Medical Staff Volume 6, Number 6 Progress Notes May, 1993

President for Medical Staff Services, From the and members of TROIKA. A report President from this group would be sent to the Medical Executive Committee for At its April informational purposes and sent meeting, the Medical Executive directly to the Quality Committee voted on several important Assurance/Medical Allied Health Staff issues. The committee endorsed the Development Committee of the Board Board of Trustees' reports on which would then submit its Education and Chairpersons. These recommendations to the Board of two documents express the direction Trustees. and intent the Board envisions for our hospital. As previously noted, these A modification of the so called two documents have been available in the year rule was also passed. Medical Staff Office; however, as the Immediately upon receipt of contents of these documents are notification from a private practice important for our active :¥edical Staff, group that an individual has been copies will be provided at the next involuntarily terminated from the General Medical Staff meeting. group, or when an individual is no longer employed under a contract with The Medical Executive Committee also the hospital, that individual would lose voted to remove itself from the process medical staff privileges and In This Issue ... of reviewing and making membership. These individuals would, recommendations concerning requests however, be permitted to request a slot At-Large Members for Medical Staff Development slots. within 60 days of such notification, Needed forMed We struggled to this conclusion after requiring immediate consideration by Exec Committee considering the tangled deliberations of the new hospital group mentioned -Page 2 the Medical Executive Committee above, the Quality Assurance/Medical Parking when reviewing slots/slot applications. Allied Staff Development Committee of Changes The department chairperson would the Board, and the Board of Trustees at -Page 3 solicit input from his division and their next scheduled meeting. UltlfiSound make his recommendations (as well as Voluntary termination from either Changes the division recommendations, if private practice groups or hospital -Page 5 contrary) to a group consisting of the contracts will be reviewed only during P & T Highlights 11 departmental chairpersons, the the normal Semiannual Needs Survey - Pages 17-19 hospital CEO, COO, Chief of Clinical cycle. Services, hospital counsel, Vice Continued on Page 2 Continued from Page 1

The Medical Staff Development Plan Managed care Committee for further has been a source of much discussion and revision. We have been consternation in its individual very active in formulating our plan at a application. The general principles of rapid pace. The issue of capitation/ the plan, however, remain an important gatekeeper concept also needs to be document which the Medical Staff, faced if we are to be perched through the Medical Executive competitively in the managed care Committee, must maintain input and arena. A group of primary care provide insight. In that regard, we practitioners and Tom Hansen, Senior will be reviewing those principles in a Vice President, are grappling with this upcoming meeting of the Medical issue. Executive Committee. Best wishes, Finally, a quick update on the Managed Care initiative. The first draft of the Business Plan has been completed, and TROIKA reviewed it with Dan Grauman of the Raleigh I..i:::Candio M.D. Group. It is being distributed to our President, Medical Staff

At-Large Members Needed for Medical Executive Committee

The Medical Staff Nominations If you have any questions regarding Committee is soliciting nominations for this issue, please contact Dr. Castaldo four at-large seats, each for a three- or Mr. Hart at 402-8968. year term beginning July 1, 1993, on the Medical Executive Committee.

Nominations should be submitted in writing to John E. Castaldo, M.D., Chairman of the Nominating Committee, via the Medical Staff Services Office, Cedar Crest & 1-78, or verbally to Joseph A. Candio, M.D., Medical Staff President, John Jaffe, M.D., Past President, Medical Staff, or John W. Hart, Vice President. All nominations must be submitted prior to June 1, 1993.

Page 2 Physician Parking Changes- Cedar Crest & 1-78

Effective Monday, May 17, 1993, After the trench work is completed, the physician parking was expanded and parking spaces formerly occupied by temporarily relocated to a new lot will be dedicated to which provides physicians with over 30 accommodate the additional patient new spaces (please refer to the map on parking needed. It is anticipated that page 16). The new lot is gated and physician parking will return to the card accessible as it has been in the original lot upon completion of the past. Dorothy and John Morgan Cancer Center. Additionally, the relocation and expansion of physician parking Thank you for your continued provides an increased number of cooperation since the early stages of patient parking spaces in response to the construction for the John and the growing demand from patients of Dorothy Morgan Cancer Center. In the 1210 Medical Office Building. particular, a special thank you to the tenants of 1210, 1220 and 1230 S. The relocation of physician parking is Cedar Crest Blvd., for their patience timely because of an upcoming with regards to parking and other construction project that will displace issues that have affected them during many spaces in the current physician this time. lot. In June, temporary trenching will ) occur so that pipework can be laid to If you have any questions regarding connect the hospital boiler system to this issue, please contact either John the John and Dorothy Morgan Cancer W. Hart, Vice President, or Joseph A. Center. The trenching will pass Candio, M.D., Medical Staff through the former physician lot President, at 402-8968. (please refer to the map).

