Odyssey Accuracy and Timeliness Of Final Pathology Report. Poster Reinsurance Group, Stamford, CT October 1, 2014. Presentation for the Society of Surgical Oncology Annual Conference, March 25-28, 2015, Houston, Texas. • “Breast Health and You” invited lecture YMCA, Darien, CT, October 8, 2014. Papers • “Management of the Axilla in the Era of Z11 and MA20: Chafe S, Moughan J, McCormick B, Wong J, Pass H, A Surgeon’s Perspective” invited lecture Interdisciplinary Rabinovitch R, Arthur DW, Petersen I, White J, Vicini FA. Oncology Symposium William Beaumont Hospital, Troy, Long-term Update of NRG Oncology/RTOG 0319: A MI, October 17, 2014. Phase I/II Trial to Evaluate Three Dimensional Conformal • “What is New in Breast Wellness” invited lecture for Radiation Therapy (3D-CRT) Confined to the Region of the NBS Sports Lunch and Learn Series, Stamford, CT, Lumpectomy Cavity For Stage I and II Breast Carcinoma. October 22, 2014. Submitted Int J Radiat Oncol. • “Women’s Breast Health” invited lecture YMCA, New Canaan, CT, October 22, 2014.

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CARDIOVASCULAR SURGERY COLON AND RECTAL SURGERY Division Leadership Section Leadership

Charles E. Littlejohn, MD Michael A. Coady, MD, MPH Director of Colon and Chief of Cardiovascular Surgery Rectal Surgery

Active Staff: Active Staff: • William C. Feng, MD • Marilee Freitas, MD

Stamford Hospital offers patients a full spectrum of surgical • James McClane, MD procedures within the field of Cardiac Surgery, ranging • Shahzad Zafar, MD from elective to immediate and life-saving. The surgical Dr. Charles Littlejohn was named President of the American team continues to have outstanding clinical outcomes Society of Colorectal Surgeons (ASCRS). This is a prestigious with a zero percent mortality rate during the past year. position in the world’s premier society of surgeons The Division continues to provide the Convergent Ablation dedicated to the practice of colorectal surgery. Dr. Freitas has Procedure for patients with long-standing atrial fibrillation, led the Division’s efforts in starting up an anal manometry and actively participates with the Division of Cardiology in program to provide better care for patients with pelvic floor the new TAVR Program for aortic valve replacement. Unlike problems. Dr. Zafar’s efforts have been in advancing robotic other institutions offering similar programs, Stamford colonic surgery at Stamford Hospital. Hospital’s surgical team is very focused on making each The Colorectal Surgery Division implemented the use of individual patient experience extraordinary. We have a one of the first 3D laparoscopes in the state to enhance full-time, dedicated patient navigator to coordinate care visualization in patients having minimally invasive colon and guide patients through the process from pre-surgery and rectal surgery. through surgery and beyond. This Planetree approach to patient-centered care makes Stamford Hospital a very HAND SURGERY special place to practice medicine. Section Leadership 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 John D. Dowdle, MD of Thoracic Surgery. Feng W, Coady M. “Epicardial Tachosil Director of Hand Surgery patch repair of ventricular rupture in a 90-year-old following mitral valve replacement.” In press, Annals Thoracic Surg, 2015.

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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 • Gregory Gallousis, MD Andrea Douglas, MD • Joan Gewirtz, MD Chief of Neurosurgery • Paul A. Goldberg, MD • Jacqueline J. Littzi, MD • Philip A. Piro, MD • Lauren Schneider, MD Active Staff: • 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 ORAL AND MAXILLOFACIAL SURGERY • Avinash Mohan, MD • Marc Otten, MD Division Leadership • C. Cory Rosenstein, MD • Scott Simon, MD

Dr. Andrea Douglas has assumed leadership of the Division. Robert M. Yudell, DDS, MD We have continued to identify and recruit new surgeons Director of Oral and with expertise in stereotactic neurosurgery, minimally Maxillofacial Surgery invasive skull base surgery and cranial tumors. Dr. Marc Otten, who specializes in minimally invasive skull base surgery, joined the staff.

