Healing. Reimagined. 2016 Clinical Annual Report Photograph: © Anton Grassl/Esto Dear Colleagues,

As we approach the end of the calendar year and enter the holiday season, it is time to reflect on our achievements of the past year and look to the excitement of 2017. I am pleased to share the 2016 Clinical Annual Report, which has been carefully prepared by each of your Department Chairs.

2016 will forever be defined by the opening of the long-awaited new Stamford Hospital. The opening reception for the Medical Staff, held in the lobby of the new hospital, was intentionally the first of many celebrations and a recognized tribute to the importance of our physicians. The number of physicians in attendance was a new record for any single event in the history of Stamford Hospital.

In this Annual Report, you will see the continued focus on safety and quality from each of the departments and now, with the opening of our new hospital, an incomparable level of service. As a result of this, our medical staff continues to grow and we consistently see an increase in the number of physicians joining our impressive, loyal and experienced staff. The 2015 and 2016 Engagement Surveys show the level of engaged and aligned physicians increasing, especially in the largest group, the independent physicians. And finally, our Physician Participation Campaign has almost reached the anticipated goal of an unprecedented $4 million in contribution to the Stamford Hospital Foundation.

So with gratitude, appreciation and pride, I prepare this letter for the third and final time, as I reflect on what a privilege and a pleasure it has been to serve this extraordinary medical staff. I look forward to a continued partnership with the physicians of our medical staff, Department Chairs, Hospital administrators and executive leaders of Stamford Hospital.

I wish you and your families a happy and healthy holiday season and an exciting 2017!

Josh Herbert, MD President, Medical Staff Dear Colleagues,

It is that time of year again and I am pleased to share with you the 2016 Clinical Department Annual Report, prepared by your respective Chairs. This year, our focus was on our journey of Healing. Reimagined. changing the way patients think about their health.

The Chairs begin 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 multidisciplinary collaboration for the purpose of providing high-quality patient-centered care. This is exemplified in the development of new programs and the expansion of others; recruitment of new talent – adding 70 members to the medical staff; medical education and research; and many accreditations and accolades. This work would not have been possible without a dedicated medical staff committed to improving the health of our patients and community.

In the past year, there have been many remarkable achievements and growth. We opened a new hospital, expanded our ambulatory footprint and significantly expanded our physician practice network; steps towards solidifying our vision to be the recognized regional center of health. We announced several strategic collaborations: the Bennett Cancer Center joined the Dana-Farber/Brigham and Women’s Cancer Care Collaborative and became the first member in Connecticut; we partnered with Hospital for Special Surgery to develop a premier center for specialty orthopedic care in New England; and we joined forces with Sacred Heart University to serve as the primary clinical rotation placement site for the Physician Assistant training program. Additionally, in May we had our 1st Annual Research Day, which was very successful. To date, 232 patients have been enrolled in clinical research trials. Also, we exceeded our goal to decrease preventable harm to patients by 50% in two years, with a decrease of 64%.

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. Towards this end, physician engagement is at an all-time high, with improvements in all physician categories. Attendance at both the Doctor’s Day and the new hospital physicians’ opening reception set historical records for physician attendance.

I want to personally thank the Chairs, medical staff and all the Hospital departments for this incredible body of work and for all that you do for our patients. Together we move forward faster, and I look forward to our continued collaboration and sharing this journey with each of you.

I wish you and your families a happy holiday season and a healthy and prosperous New Year.

Sharon C. Kiely, MD, MPM Senior Vice President, Medical Affairs Chief Medical Officer Patient Safety Officer Stamford Health: Annual Report 2016

Table of Contents

Anesthesiology 04

Emergency Medicine 10

Family Medicine 18

Medicine 26

Obstetrics & Gynecology 58

Pathology 66

Pediatrics 74

Psychiatry 84

Radiology 92

Surgery 104

2016 Clinical Annual Report 3 Recovery. Enhanced.

Anesthesiology

We have extended our regional anesthesia service to include a broad range of surgical subspecialities, thereby decreasing intra-op anesthetic requirements, reducing narcotic usage and greatly enhancing a patient’s post-operative comfort.

4 2016 Clinical Annual Report Department of Anesthesiology: Annual Report 2016

Betty Ann Robustelli, MD Chair, Department of Anesthesia

A Message From The Chair The Year in Review

This is a momentous year for Stamford Hospital with the opening Every anesthetizing location is equipped with an iPad that is used of the beautiful new hospital. Stamford Anesthesiology Services strictly for the iPro EMR system. Eric Jankelovits, MD has dedicated (SAS) is proud to be a part of the Stamford Hospital team and the countless hours in preparation for launching this system, and extraordinary effort, time, planning and preparation by all involved we thank him for all of his hard work. to ensure a seamless transition to the new hospital. With all new things come change, and I am proud to say that SAS has made The iPro EMR has enhanced the Department’s quality measures advancements and growth of its own. reporting and compliance. The Quality Measures Reporting portal is a clinical data repository used for automatic registry reporting Stamford Anesthesiology’s ever-growing Department continues of clinical outcomes and quality measures data required by to recruit highly qualified anesthesia providers. This year, the pay-for-performance metrics. The application collects the required SAS Cardiac Anesthesia team welcomed Devon Jeffers, MD, after measures for AQI. Stamford Anesthesiology reports on the following completing his training in cardiothoracic anesthesia at Johns Hopkins PQRS and non-PQRS measures: Preoperative Beta-Blocker in and working at Suburban Hospital for two years. We also welcomed Patients with Isolated CABG Surgery; Prevention of Central Venous Kanishka Rajput, MD, who completed her fellowship in Interventional Catheter-Related Bloodstream Infections; Documentation of Pain at Medical College of Wisconsin in 2013. Dr. Rajput is board Current Medications; Post-Anesthesia Transfer of Care Measure; certified in both anesthesia and pain management and has proven to Anesthesiology Smoking Abstinence; Prevention of Post-Op be a great resource for our team. Suhaib Chaudry, MD joins us after Nausea and Vomiting; Composite Anesthesia Safety; Perioperative finishing his residency at the University of Connecticut this summer. Mortality Rate; Injury from Central Line; Perioperative Temperature SAS has also added five CRNAs to the group: Yana Krmic, Holly Thiel, Management; Overall Anesthesia Safety; Dental Injury; Corneal John Martinez, Jillian Davis and Vince Brunelli, who bring years of Abrasions; and Care Plan. experience to our practice. The nerve block program remains strong and SAS maintains an Thanks to the support of Stamford Hospital, SAS has implemented extraordinary number of providers who maintain clinical proficiency an electronic medical records system in partnership with iProcedures. in regional anesthesia. This is highlighted by a core team who, It is a cost-effective, comprehensive end-to-end mobile perioperative through fellowship training or demonstration of clinical excellence, information management solution designed and perfected serve as leaders. Although our number of regional anesthetics by practicing anesthesiologists. This anesthesia information has declined slightly, our percentage of patients receiving nerve management system supports fast, accurate clinical documentation blocks continues to increase. Regional anesthesia has always been and helps reduce medical errors, resulting in complete, compliant, a mainstay for orthopedic surgery, but SAS has extended this type legible anesthesia records. It will now streamline the preoperative, of service to include a broad range of surgical subspecialties. These intraoperative and postoperative anesthesia workflow. include: obstetrics and gynecology, general surgery, breast, colon

2016 Clinical Annual Report 5 Department of Anesthesiology: Annual Report 2016

and rectal, bariatric, thoracic, trauma, urology and gynecologic • Jay Freilich, MD • Richard Morgulis, MD oncology. These adjuncts decrease intra-op anesthetic requirements, • Ronald Giannotto, MD • Benjamin Unger, MD reduce narcotic usage and greatly enhance a patient’s post-operative • Ewelina Gibek, CRNA • Shiry Weisberg, MD comfort. We anticipate, with the addition of the HSS/Stamford • Juliet Jackson, MD • Thomas Wong, MD Hospital collaboration in February 2017, our orthopedic volume • Eric Jankelovits, MD • Kristen Butkovsky, CRNA will increase, only furthering our regional block program. • Jeffrey Klein, MD • Jen-Hwei Cheng, CRNA • Alla Koorn, MD • Richard Libutti, CRNA • Adnan Malik, MC • Rodrigo Mendes, CRNA Scope of Clinical Services • Sergio Manimbo, MD • Donna Nunno, CRNA • Maria Mazzeo, MD • Alan Summerfield, CRNA The Department of Anesthesia provides services throughout Stamford Hospital at over 27 anesthetizing locations. In addition Hospital Committees: to supporting basic surgical needs, the Department is an integral Department members participate in various Hospital part of obstetrical and maternity cases in Labor & Delivery, committees, including: Endoscopy, Interventional Radiology, MRI and CT Scan Studies, the Cardiac Catheterization Lab, EP Studies and Emergency Room. • Credentialing Committee – Dr. Steven Finkel As shown in Figure 1, overall case volume for FY2016 was 20,891, • Trauma Committee – Dr. Brian Sullivan and Dr. Tara Doherty which was a slight decrease from 21,154 in FY2015. • Pharmacy & Therapeutics Committee – Dr. Joseph D’Agosto • Resuscitation Committee – Dr. Betty Ann Robustelli Figure 2 highlights our surgical case volume by campus. • Medical Executive Committee – Dr. Betty Ann Robustelli As shown in Figure 3, Stamford Anesthesiology delivered anesthetics • OB/Safety Culture Committee – Dr. Ronald Giannotto to 95% of the total Labor & Delivery cases for FY2016. • Culture of Safety Committee – Dr. Benjamin Unger • Quality & Safety Committee – Dr. Betty Ann Robustelli Figure 4 shows the number of procedures for single-shot nerve • OR Committee – Dr. Betty Ann Robustelli blocks in FY2016 vs. FY2015, and Figure 5 shows the number of • Total Joint & Spine Committee – Dr. Brian Sullivan continuous infusion procedures for the same time period. • Peer Review Committee – Dr. Betty Ann Robustelli

Figure 1: Overall Anesthesia Case Volume Medical Staff FY2016 CASES New Hires: Hospital Tully The Department of Anesthesiology welcomed the following October-15 825 942 physicians and CRNAs in 2016: November-15 814 919 • Vince Brunelli, CRNA • Yana Krmic, CRNA December-15 773 981 • Suhaib Chaudry, MD • John Martinez, CRNA January-16 722 869 • Jillian Davis, CRNA • Kanishka Rajput, MD February-16 707 879 • Devon Jeffers, MD • Holly Thiel, CRNA March-16 812 1,048 Active Staff: April-16 761 860 • Amy Crane, MD • Yevgeniy Printsev, MD May-16 844 880 • Joseph D ’Agosto, MD • Shahid Rafiq, MD June-16 801 965 • Margot Denham, MD • Betty Ann Robustelli, MD July-16 772 777 • Kaili Dilts, MD • Elizabeth Rozen, MD August-16 851 888 • Tara Doherty, DO • Nousheh Saidi, MD • Elyse Goldblum, MD • Andrew Sosa, MD September-16 745 922 • Steven Finkel, MD • Brian Sullivan, MD Total 9,427 10,930

6 2016 Clinical Annual Report Figure 2: Highlights our surgical case volume by campus Figure 3: Total Deliveries at Stamford Hospital

FY2016 CASES Total Deliveries Labor Emergency Planned w/ Anesthetic Epidural C-Section C/S Cardiac OB OR NORA ENDO October-15 214 109 36 60 Main Hospital November-15 177 107 21 59 October-15 11 187 497 34 52 November-15 10 198 444 37 52 December-15 178 92 17 72

December-15 13 211 476 36 60 January-16 183 102 25 51 January-16 6 186 408 46 53 February-16 7 156 394 36 57 February-16 165 90 17 58

March-16 9 195 473 46 60 March-16 208 106 32 70 April-16 12 156 453 50 55 April-16 216 118 20 78 May-16 10 194 432 38 54

June-16 10 171 509 43 57 May-16 231 134 27 70 July-16 11 180 442 51 46 June-16 181 109 22 50 August-16 6 221 445 36 74 September-16 6 220 448 43 59 July-16 222 132 33 57

Total 111 2,353 5,562 702 699 August-16 203 115 30 58

Tully September-16 175 100 23 52 October-15 – – 401 – 541 Total 2,353 1,314 303 736 November-15 – – 432 – 487 December-15 – – 407 – 574

January-16 – – 388 – 481 February-15 – – 407 – 472 March-16 – – 439 – 609

April-16 – – 365 – 495 May-16 – – 375 – 505 June-16 – – 382 – 583 July-16 – – 382 – 440 August-16 – – 334 – 554 September-16 – – 390 – 532 Total – – 4,657 – 6,273

2016 Clinical Annual Report 7 Department of Anesthesiology: Annual Report 2016

Figure 4: Nerve Block Growth Single Shot Blocks FY2015 FY2016 CPT code Description # of Procedures # of Procedures

62310 Cervical or Thoracic 21 2 62311 Lumbar or Scaral (Caudal) 13 16

64413 Cervical Plexus 2 1

64415 Brachial Plues 407 378 64417 Axillary Nerve Block 1 2

64420 Intercostal Nerve 32 90

64425 Ilioinguinal, Iliohypogastric Nerve 83 1 64445 Sciatic Nerve 95 23

64447 Femoral Nerve 92 79

64461 PVB = Paravertebral block thoracic, single – 18 New Block Code 2016 64462 PVB = Paravertebral block thoracic, (add-on additional) – 5 64450 Other Peripheral Nerve or Branch 714 578 64520 Lumbar or Thoracic (Paravertebral Sympathetic) 66 2 64530 Celiac Plexus 2 0

64486 Transversus Abdominis Plane, Unilateral w/US 258 321

64488 Transversus Abdominis Plane, Bilateral w/US 249 318 2,035 1,834

Continuous Infusion FY 2015 FY 2016

CPT code Description # of Procedures # of Procedures

62318 Cervical or Thoracic, Indwelling Cath, Continuous Infusion 64 31

62319 Lumbar or Sacral, Indwelling Cath, Continuous 39 9

64416 Brachial Plexus, Continuous Infusion 246 174

64446 Sciatic Nerve, Continuous Infusion 0 3

64448 Femoral Nerve, Continuous Infusion 268 226 New Block 64464 PVB = Paravertebral Block Thoracic, Continuous Infusion 0 1 Code 2016 64487 TAP by Continuous Infusions, Includes US 8 8

64489 TAP Bilateral by Continuous Infusions, w/ US 90 134 715 586

8 2016 Clinical Annual Report Emergency2016 Department Clinical Annual Report Entry9 Innovation. Ignited.

Emergency Medicine

People come to our emergency room in their moments of distress to be comforted and healed. They are greeted by smiling faces and received into an open and airy, dedicated 52,000-square-foot, state-of-the-art Emergency Department that is staffed by caring providers.