Physician Hotline for Patient Census

Effective May 8, Information Services is pleased to the date of support this request, and will be PHAMIS automating the process as soon as "Go-Uve," the possible, offering fax service and telephone number computer notification directly off the 402-4508 will be computer mainframe. Unfortunately, manned and accepting calls from availability of these services is not physicians who wish to inquire as to anticipated for at least 60 to 90 days, the daily census of their patients at but it is hoped that this telephone both sites of Lehigh Valley Hospital. number and staffing will be helpful.

Pagel Laboratory News from the Update infections. According to the NCCLS Microbiology Division guidelines, enterococcal endocarditis requires combined with high a Sporadically, the Microbiology dose penicillin or high dose ampicillin, Division of Health Network or vancomycin, or teicoplanin plus Laboratories receives urine specimens gentamicin or streptomycin for obtained by "suprapubic" collection. bactericidal action. Detection of When these are received, the ampicillin or penicillin resistance for laboratorian must call the nursing unit enterococci due to B-lactamase in order to establish whether the production is not possible by the specimen was collected by suprapubic routine disk diffusion or dilution MIC "aspiration" or "catheterization" since methods. Therefore, blood and CSF they are processed differently. In isolates will be tested using a method contrast to catheterized specimens, that will detect B-lactamase. We will aspirates are cultured as closed body continue to screen for aminoglycoside site fluids and all organisms isolated susceptibility as a means of identifying are identified. It has been found, isolates that will respond however, that most, if not all, synergistically to ampicillin or specimens received are, in fact, penicillin and an aminoglycoside. collected by "suprapubic catheterization. " a The Microbiology Division of Health Network Laboratories has In order to assure that urines collected implemented the following policy basa. by aspiration are processed correctly, on recent reports in the literature please mark the chart under physician related to inappropriate testing for orders "suprapubic aspirate for C&S" diarrheal disease. and submit the specimen in a sterile Port-A-Cui transport vial. All other o The laboratory performs a specimens marked as "suprapubic" on screen for direct Giardia the Microbiology Request Form will be antigen testing. Since the processed as a catheter collected greater percentage of specimens specimen. are positive for this parasite, the lab recommends ordering a a Based on new National Committee Giardia antigen screen rather of Clinical Laboratory Standards than a comprehensive Ova & (NCCLS M110-S4) recommendations, Parasite examination. Orders the "moderately susceptible" category must specify Giardia antigen for ampicillin and penicillin screen or Comprehensive Ova susceptibility testing of Enterococcus & Parasite exam. Specimens spp. has been deleted. There are now will be stored in the laboratory two categories that may be reported, for five days following the final i.e., "susceptible" and "resistant." The Giardia screen report, before "susceptible" category for penicillin or discarding them. ampicillin implies the need for high dose therapy for serious enterococcal Continued on Page 5

Page 4 Continued from Page 4 o Stool specimens for Culture The lab may be contacted and Ova and Parasites will not within this five-day period at routinely be processed when 402-8190 if further parasite collected from inpatients who evaluation is required. have been hospitaliml for more than three days. However, if o Only one stool specimen for the epidemiology or clinical ova and parasite should be findings, e.g., submitted in order to document immunocompromised host, a parasitic infection. The warrant processing of a previous recommendation specimen submitted more than requiring three samples was three days post-admission, based on an old epidemiological physicians may contact Georgia study with asymptomatic Colasante, Microbiology patients. An exception to this Supervisor, at 402-8190, or relates recommendation to Diane C. Halstead, Ph.D., intermittent shedding associated Director, Microbiology/ with Giardia Iamblia. If the Virology//FCM, at Giardia antigen screen is beeper 1193. negative, but you still suspect this parasite, submit a second specimen at least three days after the first specimen for a repeat Giardia antigen screen.

Scheduling of Ultrasounds

a Recently' the Department of sound at 17th & Chew, call 402-2450; /Diagnostic Medical Imaging at Cedar Crest & 1-78, call 402-8080. discontinued obstetrical ultrasound services. As a result, the previous If you have any questions regarding backlog of other ultrasound requests, this issue, please contact Thomas R. as long as several weeks at 17th & Fitzsimons, M.D., radiologist, at Chew, has been eliminated. 402-2214. Routine outpatient ultrasound studies a Obstetrical ultrasounds are now can now be performed in one or two handled through the Perinatal days of request at 17th & Chew. In Diagnosis Testing Center located in the addition, prostate ultrasound· and Center for Women's . biopsy protocols are now uniform at Obstetrical ultrasounds may be both sites. These procedures can be scheduled by called 402-9595 (until scheduled with little or no delay at May 24). After. May 24, the number 17th & Chew. To schedule an ultra- to call for scheduling is 402-7100. )

Page 5 1 Library a The Health Sciences Library at a New acquisitions to the Health Cedar Crest & I-78 is seeking Sciences Library at 17th & Chew News donations of the following journals: include:

Mayo Clink Ptvceldings - Volume 67 Gabbe. Ob*lrlcs: Nol'llllll tllld 115 (May), 16 (June), #7 (July), and #8 Ptvblem Preg111111CU1. 2nd ed., (August), 1992. Churchill Livingstone, 1991. Joul'lllll of Nru:lear Ml4idae - Volume 32 #11 (November), #12 Guyton. HUIIUIIJ PhyliolDgy tllld (December), 1991. Mecluudsm of Dis~~Ue. 5th ed., W.B. Bmergeney Medkine - Volume 23 Saunders, 1992. #14, #15, #18, #20, 1991. Emergency Medkine- Volume 24 #1, a Remote Access to Medline is still 1992. going strong. For current information regarding additional databases a The following journals are now available, contact Sherry Giardiniere at available in the Computer Laboratory 402-8406. section of the library:

Conaputen tllld Biomediclll Eductltion Conaputen cl Ml4idae M.D. Conaputing Phyricilm1 tllld Conaputen

Celebration of Life -

Lehigh Valley Hospital is sponsoring a Office displays with seed packets are also being distributed to participating Celebration of Ufe to heighten awareness of the importance of physician offices specializing in and gynecology, internal mammography and to increase patient awareness of Lehigh Valley Hospital's medicine, family practice, and general women's health services. . In July, Comprehensive Breast Services The campaign kicked off on May 1 brochures be sent to all with 20,000 seed boxes mailed to will participating physician offices to women ages 40 to 64 in Lehigh Valley replace the seed packets in the waiting Hospital's primary service area. The boxes contain a packet of flower seeds, room displays. a booklet on mammography and breast self examination, and a $10.00 For more information or to participate, discount off mammography services at please call WomanCare at 402-3800. Lehigh Valley Hospital.

) Page& Neurophysiology Lab Extends Hours

The Lehigh Valley Hospital o 24° Ambulatory Monitoring (BEG) Neurophysiology Laboratory is o Long Term Video Monitoring (BEG) dedicated to meeting the growing needs o Brainstem Auditory Evoked of the community. Therefore, in order Potentials to provide more convenient service for o Visual Evoked Potentials your patients, beginning May 10, the o Somatosensory Evoked Potentials hours for outpatient services will be - Upper & Lower Extremities, OR extended. Monitoring o Visual Fields Testing New hours for the Neurophysiology o Multiple Sleep Latency Testing Laboratory at Cedar Crest & 1-78 are (MSLT) Monday, Tuesday, Wednesday, and o EMGINC Testing Friday from 7 a.m. to 5:30p.m.; o Botulinum Toxin Injections (Botox) Thursday from 7 a.m. to 8 p.m.; and - for treatment of Dystonia Saturday from 8 a.m. to 2 p.m. (Torticollis, Blepharospasm, Hemi-facial Spasm, and focal The hours for the laboratory at 17th & limb Dystonia) Chew will remain the same - 8:30 o Autonomic Testing a.m. to 4:30p.m., Monday through Friday. For additional information or scheduling, please call the Services currently available for Neurophysiology Laboratory at 402- pediatric and adult patients include: 8860 (Cedar Crest & 1-78) or 402-2297 (17th & Chew). o Electroencephalography (BEG) -Routine - Sleep/ Awake - with Anterior Temporal Leads

News from Home Care

Richard Steigerwalt has returned to the Lehigh Valley Hospital family as from 1970 to 1974 at Physical Therapy Manager of Lehigh Allentown Hospital, and Director of Valley Home Care. Many of you may Physical Therapy at Lehigh Valley remember Dick, who has 32 years Hospital Center from 1974 to 1984. experience in physical therapy. Prior to the hospital merger, Dick was Chief During the last nine years, Dick has of Physical Therapy from 1962 to 1969 . served as Director of Physical Therapy at Allentown Hospital, Director of at Palmerton Hospital. Welcome back! )

Page 7 Frequently, the Department of Legal Pennsylvania, you generally do not Services/Risk Management receives have to be concerned about deciding telephone requests for information how much insurance you should carry. from the Medical Staff related to legal The primary limits will be provided as issues, ethical concerns, risk required by state law, and of course, Legal management, and insurance questions. every health care provider in In response to these requests, this Pennsylvania also has a million dollar Briefings column will appear in Medical Stqff secondary layer provided by the CAT Progress Notes every other month. Fund. (The Medical CAT Fund is not Your input and questions are welcome. to be confused with the Automobile CAT Fund.) Insurance policy questions are a frequent area of concern. Good advice Most malpractice policies today are includes re-reading your policy at least claims-made, this pays only if the once a year to make sure it covers you incident occurs and the claim is for what you actually do. If you are brought within the policy period. If changing insurance companies, you you leave a claims-made policy, you may want to call the State Insurance may need to buy a tail, which can cost Department for information about the as much as six times the cost of your solvency of the company. A new last years premium. It is vitally company offering lower rates to secure important that you notify the carrier as your business may be placing soon as you become aware of a themselves at a high risk (and you potential claim. Many policies do not also, if the company folds just when cover libel and slander, intentional, you need them!). You may also want criminal, grossly negligent acts, as to check the rating assigned by Best. well as sexual misconduct. In assigning letter grades to each company, consideration is given to If your carrier doubts that a particular assets, management, loss reserves, and claim should be covered, they will profitability. Obtaining a copy of the send you a "Reservation of Rights" company's financial statement is also letter. Your defense will continue, but helpful. Check to see if it is certified the carrier may refuse to pay the by one of the national accounting ultimate judgment. If you receive such firms. Ask your own accountant to a letter, you should inform your look at it to see if the carrier's reserves personal attorney immediately. seem adequate. Find out if the company is backed by the State Guaranty Fund, which pays claims against insurers if the company goes bankrupt. Check with your colleagues to find out what kind of service you will receive after you are sued. You should determine what your rights are in choosing counsel if you are sued.