Active Staff: • Donald Case, DMD • Clifford Evans, DMD • Christine Hamilton-Hall, MD, DMD

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ORTHOPEDIC SURGERY • Craig D. Tifford, MD Division Leadership • Allen I. Troy, MD • Corrine VanBeek, MD • Avi Weiner, MD • Daniel Zelazny, MD In 2015, the Division of Orthopedic Surgery continued Rudolph F. Taddonio, MD to grow with the addition of surgeons from Westchester. Director of Orthopedic Surgery 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 Active Staff: integrative medicine physicians. Construction is underway • Jeffrey Alwine, DO for Sports Rehabilitation services at the Chelsea Piers • David Aspirino, MD Connecticut campus. • Theodore A. Blaine, MD Both the Hip and Knee Replacement Programs and Spine • Adam R. Brodsky, MD Fusion Program achieved initial Certification in 2010, and recertification in 2013 without any deficiencies. The Spine • Jeffrey J. Brooks, MD Fusion Program was site visited in September 2015 and we • Russell J. Cavallo, MD await a final report with a highly favorable preliminary report. • Robert Cristofaro, MD The Division seeks to lead the way in advancement • Joseph M. D’Amico, MD in clinical practice and the adoption of additional • Frank A. DiFazio, MD technologies that will allow a more personalized approach to spinal deformity correction such as custom implants. • John D. Dowdle, MD • Albert Dunn, DO OTOLARYNGOLOGY AND HEAD AND • Edward Feliciano, MD 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 106 | DEPARTMENT OF SURGERY DEPARTMENT OF SURGERY: ANNUAL REPORT 2015

The Division of Otolaryngology and Head and Neck Surgery PODIATRY has continued to increase the number of minimally invasive approaches to surgery and now have over 98% or our Division Leadership 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 Jeremy A. Bier, DPM for increased safety. We collaborate with our Neurosurgery Director of Podiatry 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 Active Staff: have also been actively involved in the treatment of balance, • Rui DeMelo, DPM hearing, taste and smell disorders. • Sarah Edgar, DPM Additionally, Division members teach residents and medical • Marissa Girolamo, DPM students, provide lectures at the Hospital and to community groups, and are on the faculty of both Columbia and Yale • Ellen Golden, DPM medical schools. • Jeffrey Gross, DPM Members of the Division have had extensive recognition as • Matthew Juriga, DPM outstanding practitioners in many distinguished lists such as • Pedram Hendizadeh, DPM Castle Connolly’s Top Doctors, New York Magazine, Connecticut magazine, Westchester WAG and other regional publications. • Chris Kassaris, DPM • Francisco Lago, DPM PLASTIC AND RECONSTRUCTIVE SURGERY • Kelly Powers, DPM, MS Division Leadership • Mary Reilly, DPM • Andrew Rice, DPM • David Rosenzweig, DPM • Steven Shindler, DPM Harold S. Gewirtz, MD • Peter Siroka, DPM Director of Plastic and • Josephine Velasquez, DPM Reconstructive Surgery • Robert Weiss, DPM • Scott Weiss, DPM

Dr. Kelly Powers joined Associated Podiatrists in Fairfield and Greenwich. She was a resident in Podiatry at Boston Active Staff: University with a fellowship in Plastic Reconstruction at • Chang Soo Kim, MD Georgetown University Medical Center.

• Sandra L. Margoles, MD Drs. Robert and Scott Weiss have added a third associate, • Leif O. Nordberg, MD Dr. Matthew Juriga. Dr. Juriga was trained at the Beth Israel • David Passaretti, MD Deaconess Medical Center where the Podiatry Department works closely with vascular and medical physicians from the • Arthur R. Rosenstock, MD Joslin Diabetes Center to produce some of the highest rates • Alfred Sofer, MD of limb salvage in the country. • Julie V. Vasile, MD

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Drs. Bier, Weiss and Juriga provide Podiatric Surgery THORACIC SURGERY Emergency Department call services at Stamford Hospital to ensure high-quality care to our patients with Division Leadership podiatric emergencies.