10 2016 Clinical Annual Report Department of Emergency Medicine: Annual Report 2016

Arun Nandi, MD Chair, Department of Emergency Medicine

A Message From The Chair The Year in Review

Imagine…healing reimagined and innovation ignited. Many of these people require an extensive work-up and may These are the underpinnings of a new Emergency Department, be admitted to the hospital. one in red brick and glass that stands boldly against the skyline of Stamford. People come to our emergency room in their The critically ill arrive by ambulance into the red zone and are moments of distress to be comforted and healed. They are greeted by an experienced triage nurse, then swept into one of greeted by smiling faces and received into an open and airy, our state-of-the-art trauma rooms or cardiac resuscitation rooms. dedicated 52,000-square-foot, state-of-the-art ED that is Teamwork is critical at this point, and the emphasis is on speed, staffed by caring providers. quality and compassion. Heart attacks and strokes are treated in the cardiac rooms by both emergency and stroke or cardiac teams. Life-saving treatment within minutes, such as cardiac Our Zones catheterization in the Cath Lab just above the ED, is made possible by this team approach. Stroke teams evaluate those with treatable Much like a traffic light signals a driver, the zones in our symptoms and medication can be administered in the ED within emergency room signify the level of a patient’s acuity. the optimal treatment window. The trauma rooms are capable Green – Ambulatory patients who may possibly go of being converted to operating rooms within 30 minutes, home soon -- green is good to go if a procedure must be performed emergently in the ED. Yellow – Sicker patients who may need multiple tests and possibly admission Children are cared for in the purple zone, where our youngest, Red – Critically ill or trauma patients requiring the most most fragile and vulnerable patients receive the best attention in intense and immediate care the hands of our pediatric emergency team. The equipment in our Purple – Our pediatric patients Pediatric ED is state-of-the-art and is backed by a team of specialists Blue – Our behavioral health patients from other disciplines such as Cardiology, Anesthesiology and Urology. The nautical theme in our specially designed pediatric In the green zone, or the rapid evaluation unit, patients are area creates a calm and soothing atmosphere for our youngest triaged by a doctor and nurse team, have their blood tests done patients and their families, sheltering our youngest and most and imaging ordered in start-up rooms and then are observed vulnerable patients from the main ED. until they may be ready to go home without having to enter the main ED. Fast-track patients are also treated in this area. During their evaluation, patients may also move to the yellow zone if a more detailed work-up is necessary. Scope of Clinical Services

The yellow zone sees the majority of our patients who need The ED sees approximately 150 patients per day or 55,000 per multiple tests, x-rays, CT scans and consultations with specialists. year and we anticipate growth of 5% per year. Figure 1 shows

2016 Clinical Annual Report 11 Department of Emergency Medicine: Annual Report 2016

the number of monthly visits and average daily visits for FY16 Multidisciplinary teams help coordinate the care and standardize compared to the prior year. the approach to management of complex patients, such as trauma, STEMI, sepsis and stroke. ED throughput is monitored closely by Some of our key metrics for the year include: USACS in partnership with Stamford Health. Metrics are monitored • Door-to-bed time = 24 minutes daily in the form of a dashboard and reported out to the unit at • Door-to-provider time = 25 minutes safety huddles each morning. A data-driven approach to streamlining • Door-to-discharge time = 182 minutes patient safety and patient flow is the cornerstone of this organization. • Door-to-admission time = 304 minutes • Left Without Being Seen (LWBS) is well below the All of the rooms in the new ED are private and spacious. Digital national average at 0.5% x-rays and ultrasounds are performed at the bedside to avoid having to move the patient. The CT scan located in the ED is a dedicated, Figures 2 through 7 provide more detail on Arrival-to-Bed state-of-the-art GE 128-slice scanner that delivers advanced image Time; Arrival-to-Provider Time; Left Without Being Seen; clarity with an average of 50% less radiation than traditional scanners. Length of Stay/Admissions; Total Length of Stay; and Length of Stay/Treat & Release. Pediatric Emergency Department Stamford Health is recognized as being among the top 10% of hospitals in the state to meet the door-to-provider time in under Stamford Hospital has the first dedicated Pediatric Emergency the 30-minute benchmark. Department in the region. The Department has its own waiting and triage rooms, and children are seen in colorful, specially US Acute Care Solutions (USACS) is a physician-owned group designed private rooms completely separated from the adult that partners with Stamford Health in managing the Emergency ED. The Pediatric ED currently operates between the hours Department. USACS employs 1,400 physicians and 800 APPs of 12 noon to 10 p.m. and is staffed by doctors experienced in nationally, providing care to 4.3 million patients in 120 sites all over pediatric medicine and nurses who are specially trained for our the country. As physician owners, USACS physicians are motivated youngest and most fragile patients. to solve problems, find opportunities and create successes. Working in a dynamic environment like Stamford Health provides USACS The Pediatric Emergency Department is headed by employees the opportunity for self-improvement and leadership. Dr. Heather Machen, who trained in pediatric emergency Care delivery has been carefully crafted to maximize safety, medicine at Texas Children’s Hospital, one of the premier throughput and quality. Physician-in-triage is an example of an children’s hospitals in the nation. Under her guidance, the innovative process whereby a physician and nurse team are the focus has been on providing excellent and compassionate first point of contact for most of the patients arriving in the ED. care with established protocols and on reducing radiation exposure and performing appropriate testing.

Figure 1: ED Volume

5,000 145 4,500 141 142 142 141 141 139 140 140 4,000 138 140 138 138 137 136 3,500 137 136 134 136 135 135 135 3,000 133 132 2,500 131 130 129 2,000 126 1,500 125 1,000 120 500 0 115 Jul15 Jul16 Oct15 Oct16 Jan15 Jan16 Jun15 Jun16 Apr15 Apr16 Feb15 Feb16 Dec14 Dec15 Sep15 Sep16 Nov14 Nov15 Mar15 Mar16 Aug15 Aug16 May15 May16

LWBS % LWBS % Target FY15 FY16 FY17

12 2016 Clinical Annual Report Figure 2: Arrival-to-Bed Time 70 60 61 60 41 56 55 53 52 51 52 50 50 47 48 46 46 43 44 43 41 39 40 40 37 36 33 30 24 20 10 0 Jul16 Jul15 Oct16 Oct15 Jan16 Jan15 Jun16 Jun15 Apr16 Apr15 Feb16 Feb15 Dec15 Dec14 Sep16 Sep15 Nov15 Nov14 Mar16 Mar15 Aug16 Aug15 May16 May15

Arrival to Bed Arrival to Bed Target FY15 FY16 FY17

Figure 3: Arrival-to-Provider Time

60 53 50 50 44 46 45 46 41 39 40 37 38 33 32 33 33 33 29 27 27 30 26 24 24 25 26 25 20 10 0 Jul15 Jul16 Oct15 Oct16 Jan15 Jan16 Jun15 Jun16 Apr15 Apr16 Feb15 Feb16 Dec14 Dec15 Sep15 Sep16 Nov14 Nov15 Mar15 Mar16 Aug15 Aug16 May15 May16

Arrival to Provider Arrival to Provider Target FY15 FY16 FY17

Figure 4: Left Without Being Seen (%)

1.8% 1.7% 1.6% 1.5% 1.5% 1.4% 1.4% 1.4% 1.3% 1.3% 1.3% 1.2% 1.2% 1.2% 1.2% 1.2% 1.2% 1.1% 1.0% 1.0% 0.9% 0.9% 0.8% 0.8% 0.8% 0.8% 0.7% 1.7% 0.6% 0.6% 0.4% 0.2% 0.0% Jul15 Jul16 Oct15 Oct16 Jan15 Jan16 Jun15 Jun16 Apr15 Apr16 Feb15 Feb16 Dec14 Dec15 Sep15 Sep16 Nov14 Nov15 Mar15 Mar16 Aug15 Aug16 May15 May16

LWBS % LWBS % Target FY15 FY16 FY17

2016 Clinical Annual Report 13 Department of Emergency Medicine: Annual Report 2016

The equipment in our Pediatric ED is state-of-the-art and is backed As Chair of the ED Quality Review Committee, Alex Rafailov, MD, by a team of specialists from other disciplines such as Cardiology, oversees all quality-related reviews conducted by the Department. Anesthesiology and Urology. The nautical theme in our specially Partnering with nursing leadership, he revises and improves designed pediatric waiting area creates a calm and soothing various departmental policies to ensure that we deliver the highest atmosphere for our youngest patients and their families. possible quality of care. In addition, Dr. Rafailov reports to USACS monthly to ensure that the clinicians are abiding by all clinical policies set by the company.

Departmental Safety and Quality As the EMS Medical Director for the Hospital, Douglas Gallo, MD, is responsible for working with various community-based EMS services Members of the Department of Emergency Medicine play key roles to ensure the highest quality of training and medical oversight of in ensuring and furthering the safety and quality of care we deliver. crews responding to those in need. As the Department considers Assistant Medical Director Suzy Shukovsky, MD, is responsible application to be an ACS-accredited Level 1 Trauma Center, Dr. Gallo’s for day-to-day operations of the Immediate Care Center (ICC) and leadership will help to make the transition as seamless as possible. works with nursing leadership on ways to improve care delivery. One of the main goals in the ED is to provide care in a timely Through her collaboration with the ICC staff, she has worked to manner. Through the “Physician First” staffing model, a board-certified improve the efficiency of the Department, and is focusing her emergency physician is in triage during the busiest times of the day, efforts on mechanisms to improve the overall patient experience serving as the first point of contact for patients arriving at the ED. at the ICC.

Departmental Education and Teaching Activities

Suzy Shukovsky, MD The success of our team depends on ensuring our providers and Assistant Medical Director nurses work together and participate in regular teaching activities to remain abreast of evidence-based care that is both high in quality and cognizant of the compassion that every patient deserves. In addition to training our Department personnel, the Department also provides medical oversight to Stamford EMS and other EMS providers.

The ED also serves as a teaching center for Sacred Heart University Alexandr Rafailov, MD physician assistant students, as well as for Internal Medicine and Chair, ED Quality Review Committee Family Practice residents. Additionally, we have medical students from Columbia rotating through the Department as a part of their educational experience. Recently, we were contacted by Fairfield University to have its students rotate through our Department as well.

Douglas Gallo, MD EMS Medical Director

14 2016 Clinical Annual Report Figure 5: Length of Stay/Admissions 400

350 333 339 327 335 320 317 322 314 322 315 318 321 309 307 303 308 306 300 303 300 297 298 295 287 291 250 200 150 100 50 0 Jul16 Jul15 Oct16 Oct15 Jan16 Jan15 Jun16 Jun15 Apr16 Apr15 Feb16 Feb15 Dec15 Dec14 Sep16 Sep15 Nov15 Nov14 Mar16 Mar15 Aug16 Aug15 May16 May15

Length of Stay-Admits Length of Stay-Admits Target FY15 FY16 FY17

Figure 6: Total Length of Stay 250 231 339 327 230 229 228 228 216 221 220 212 211 212 211 210 213 212 208 209 204 198 202 201 205 200

150

100

50

0 Jul15 Jul16 Oct15 Oct16 Jan15 Jan16 Jun15 Jun16 Apr15 Apr16 Feb15 Feb16 Dec14 Dec15 Sep15 Sep16 Nov14 Nov15 Mar15 Mar16 Aug15 Aug16 May15 May16

Length of Stay-Total Length of Stay Total Target FY15 FY16 FY17

Figure 7: Length of Stay/Treat & Release

250 206 188 207 207 208 206 204 198 198 203 187 189 193 193 193 194 182 181 200 181 186 176 176 182 181

150

100

50

0 Jul15 Jul16 Oct15 Oct16 Jan15 Jan16 Jun15 Jun16 Apr15 Apr16 Feb15 Feb16 Dec14 Dec15 Sep15 Sep16 Nov14 Nov15 Mar15 Mar16 Aug15 Aug16 May15 May16

Length of Stay-T&R Length of Stay-T&R Target FY15 FY16 FY17

2016 Clinical Annual Report 15 Department of Emergency Medicine: Annual Report 2016

Medical Staff

Full-Time Physicians Full-Time Advanced Practice Partners/PAs • Miriam Ambalu, MD • Sarah Feigenbaum, PA-C • Vanessa Brown, MD • Tyler Ferraro, PA-C • Michael D’Angelo, MD • Anthony Giannuzzi, PA-C • Douglas Gallo, MD • Antonia Green, PA-C • Amy Gandhi, MD • Joy Mullins, PA-C • Randall Grant, DO • Vanie Mangal, PA-C • Stephanie Hanna, DO • Michael Moi, PA-C • Richard Katz, MD • Laura Olson, PA-C • Heather Machen, MD • Mordechai Sacks, PA-C • Samuel Maryles, MD • Ryan Mazin, MD • Vanie Mangal, PA-C • Jose Mejia, MD • Julie Wilmot, PA-C • Arun Nandi, MD • Alexandr Rafailov, MD • Suzy Shukovsky, MD • Despina Trigenis, DO • Dorothy Turnbull, MD • Kim Marie Zeh, MD

Summary

The new Emergency Department remains committed to providing prompt, exceptional and compassionate care in a modern and state-of-the-art environment. Our goal remains to be safe and swift, while never losing sight of the patient who has trusted us in their most vulnerable moments.

16 2016 Clinical Annual Report Pediatric Emergency2016 Clinical DepartmentAnnual Report 17 Practice. Strengthened.

Family Medicine

The unique and special relationship of the family physician with his or her patient continues to be one of the most important and meaningful of all human relationships. Family physicians strive daily to limit the intrusions and obstructions that threaten to impact the care they give to and for their patients.

18 2016 Clinical Annual Report Department of Family Medicine: Annual Report 2016

Joseph Connelly, MD Chair, Department of Family Medicine

A Message From The Chair The Year in Review

Family physicians continue to feel the extraordinary burdens of The top DRGs for admissions by Department members in 2016 were: payment and regulatory changes. No longer is it sufficient to know • Chest pain • Syncope the important clinical conditions such as NSVD, MI, CVA and CKD. • Sepsis • Coronary artery disease Now family physicians must also master things like MACRA (Medicare • Congestive heart failure • Pneumonia Access and CHIP Reauthorization Act), MIPS (merit-based incentive • Atrial fibrillation • Kidney and urinary tract infections systems), APM (alternative payment models), PQRS (Physician • Renal failure • Cellulitis Quality Reporting System), VPBM (Value-based Payment Modifier), MU (meaningful use), CPIA (clinical practice improvement activities) and CPC+ (Comprehensive Primary Care Plus). These abbreviations, among many others, are essential for physicians in order to be Scope of Clinical Services successful, if not survive, in their practices. Financial pressures on top of pressure to see high volumes of patients, the shortage of primary The members of the Department of Family Medicine continue care physicians, liability concerns and less personal connections with to provide a wide range of essential health services to the patients has led to a national crisis of burnout in family physicians Stamford community and Stamford Hospital, and serve in a variety and primary care physicians in general. Fortunately, there is a light at of roles including: the end of the tunnel. The new payment systems in general are finally • School health physician • Indigent care recognizing the bedrock importance of a strong and vibrant primary • Palliative care • Hospitalists care base for an effective, safe, patient-centered, timely, efficient and • Geriatrics and nursing • Integrative medicine affordable healthcare system. home practice • Medical missions abroad In keeping with Stamford Health’s s theme of Healing, Reimagined, • Public health director • Graduate medical education members of the Department of Family Medicine continued to have • Medical IT • Graduate nursing education an enormous impact on the health and well-being of their patients The geographic area served is from North Stamford to the South End, and the Stamford community in 2016. The unique and special from New Canaan to Stamford’s West Side. The patients cared for relationship of the family physician with his or her patient continues include newborns, children, teens, maternity patients, adults, nursing to be one of the most important and meaningful of all human home patients and palliative care patients. The settings in which relationships. Family physicians strive daily to limit the intrusions and care is provided range from solo, partnership and group practices to obstructions that threaten to impact the care they give to and for Stamford Health Medical Group and community health centers. their patients. Nine members of the Department continue to admit their patients to the Hospital, the same number as last year, while others use the increasingly popular hospitalist service for their inpatients.