Since the limits of insurance coverage are actually state mandated in

Page 8 Clinical In an effort to provide you with their hospital stay. Family members nutrition information which may and caretakers are welcome and 1Nutrition benefit your patients, this column will encouraged to attend. News appear in the newsletter regularly. Topics covered in the class include: The Prudent Diet by Barbara CarlsonM.S., lt.D. o selecting a diet with 20% or less of the calories from fat ., How many inpatients are educated on (under 7% saturated) • o limiting cholesterol to 175mg the prudent, low fat, low cholesterol diet every month at Lehigh Valley per day or less Hospital? The answer: over 200 o increasing dietary fiber and individuals receive education on this decreasing simple sugars diet prior to discharge. o the relationship of blood lipids (cholesterol and triglycerides) to Looking toward the future, however, coronary artery disease and clinical dietitians, along with all other current knowledge about diet hospital departments, anticipate shorter control patient stays. Shortened patient stays o interpreting food ·labels will require more rapid education and correctly intervention. The short time o dining out and special occasions constraints will require diet education to be accomplished when patients are This class is free of charge to any still acutely ill and unable to fully patient referred by a member of Lehigh comprehend their diet. Valley Hospital's Medical Staff. A prescription slip should be sent with However, the clinical dietitians have a the patients you refer. Notification strong desire to provide quality will be sent to your office after your education with useful, workable patient attends the class. guidelines and goals which will give patients the information needed to A brochure describing the class, dates modify their diet after they leave offered, and reservation information is Lehigh Valley Hospital. available through Clinical Nutrition Services. For copies of the brochure The Clinical.Nutrition Department or if you have any questions regarding decided to try a new approach toward this new class, call the Clinical cardiac diet education. Beginning Dietitians's Office at 402-8313. April 12, an early evening class for cardiac patients and their families was initiated. The class is offered from 6:30 to 7:30p.m., two Monday evenings each month.

The one-hour class is available and appropriate for patients prior to ) admission, after discharge, or during PageS Short Stay Unit Changes Name

Effective May 8, the Short Stay Unit If you have any questions, please changed its name to 3C with the contact Julia Clelland, Director, Patient implementation of PHAMIS I..astWord. care Services, 3C, at 402-8228. All signs will be changed to reflect 3C. Patient location in the LastWord system will be 3C plus the room number, i.e., 3C11A.

News from Research

Calls for abstracts have been issued by the American College of For instructions, forms, and further for the 58th Annual information, contact Kathleen Moser in Scientific Meeting to be held in New the Research Department at 402-8889. York on October 4, 1993. Submission due date is May 31.

Letters of Appreciation

) Page 10 Congratulations!

Jeffrey L. Gevirtz, M.D., urologist, Dolores M. Sarno-Kristofits, Ph.D., was recently informed that he psychologist, successfully completed successfully completed all the her doctorate at Temple University. requirements for certification and is The title of her dissertation is now certified as a Diplomate of the Ericksoulan Psychosocial Stqes of American Board of . Development and its Relatio:nsbip to Post-Traumatic Stress Syndrome. Lester Rosen, M.D., colon-rectal surgeon, has been appointed to a two- Edward A. Tomkin, D.O., year term as an Associate Examiner by otolaryngologist, was recently certified the American Board of Colon and in and Facial Rectal Surgery. As an Associate by the American Examiner, he will be involved in all Osteopathic Board of & aspects of the examination process for Otorhinolaryngology. board certification in colon and rectal surgery, including preparation of test items for the written examination and participation in the oral examination.