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

The Lung Cancer Screening Program continues to progress and is one of the largest and most successful in the area. Active Staff: Details include standardized readings, developing a • Michael D. Stone, MD patient database and working with the Department of Radiology in providing real-time results to patients and The Section of Surgical Oncology provides rapid access to their doctors. A one-to-one smoking cessation program is a complete range of surgical expertise in oncology care now up and running. from highly experienced, fellowship-trained practitioners. Our experience in endocrine surgery, complex Dr. Ebright was appointed Editor of the International gastrointestinal cancers, hepatobiliary cancer, melanoma Thymic Malignancy Interest Group Newsletter. and other cutaneous malignancies is unmatched in the Additionally, he has given the following lectures: region. Members of the Section participate in several multidisciplinary conferences to ensure a complete NewYork-Presbyterian Lung Cancer 2015: New Discoveries, approach to evaluation, diagnosis and therapeutics. New Directions CME Symposium, Weill Cornell Medical We continue to incorporate minimally invasive surgery, College, June 2015, Lymph Nodes 101: Diagnosis, Prognosis, including robotic surgery, in the care for our patients. Resection—What is the Data?

Michael Stone, MD, (Department Chair and Surgical Medical Grand Rounds, NewYork-Presbyterian/Lawrence Oncology) co-authored three publications this year: Hospital, Bronxville, NY, June 2015, Beyond the Scan: Screening, Diagnosis, and Treatment of Early Stage Sissoko M, Josenia N, Uyeda , Stone M, Hartshorn, Roehrl Lung Cancer. M. A Rare Case of Primary Ampullary Squamous Cell Carcinoma and Review of the Literature. Gastrointestinal In addition, the Section was represented at the Cancer Research. 2014. following meetings:

Falcone T, Holick M, Pearce E, Devaiah A, Stein D, Jumaily Zanbrakji M, Ebright MI. Management of unusual and J, Jalisi S, Grillone G, McAneny D, Stone M, Noordzij JP. difficult post-operative complications. Presented at the New Correlating Preoperative Vitamin D Status with Post York General Thoracic Club Spring Meeting, New York City, Thyroidectomy Hypocalcemia. Endocrine Practice April 2015. 10/20/14. Gesthalter Y, Berman J, Fernando HC, Ebright MI. Buch K, Qureshi M, Carpentier B, Cunningham D, Direct comparison of endobronchial ultrasound Stone M, Jaffe C, Quinn M,Gonzalez C, LaVoye1 J, Hines N, guided transbronchial needle aspiration and cervical Bloch B. Surveillance of Probably Benign(BI-RADS 3) Lesions mediastinoscopy for the diagnosis of suspected sarcoidosis. in Mammography: What Is The Right Follow-Up Protocol? Presented at the CHEST Annual Meeting, October 2014. The Breast Journal 02/2015; 21(2).

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Dr. Ebright has two upcoming presentations at the The Trauma Center has three fellowship-trained Trauma Connecticut Chapter of the American College of Surgery and Critical Care surgeons, and is the regional leader Meeting and has published the following articles and for outreach, injury prevention, education and research. book chapters: The Center had a site visit from the American College of Surgeons in November. Hewes PD, Jachey KJ, Zhang X, Tripodis Y, Rosenkranz P, Ebright MI, McAneny D, Fernando HC, Litle VR. Evaluation In FY15, Stamford Hospital’s Emergency Department of the Caprini model for venothromboembolism in saw 9,714 patients for minor to severe traumatic injury. esophagectomy patients. Annals of Thoracic Surgery. 2015; Of those, 1,144 patients were admitted to the Hospital. August 14 [Epub ahead of print]. Additionally, the Immediate Care Center at the Tully Health Center saw 6,950 patients for a minor trauma injury. Ebright MI. Seeing cancer in a new light. Journal of Thoracic and Cardiovascular Surgery. 2015; 150(1): 8-9. The Division hosted the Southwestern Connecticut Trauma Symposium for trauma professional staff in November Stevenson EK, Sloan KA, Narsule CK, Kretschman DM, 2014. This past year’s symposium included presentations Sarita-Reyes CD, Steiling K, Ebright MI. Catamenial on new ventilator modes, burns, blast injuries, EMS issues, hemothorax in a patient with multiple sclerosis. Am J Respir reconstructive surgery after trauma and caregiver burnout. Crit Care Med. 2014; 190(12): e69-70. The Trauma Center is engaged in public and professional Ebright MI, Krasna M. Overview of esophageal and proximal education. There is a dedicated referral and access line to stomach malignancy. Adult Chest Surgery, 2nd Edition. Trauma Center resources. Prevention activities center on Editors, David J. Sugarbaker et al. priorities based on local injury data. Examples of injury CK, Ebright MI, Fernando HC. Esophageal malignancy: prevention activities include an Annual Trauma Fair, palliative options and procedures. Adult Chest Surgery, which focuses on distracted driving. The Trauma Center 2nd Edition. Editors, David J. Sugarbaker et al. collaborates with national, regional and state programs, including the Trauma Quality Improvement Program (TQUIP). The Trauma Program Manager (TPM) participates TRAUMA SURGERY AND CRITICAL CARE in senior and family health fairs where information is Division Leadership 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 Kevin M. Dwyer, MD courses, the Annual Trauma Symposium, roundtable sessions provided for pre-hospital providers, an annual Director of Trauma and Critical Care 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.