2016 Clinical Annual Report 19 Department of Family Medicine: Annual Report 2016

Ten members of the Department are in independent practices, Milestones 10 are employed by the Stamford Health Medical Group, eight The following Department members celebrated milestone work for the hospital, and two are employed by community health anniversaries as members of Stamford Hospital’s medical staff: centers. There are 24 active medical staff members and six affiliate staff members in the Department. • Jennifer Bendl, MD — 5 years • Lawrence Leibowitz, MD — 5 years Stamford Hospital is fortunate to have one of the four Family • Chander Devaraj, MD — 15 years Medicine Residency Programs in Connecticut. At this time, 17 of • Henry Yoon, MD — 15 years the 30 current members of the Department of Family Medicine • J. Robert Shapiro, MD — 35 years have come from this program. With the country in the midst of an increasing shortage of primary care physicians, the value of the Family Medicine Residency Program as a “feeder” of primary New Staff care physicians into the community continues to increase. This is The Department of Family Medicine welcomed one new an important factor in insulating the Hospital and community from physician in 2015 – 2016: the serious quality and cost problems seen in areas with a dearth of primary care physicians. • Deborah Pinto, MD, MPH joined the Family Medicine Residency Program as faculty.

Honors and Recognition Medical Staff • Drs. Rod Acosta and Angelo Mallozzi were selected by Connecticut magazine as “Top Docs.” • Drs. Alan Falkoff, Joshua Herbert, Lawrence Leibowitz, Angelo Mallozzi and Ann Williams were listed as a “Top Doctor” by Castle Connolly in 2016. Henry Yoon, MD Associate Chair • Dr. Lawrence Leibowitz served as Health Director of the Town of Redding and as the advisory physician for the town’s elementary and middle schools.

• Dr. Joshua Herbert served as Chair of the Medical Staff.

• High Ridge Family Practice (Dr. Alan Falkoff) was designated as a High-Performance Practice by the Medical University of J. Robert Shapiro, MD South Carolina. Member at-Large to Department Executive Committee • Dr. Rod Acosta served as President of Stamford Health Medical Group.

Hospital Committee Participation

• Continuing Medical Education Committee — Drs. Joseph Connelly, Henry Yoon Kathleen Nurena, MD Member at-Large to • Credentials Committee — Drs. Joshua Herbert, Henry Yoon, Medical Executive Committee Jack DiTeodoro

• Graduate Medical Education Committee — Drs. Joseph Connelly, Henry Yoon

20 2016 Clinical Annual Report • Information Technology Leadership Council — Dr. Henry Yoon Five physicians graduated from the Residency Program in 2016 and, for the fifth consecutive year, all satisfactorily passed the • Infection Control Committee — Dr. Clarke Latimer American Board of Family Medicine certification exam. Additionally: • Internal Medicine/Family Medicine Performance Improvement Committee — Drs. Henry Yoon (Co-chair), Anne Brewer • Dr. Henry Yoon succeeded Dr. Joseph Connelly as Program Director of the Family Medicine Residency Program. • Medical Executive Committee — Drs. Joshua Herbert (Chair), Rod Acosta (Outgoing Chair), Joseph Connelly, Kathleen Nurena • Dr. Lawrence Liebowitz was re-appointed Clinical Assistant Professor of Medicine at New York Medical College • Medical Ethics Committee — Drs. Joseph Connelly, Anne Brewer • Dr. Alan Falkoff had faculty appointments at NYU, Columbia, • Ancillary Provider Committee — Dr. Jack DiTeodoro (Chair) Sacred Heart, Pace University and Quinnipiac University. • Obesity Task Force — Dr. Anne Brewer • Dr. Clarke Latimer had faculty appointments at UCONN and Quinnipiac University. • Palliative Care Committee — Drs. Anne Brewer, Joseph Connelly • Dr. Marc Brodsky had a faculty appointment • Pediatric Peer Review Committee — Dr. Kathleen Nurena at Columbia University • Perinatal Infectious Disease Committee — Dr. Anne Brewer • Dr. Joseph Feuerstein had a faculty appointment • Pharmacy and Therapeutics Committee — Dr. Shanthi Devaraj at Columbia University.

• Planetree Committee (SHMG) — Dr. Lawrence Liebowitz • Dr. Katie Takayasu had a faculty appointment at Columbia University. • Primary Care Committee (SHMG) — Dr. Lawrence Leibowitz • Dr. Joseph Connelly had a faculty appointment • Primary Care Integration Steering Committee — Dr. Henry Yoon at Columbia University. • Quality Assurance Committee (SHMG) — Dr. Clarke Latimer • Dr. Ann Williams had a faculty appointment at Quinnipiac University. • Utilization Management Committee — Dr. Joseph Connelly

• Dr. Anne Brewer served as Medical Director of the Palliative Medicine service at the Hospital. Departmental Research and • Stamford Hospital Breast Leadership Committee — Dr. Katherine Scholarly Activities Takayasu High Ridge Family Medicine participated in various research projects in primary care with PPRNet. Departmental Education Dr. Joseph Feuerstein published a book in the popular press and Teaching Activities entitled Dr. Joe’s Man Diet: Lose 15-20 Pounds, Drop Bad Cholesterol 20% and Watch Your Blood Sugar Free-Fall in 12 Weeks that received The Family Medicine Residency Program had another successful very positive reviews on Amazon. year in 2015. For the fourteenth straight year, the program filled completely in the match with excellent candidates. The additions Dr. Joseph Feuerstein published articles on “Teaching lifestyle to the residency staff include: changes to a cohort of local physicians” and “Hypnosis and acupuncture for anxiety states” in The Journal of Alternative Daniel Bal, MD (joined in PGY-2 year) • and Complementary Medicine. • Thomas Collins-Pallett, MD • Nivi Devaraj, MD Dr. Joseph Feuerstein did poster presentations on “Teaching • Paul Frenette, MD lifestyle changes to a cohort of local physicians” and “Hypnosis and • Lyuba Polinkovsky, MD acupuncture for anxiety states” at the International Congress on • Jimena Repetto, MD Integrative Medicine & Health (CIMH) 2016 in Las Vegas.

2016 Clinical Annual Report 21 Department of Family Medicine: Annual Report 2016

Community Outreach

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

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

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

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

Dr. Henry Yoon was Coordinator of Stamford Hospital’s Mini-Medical School.

Dr. Joseph Connelly served on the board of directors for Optimus Health Care.

Dr. Lawrence Leibowitz served as Director of Health of the Town of Redding.

Drs. Joseph Feuerstein served on the Board of Trustees of Dr. Joseph Feuerstein did a poster presentations on “Hypnosis and the Fairfield County Medical Association. acupuncture for anxiety states” at Stamford Hospital Research Day. Dr. Joseph Feuerstein served as Associate Counselor for Three Family Medicine residents submitted articles and/or the CSMS governing council. He also served on the CSMS questions to the Core Content Review of Family Medicine. Charitable Trust Board of Directors. Dr. Robert Shapiro served as Co-medical Director of the Dr. Lawrence Leibowitz completed a two-year fellowship in AmeriCares Stamford mobile van. Integrative Medicine sponsored by the University of Arizona. Dr. Katherine Takayasu served as Physician Advisor on the Dr. Katherine Takayasu presented several lectures to attending Caring Hospice Professional Advisory Committee. physicians and residents at Stamford Hospital and Columbia University. Dr. Lawrence Leibowitz served as Camp Director for summer Dr. Kathleen Nurena and two Family Medicine Residents, Lidya Bal camps in Stamford, Ridgefield and Redding. and Jessica Reichbind, presented a research project on “Dog Bite Dr. Katherine Takayasu volunteered in the Network of Working Prevention” at Stamford Hospital Research Day. Women group at the YWCA of Darien/Norwalk.

Dr. Marc Brodsky was the principal investigator of a study based Dr. Alan Falkoff lectured at UCONN about Baseball in Society at the Wilton Y comparing a particular stretching exercise program while batting .378 in his 28th season with the Stamford Mets to self-care for patients with back pain. this year.

Dr. Marc Brodsky did a poster presentation on “Protocol Dr. Katherine Takayasu made several presentations about development and feasibility study of group stretching exercise stress management and optimal health to community groups program for chronic low back pain” at the International Congress in Darien, New Canaan and Stamford. on Integrative Medicine & Health (CIMH) 2016 in Las Vegas. Dr. Joseph Feuerstein served as secretary on the Weston Newcomers and Neighbors Association. Dr. Marc Brodsky published a paper on “Change in health-related quality-of-life at group and individual levels over time in patients Dr. Ann Williams continued to inspire everyone to greater treated for chronic myofascial neck pain” in the Journal of Evidence- attention to their physical activity level by participating Based Complementary and Alternative Medicine. in (and winning) numerous running and triathlon events

22 2016 Clinical Annual Report throughout the year, culminating in her qualifying for the Practitioners third time for the Kona Ironman World Championship race in Hawaii. The CIMW employs three full-time board-certified Family Physicians who provide all treatments. The physicians oversee interdisciplinary Dr. Kathleen Nurena, a certified dog trainer, presented classes aspects of care by conventional and complementary practitioners, on scent detection to the community. both Hospital- and community-based. Practitioners who share common patients with the CIMW physicians are vetted to assure proper credentialing and are included in a monthly meeting, to Integrative Medicine which all Stamford Hospital physicians are welcome, at the Center to discuss the care of mutual patients, improve communication among practitioners and optimize patient outcomes. Overview

The Stamford Health Center for Integrative Medicine & Wellness Services Offered (CIMW) is comprised of a Hospital-based clinic that offers an integrative medicine consultation service. It is situated in the The Center offers the following Integrative Medicine programs: Tully Health Center. Pain Management — The pain management service accounts The Center’s model is a high-volume, outpatient, sub-specialty medical for the majority of patient visits and revenue for the CIMW. Most clinic that provides the following Integrative Medicine services: patients with pain are seen for neck pain and associated symptoms that include headaches. Other conditions include low back pain, 1. Pain management occupational- and sports-related overuse injuries, osteoarthritis, 2. Nutrition and supplement consultation neuropathy, fibromyalgia and autoimmune-related and cancer- related pain conditions. 3. Mind-body stress reduction 4. Lifestyle medicine Nutritional/Supplement Consultation — Weight loss is the most common condition that is treated in the nutritional consultation

Philosophy service. The weight loss plan is made up of three components: a personalized diet, referral to a medical fitness program and The philosophy of the CIMW is well-aligned with the Planetree behavioral strategies. Nutrition is an important aspect in the philosophy that is based on the simple premise that all care should treatment plan of all patients and includes attention to metabolic be organized around the needs of patients. As a result, the CIMW syndrome, digestive symptoms, autoimmune and cancer-related focuses on its patients as people, how they live and what their conditions and attention deficit and hyperactivity disorders personal goals may be, as well as how their lifestyle affects illnesses, injury and chronic medical conditions. Women’s Health — In addition to issues related to reproductive health such as pelvic pain, fertility, childbearing, perimenopause The CIMW treats the whole person — body, mind and spirit — and menopause, the Center complements standard care in the using a safe and evidence-based approach customized for each treatment of female patients with depression, heart disease risk individual. Working in collaboration with the patients and their factors, arthritis and digestive issues. Dr. Katherine Takayasu leads medical teams, the CIMW offers patient-centered care that blends a multidisciplinary biopsychosocial pelvic pain program that conventional and complementary medicine tailored to achieve includes meetings with specialists, community presentations and the patient’s personal needs and goals for health and wellness. presentations at national meetings to improve the quality of life of patients suffering with this very challenging problem.

Patients Stress Reduction — The CIMW provides patients with the tools to reduce stress and support lifestyle changes, such as Mindfulness The Center treats children, adolescents and adult patients. Meditation. The program also helps patients reduce anxiety and Most patients are referred for consultation by physicians and pain through hypnosis and guided imagery. The signature service word of mouth. CIMW practitioners conduct over 9,000 patent of the Mind-body Stress Reduction service is the Peg Huttleston visits per year.

2016 Clinical Annual Report 23 Department of Family Medicine: Annual Report 2016

Prepare for Surgery Program to reduce perioperative anxiety. Financial Data The Prepare for Surgery program, which is available to all surgical patients at Stamford Hospital, was featured in a Stamford Health’s Philanthropic funding originally helped open the CIMW Pulse newsletter published in 2016. seven years ago, but the clinic is now self-sustaining. Philanthropy continues to support the education of Center The Athletes and the Arts Program — The Athletes and the Arts Fellows at University of Arizona and the acupuncture course. Program was created by the CIMW in conjunction with specialists in The number of patient visits in the pain management, Orthopedics and Sports Medicine to optimize performance in athletes mind-body stress reduction and evidence-based nutrition and performing artists. The focus of the program is to prevent services continue to increase each year. and treat injuries, inform athletes and performers about optimal nutrition and hydration and reduce performance anxiety. Treatment Services at the CIMW are covered by most major medical methods may include lifestyle approaches to include instruction insurance plans, including Medicare. in self-care acupressure and stretching exercises, physician- administered acupuncture, trigger point injections, non-opioid pain medication recommendations, nutritional counseling, botanical Collaborations and supplement consulting and physician-administered mind-body A key strategy of the Center is to build relationships within stress-reduction therapies. the Hospital system and community. As such the CIMW is engaged in the following collaborative process improvement programs: Education and Research 1. Breast pain with breast surgeons The clinical stories and patient care outcomes at the Center 2. Pelvic pain with gynecologists offer a rich resource for teaching Integrative Medicine Fellows 3. Cancer and pain with oncologists at the CIMW as well as for learning activities for medical 4. Dietary approaches to reducing cardiac risk factors students and medical residents. with primary care physicians and specialist physicians

A full-time, two-year Integrative Medicine Fellowship provides 5. Concussion program with neurologists, neuropsychology a unique clinical experience in evidence-based complementary and physical therapy therapies in pain management, nutrition/supplement consultation 6. The Athletes and the Arts Program with Orthopedics and mind-body stress reduction with guided imagery and mindfulness 7. Reducing perioperative anxiety as part of the standardized meditation. Fellows are funded to complete the 1,000-hour University pre-operative process with surgeons throughout the Hospital of Arizona distance learning and residential Fellowship in Integrative Medicine curriculum, as well as a 300-hour CME acupuncture program. Fellows spend 50% time at the CIMW and 50% time at Optimus, a Strategy/Future Direction Federally Qualified Health Care Center that is affiliated with Stamford Hospital and primarily funded by U.S. Department of Health and The members of the Department of Family Medicine are proud Human Services. Two fellows graduated from the program in June and of the many achievements of Stamford Hospital over the past year, a new fellow, Dr. Danielle Greenman, began her fellowship this year. including the opening of the new Hospital, and are gratified to be part of these successes. We value our relationship with the Hospital as we The Center is a partner in an educational grant from Health Resources collaborate to maintain and improve the health of our patients and the and Services Administration (HRSA) for Integrative Medicine Training community in the spirit of Healing: Reimagined. Grant awarded for Griffin Hospital (Yale Teaching Affiliate) Residents. The presence of a strong Department of Family Medicine will The CIMW receives no research funding. Center physicians participate become even more important as the healthcare system evolves. in quality improvement initiatives and frequently present the findings We look forward to continuing to work with the Hospital to provide in peer-reviewed publications and as abstracts at conferences. 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.

24 2016 Clinical Annual Report 2016 ClinicalPatient Annual Report Room25

Photograph: © Anton Grassl/Esto Medicine. Advanced.

Medicine

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. Emblematic of the clinical excellence to which we will always strive is the new Stamford Hospital tower, a metaphoric beacon of our departmental and institutional commitment.