Publications, Papers and Presentations

Glen L. Ollver, M.D., ophthalmol- February, 1993 issue of the British ogist, recently attended the fourth Journal of OphtluJlmology. meeting of the Schepens International Society jointly organized with the Robert B. Kevitch, M.D., plastic and Chinese University of Hong Kong in reconstructive surgeon, participated in Hong Kong. He presented a 27-year a panel discussion as part of a program follow-up of the Oliver-McFarlene entitled Breast Health in the 90's. Syndrome (Congenital Trichomegaly The program took pl8ce in East with Associated Dwarfism, Pigmentary Stroudsburg and was sponsored by the Retinal Degeneration, Mental American Cancer Society. Retardation and Cerebellar Degeneration). Nine other cases have lndm T. Khubchandani, M.D., now been reported in the literature. colon-rectal surgeon, was invited to Evidence of axonal peripheral participate in a Round Table on neuropathy and cerebellar degeneration Compllc:atious in DJaestive Stoma at was found in this patient and its the First World Ostomy Congress for development should be anticipated Health Professionals in Madrid, Spain, when the syndrome is recognized in on Apri113 to 16. The meeting was younger people. organized by the Spanish Ostomy Association with International Dr. Oliver also co-authored an article, Cooperation from World Health Necrotic Orbital Melanoma Arising Organization (WHO) and International ) De Novo, which was published in the Ostomy Association (lOA).

Page 11 Upcoming Seminars, Conferences, and Meetings

Medical Grand Rounds Update on Urioary Tract Infectious will be presented by Charles Reed, Rheumatic Fever in the 90's and Post M.D., Chief, Section of General Streptococcal Diseases will be , St. Christopher's Hospital presented by Donald D. Goldsmith, for Children, on Friday, June 4, at M.D., Professor of Pediatrics, Temple noon. University School of Medicine, and Director of , St. Case ·Presentations in Pediatric Christopher's Hospital, Philadelphia, Emer&enc:ies will be presented by on Tuesday, May 18. Douglas Baker, M.D., Division of , Children's Non-Steroidals in the Elderly will be Hospital of Philadelphia, on Friday, presented by John DiGreggorio, M.D., June 18, at noon. Professor of Pharmacology and Medicine, Hahnemann University, All conferences, except the Pediatric Philadelphia, on Tuesday, May 25. Symposium, will be held in the Auditorium at 17th & Chew. Medical Grand Rounds are held on Tuesday of each week beginning at For more information, contact Beverly noon in the Auditorium of Lehigh Humphrey in the Department of Valley Hospital, Cedar Crest & 1-78. Pediatrics at 402-2410. For more information, contact the Psychiatric Grand Department of Medicine at 402-8200. Rounds Department of Pediatrics Review of the Catatonic Syndrome will be presented by Gregory Members of the faculty of St. Fricchione, M.D., Department of Christopher's Hospital for Children, , Health Sciences Center, Philadelphia, will participate in the State University of New·York at Stony Pediatric Symposium on Thursday, Brook, on Thursday, May 20, at noon, May 20, from 1 to S p.m., in the in the Auditorium of Lehigh Valley Auditorium of Lehigh Valley Hospital, Hospital, 17th & Chew. Cedar Crest & 1-78. Topics and speakers include What's New in the As lunch will be provided, DiGeoqe Syndrome to be presented preregistration is requested. For more by Angelo DiGeorge, M.D.; Chrome information or to register, call Lisa in Pain in ChUdren and Adolescents by the Department of Psychiatry at David Smith, M.D.; and Kidney 402-2810. Transplants in ChUdren: ll Years' Experience by H. Jorge Baluarte, M.D. Waldo Nelson, M.D., will serve as Panel Moderator. ) Page 12 • For Sale or Leae - Springhouse • For Leae - Medical office space located In ProfealoMI c.. t •• 1575 Pond Road. Ideal Southeest Allentown ....- Mounulnvlle for phyllc:IM's office. Approxlmetely 2,500 Shopping Cent•. sq. ft. Wll finish spece to specifications. • For Leese - Slota .. currently ..,....,._ for • For Sale or Leae - Medlcal-profealoMI the Brown Beg suite et Kutztown Profeulonal office building on South C... Crest C..t•. Boulftn, just mhlt• tram Ceder Crest • 1- 78 8lld 17th. Chew. 3,580 tOUIIsq. ft. • For Leae - SMre l•ge medical office n.. Ample pMdne. ucurltylftre alarms Installed. Ceder Crest • 1-78. Fuly fumllhed llld Ideal for .,...,.._. group. staffed. Multiple lne phone ~em. Computerized ...... ,....,.., • For Sale - Office building et Northeat c:onw of 19th 8lld T..,... Streets In • For Leae - Spec:llfty prectlce tlme-stwre Alentown. UPI* level- 2,400+ sq. ft., large spece ..,...... In • comprehensive heelth -=-• welting room, two a.ge COR8Uitatlon rooms. fedlty...... Profenlonel en.. 4019 five uem rooms. etc. Low• level - 2,300 + Wymewood Drive. Leurya Stetlon. Helf- or sq. ft. Perking lot for 18 '*-· ful.dey llotlllmrnedletely ..,......

• For Leae - Medlcel office space located In • For L... e - Shere spece In MOB 1 on the Puchtree Office Plue In Whltehell. One suite campus of Lehigh Veley Hospital. Ceder Crest with 1 ,500 sq. ft. (Wiflnlthed - allowance • 1-78. Approxlmetely 1 ,000 sq. ft. Three avellableJ, and one 1,000 sq. ft. finished suite. exam rooms.