Active Staff: 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 • Richard P. Santarosa, MD Stamford Hospital is a Level II Trauma Center designated by the Office of Emergency Medicine of the State of • Vincent J. Tumminello, MD Connecticut and verified by the American College of • Paul F. Zelkovic, MD Surgeons (ACS) to care for acutely injured trauma patients.

2015 CLINICAL ANNUAL REPORT | 109 DEPARTMENT OF SURGERY: ANNUAL REPORT 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 Matthew Juriga, DPM device at Stamford Hospital in 2015. 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

110 | DEPARTMENT OF SURGERY DEPARTMENT OF SURGERY: ANNUAL REPORT 2015

Ancillary Staff • Stephanie E. Beierle, PA-C, Surgical Physician Assistant

Bart Muhs, MD, PhD Transitions Vascular Surgery 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 • Dr. Martin Lederman received the Humanitarian Award from Westchester County Doctors of Distinction. Orthopedics and Hand Surgery • 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. • Dr. Josephine Velazquez received the 2015 Darien YWCA Shahzad Zafar, MD Woman of Distinction Award. Colorectal Surgery • 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

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Stamford Hospital surgeons were listed among the Top • Karen J. Nishida, MD Doctors in Fairfield County, New York or Connecticut in • Michael J. Nurzia, MD 2015. They are: • Glenn E. Ostriker, 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 • Joan T. Gewirtz, MD • Peter W. Hughes, MD DEPARTMENTAL SAFETY AND QUALITY • Haik G. Kavookjian MD The American College of Surgeons National Surgical • Bruce H. Klenoff, MD Quality Improvement Program (ACS NSQIP®) is the first • Jason R. Klenoff, MD nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical • Biana Lanson, MD care. The Department of Surgery has participated since • Charles E. Littlejohn, MD 2012 and also participates in the Connecticut Surgical • Richard Magill, MD Quality Collaborative, a NSQIP subgroup. Entering data to compare our performance to others, and the opportunity • Ben Marsan, MD to learn from our colleagues across the state and country • James McClane, MD are key components of the program. • Guy M. McKhann II, MD Our first outcomes report showed that our mortality • Martin Lederman, MD rate, adjusted for the severity of illness of our patients, put us in the top 10% nationally. Importantly, the report • Kevin D. Miller, MD identified areas for improvement: reducing surgical site • John Nelson, MD infections, especially in colorectal surgery and pulmonary • Frederic A. Newman, MD complications across all subspecialties.