26 2016 Clinical Annual Report Department of Medicine: Annual Report 2016

Noel I. Robin, MD, MACP Chair, Department of Medicine and DIO, Stamford Hospital Professor of Clinical Medicine and Associate Dean at Stamford Health Columbia University College of Physicians & Surgeons

A Message From The Chair The Year in Review

As a “department of departments,” the Department of Medicine The continued growth of the Department has resulted in the largest is involved in a wide range of clinical care, medical education and number of physicians on its staff in its history. There are a total of research. The achievements of the individual departments that make 271 medical practitioners representing 18 primary care and specialty up the Department of Medicine are detailed in their respective divisions. A breakout of medical staff specialty representation is annual reports and presented under “Scope of Clinical Services.” shown in Figure 1. This has been the result of a concerted effort

Figure 1: Medical Staff Specialty Representation in the Department of Medicine Courtesy Affiliate Ancillary Provisional Provisional Provisional Specialty Active Staff Staff Staff Staff Active Affiliate Ancillary Honorary Internal Medicine 49 – 12 2 2 – 4 5 Allergy and Immunology 3 4 – – – – – Cardiovascular Disease 19 4 – 3 2 – 1 2 Clinical Cardiac Electrophysiology 3 – – – 1 – – Dermatology 15 – – – 1 – – Endocrinology 5 2 1 1 1 – – Gastroenterology 9 1 2 – – – – 1 Geriatric Medicine 3 Hematology and Oncology 7 – – 4 1 – 1 Hospice & Pallative Medicine 3 Infectious Disease 6 2 – 2 – – – Interventional Cardiology 6 3 – – 3 – – Nephrology 4 2 – – 1 – – Neurology 4 2 – – 4 – – Pulmonary Medicine 6 – – – 3 – – 2 Rheumatology 5 – – – 1 – – Physical Medicine and Rehabilitation 9 – 2 – – – – Hospitalist 25 1 – 5 5 – – Total 178 21 17 20 25 – 7 10

2016 Clinical Annual Report 27 Department of Medicine: Annual Report 2016

by Stamford Hospital to develop primary care centers in adjacent Scope of Clinical Services communities where patients historically might have related to other hospitals. The growth of hospitalism has also contributed substantially to these large numbers and second only to general Allergy and Immunology Internal Medicine, the professional hospitalist staff at 36 is the largest

single specialty within the Department. This represents a 13%

increase compared with 2015. The parallel growth of the Stamford Paul S. Lindner, MD

Health Medical Group (SHMG) and the commitment of new Director, Allergy and Immunology

physicians to be a part of this multidisciplinary organization has been Assistant Clinical Professor

a catalyst to the vitality of the Department of Medicine. A parallel of Medicine, Columbia University College of increase in the Ancillary Staff took place with 27 members now Physicians and Surgeons serving in that capacity, as compared with 22 in 2015.

The following new members joined the Department of Medicine Active Staff: since September 2015: • Denis A. Bouboulis, MD • Mitchell R. Lester, MD • Erik Beger, MD – Rheumatology • Ora Burstein, MD • Paul S. Lindner, MD • Meghan Newman, APRN – Internal Medicine • Leslie R. Coleman, MD • Donna O’Hara, APRN – Interventional Cardiology Members of the Department of Allergy and Immunology with active • Maura Sparks, MD – Internal Medicine full staff privileges include Denis A. Bouboulis, MD; Ora Burstein, MD; • Paul Huang, MD – Hospitalist Leslie R. Coleman, MD; Mitchell R. Lester, MD; and Paul S. Lindner, • Erin Krajci, APRN – Cardiovascular Disease MD. The physicians in the Department of Allergy and Immunology • David Hahn, MD – Neurology function in an outpatient setting and provide inpatient consultations, • Scott Martin, MD – Interventional Cardiology treating patients for a variety of allergic and immunologic conditions. • Dmitriy Khodorskiy, MD – Hospitalist These include allergic rhinitis, asthma, sinusitis, skin disorders such as • Joahd Toure, MD – Hospitalist urticaria, contact dermatitis and eczema, food allergy, stinging insect • Shuaib Latif, MD – Clinical Cardiac Electrophysiology allergy, drug allergy and immunodeficiency. • Sylvie Rosenbloom, APRN – Internal Medicine • Susheel Kodali, MD – Interventional Cardiology In this specialty, specific allergens causing an allergic response are • Yumi Koh, DO, MPH – Internal Medicine pinpointed using various techniques that include skin testing, patch • Elizabeth Marsh, MD – Dermatology testing, in-vitro analysis of antigen-specific IgE, oral and parenteral • Lindsay Burke Naughton, APRN – Hematology and Oncology challenges. In addition to avoidance techniques and allergy/asthma • Christine Couture, PA-C – Gastroenterology medications, we offer a program of desensitization, which helps • Marlon Rosenbaum, MD – Cardiovascular Disease patients develop immunologic tolerance to offending allergens. • Daniel Brooks, MD – Neurology Desensitization can be provided for all major environmental • Rebekah Gospin, MD – Endocrinology allergens such as dust mites, molds, pollens and cat and dog dander. • Sarah Buckingham, MD – Neurology Individuals can be desensitized for bees, hornets, wasps and yellow • Tatjana Gavrancic, MD – Hospitalist jackets, antibiotics and other medications including penicillins, • Anna Monidois, MD – Pulmonary Medicine cephalosporins and chemotherapy agents. A major push toward • Jamie Stratton, MD – Hematology developing desensitization techniques for food allergens, such as • Desh Nandedkar, MD – Pulmonary Medicine peanuts, is underway in many academic centers due to the rising • Danielle Greeman, MD – Internal Medicine prevalence of food-induced anaphylaxis over the past two decades. • Arzhang Fallahi, MD – Interventional Cardiology • Ilnaz Salehi, MD – Hospitalist Allergists in our community work closely with other subspecialists • Maryana German, APRN – Cardiovascular Disease and general practitioners to provide comprehensive care of the allergic patient. We work with pulmonologists to provide Comparison of the most common DRGs resulting in admission to asthma care; dermatologists can obtain input regarding potential the inpatient medical service are noted in Figure 2. food allergies as a trigger for eczematous conditions; and

28 2016 Clinical Annual Report Figure 2: Department of Medicine, Comparison of Most Common DRGs % of DRG DRG Description FY16 IP Dc % of All FY15 IP Dc % of All FY14 IP Dc All FY13 IP Dc % of All Rank Inpts Rank Inpts Rank Inpts Rank Inpts Septicemia or severe sepsis w/o 871 MV 96+ hours w/MCC 1 428 4.58% 1 397 6.8% 1 301 5.1% 1 253 4.4% Esophagitis; gastroent & misc digest 392 disorders w/o MCC 2 236 2.51% 4 133 2.3% 5 138 2.4% 3 141 2.5% 603 Cellulitis w/o MCC 3 170 1.81% 5 125 2.1% 2 158 2.7% 2 191 3.3% Septicemia or severe sepsis w/o MV 872 96+ hours w/o MCC 4 157 1.68% 3 142 2.4% 8 105 1.8% 12 78 1.4% 291 Heart failure & shock w/MCC 5 155 1.66% 2 157 2.7% 3 146 2.5% 4 126 2.2% Alcohol/drug abuse or dependence 897 w/o rehab therapy w/o MCC 6 150 1.21% 9 103 1.8% 4 141 2.4% 5 126 2.2% 292 Heart failure & shock w/MCC 7 141 1.51% 6 118 2.0% 6 114 1.9% 6 122 2.1% Intracranial hemorrhage or cerebral 65 infarction w/CC 8 126 1.34% 17 70 1.2% 18 81 1.4% 16 73 1.3% 378 G.I. hemorrhage w/CC 9 113 1.21% 7 118 2.0% 9 97 1.7% 10 94 1.6% 812 Red blood cell disorders w/o MCC 10 110 1.16% 8 105 1.8% 7 118 1.9% 7 116 2.0% Misc disorders of nutrition; 641 metabolism; fluids/electrolytes 11 103 1.10% 19 67 1.1% 14 89 1.5% 14 76 1.3% w/o MCC 193 Simple pneumonia & pleurisy w/MCC 12 100 1.07% 16 71 1.2% 15 86 1.5% 22 62 1.1% Perc cardiovasc proc w/ 247 drug-eluting Stent w/o MCC 13 95 0.95% 13 81 1.4% 16 84 1.4% 23 60 1.1% Cardiac arrhythmia & 309 conduction disorders w/CC 14 90 0.93% 22 60 1.0% 14 88 1.5% 11 91 1.6% Kidney & urinary tract 690 infections w/o MCC 15 88 0.90% 11 86 1.5% 12 90 1.5% 17 71 1.2% Cardiac arrhythmia & conduction 310 disorders w/o CC/MCC 16 84 0.90% 15 74 1.3% 17 83 1.4% 13 77 1.7% 683 Renal failure w CC 84 0.81% 10 101 1.7% 10 97 1.7% 9 106 1.9% 682 Renal failure w/MCC 17 76 0.80% 12 82 1.4% 22 58 1.0% 15 76 1.3% 194 Simple pneumonia & pleurisy w/CC 18 75 0.80% 14 75 1.3% 11 95 1.6% 8 114 2.0% 638 Diabetes w/CC 19 72 0.77% 20 61 1.0% 30 52 0.9% 47 32 0.6% Kidney & urinary tract 689 infections w/MCC 20 66 0.71% 18 69 1.2% 32 49 0.8% 33 49 0.9% 312 Syncope & collapse 21 61 0.65% 27 52 0.9% 19 65 1.1% 25 56 0.9%

Poisoning & toxic effects of drugs 918 w/o MCC 22 49 0.37% 41 38 0.6% 20 60 1.0% 40 42 0.7%

313 Chest pain 23 25 0.27% 62 22 0.4% 34 47 .08% 18 70 1.2%

SUBTOTAL 2,854 2,406 41.1% 2,435 40.2% 2,302 40.2%

Total Inpatient Discharges 5,643 5,860 5,855 5,710 Inpatient Days 28,867 31,688 32,418 32,068 Total Observation Discharges 1,733 1,559 1,547 1,160 Observation Days 2,273 2,192 2,103 2,314

2016 Clinical Annual Report 29 Department of Medicine: Annual Report 2016

otolaryngologists are helped by having the allergist identify and treat an abundance of CPG motifs to enhance a TH1 protective response. the allergic triggers, which can often complicate a case of chronic Other monoclonal antibodies on the horizon include anti-IL5 for sinusitis and nasal polyposis. hypereosinophilic syndromes and anti-IL4, anti-IL13 for asthma.

Many of our allergists are involved in clinical research projects. The Department of Allergy and Immunology has an active role in Dr. Denis A. Bouboulis published two original research articles this the teaching program for medical students, interns and residents at year including, “PANDAS: Baseline Immunoglobulin Levels Predict Stamford Hospital. Residents spend many weeks with our physicians Achievement of Remission at One Year Following IVIG Therapy.” in elective rotations. Our Department provides lectures for Grand J Neurol Neurosurg 3(2):122 and “Infection-Induced Autoimmune Rounds in Medicine as well as lunch conferences for Residents and Encephalopathy: Treatment with IVIG. A Report of Six Patients.” Medical Students. This year, Dr. Lindner presented “An Update in the Int J of Neurology Res 2016 March 2(1):256-258. Field of Allergy & Immunology” as part of the Medical Grand Rounds series in September. Allergists in the Department also diagnose and treat a variety of primary and secondary immunodeficiencies. The most Our Allergy staff is also active in regional and national allergy prevalent of these is common variable immunodeficiency (CVID), societies. Dr. Lester was recently elected to the Board of Regents of which responds well to Intravenous Immunoglobulin (IVIG) the American College of Allergy, Asthma and Immunology (ACAAI) therapy. The newest form of gammaglobulin therapy is through and gave a lecture at the New England Allergy Society this year. the subcutaneous (SCIG) route. With SCIG, patients no longer need to spend time at an outpatient infusion center and can In the coming year, our Department looks forward to providing administer their own gammaglobulin therapy at home. The latest excellent care in the field of Allergy and Immunology as clinicians developments in the treatment of allergic disorders are the newly and educators, and will continue to bring the latest developments approved therapies for hereditary angioedema including purified in our specialty to the greater Stamford Hospital community. human C1 esterase inhibitor (Berinert — for acute attacks, Cinryze

for maintenance prevention) and a reversible kallikrein inhibitor, Cardiology Kalbitor (ecallantide) for acute attacks. A newly approved selective bradykinin B2 receptor antagonist, Firazyr (icatibant) has also been found useful in reversing acute angioedema attacks. David H. Hsi, MD, FACC, FASE

Newer forms of immunotherapy are in current development. Chief of Cardiology

The first monoclonal anti-IgE antibody to be released is Xolair Co-Director of the Heart & Vascular Institute, Stamford Hospital (omalizumab), which has been shown to improve asthma control

while decreasing the need for systemic and inhaled steroids. Xolair Clinical Professor of Medicine, Columbia University College of theoretically will also work for allergic rhinitis and food allergies Physicians & Surgeons by decreasing total IgE on mast cells, however these additional

indications are currently being evaluated. Xolair has just been Active Staff: approved for treating severe chronic idiopathic urticaria. • Charles Augenbraun, MD • Susan Eysmann, MD Monoclonal antagonists of IL5 have recently been approved for the • Jeffrey Berman, MD • Arzhang Fallahi, MD treatment of severe asthma. As IL5 stimulates eosinophil activation, • Samuel Brodsky, MD • John Fisher, MD these agents are useful to treat asthma patients with an eosinophilic • Salvatore Carbonaro, MD • Glenn Gandelman, MD phenotype. Nucala is administered SQ monthly and Cinquair is given • Joonun (Chris) Choi, MD • Jeffrey Green, MD monthly by IV. Both medications can be useful as steroid-sparing • Evelyn Cusack, MD • Mark Heiman, MD agents in treating asthmatics requiring high dose inhaled steroids • Sandhya Dhruvakumar, MD • David H. Hsi, MD or systemic steroids to maintain adequate asthma control. • Gregory D’Onofrio, MD • Steven F. Horowitz Studies looking at a variety of future immunotherapy options The Cardiology Division is now located on the second floor in the include the use of T-cell peptides to stimulate a preferential TH1 new Hospital. Within this sophisticated facility, we have state-of- vs. TH2 response, the use of adjuvants such as lipopolysaccharide the-art Cardiac Catheterization and Electrophysiology Laboratories, and immunotherapy with bacterial DNA oligonucleotides containing nuclear cardiology cameras, 3-D echocardiography and a hybrid

30 2016 Clinical Annual Report operating room for special procedures. Stamford Hospital is the Dr. Martin is highly skilled in transradial artery-based complex region’s only full-service cardiovascular center in Fairfield County. coronary procedures. Dr. Latif was trained in the top EP program and specializes in atrial fibrillation ablation and other procedures. We cherish our tradition of the Planetree philosophy and providing Dr. Fallahi received intense training in TAVR procedures and is patient-centered care. We are proud to announce the addition of proficient in peripheral vascular interventions. three new cardiologists joining the team in 2016: The Interventional Cardiologists and support staff provide around- Scott Martin, MD, FACC, FSCAI the-clock coverage for the acutely ill patient. They have achieved Specialty: Cardiovascular Disease and Interventional Cardiology 98% door-to-balloon times for all eligible ST elevation myocardial infarction patients admitted to the Hospital in 2016. The procedures Medical School: SUNY Downstate Medical Center offered include advanced imaging and coronary interventions Residency: Washington University School of Medicine and hemodynamic support using percutaneous left ventricular Fellowship: University Hospital at SUNY Stony Brook assist devices. Board Certifications: Cardiovascular Disease - American Board In addition, our Interventional Cardiologists have significant of Internal Medicine experience with TAVR procedures. Some on our team have been Shuaib Latif, MD, FACC, FHRA involved in the field of TAVR for over a decade and others have performed hundreds of cases during a dedicated training program Specialty: Cardiovascular Disease and Clinical Cardiac in structural heart interventions. We work closely and collaborate Electrophysiology with a multidisciplinary team of anesthesiologists and heart Medical School: Washington University School of Medicine specialists, including the world renowned interventional cardiologist Residency: Johns Hopkins University School of Medicine Dr. Antonio Colombo, at Stamford Health’s Structural Heart Disease Fellowship: Hospital of the University of Pennsylvania; University (SHD) Center and Valve Clinic, which is affiliated with Columbia/ of Texas Southwestern NewYork-Presbyterian Hospital to provide comprehensive screening, Board Certifications: Clinical Cardiac Electrophysiology - American evaluation and life-saving treatment to patients with structural Board of Internal Medicine heart and valve disease.