• For LeMa- Medlcel-prof•slonel office For more lnformetlon or for •~ce In spece located on Route 222 In W•cosvlle. finding epproprlllte office spece to meet your Two 1 ,000 sq. ft. offices available or combine needs, contect Joe Pile, POPS Rep, et to form l•ger suite. 402-9856.

WHO'S NEW Daniel M. Rappaport, MD Mishkin, Rappaport, Shore The Who's New section of Medical 3321 Chestnut Street Whitehall, PA 18052 Skiff Progress Notes contains an (215) 262-7123 update of new appointments, address (Effective June 1, 1993) changes, newly approved privileges, etc. Jo-Anne A. Steward, MD Fogelsville Medical Associates Please remember that each department 7671 Schantz Road or unit is responsible for updating its P.O. Box 952 directory, rolodexes, and approved Fogelsville, PA 18051-0952 privilege rosters. (215) 395-3400

Medical Staff Lehigh Valley Medical Associates (James T. McNelis, DO, Michael R. Goldner, Change of Address DO, and John M. Kauffman, Jr., DO) 1255 S. Cedar Crest Blvd. Suite 2200 Domenic M. Falco, DO Allentown, PA 18103 Emaus Avenue Family Practice (Effective June 11, 1993) 1101 W. Emaus Avenue Allentown, PA 18103 Continued on Page 14

Page 13 Continued from Page 13

Appointment of Medical Allied Health Director - Ambulatory Professionals Pediatrics Appointments Cbarles F. Smith, MD 1bomas W. Lane, PbD Additional Privileges Associate Scientific Psychologist 1bomas D. Meade, MD (The Guidance Propam) Department of Surgery Division of Beverly C. Woodward, RN Section of Orthopedic Trauma Physician Extender Endoscopic Carpal Tunnel Release Professional - RN Privileges (Falnily Pecliatriciaoa - Dr. Kean)

Daniel M. SUverbeq, MD Change of Category Department of Surgery Division of Urology Elizabeth D. Hawley YAG and C~ Laser Privileges Physician Extender Technical to Professional F. Geoffrey Toonder, MD Dental Assistant to Dental Hygienist Department of Surgery Division of Cardio-Thoracic Surgery Jane L. Kulhamer Video Assisted Thoracic Surgery and Physician Extender Thoracoscopy Privileges Technical to Professional Dental Assistant to Dental Hygienist Change of Status ' Supervising Physician Joseph J. Prorok, MD Changes Department of Surgery Division of ~na M. Filla, RN From Active/LOA to Honorary Physician Extender Professional - RN Resignation (ramar D. Baroelt, MD) Change Alternating Supervising Physician from Alan Berger, MD to Roberta B. Gonzalez, MD Linda Lapos, MD Department of Psychiatry Ruben P. Romero, PA-C Physician Extender Physician Assistant (F. Geoffrey TOODder, MD) Add Substitute Supervising Physician - Nercy 1afari, MD

Continued on Page 16

Page 14 Continued from Page 14

Resignations Richard R. Grabowski, PbD Associate Scientific Mary Ann Butler, RN Audiologist Physician Extender Professional - RN Gretchen C. Gray, RN (Mahmood A. Tahir, MD) Physician Extender Diane C. Fabiani, CMA Professional - RN (Gregory M. Lang, MD) Physician Extender Technical CllrWtine S. BDienbrand, CMA Medical Assistant Physician Extender (Children 'a HealthCare) Technical Jean E. F1sc:ber, PA-C Medical Assistant (Children's HealthCare) Physician Extender Physician Assistant Patti A. Hutehiawn, RN PA-C Extender (F. Geoffrey Toonder, MD) Physician Professional - RN (Concepcion Tan Yen, Greta Flederbach, PA-C MD) Physician Extender Mary-Lou T. Mayernick, RN Physician Assistant Physician Extender PA-C (Levine and Busch, PC) Professional - RN (Iohn J. Cauel, MD) Sheri L. Fredrick-Deeb, RN JUI D. Moyer, RN Physician Extender Physician Extender Professional - RN ( Care Specialists) Professional - RN (Valley OB-GYN Associates) Sharon K. Gable Physician Extender Technical Dental Assistant (David H. Packman, DDS)

Vldd L. Givler Physician Extender Technical Medical Assistant (Lehigh OB/GYN, PC)