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Our efforts to develop a Culture of Safety are bearing Surgical Residency Program fruit as evidenced by the reduction in our surgical site The Surgical Residency Program continues to attract infections overall, and in colorectal surgery patients bright students from much of the East Coast with over 500 specifically (see Figure 2). We continue to review our applicants this past year. Our graduates leave with a deep outcomes through reports from the Infection Prevention and broad comprehension of surgical care and technique. and Control team and the National Healthcare Safety Almost all go on to highly competitive fellowships Network (NHSN, a subsection of the CDC) and in subspecialties. This year, our graduates went on to through NSQIP. fellowships in colorectal surgery, minimally invasive surgery Figure 2: Stamford Hospital Colorectal Surgery and trauma surgery at SUNY-Stonybrook, Lahey Clinic Standardized Infection Ratio 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 • Hebroon Obaid, MD, St. George’s University Dr. Kevin Dwyer is leading a multi-disciplinary approach • Kristin McCoy, MD, American University of the Caribbean to reducing pulmonary complications through a multi- School of Medicine step process based on a successful program at other sites across the nation. We have already seen improvements in • Marissa Novack, MD, Ross University School of Medicine this regard for the Department as a whole and for higher risk subspecialties. Current Residents We are enhancing our methods of data collection, PGY 2 review and assessment, to better understand the costs of • John Calhoun, MD, University of Central Florida College surgical care to improve our financial performance while of Medicine maintaining quality and safety. • Elise McKenna, MD, New York Medical College DEPARTMENTAL EDUCATION AND • XueWei Zhang, MD, Boston University School of Medicine TEACHING ACTIVITIES PGY 3 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 • Basil Nwaoz, MD, Tufts University School of Medicine Columbia University College of Physicians and Surgeons, • Kostantinos Poulikidis, MD, New York Medical College Mercy Hospital and Quinnipiac University. We continue to get very high marks for teaching from some of the PGY 4 brightest students across the country. As Dr. Dong moves • Christian Cain, MD, University of Illinois College of Medicine to a new position in Ohio, Dr. Marissa DeFreese will assume • Mohamad Zanbrakji, MD, Ross University School that role. She is working with Dr. Stone and the Dean’s of Medicine Office at Columbia to introduce newer, more formalized approaches to the educational process, student and • Kristina Ziegler, MD, University of Connecticut School faculty assessment and outcomes. of Medicine

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PGY 5 The Stamford Hospital resident team, John Calhoun, • Debbie Bakes, MD, Tufts University School of Medicine Heather Player and Kristina Ziegler, won First Place in the statewide “Top Gun” Surgical Technical Competition at the • Elijah Min, MD, Ross University School of Medicine Connecticut ACS meeting. • Heather Player, MD, Weill Cornell Medical College Resident Awards 2014 2015 Graduates and Positions Taken • Research Award: Kamal Addagatla, MD • Ryan Bendl, DO, Colon Rectal, State University of New York • Patient Care Award: Christian Cain, MD at Stony Brook • Teaching Award: Ryan Bendl, DO • John Hwang, MD, Minimally Invasive Surgery, Lahey Clinic in Boston, MA Residency Program: Scholarly Activity • Katherine Petersen, MD, Surgical Critical Care, University Residents were highly visible as presenters at state and of Kentucky 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. Comparing the Risk Profiles of Intracranial Hemorrhage Seen on Initial Computerized Kamal Addagatla, MD# Tomography Scans in Patients Who Fall on Warfarin versus other Antithrombotic Therapy. *Best Paper Award #State winner Trauma Award

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Departmental Lectures/Visiting Professors STRATEGY/FUTURE DIRECTION • Karmel Lecture: “What’s New and Evidence-based in Technology, healthcare delivery and financing are Pediatric Surgery” Brendan T. Campbell, MD Director, changing rapidly. We heed the rejoinder from Satchel Pediatric Trauma and Injury Prevention Center; Connecticut Paige “Don’t look back. Something might be gaining on you.” Children’s Medical Center. We will continue to bring that newest and most advanced Other Educational and Scholarly Activities care to the people of Fairfield County, but we will also remember to bring the most personal care. We are looking Michael Stone, MD, (Department Chair and Surgical ahead toward, and with a plan to be, the future of surgical Oncology) co-authored three publications this year: healthcare in Fairfield County. 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 CLINICAL ANNUAL REPORT | 115 the new stamford hospital and

integrated care pavilion OPENING 2016

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