Arzhang Fallahi, MD, FACC Additional achievements include the following:

Specialty: Cardiovascular Disease and Interventional Cardiology • Dr. Wayne Miller, who specializes in 3-D echocardiography and Medical School: University of Washington School of Medicine advanced TAVR imaging, has participated in every TAVR procedure Residency: Icahn School of Medicine at Mount Sinai at Stamford Hospital and provided real-time and accurate diagnostic information for the TAVR team. Fellowship: Icahn School of Medicine at Mount Sinai Beth Israel; New York University School of Medicine • Dr. Thomas Nero successfully implanted the first CoreValve TAVR Board Certifications: Cardiovascular Disease - American Board prosthesis at Stamford Hospital with excellent clinical outcome. of Internal Medicine Diplomate - Adult Comprehensive Echocardiography - National • Dr. Thomas Nero, Dr. Scott Martin and Dr. David Hsi have started Board of Echocardiography an acute pulmonary embolism alert program using ultrasound- facilitated thrombolysis in patients with massive or sub-massive Internal Medicine - American Board of Internal Medicine pulmonary embolism with appropriate clinical indications. Interventional Cardiology - American Board of Internal Medicine They worked closely with the ICU team, Dr. Michael Bernstein, Nuclear Cardiology - Certification Board of Nuclear Cardiology the hospitalists and Dr. Christina Suh. Registered Physician in Vascular Interpretation - American Registry for Diagnostic Medical Sonography • Dr. Antonio Colombo was named as the Deputy Editor of the prestigious Journal of the American College of Cardiology Diplomate - Adult Comprehensive Echocardiography - National Board of Echocardiography (JACC) in 2016. • Stamford Hospital is the first and only hospital in Connecticut to offer the sophisticated hemodynamic monitoring for patients with

2016 Clinical Annual Report 31 Department of Medicine: Annual Report 2016

severe congestive heart failure by implanting the CardioMEMS™ Rosenbaum, MD, Associate Professor of Medicine and Pediatrics in the pulmonary arteries. Dr. Jeffery Green and Dr. Portnay at Columbia University College of Physicians and Surgeons and successfully performed all procedures. Director of the Schneeweiss Adult Congenital Heart Center at Columbia University Medical Center. • Dr. Chris Choi led the system-wide effort and received a Gold Plus Award in Heart Failure care from the American Heart Association Get With The Guidelines® program in 2016. Dermatology

Under the leadership of Dr. Sandhya Dhruvakumar, Director of Electrophysiology, we are the regional leaders in the diagnosis and treatment of complex arrhythmias including atrial fibrillation, offering a full spectrum of treatment options including Ellen S. Naidorf, MD radiofrequency ablation, cryoablation and hybrid surgical-catheter Director of Dermatology ablation procedures. We were the first hospital in Connecticut to perform cryoballoon ablation, an innovative treatment for atrial fibrillation, and remain the only hospital in our region to offer this technology. The Electrophysiology team consists of our board-certified electrophysiologists and a dedicated, trained Active Staff: team including full-time nurse practitioners, EP technicians and • Severine Chavel, MD • Rebecca Hall, MD EP nurses. Our new Electrophysiology Lab is replete with cutting- • Debra Pruzan-Clain, MD • Omar Ibrahimi, MD edge equipment in a spacious suite that permits the seamless • Rhett Drugge, MD • Steven Kolenik, MD integration of technologies in real time, which helps to improve • Robin Evans, MD • Sharon Littzi, MD diagnosis and to better guide treatment. • Rena Fortier, MD • Fern Meyer, MD Dr. Evelyn Cusack, our Director of Community Outreach, has • Elizabeth Gaines, MD • Ellen Naidorf, MD continued her popular “Walk with the Doc” program, visited many • Samuel Gettler, MD • Donald Savitz, MD community physicians and given lectures to the EMS, AHA and

at other public events. Provisional Active Staff Dr. Edward H. Schuster serves as the Medical Director for Cardiac Elizabeth Marsh, MD Rehabilitation. The program incorporates contemporary concepts of wellness, fitness, and lifestyle modification for the benefit of The Department also acknowledges the outstanding skill, patients with known heart disease. The Cardiac Rehab Program educational endeavors, and kindness of Elgida Volpicelli, MD, includes both ECG monitoring and lifetime wellness maintenance Stamford Hospital’s dermatopathologist. under the leadership of Dr. Murray Low. As a specialty, Dermatology focuses on skin cancer prevention The Division provides an educational program combining clinical and public education about the perils of sunbathing. Department discussions and exemplary, formal didactic presentations from members participate in various community forums and events hospital-based cardiologists and many distinguished guest including corporate skin cancer screenings. We volunteer at the speakers including: Dr. Paul Thompson from Hartford Hospital, outpatient clinic at 1351 Washington Boulevard and consult at the Dr. Daniel Jacoby from Yale-New Haven, Dr. Valentin Fuster Hospital. The Department's dermatologists also supervise and teach from Mount Sinai Heart and Dr. Gilbert Tang from Westchester the medical residents and rotating medical students, and lecture Medical Center. within the Hospital as well as the outside community.

We are very proud to be collaborating with Columbia/NewYork- Great strides are being made in the treatment of many refractory Presbyterian Hospital, one of the nation’s oldest, largest and skin conditions, with the approval of multiple biologics for diseases most experienced ACHD programs, to provide the best treatment such as psoriasis, hidradenitis supporativa and chronic urticaria. possibilities with the goal of improving our patients' longevity The cosmetic arena also is expanding with newer fillers, heat and and quality of life. The HVI’s ACHD program is led by Marlon S. cold generated body sculpting and improved laser treatments.

32 2016 Clinical Annual Report 2016 ClinicalPatient Annual Report Room33 Department of Medicine: Annual Report 2016

Endocrinology This will additionally comprise a dedicated nurse navigator who will coordinate care and assist the patient along the care continuum.

On the education front, Endocrinology sessions for colleagues, house staff and students take place throughout the year through Noel I. Robin, MD inpatient teaching rounds, The Academic Half Day, student tutorial Director of Endocrinology and preceptorship sessions, Endocrinology Tumor Board and Medical Grand Rounds, including the Summer Syllabus. In addition, residents spend one-on-one time with certified diabetes educators (CDEs) at the Stamford Hospital Diabetes Education Center, an American Diabetes Association (ADA)-recognized center for diabetes Active Staff: education. Endocrinology support through consultation and • Mary E. Arden-Cordone, MD • Mary M. Kane-Brock, MD clinical involvement takes place on all Hospital units, and a regularly • Maria Asnis, MD • Bismruta Misra, MD scheduled and dedicated outpatient clinic at 1351 Washington • Anna C. Freitag, MD • Antonio Pantaleo, MD Boulevard is staffed by the Department. Melissa Goldstein, MD Noel I. Robin, MD • • Fairfield County Diabetes and Endocrinology has dedicated • Rebekah Gospin, MD • Leonard Vinnick, MD endocrinologists and is part of the Stamford Health Medical Group (SHMG) network. The practice is led by Medical Director Dr. Bismruta The field of Endocrinology continues to see significant growth in Misra with Drs. Maria Asnis, Melissa Goldstein and Rebekah Gospin the understanding of the pathophysiology of disease processes, as attending endocrinologists. The practice is now located in a and in earlier and more accurate disease detection. There also new facility at 292 Long Ridge Road in Stamford. has been continued application of newer pharmacologics and technical skills to address endocrinologic dysfunction. The Diabetes Education Program Type 2 diabetes remains the most prevalent disease seen by at Stamford Health endocrinologists, a result of prevailing patterns of diet and lifestyle. Balanced glycemic control that matches the physiologic Diabetes education programs apply for American Diabetes needs of the individual diabetic patient remains the mainstay of Association (ADA) Education Recognition voluntarily. Stamford diabetes management, with new insulin preparations currently Hospital first acquired this Education Program Recognition from available. In addition, today there are various other categories the ADA in 2001 and currently has maintained program recognition of pharmacologics that can play a role in diabetes management. extending through 2019. The application process is rigorous with All of these treatment options are available at Stamford participant data collection and interpretation. The ADA’s Diabetes Hospital and are tailored to the unique needs of each patient. Education Recognition Program is the process through which The optimal management of the diabetic patient underscores programs that meet the National Standards for Diabetes Self- the indispensable necessity of interdisciplinary and collaborative Management Training and Support (DSMT) are formally identified medical practice. Notwithstanding the nine available categories for their performance and quality. (including insulin) of drugs to manage diabetes, nowhere in clinical practice is personalized medicine more applicable. The ADA Education Recognition Program has grown to become The pathophysiology of diabetes is exquisitely elegant, but the the leading quality assurance mechanism for all diabetes self- needs of each patient must be individually addressed so that management education programs across the country. To that point the blood glucose response is congruent with the therapeutic Medicare will cover diabetes education sessions for their beneficiaries goal. Essential to effective management must be patient only if provided through an ADA-accredited diabetes education enfranchisement in a healthy lifestyle. program. Programs that do receive this recognition are viewed as having met the criteria for having a staff of knowledgeable health Endocrinology has also assumed an even higher level of professionals (registered nurses and registered dieticians) who can commitment to bone health in a structured program that would provide state of the art diabetes education. Currently all educators comprise preemptive evaluation and screening for potential bone at the Diabetes and Endocrine Center are CDEs. A multidisciplinary, issues as well as secondary fracture prevention. interactive and proactive approach to diabetes education has

34 2016 Clinical Annual Report been created to include a thorough assessment, sound educational through their continued support of Stamford Health-sponsored curriculum, diabetes support management planning and follow wellness and Speakers Bureau events. We also: up with behavioral outcome measurement. The Stamford Health Diabetes Education Program is designed to offer outpatient • Conducted a half-day academic session for residents related to individual instructional sessions, as well as group self-management delivering comprehensive diabetes care. classes. The sessions begin with an individual assessment to • Held full-day quarterly education sessions on diabetes awareness develop a plan of care. Classes are offered on different days and at for GEMS and RN staff. different times, and staffing schedules are flexed, when necessary, to meet participant needs. Additionally, Barbara Nadolny BSN, RN, CDE, serves as the legislative point person for Connecticut Alliance of Diabetes Educators (CADE). Instructional methods include demonstrations, return She is actively involved in the State of Connecticut Department of demonstrations, audiovisual presentations and interactive Public Health coalition where the goal is to achieve reimbursement sessions. There is adequate time during each session for questions from Connecticut Medicaid for Diabetes Education services. and answers. Our teaching approach is interactive, as well as patient- and family-centered, and supports the evolution of problem solving skills. Hearing-impaired patients are offered sign Gastroenterology language interpretive services, and TDD devices are also available. Additionally, we can utilize the ATT Language line, in which instructors engage interpreters by speakerphone for the many Stuart Waldstreicher, MD different languages spoken in the service area. There is no cost to Director of Gastroenterology the patient for these interpretive services. Assistant Clinical Professor of Medicine, Columbia University College of Follow up is considered an integral part of the educational Physicians and Surgeons experience for the individual with diabetes. Behavioral goals are formed during the instruction sessions, and are evaluated and/or modified. Follow-up may also occur in person or on the telephone as needed. The participants in the Diabetes Education Program Active Staff: will be seen on an as-needed basis following instruction. Phone • Neeraj Anand, MD • William Pintauro, MD contact is always encouraged to solve self-management problems • Henry Grafton Beecher, MD • Robin Forman Rose, MD that may arise. Diabetes Self- Management Support Planning • Robert Dettmer, MD • Neil Schamberg, MD (DSMSP) is provided in collaboration with the participant, and is • Sarah Kahn, MD • Amy Smithline, MD communicated with other healthcare providers involved in the • Darlene Negbenebor, MD • Stuart Waldstreicher, MD patient’s care. The referring Primary Care Physician and /or Specialist are notified for an urgent health issue needing to be resolved and The Department of Gastroenterology has enjoyed another on overall education program progress. successful year. Our Division continues to diversify the services it offers to patients and the healthcare community. Over the past year, we performed over 6,000 endoscopic procedures at The Diabetes Education Program Staff both the Hospital and the Tully Health Center. In addition, under Debra Milne, BSN, RN, CDE the direction of Dr. Amy Smithline, we are currently providing Director, Ambulatory Nursing and Diabetes Education esophageal motility and impedance studies along with 24-hour Sangeeta Ahuja, MS, RD, CDE pH monitoring. This has enhanced our ability to evaluate and Jill Ely, APRN, CDE treat patients with problematic gastroesophageal reflux and Barbara Nadolny, RN, BSN, CDE – Lead RN, CDE esophageal motility disorders. We are currently working with Gavin Pritchard, RDN, CDE our Colorectal Surgery colleagues in coordinating pelvic floor Ann Rupp, RN, BSN, CDE physiology dysfunction testing. This includes high-resolution anorectal manometry and pudendal nerve testing methodologies In 2016, there were 3,180 diabetes education visits (2,700 budgeted). used for evaluation of function and coordination of anal sphincter Diabetes education actively participate in community outreach and pelvic floor muscles. The Endoscopy Center at the Tully

2016 Clinical Annual Report 35 Department of Medicine: Annual Report 2016

Health Center received designation as an American Society of A new Delirium Policy has been approved by the Medical Gastrointestinal Endoscopy Center of Excellence. Our Division Executive Committee and is being implemented for the entire acquired the Fuse® full spectrum endoscopy system designed to Hospital. Only 17% of delirium cases are currently identified enhance colorectal polyp detection. We have also incorporated in hospitals nationwide and early identification will help both the ProVation® dictation system to provide improved patient and hospital outcomes. We have also created new patient documentation for our endoscopic reports. Our new endoscopy education materials on delirium to better educate families to suite located on the first floor of the new Hospital is equipped the condition and to manage their expectations. with full anesthesia capabilities and fluoroscopy, allowing us to perform all of our procedures, including ERCP, in our new suite. We are working with the hospitalists to develop an inpatient We are appreciative for all the support of our colleagues and geriatric consultative service and are actively recruiting to administration that allows us to provide state-of-the-art care for fill this role. our patients and community. The Connecticut Chapter of the Alzheimer’s Association has also elected Dr. Allison Ostroff to its board of directors. We are working Geriatrics on creating a “dementia-friendly community” and Stamford was selected as the pilot city for this initiative. While it is still in its early stages, this initiative includes collaboration from the Hospital, City leadership and area businesses to identify ways to best manage our elderly population with cognitive deficits. Currently there is Allison B. Ostroff, MD only one of these communities in the United States in Minnesota. Director of Geriatric Medicine These communities exist and flourish in Belgium, Holland and Great Britain. Once again, we hope to present our pilot data at the Connecticut Annual Meeting of the Alzheimer’s Association in April 2017.