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The following actions were taken attha April12, 1993, and Therapeutics Committee Meeting James A. Giardina, Diractor Fonnulaty Considerations of Pharmacy Strrmp-tbtm Wbtlt1 moderately emerogenic cancer chemotherapy. Oral Ketorolac (I'orrttiDI, SyRia-) was discussed Ondansetron inhibits 5-HT1 Receptors and fur fOrmulary addition. Key data discussed were appears to block serotonin in the area posttema of its lack of advantage in clinical trials over the 10 the brain, the gut, and/or other regions of the other NSAIDs on funnulary and its cost relative central nervous system. Oral bioavailability is to other NSAID'S. Ketorolac produces similar 60% with peale levels seen in 1.5 hours and half pain relief to ibuprofen, naproxen and diilunisal in life of 3-6 hours. Ondansetron is extensively trials in post-op orthopedic and dental and oral metabolized via the Cyux:hrome P-450 System. surgery procedures. Table 11ists some key Studies to date have compared it only to placebo comparative data. in various chemotherapy regimens. The most common adverse drug reactions include head- Oral Oadanletron (ZDfrM, Glco) -is the oral ache, diarrhea and coostipation. funn of the previously approved injectable antiemetic. Oral ondansetroo is indicated fur the The recommended oral dose is 8mg given 30 prevention of nausea and vomiting associated with minutes befOre emetogenic chemotherapy and subsequent doses 4 and 8 hours after the first dose. It should then be given as 8mgTID fur 1-2 days after completion of chemotherapy. Ondansetron has not been studied in renal patients. The total dose should not exceed 8mgl day in severe hepatic insufficiency. The cost of8mg ondansetron is $15 .00/tablet Aspirin• 500-lOOOmg Q4-&H *».13 (yes, you did read it axrectl.y). The Committee Acetaminophen Tylenol 500-UXXJmg Q4-&H «XJJmg IUl5 requested that usage guidelines be developed to assure appropriate use. Ibuprofen Motrin 200-800mg Q4-8H 3200mg ll.20 Naproxen Naprosyn 500mg initial, Q6.8H 1500mg $3.36 Parmetine (P.U, SKB) - is the latest Selective then Serotonin Reuptake Inhibitor (SSRI) to be 250-375mg approved. It is indicated fur the treatment of depression. Paroxetine is more potent and more Naproxen Anaprox 550mg initial, 0&-8H 1375mg $2.70 selective than either Buoxetine or senraline. Sodium then 275mg Parmretine is well absorbed although availability is Oiclofenac Voltaren 25-75mg Q6.8H 200mg $2.96 reduced due to first pass metabolism. Paroxetine Indomethacin lndocin 25-50mg 08-12H 200mg 1).12 has a half life of 12-20 hours; is highly protein (95% Oiflunisal Dolobid 1000mg initial, 08-12H 1500mg $2.60 bound ), and metabolized to essentially then 500mg inactive metabolites prior to excretion in the urine and feces. There appears to be wide interpatient Nabumetone Relafen 1000mg initial, Q12-24H 2000mg $1.50 phannacokinetic variability due primarily to the then 500mg existence of exten5ive and poor metabolizers. Piroxicam Feldene 10-20mg Q12-24H 20mg $1.40 This vuiabil:ity is also obsenred in renal impaired kulindac Clinoril . 150-200mg • Q12H 400mg 1).40 and cirrhotic patients and dosages should be adjusted. UnliJce Buoxetine, Paroxetine is Tolmetin Tolectin 200mg-400mg 08H 2000mg $3.90 excreted in pharmacologically significant quanti- KETOROlAC PO TORAOOL 0811 ... sus ties in breast mille. Therefure it should not be • Aspirin in higher doses may be used for rheumatic diseases. Page 17 Formulary Considerations

Conlillllll ...... , used in breast feeding women. 20mg daily. Doses may be adjusted upward in 10mg increments no more often than weekly to Commoo side effects are similar to other SSRis. SOmg/day. With the addition ofParoxetine and Parmetine appears 1D cause more sedation and apparent shift away &om Trilfet:racyclics. the amstipation than other SSRis and mere headache Conunittee asked Psychiatry to review these and dry mouth than fluoretine (similar to apnts fDr possible formulary deletions. senraline). Parozetine causes less anorexia than Parmetine oosts $1.S0/20mg tablet. flUOllletine. When rakm at night, Parmetine has caused some sleep disturbances. Consequently, Dyprota (Blirlc&) - is a combination product the dose should be rakm earlier in the day. Drug cmClining nne oxide, peaolatmn and other intenctions include MAO inhibitors .(significant). protectants used to prevent/treat diaper rash. . and agents metabolized by the Cytnchrome P- Dyprotex bas similar ingredients to Desitin and is 450 System (cimetidine. phenytoin. used similarly. Dyprou:x oomes in individual phenObamtal, wufirin, etc.). Patients should applicaur packages. Dyprou:x was added to the have a two week free intenal between Parmetine fOrmulary. and MAOI . The usual starting dose is