Active Staff: We are hoping to expand the division of Geriatric Medicine soon so that we can provide the most comprehensive and fluid care to • Rodrigo Acosta, MD • Allison B. Ostroff, MD our patients and make transitions of care as seamless as possible. • Rohit Bhalla, MD • Santi Neuberger, MD We greatly look forward to working with everyone in caring for • Anne Brewer, MD • Meghan Newman, APRN our older population. • Doreen Chimblo, APRN • Noel Robin, MD • Tzivia Moreen, MD • Monika Tello, APRN

This has been a very busy and productive year for the Division of Geriatrics. Our geriatrics task force, which includes representation from nursing, nursing education, discharge planning, case management, Planetree, chaplaincy and the departments of Psychiatry, Neurology and Internal Medicine, has finalized a protocol for the identification and management of patients with delirium and our pilot began on the 8th floor of the new Hospital on November 1. We are partnering with the Alzheimer’s Association in training a dedicated group of volunteers who will work one-on-one with this patient population. These volunteers will be obtaining information about the patients from their family/caregivers to best target interventions for the individual. The Alzheimer’s Association has also provided us with tool kits containing everything from information for family and caregivers to a deck of cards and coloring pads to provide stimulation to this patient population.

36 2016 Clinical Annual Report 2016 Clinical AnnualMain Report Lobby37 Department of Medicine: Annual Report 2016

Hospitalist Medicine 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 Maher Madhoun, MD care in the oversight of inpatients seen in our hospital. Hospitalists have Hospitalist Director also meaningfully complemented the role of practicing physicians, as Infectious Disease Specialist the need for seamless and effective care of their inpatients has grown. Assistant Clinical Professor, Columbia Notably, the Stamford Hospital Hospitalists group treats approximately University College of Physicians 90% of the Medicine inpatient census. Hospitalist Medicine remains & Surgeons the fastest-growing specialty in clinical practice. Assistant Program Director for Inpatient Teaching, Internal Medicine Residency The Hospitalists continue to have a preeminent role in resident Program education. This has been both a natural and an evolutionary trend in medical education, promulgated by changing requirements mandated by the Accreditation Council for Graduate Medical Peter J. Tenicki, MD Education (ACGME), as well as the reality of the intensive involvement Associate Director of Hospitalists in the care of patients also managed by medical house Assistant Clinical Professor, Columbia staff. Hospitalists’ importance in resident education is underscored University College of Physicians by the appointments of Dr. Maher Madhoun, Dr. Paul Huang and & Surgeons Dr. Hiren Mody as Assistant Program Directors in Inpatient Medicine Assistant Program Director for Inpatient for the Residency Program in Internal Medicine. The Hospitalist Teaching, Internal Medicine Residency Program group also provides clinical education to Quinnipiac University students for their Internal Medicine rotation. Hospitalists continue to play a leadership role in developing and Active Staff: implementing the MediTech inpatient EMR; improving accountability; • Jennifer Bendl, DO • Michael Marchese, MD and collaboration between various Hospital departments, particularly • Iulian Benetato, MD • Santy Mathew, MD among the medical staff and ED. Over the last year, we identified a • MaryAnne Bhojwani, MD • Hiren Mody, MD need to have a Hospitalist Census Surge Alert/Policy. This has been • Alfred Bircaj, MD • Girija Narayanaswamy, MD created and has been used on numerous occasions. This is activated • Sasha Cobotic, MD • Aye Omoruyi, PA during times of high census, high acuity, severe weather, mass influx • Resul Dalipi, MD • Chinyelu Oraedu, MD in ED and or lack of surge capacity. Our organizational goal is to avoid • Satish Deshpande, MD • Kwen Ortega, MD diversion, prevent ED overcrowding and prevent delays in discharging • Jenifer Drummond, MD • Miroslav Radulovic, MD by activating all available resources. This has aided in floor and • Joseph Elassal, MD • Praveen Reddy, MD ED efficiency throughout. • Betty Exume, PA • Rolando Santos, MD We are also always working to improve the patient experience. • Christiana Famodimu, MD • Ilnaz Salehi, MD We have teamed up with the Patient Satisfaction team to assist in • Mary Fedor, MD • Asha Shah, MD improving our patient satisfaction metrics. We have instituted a • Tatjana Gavrancic, MD • Danielle Sry, PA direct observation tool when engaging the patient and family in • Kakra Gyambibi, MD • Christina Suh, MD efforts to improve the patient experience, and work on this feedback • Paul Huang, MD • Peter Tenicki, MD metric remains in progress. In addition, our group continues to • Clive Johnson, DO • Joahd Toure, MD work on improving care of sepsis patients and we have formed a • Chinenye Kalu, APRN • Phi Tran, DO multidisciplinary task force to work on this. All cases of severe sepsis are • Dmitriy Khodorskiy, MD • Marcos Valerio, MD identified and reviewed, and any areas of opportunity of improvement • Maher Madhoun, MD identified and discussed with the team members. This continues to be a work in progress. Since July 2003, when the program of full-time hospital-based physicians (Hospitalists) was formally inaugurated, Hospitalist In conjunction with Neurology, Hospitalists play a major role in the Medicine has developed into a strong and relevant in-hospital neurologic care at Stamford Hospital. The entire Division is an active

38 2016 Clinical Annual Report participant in the Stroke Program, which was recertified by the Joint Hospitalist Medicine’s goals for 2017 include continued growth and Commission in 2015. The Hospitalist team is available around the expansion in developing Hospital protocols and efficiency-related clock to expedite the treatment of patients with stroke, working projects such as LOS reduction, SNF utilization, reducing re- collaboratively with Neurology. admissions from both home and SNFs, improved case mix index and medical record documentation, improved early discharge metrics, With an aging population, limitations on medical residents’ hours improved PCP satisfaction, improved sepsis bundle performance and increased daily physician responsibilities, mid-level providers and ED throughput. Due to the climate of the new healthcare law, are delivering care not only in the outpatient setting but also in Hospitalists have been called upon to participate in a bundle savings the Hospital. Currently, we have five full-time and per diem mid- program and revenue-sharing with multiple entities during the level providers. Mid-levels are improving quality and safety with patient’s continuum of care. We consistently strive to provide a higher quality-improvement projects by sitting on various committees in quality of patient care. Therefore, we aim to increase our Medicare the Hospital and by using evidence-based best practice protocols. core measure metrics by giving patients the best-possible care, In addition, by informing patients and patients’ families about what exceeding their expectations and preventing readmissions. We have is to happen and future treatment steps to take, patient satisfaction ongoing initiatives to increase patient satisfaction scores with regards for our Division has increased and avoidable readmissions reduced. to physician communication. Physicians can delegate care to mid-level providers, within their scope of practice, which frees up physicians for more complex Figure 1: FY 2016 Payor Mix cases. They are a crucial part of our Division and are accessible to answer nurses’ questions, complete histories and physicals, aid in ED throughput times, assist in minor procedures, respond to Payor Mix emergencies, complete discharge summaries, facilitate discharges earlier in the day and provide other care when needed.

Members of the Hospitalist Medicine group continue to serve on many Hospital committees, including ED Leadership Throughput Committee, Pharmacy and Therapeutics Committee, Graduate Medical Education Committee, IT Leadership Committee, Resuscitation Committee, Sepsis Committee, Clinical Competence Committee Meeting for Internal Medicine, Infection Control Committee, Patient Satisfaction Committee, Medicine Peer Review, Medical Executive Committee, Core Measures work group, Infection Prevention and Patient Safety and Quality Committee.

The top 10 admitting diagnoses include:

1. Unspecified Chest Pain 6. Atrial fibrillation, unspecified type 2. Syncope & Collapse 7. Seizure 3. Sepsis 8. TIA 4. Acute Respiratory Failure 9. AKI 5. CVA 10. COPD exacerbation

Some of our quality, productivity and strategy metrics are included below. Figure 1 shows Stamford Hospital’s payor mix; Figure 2 highlights ED hold to admit status for FY16 vs. FY15; Figure 3 shows the trend for readmission rates for 2014-2016; Figure 4 demonstrates the average length of stay for patients from 2014-2016; Figure 5 shows the percentage of discharge orders by 10 a.m.; and Figure 6 highlights the e-prescribing rate for June, July and August 2015.

2016 Clinical Annual Report 39 Department of Medicine: Annual Report 2016

Figure 2: Highlights ED hold to admit status for FY16 vs. FY15

ED Hold to Admit Status FY 2015 FY 2016 31 30 31 27 28 27 30 29 23 23 24 24 22 23 24 24 24 23 23 21 22 20 19 21 Minutes

381 410 334 355 335 332 345 348 378 347 336 307 302 314 306 311 322 318 328 318 283 234 226 224 Volume

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

All Cause Re-admission Rate All Cause Re-admission Rate 9.69% 9.80% 9.07% 8.79% 10.30% 10.55% 8.62% 10.23% 9.44% 8.79% 8.73% 9.45% 7.33% 8.32% 8.17% FY 2016

FY 2014 FY 2015 FY 2016 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Avg LOS: (excludes > 30 day stays) Avg LOS: (excludes > 30 day stays)

4.64 4.82 4.75 5.10 5.10 5.06 4.90 4.73 4.77 4.91 4.59 4.76 4.75 3.92 4.28 FY 2016

FY 2014 FY 2015 FY 2016 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep a) Includes all inpatient accounts, except Account Types – 'IPHOBPIC', 'IPPSYCH', 'IPREHAB', 'OPOBSERV', and 'OPSOC-H'. b) Data reported as of patient's 'Discharge Date'. c) Data excludes patients with Diaschrge Disposition Name – '02 XFER TO ACUTECARE HOSPITAL', '07 AGAINST MEDICAL ADVICE, and '20 EXPIRED'. d) Data excludes outliers (i.e., patients with LOB>30). e) Hospitalists acting as 'Physician of Record'.

%D/C Ordered by 10 a.m. FY 2016 58.0% 57.4% 58.9% 57.5% 58.3% No 57.9% 52.3% 57.6% 55.2% 52.0% 53.3% 48.5%

51.5% Yes 42.1% 47.7% 42.4% 42.0% 42.6% 44.8% 48.0% 41.1% 42.5% 46.7% 41.7%

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep a) Data reported as of patient's 'Discharge Date' b) Hospitalists acting as 'Physician of Record' No Yes

E-Prescribing Rate

65.7 64.7Jul Aug

2016 October 2015 to present

Jun Jul Aug

40 2016 Clinical Annual Report Figure 3: Trend for readmission rates for 2014-2016

New Admissions New Admissions (Daily Average)

639 580 635 597 607 599 600 20.6 18.7 20.5 20.6 19.6 20.0 19.4 540 540 525 496 18.0 18.0 16.9 426 16.0 14.2

FY 2016 FY 2016

589 562 578 613 613 19.0 19.7 20.4 20.4 548 509 508 559 544 539 557 17.7 17.0 18.1 18.0 19.3 17.5 17.4 18.0

FY 2015 FY 2015

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

a) Data reported as of patient's 'Admit Month' a) Data reported as of patient's 'Admit Month' b) Hospitalists acting as 'Admitting Provider' b) Hospitalists acting as 'Admitting Provider'

Discharges - Hospitalist: Physician of Record Discharges - Hospitalist: Physician of Record (Daily Average)

610 616 566 591 612 560 555 19.7 19.1 20.4 514 556 552 544 528 17.1 17.9 19.9 19.5 18.1 18.5 17.8 17.5 17.6

FY 2016 FY 2016

590 589 19.7 19.6 522 561 563 513 543 536 528 578 18.1 18.2 17.6 17.5 17.3 19.3 485 499 16.8 16.2 16.5 17.0

FY 2015 FY 2015

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

a) Data reported as of patient's 'Discharge Date' a) Data reported as of patient's 'Discharge Date' b) Hospitalists acting as 'Physician of Record' b) Hospitalists acting as 'Physician of Record'

New Consults H&P Bills

206 692 642 673 640 657 648 640 615 607 632 561 594

111 FY 2016 90 FY 2016 53 62 54 38 43 50 49 40 21

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep a) New Consults – H&P Bills Volume reported by Ingenious Med - New Admissions as per Meditech a) NBounce: Ingenious Med. b) Only Hospitalists data

Average Daily Cenus

114.1 107.8 113.5 112.3 114.5 116.9 106.9 104.3 100.3 94.2 100.2 100.6 FY 2016

115.6 105.2 97.2 110.4 110.5 106.3 108.8 99.7 107.3 98.3 101.6 110.4 FY 2015

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep a) Source: Ingenious Med.

2016 Clinical Annual Report 41 Department of Medicine: Annual Report 2016

Infectious Diseases bimonthly adult immunology clinic. She expertly supervises the care for a client base of up to 100 individuals, working both at Optimus Healthcare and Stamford Hospital. The Department was again successful in its reapplication for three federal Ryan White Michael Parry, MD Grants in support of the Infectious Disease Nurse Practitioner, Thomas Jay Bradsell Chair of Infectious

Diseases, Stamford Hospital Adherence Nurse Rheajeanne Britt, RN, and Nutritional Counselor

Professor of Clinical Medicine, Lisa Lasorsa, RD. They provide dedicated service to our clients and Columbia University College of make the Stamford Hospital HIV Program a unique and highly Physicians and Surgeons 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 Active Staff: services and travel medicine. • Ralph Cipriani, MD • Ariana Kuehne, NP • Maher Madhoun, MD • Asha Shah, MD Research activities, Hospital epidemiology, environmental • Michael Parry, MD • Lynda Streett, MD infection control and antibiotic stewardship are ongoing. The Department, together with Environmental Services, continues The Infectious Diseases Department is a Division of the Department to be involved in a multi-medical center environmental study of Medicine and provides multiple services to patients and clinicians. to evaluate the effectiveness of terminal room cleaning in the The Division is responsible for infection prevention and Hospital prevention of hospital-acquired infections. The Department is epidemiology, microbiology laboratory direction, Employee Health involved in three pharmaceutical research studies: A randomized, Service direction, the antibiotic stewardship program in conjunction double blind study of Omadacycline versus Moxifloxacin for the with Pharmacy, the HIV program, clinical consult service, emergency treatment of Community Acquired Bacterial Pneumonia; Treatment management (for infectious diseases) and staff education at all of Candidemia with CD101, a new long-acting Echinocandin; levels. Scheduled and ad hoc educational programs are provided and Treatment of Severe Influenza in Hospitalized Patients with for students, residents, attending staff, nursing staff, other Hospital Oseltamivir, with or without Danirixin, a CXCR2 inhibitor. employees and the community. The Department is also actively involved in numerous medical staff and Hospital committees: Infection prevention represents the most important departmental activity at Stamford Hospital. Infection Prevention Nurses Brenda • Infection Prevention Committee – Dr. Michael Parry (Chair), Grant, Merima Sestovic and Paula Castellano-Flynn function out Dr. Lynda Streett, Dr. Asha Shah of the Department’s offices on the Terrace level of the Physicians’ • IT Leadership & Emergency Management Office Building. They perform critical roles in infection surveillance, Committee – Dr. Michael Parry outbreak investigation and control, education, policy development and regulatory compliance. Ms. Grant continues her appointment to • Regs & Accreditation Committee – Dr. Michael Parry the State of Connecticut Healthcare-Associated Infections Advisory • Pharmacy & Therapeutics Committee – Dr. Michael Parry Committee. She was also elected to a three-year term on the National • Perinatal Infection Committee – Dr. Lynda Streett, Dr. Asha Shah Board of Directors of the Association for Professionals in Infection Control and Epidemiology (APIC). Ms. Sestovic has been involved in ICU Committee – Dr. Lynda Streett • regional APIC activities. Dr. Parry is also a member of the Connecticut Department of Public Health (CT DPH) Committee on Reportable Dr. Streett recently completed certification in Wound Care Diseases and CT DPH Advisory Committee on Infectious Diseases. Management and Dr. Shah attained her Master’s Degree in Medical Epidemiology at Columbia University Mailman School of Public The Department’s quality improvement initiatives are ongoing and Health. Two part-time Division members, Dr. Maher Madhoun showed good performance in several collaborative areas for FY16. (full-time Hospitalist) and Dr. Ralph Cipriani (full-time Internist), also The Department was an active participant in two collaborative participate in committee and educational programs. projects in this regard: the PAICAP (Preventing Avoidable Infectious The most active subspecialty areas of clinical work are hospital- Complications by Adjusting Payment) study with Harvard Medical acquired infections and HIV/AIDS. Ariana Kuehne, NP, Director of School; and the Sentinel Laboratory RSV and Influenza Surveillance Outpatient HIV Services, coordinates HIV clinic services and the Program through CDC. Infection prevention targets include

42 2016 Clinical Annual Report reduction in all device-related infections including hospital-wide the NxStage machine), and 44 peritoneal dialysis patients. We have central line-associated bacteremia (CLABSI), hospital-wide catheter been designated a Five-Star Clinic by CMS (its top rating) and have associated urinary tract infections (CAUTI) and colon surgical won a Fistula First Award from the ESRD Network of New England. infections (with surgery). Increasing demands for surveillance and Our clinic serves the greater Stamford area with patients residing in public reporting have taxed our resources as 2016 saw an increase towns stretching from Norwalk to Port Chester and South Salem. in monthly requirements for reporting for CLABSI and CAUTIs, C. The principal modality for peritoneal dialysis is CCPD, which is dialysis diff cases and MRSA bacteremia from all Med-Surg units, Pediatrics, done overnight using a simple machine. Daily home hemodialysis Rehab and the ICU. Urinary catheter utilization rates remain 50% is an important modality due to the greater degree of rehabilitation lower than CDC benchmarks. Hand hygiene monitoring is an that it affords as well as superior phosphate and blood pressure integral part of our hospital-acquired infection (HAI) reduction control, we plan to offer nocturnal hemodialysis immininently. effort but it has been a challenge to reach the 95% target. We continue to aggressively refer patients for renal transplant Nevertheless, HAI rates for 2015 reached all all-time low, falling and retain affiliations with the programs at Columbia and Yale. to 0.8% and surgical site infections were 0.61%. DaVita continues to provide outpatient dialysis services and, since March, 2014, supplies inpatient hemodialysis and CRRT. Nephrology The Division of Nephrology supports the teaching program of the Hospital. All members of the Division participate in clinical teaching, morning report, formal lectures and renal conferences. Eric Brown, MD Two members participate in third-year medical student Director of Nephrology preceptorship for four weeks each year. One member supervises Assoc. Professor of Clinical Medicine, the Department of Medicine Journal Club, an important Columbia University College of Physicians and Surgeons educational vehicle that teaches house staff analytic reading, interpretative skills, statistical analysis and critical thinking. One member is an active participant in the outpatient Medicine Clinic at Optimus. Two physicians are active members of the Department Active Staff: of Medicine Clinical Competence Committee. We collaborate • Revekka Babayev, MD • William Hines, MD with the Department of Medicine in arranging outside nephrology speakers regularly and last year hosted Dr. Andrew Bomback and • Eric Brown, MD • Nazanine Khairkhah, MD Dr. Jai Radhakrishnan from Columbia and Drs. Peter Aronson, • Brenda Chan, MD • Francis Walsh, MD Mark Perazella and Aldo Peixoto from Yale. • John Fitzgibbons, MD The Division continues to participate in clinical research. We are The Division of Nephrology continues to offer acute inpatient actively recruiting for the SONAR Study, an endothelin agonist to hemodialysis, acute inpatient peritoneal dialysis, and CRRT slow the progression of diabetic nephropathy, and are participating (continuous renal replacement therapy). For the period in a study providing external defibrillators ro new dialysis patients October 1, 2015 to September 30, 2016, we performed 843 and four different studies of Vadadustat, a novel medication to treat inpatient hemodialysis treatments and 71 days of CRRT. Our the anemia of kidney disease. glomerulonephritis practice remains active and has benefited immensely from the cooperation of Interventional Radiology (for Dr. Revekka Babayev joined our practice a year ago after completing biopsies), Stamford Pathology (which performs an immediate her training at Columbia and has already won the Specialist of the assessment of the adequacy of the biopsy and sends the tissue Year Award from the house staff, an honor which barely touches to Columbia) and the world-class renal pathologists at Columbia her contributions to our practice and community. In addtion University. We actively recruit patients for the CureGN Study in to the Stamford practice, clinical services are performed by Drs. cooperation with Columbia and host the study staff quarterly for John Fitzgibbons, Nazanine Khairkhah and Francis Walsh, whose the convenience of our subjects. dedication continues to expand the clinical and academic services that the Division provides. The Stamford DaVita dialysis center currently has 160 in-center hemodialysis patients, seven home hemodialysis patients (who use

2016 Clinical Annual Report 43 Department of Medicine: Annual Report 2016

Neurology

Louise D. Resor, MD Director of Neurology

Active Staff: • Daniel Brooks, MD • Charisse Litchman, MD care immeasurably. Their immediate availability has served to • Sarah Buckingham, MD • Sarah Mulukutla, MD improve our care of stroke patients in particular. As a result, over • David Hahn, MD • Louise D. Resor, MD the past year the number of patients who received TPA rose to an • Eric Kung, MD • Evangelos Xistris, MD all-time high and our door-to-needle times for the administration of IV-TPA decreased dramatically. Drs. Charisse Litchman and Eric Kung received special certification from the American Academy of Neurology in the Dr. Kung continues to supervise the neurologic care of brain- management of headaches. Dr. Louise Resor completed training injured patients as he leads the concussion program, a multi- in electroencephalography. Dr. Evangelos Xistris has extensive disciplinary group of neurosurgeons, neurologists, orthopedists, experience in the diagnosis of neuromuscular problems and neuropsychologists, speech, occupational and physical therapists. performs EMGs. Neurologists supervise electrodiagnostic services at Stamford In 2015, Dr. Sarah Mulukutla joined the staff as a neuro-hospitalist Hospital. In addition to routine outpatient EEG and evoked potential devoting her full time to the care of hospitalized patients. She exams, 24-hour ambulatory EEG testing is available. In the Hospital, provides urgent and intensive management to patients with the Department provides prolonged video EEG monitoring for neurologic problems. She was joined in that endeavor in November the evaluation of undiagnosed episodes of altered consciousness by Dr. David Hahn, a stroke-trained neurologist, who spends half-time and monitoring of critically ill ICU patients. With the acquisition in the office, and more recently by Dr. Daniel Brooks. Dr. Brooks, also a of new equipment this fall, real-time remote monitoring of the graduate of the Yale Neurology program, completed a neurovascular EEG will be available. fellowship at the Albert Einstein College of Medicine. Dr. Sarah The addition of four recently trained neurologists has added Buckingham, another Yale-trained neurologist with sub-specialty to the depth and breadth of neurologic care in Stamford. training in movement disorders, was the most recent addition to The neuro-hospitalists have enabled us to provide superior the Department. Her expertise in the management of patients with care for inpatients with neurologic problems. Parkinson’s disease and tremor is a major asset to the community.

The members of the Department continue to staff the stroke program at Stamford Hospital. They are on call around-the-clock to respond to “stroke alerts.” Intravenous TPA, a “clot busting” medicine aimed at improving stroke outcomes, must be given within four- and-a-half hours of the onset of symptoms. Our stroke protocol is designed to provide rapid assessment of stroke patients in the ER and in the Hospital to ensure the medication is administered in a safe and timely manner. In September 2015, we received recertification by The Joint Commission, having already achieved Gold Award status from the American Heart Association’s Get With The Guidelines® program. The three neuro-hospitalists have enhanced inpatient neurologic

44 2016 Clinical Annual Report Oncology and Hematology malignant blood diseases. During the first nine months of 2016, over 600 unique patients with primary hematologic malignancies were seen and managed by the physicians of the BCC. Additionally, the benign hematology program remained equally robust, as the majority of new consultations for hematologic disorders related to Paul Weinstein, MD helping patients with benign abnormalities of their blood counts, Director of Oncology metabolic disorders such as Gaucher disease, autoimmune diseases, bleeding disorders such as hemophilia and von Willebrand disease and disturbances of the coagulation system predisposing to thromboembolic disease, including those afflicting women with infertility or maternal-fetal issues related to hypercoagulability. There is also an active inpatient consultation service focused on providing guidance on the management of the frequent transient hematologic complications of acute illnesses. Dedicated full-time genetic Michael Bar, MD counseling for inheritable disorders is available to all patients and Director of Hematology their families.

Hematologists at the BCC continue to work closely with two dedicated hematopathologists, who utilize the most sophisticated and ever evolving cytogenetic, molecular and immunologic tools Active Staff: available for state-of-the-art molecularly-defined pathology. These • Anne Angevine, MD • Steve Lo, MD tools include: fluorescence-activated cell sorting (FACS) for the rapid diagnosis of malignant hematologic disorders; qualitative • Michael Bar, MD • Jamie Stratton, MD and quantitative polymerase chain reaction (PCR) studies of both • Salvatore Del Prete, MD • Isidore Tepler, MD DNA and RNA, which have the ability to detect one malignant • Anthony Gulati, MD • Paul Weinstein, MD cell/1,000,000 cells; and fluorescent in situ hybridization (FISH), The Divisions of Hematology and Oncology are composed of the a technology that provides information on multiple genetic eight physicians practicing as Hematology Oncology PC (HOA), abnormalities (“molecular signature”) critical to the treatment of administratively named Medical Oncology and Hematology acute and chronic leukemias, lymphomas and multiple myeloma. (MOH), as part of the cancer service line within the Bennett Cancer During 2016, the Department increasingly adopted direct deep Center (BCC). Dr. Jamie Stratton joined HOA in August 2016, after sequencing technologies, including next generation sequencing completing her medical training at New York Medical College and (NGS), to help identify mutations amenable to targeted drug therapy. a fellowship at Yale-New Haven Hospital. Skilled medical colleagues This technology has proven particularly useful in patients with including Radiation Oncologists, cancer-oriented Surgeons, poorly classified hematologic malignancies or advanced relapsed/ Pathologists, Diagnostic Radiologists and other medical staff refractory disease without available standard treatment options. provide dedicated support. We are greatly aided by subspecialty Continued rapid adaptation of an increasingly broad menu of new Nurse Navigators Dominique Srdanovic (GU, Supervisor), Melissa assays are made in real time to both provide patients with the most Ronk (Thoracic) and Katharine Radziewicz (GI). We serve the needs precise diagnostic and monitoring tools, and to allow patients to of patients with oncologic and hematologic (both benign and access the increasing array of targeted agents available to patients malignant) disorders in the Hospital’s primary catchment area and, with hematologic disorders as part of the momentous change to increasingly, secondary, tertiary and even more distant markets. “personalized” medicine. We are very often involved in the care of the nearly 900 patients A burgeoning array of sophisticated therapies are available to diagnosed with cancer in Stamford Hospital each year. More than patients and include traditional systemic chemotherapy; small 100 patients typically are seen daily, accounting for more than molecule targeted therapies, such as the recently approved 20,000 visits to the Bennett Cancer Center annually. and revolutionary Bruton kinase inhibitors, BCL-2 inhibitors The Divisions of Hematology and Oncology at the Bennett Cancer and phosphatidylinositol 3-kinase inhibitors for low-grade Center offers a comprehensive range of treatments for adult non-Hodgkin’s lymphomas and chronic lymphocytic leukemia;

2016 Clinical Annual Report 45 Department of Medicine: Annual Report 2016

traditional monoclonal antibodies as well as both radio-conjugated with our Gastrointestinal Cancer Family Tumor Registry) and other and toxin-conjugated monoclonal antibodies for malignant malignancies. To that end, multigene mutation panel assays are being lymphoproliferative disorders and leukemias; anti-CD38 and natural used more frequently. In 2015, we counseled 276 new persons, and killer cell activating antibodies to treat multiple myeloma; epigenetic discovered high-risk genetic mutations in 14 of them, undoubtedly hypomethylating agents for myelodysplastic syndromes and fulfilling the maxim that knowledge is power. acute myelogenous leukemia of the elderly; immune modulation therapy for lymphoproliferative disorders, plasma cell dyscrasias Our Survivorship Program, championed by Drs. Anne Angevine and aplastic anemia; enzyme replacement therapy for metabolic and Steve Lo, and under the direction of Deanna Xistris, RN, MSN, disorders, such as Gaucher disease; complement inhibition therapy and Fran Becker, LCSW, is ready to accept persons completing for rare disorders, such as paroxysmal nocturnal hemoglobinuria their treatment for early-stage cancer. A summary of their therapy and atypical hemolytic uremic syndrome; and recombinant factor and recommendations for future follow-up is supplied to patients, replacement therapy for congenital and acquired bleeding disorders. their families and their physicians via a formal report with updates Plasmapheresis, apheresis and exchange transfusions are available as appropriate. to both inpatients and outpatients. The Center for Medicare and Medicaid Innovation has developed the Oncology Care Model in an effort to provide high- quality Our latest accomplishment was being selected as the newest care with cost savings achieved by care delivery in less expensive member of the Dana-Farber/Brigham and Women’s Cancer Care settings. We are one of the select practices in the country to Collaborative. The relationship will provide our medical staff with participate in this pilot program. We are charged with providing increased educational opportunities, and the ability to consult outpatient services designed to keep patients from needing with internationally recognized specialists in all aspects of cancer referrals to the Emergency Department and/or hospitalization. care. Our patients may not have to travel to Boston to receive The Hospital is underwriting the cost of the support staff needed these benefits because virtual tumor boards will allow for case to educate providers, and to track, and analyze the results presentations and recommendations. Our patients will have of our effort. If successful, the model will likely be expanded greater access to the latest cancer research and clinical trials. to all oncology practices in America. The Divisions’ clinical research program for both Oncology and

Hematology remains robust, under the leadership of Dr. Salvatore Pain and Pallative Care Service Del Prete and supervisor Molly Daley. In 2015, 91 of our patients were newly enrolled into studies here or at external sites (Dana-Farber, for example), encompassing a wide variety of solid tumors and hematologic malignancies. Currently, there are 155 patients actively enrolled in 52 studies at the BCC and hundreds of patients are in Anne Brewer, MD, MPH, FAAFP long-term follow-up The numbers for 2016 (YTD) are even more Medical Director of Palliative Care impressive. Examples of the importance of our activities include our participation in trials leading to the approval of imbruvica (Ibrutinib) for chronic lymphatic leukemia and ado-trastuzumab emtansine (Kadcyla) for Her-2 neu positive advanced breast cancer. This is also a very exciting time because of the rapid advances in immune- The Pain and Palliative Care Service provides an extra layer of oncology. Here too, we are enrolling patients in studies investigating support for patients from all departments who face a serious the role of these agents in lung and triple negative breast cancers. or life-threatening illness.