Drug Use Evaluation

Ifthe Gilt Wtris•••••.• U.wlt! appropriate patients. A total of91 (69%) out of 131 identified patients were axwerted. 70 (53%) Famotidi.ae IV to PO - Results from a two were changed from IV to PO, 20 (16%) had month study to couva t injectable famotidine to orders fDr either route and were converted to PO. oral therapy in patients currently receiving at least An additional24 (18%) therapy discontinued 2 scheduled oral meds were discussed. Ow-t had - this later group was not included in the 69% requests were used to SIJ8FSt conversion in cmvenion. Drug acquisition savings alone amount to $8000 annually. H other supply and labor oosts were included, the savings would nnge to $24,000. CiprofloDcia IV to PO - IV Ciprofloxacin 200mg 500mg Q12H $13.00 $2.10 patients who have had no apparent cmtnindications to oral therapy were also 750mg Q12H $25.00 $2.40 targeted for conversion requests. While the total Editor's Nots: The intrn1111ous route for bath t.motidine 1nd ciprotiDKICin should number of eligible patients (18) and number of only be used when thllf'fl 1re contrlindicltions to Ofll therlpy. Effic1cy is no successful conversion (12) were smaller, the gre1ter for either mediCition when gillen IV. Also, both medicltions m1y be were also around $8,000 annually given crushed 1nd 1dministered vii feeding tubes (i.e., NG, Dobhoff, etc.} if Gl savinas the large cost difference the PO and IV 1bsorption is felt to be 1dequ1te. · between furms. See Table 2.

Page 18 Target Antibiotics Ceftazidime High empiric use (13%) continues although average length oftheraPV (LOT) has decreased. Data from March, 1993 were presented. Areas of b:us were Ceftmdine, Oprofloxac:in and IIBcomtnendation~ Csftuidime is tlt:ommended to trelt gflm negative ucH/i in cefuolin tlli6t6nt pstientl or to Ampic:illin/Sulbac:tam. Ampicillin/Sulbactam trest pseudomon11 when piper~cilin is not sppropriltl usage review was limited to surgical prophylaxis (sllergy, resistsnceJ. cases only. Ciprofloxacin High empiric use continues (77%) also with decreased LOT. Recommend6tions - IV ciproflo1t1cin use should be limited to ruismnt 111Dbic gram-neg1tive ucilli (e.g. Temporary Shortage of Poudomon•s. Entllroblt:tflr, s.n.ti1}. Orll therspy should Hydralazine be considered in 111 pstients with 1 functioning Gl trlct The Committee was informed that IV Ampicillin/ Only 7 cases were reviewed. Data showed pre-op given in Hydnlazine is pnerally unavailable due to the Sulbactam patient care areas. LOT ranging from 1 dose to 10 days discontinuation of production by one of the only (Surgical 1 (ave. 3.5 days) and majority with no documentation of need two manu&cturers. Alternative agents should be Prophytaxis only) (+specimen.+ complications,+ signs of infection post-op). CXXISidered if at all possible until the shortage ends Recommendstion~ The 11'1iew liteflfllfl generally (hopefully May, 1993). flt:ommends cef1zolin for mOlt surgic1l procedutl& Csfuolin/MIItroniiMzole or Cefotetln (2nd generation} ,,. 11commended for prophyii1Cis in surgic11 ,,., whtfl Bnserobes msy be present M1ny references now 11commend one doss 111tt:ept in prolonged oper6tions sndlor csrtsin proceduru. The pre-op dOSB should be given within 2 hours of incision.

The Committee recommended that a more comprehensive review of surgical prophylaxis be conducted.

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liM/,_, SIII/I ,.,.,._ Nllla Harry W. BucbaaanlV, M.D. il ..... d ...... , ... Joseph A. Candio, M.D. Joaph A. Caadio, M.D. John B. Cutalclo, M.D. L'".. V*J President, Medical Staff ..,__die Vic10r J. Colaai, M.D...... s.tr ... John B. Castaldo, M.D. Robert V. Cummiop, M.D. ..,,_,..,. President-elect, Medical Staff Carl F. D'AIJaelo, M.D...... w ...... s... John Jaffe, M.D. Robert B. Doll, M.D. Ar&B ...... Put President, Medical Staff John D. Famll, M.D. John P. Faqibboal, M.D. .. J..t M. leg' d ..-, John Hart w. Micbae1 H. Oellor, M.D. ...,... Ollil:e :l'or:tim Vice President Mart A. Gittlo-. M.D. Satica, 1243 s. Cedu-Cnst Rita M. Mest Gooclreau, lame• J. M.D. PA Medical Staff Coordinator 'lbomu A. HuachiiiiOD, M.D. ••••d.11113, ., ...... _, lint ., .... John Jaft'e, M.D. Micbae1 W. K.aufmum, M.D...... If,_ ...., 81 Janet M. LaudcmsJaaer GleDD S. KraiZCr, M.D. ••estio•• about tlae Physician Office Practice Mart C. LeDr, M.D. • ...... , ...... al Mil. Services Rolllld A. Lutz, M.D. , ...... I ... at -..s3o Managing Editor Alphon~e A. Maffeo, M.D. D. LyDD Morria, M.D. Paul B. Nurick Waltor J. Olamaki, M.D. Roberti. Oriel, M.D. JohnJ. Shane, M.D. John D. VIDBrakle, M.D. Headley S. White, M.D. Johns. Ziealer, D.D.S.