The Genetic Counseling Program, directed by Drs. Isidore Tepler and The Service continues to provide both assistance in transitioning Paul Weinstein, and supervised by Erin Ash, MS, CGC, is increasingly to hospice and ongoing symptom management for those who active, serving the needs of those affected with cancer, their families are enrolled in inpatient hospice. The Service is staffed by nurse and healthy but concerned individuals. The Program has advised practitioners with physician collaboration. Monika Tello, MS, ANPBC, persons with, or worried about, their personal risk for breast and ACHPN and Doreen B. Chimblo, MS, APRN, FNP-BC, joined us in 2012, ovarian cancer, as well as increasing numbers of persons having and Maria Rivera, APRN, joined us in February 2015. This transition has or concerned about gastrointestinal cancers (in collaboration enabled the provision of a higher level of consultation for patients,

46 2016 Clinical Annual Report including more immediate improvement in pain and symptoms. Pulmonary, Critical Care and Sleep Medicine The ability to recover billable services from the NPs’ care, in Pulmonary Medicine addition to a conversion to an electronic billing process, has improved efficiency.

Because of the national shortage of specialty-trained Palliative Care Paul Sachs, MD clinicians, a major focus has been improving the primary palliative Director of Pulmonary Medicine care skills of frontline clinicians. Associate Clinical Professor of Medicine, Columbia University

Accomplishments in this regard include: College of Physicians and Surgeons

• Participation in Internal Medicine, Family Medicine and Surgical lecture series programs for residents Active Staff: • Participation in Grand Rounds and the Pastoral Care Lecture Series • Michael Bernstein, MD • Alex Ortega, MD for attendings and chaplains • Caroline Gulati, MD • Dominic Roca, MD • Weekly precepting in the Family Medicine Clinic, which facilitates • James S. Krinsley, MD • Paul Sachs, MD discussions of primary palliative care • Anna Moniodis, MD • Steven Thau, MD • Desh S. Nandedkar, MD • Participation in the Pastoral Care Advisory Committee In 2016, Pulmonary Medicine was intricately involved in the • Active planning and participation in the Third Annual “SHARE” equipment evaluation, purchasing, preparation, training, planning curricula for house staff, an interdepartmentally sponsored and implementation steps needed for the seamless flow of patients program that gives residents an opportunity to learn about into the new Hospital. The Division continued to report a high patient/physician relationships from cancer survivors utilization of its varied services. Both inpatient and ambulatory services remained active over the past year. Over 170,000 • Core rotation for Family Medicine and Internal Medicine residents procedures/interventions were performed by Respiratory Therapy (RT) in 2016. The volume of ventilator days remains very high. • Participation in the Magnet presentation The average daily ventilator census was 6.8 ventilators in use per • Daily ICU rounds by nurse practitioners with the ICU team day. The Pulmonary section remained committed to preventing ventilator-associated events (VAE), soft tissue injuries due to • Pain lectures for nursing orientation and Bennett Cancer endotracheal tube pressures and self-extubations. Among the Center staff interventions are a ventilator-associated event committee, VAE prevention bundles, oral care protocols, specialized endotracheal This year the Pain and Palliative Care Service worked with the Bennett tubes and probiotic use. Cancer Center in the training of several Social Work interns. Through this innovative interdisciplinary and interdepartmental effort, we The Division continued to perform outpatient pulmonary services were joined this year by two master’s-level Social Work interns. It on both campuses. Tests performed at the Pulmonary Function has been a true win-win to partner in their education while they are Lab on the fourth floor of the Tully Health Center predominantly active participants in providing mental health services to our patients. consisted of pediatric cases, but the Lab was available to adult The time they have been able to spend with patients and families outpatients as well. A new PFT lab will be located in the Integrated has been instrumental in supporting those families along their grief Care Pavilion. Overall, over 5,000 studies PFTs were performed by pathways, and facilitates better communication between the families the Department at the hospital campuses. The turnaround time for and everyone on the Palliative Care team. PFT interpretations was improved to less than four days.

Arterial blood gas utilization remained high. Over 8,100 ABGs were analyzed in 2016. The Pulmonary Laboratory passed its Joint Commission inspection and re-certification process. It also passed the on-site College of Pathologists Laboratory inspection.

2016 Clinical Annual Report 47 Department of Medicine: Annual Report 2016

The RT Department remained committed to education. In October, pulmonary fibrosis, sarcoidosis, asthma and s/p lung transplantation in honor of Respiratory Care Week, they organized their 3rd Annual continued to take advantage of this multidisciplinary program. Stamford Hospital Respiratory Care Symposium. This was a CME/CEU Participants continued to praise the program, documenting event attended by respiratory therapists and nurses from improved quality of life and exercise capacity. Many continued to throughout Connecticut and was once again highly successful. exercise in the Post-Rehab Fitness Program at the Sarner Health & Fitness Institute, specifically designed for Pulmonary Rehab Our RTs continued to supervise students from the Norwalk graduates. The program proudly achieved national re-certification Community College Respiratory Therapy Program. Two new from the American Academy of Cardiovascular and Pulmonary students rotated through the Intensive Care Unit and the Rehabilitation. Intermediate Care Unit every six weeks. This continues to generate energy and enthusiasm among our RT staff. It has also helped with The Pulmonary Rehabilitation team hosted its 12th Annual COPD Stamford Hospital’s recruitment of the finest of the new respiratory Day Health Fair, a patient education program that was the first of therapy graduates. Some students enjoyed their experience so its kind in the Northeast region when it was initially developed in much that they have stayed on to work here. The Department 2005, and remains unique to this area. About 60 patients and family also participated in new nursing orientations. Twice monthly members from the greater Stamford area attended the event and nurse educators and nurse managers scheduled one- to two-hour the feedback was overwhelmingly positive. sessions for their staff to review respiratory procedures, policies and equipment with the Respiratory Therapist Supervisor or Clinical Kathryn Sullivan, RRT, the Pulmonary Rehab Coordinator, continued Coordinator. Two of our therapists are certified as BLS/ACLS/PALS her new role as our COPD Patient Liaison. She met with patients instructors, and one of our therapists is now a neonatal ALS admitted to the Hospital with a diagnosis of COPD exacerbation. She instructor. 100% of our RTs are ACLS certified and over 65% of our assisted with coordinating Hospital discharge to provide continuity therapists are now certified in Pediatric Advanced Life Support as with outpatient care and to try to prevent unnecessary readmissions. well. Our Respiratory Therapists remain involved in multidisciplinary The entire Respiratory Department assisted by completing COPD committees to improve care at Stamford Hospital including worksheet/education forms on over 80% of inpatients admitted with committees on Magnet Skin Breakdown, Transition of Care, Bariatric a diagnosis of COPD exacerbation. Thanks in part to these efforts, the Accreditation, Ventilator Associated Events, Resuscitation, Quiet at Hospital COPD readmission rate fell to 17%. Night, Reusable Scopes, Regulations and Accreditation, Misuse of The Pulmonary Department, in conjunction with Thoracic Surgery Vials, Ethics, ID, Disaster Preparedness, Nursing Coordinating Council and the Bennett Cancer Center, continued our initiative to assist our and Self-Staffing. RT is also an active participant in the monthly patients and staff with tobacco cessation with the “Commit to Quit” ICU committee meetings. Diane Major-Olivant, RRT is the Facilitator Program. We now have four Association for the Treatment of Tobacco of the Pediatric Neonatal Committee. The Department is now Use and Dependence-certified counselors who are available to see participating in a statewide CHA initiative for pediatric asthma our patients. Carbon monoxide testing and spirometry screening are and three have completed certification courses. available for participants of the program, as needed. The Stamford The entire RT staff is proficient in utilizing high-flow nasal cannula Hospital’s tobacco Quit Line can be reached by dialing (203) 276- therapy. This new technology has allowed patients to tolerate high QUIT, or ext. 7848 from any Hospital phone. concentrations of oxygen via nasal cannula at flow. High flow rates The Interventional Pulmonary and Advanced Bronchoscopy of up to 60 LPM are tolerated because the delivered gas is humidified service, led by Dr. Michael Bernstein, continues to see growth and heated to body temperature. They were useful in avoiding the in our program. Stamford Hospital offers a wide array of need for bulky high flow masks and, in some cases, intubations. interventional and advanced diagnostic bronchoscopy procedures, The outpatient Pulmonary Rehabilitation Program continued to including endobronchial ultrasound capabilities, both convex thrive on the second floor of the Tully Health Center. To date, 979 and radial probe imaging, navigational bronchoscopy using the participants have graduated from the program since its inception. superDimension™ System, fiducial placement for CyberKnife® The program remained busy, graduating about 50 patients every radiation, cryobiopsy/cryoablation as well as APC ablation. In year, with anywhere from six to 12 participants in the program 2016, we had a significant increase in cryo-based biopsies, which at any one time. The variety of patient diagnoses in the program have allowed for better diagnostic yield during bronchoscopy. has increased as well. Patients with COPD as well as those with We continued to perform a wide array of both diagnostic and

48 2016 Clinical Annual Report therapeutic pleural procedures including PleurX catheters, We are pleased with the quantity and the quality of services that ultrasound guided thoracenteses, percutaneous and conventional the Pulmonary Division provided, but we are particularly proud of chest tubes, and closed pleural biopsies. With the move to the the individuals who make up our staff. They participated in other new Hospital, the program falls administratively within the scope community events such as performing screening spirometries of the OR facilities, which has allowed us flexibility to offer easier at the Women’s Expo, COPD Day, Employee Health Fair and scheduling for our patients. Our Interventional Pulmonary and Health, Wellness & Sports Expo at Chelsea Piers Connecticut. The Advanced Bronchoscopy team is a core part of the Hospital’s Pulmonary Rehab staff volunteered their time and skills to make ID multidisciplinary Lung Cancer Program working with Thoracic badge holders that were then sold to pay for light hand weights to Surgery, Medical Oncology, Radiation Oncology, Pathology and be presented to Pulmonary Rehab participants upon graduation. Diagnostic Radiology and participating in our bi-weekly lung We were proud to learn that Dr. Alex Ortega was the Medical cancer tumor boards. This year, the Bennett Cancer Center joined Residents’ choice for the “Rookie of the Year” award and Dr. James the Dana-Farber/Brigham and Woman’s Cancer Care Collaborative. Krinsley received the “Teacher of the Year” award at the Department This collaborative provides our lung cancer patients access to new of Medicine graduation dinner. trials and therapeutics and our physicians with opportunities to discuss lung cancer management with a multidisciplinary tumor board based at one the premier oncology centers in the world. Critical Care

The Pulmonary Division plays a key role Stamford Hospital’s Lung In FY16 there were 1,174 admissions to the Intensive Care Unit Cancer Screening Program. Dr. Michael Bernstein serves as the (ICU), seven fewer than in FY15. Median length of stay of patients Co-Clinical Director of the program along with Dr. Michael Ebright admitted to the ICU remained unchanged at 1.7 days. of Thoracic Surgery. Our multidisciplinary program is accredited by 65 patients were admitted to the ICU following cardiovascular the American College of Radiology. Over the last year we have seen surgery during this fiscal year, 19 fewer than in the previous fiscal a 25% growth in the number of patients screened. year. The distribution of cases was: 49% “isolated” coronary artery The Interventional Pulmonary and Advanced Bronchoscopy team bypass surgery, 28% “isolated” valvular surgery, 9% combined also has partnered with the Stamford Hospital Office of Research to coronary artery bypass and valvular surgery and 13% with other participate in two industry sponsored trials and registries. We are procedures (predominantly complicated aortic root repair, part of the Percepta registry (Veracyte) that offers an ability to including repair of emergency ruptures). Notably, for the third risk stratify patients for lung cancer based on genomic analysis of year in a row (227 cases), hospital mortality was 0%. material obtained at bronchoscopy. Moreover, we are one of five The year was marked by revision and development of numerous sites for Aminoindex Trial looking to stratify lung cancer probability multidisciplinary patient care protocols as well as creation of based on a blood test. new ones. The Pulmonary Department remained active in providing CME • Active mobilization of the critically ill patient was the major opportunities for the Stamford community. The 34th Annual initiative during the year. This required intensive involvement Pulmonary Symposium was held in May. Stamford Hospital of Nursing, Respiratory Therapy and Physical Therapy, as well Radiologist Dr. Gregory Pearson spoke on the topic “Guidelines for as physician and pharmacy involvement to modify sedation Management of Pulmonary Nodules.” This was followed by a lively practices and orders. The culture of the unit regarding this issue discussion of associated issues by a panel of experts that included has changed. Over the course of the year patients undergoing Drs. Ebright, Bernstein, Robert Babkowski and Thoracic Nurse mechanical ventilation have been routinely taken out of bed Navigator Melissa Ronk. This format was well-received and will be and several of them have walked around the ICU while considered for future Pulmonary symposiums. Pulmonary Grand undergoing mechanical ventilation via endotracheal tube. Rounds was given in July by our newest Stamford pulmonologist, Dr. Ann Moniodis. She spoke on “Understanding Upper Airway • Glucose control evolved, based on interpretation of medical Obstruction.” In addition, the Division gave numerous talks literature. Two blood glucose targets were used, based on throughout the Stamford community about pulmonary topics such preadmission glycemic control, reflected by the HbA1c level. as lung cancer screening, smoking cessation and sleep apnea. Rates of hypoglycemia were extremely low.

2016 Clinical Annual Report 49 Department of Medicine: Annual Report 2016

• The multidisciplinary effort to manage severe alcohol withdrawal Finally, following the replacement of the local Institutional Review has been associated with a significant reduction in ICU and Board (IRB) by a centralized IRB, Quorum, a group of clinical hospital length of stay of this difficult-to-treat population. investigations was initiated by Dr. Krinsley with medical and surgical In addition, the team’s success using the protocol was reflected residents, for presentation at national and regional conferences. by a 0% rate of patients who required intubation for respiratory These included: failure after being admitted to the ICU. Historic annual rates for • Diabetes is associated with increased dysglycemia and mortality this metric ranged from 15%-30%. in patients with sepsis • The multidisciplinary committee on infection control met regularly The relationship of the severity of sepsis to insulin resistance and monitored infection control practices and protocol adherence, • and dysglycemia especially relating to the prevention of ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections • Time in BG range 70-140 mg/dL is associated with survival in (CAUTI) and central line-associated bacteremia (CLAB). Foley non-diabetic medical ICU patients catheter utilization rate remained at approximately 50% of the national standard and the rate of the sentinel infections • The impact of vital sign measurement frequency on APACHE II remained low. In fact, there has been an 80% reduction in and IV severity scoring the overall rate of ICU-acquired infections regularly monitored by the nurse epidemiologists since 2008. • In an ICU with a high-intensity staffing model, is a nocturnal intensivist necessary? During the year the Director of Critical Care, James Krinsley, MD, delivered presentations relating to intensive glucose management • Time in BG range 70-140 is associated with survival in non-diabetic of critically ill patients, based on the work completed at the Stamford critically ill patients admitted with trauma Hospital ICU, 2014 Congress of the European Society of Intensive

Care Medicine in Barcelona, 2015 Congress of the Society of Sleep Medicine Critical Care Medicine in Phoenix, 2015 Congress on Advanced Technologies and Treatments of Diabetes in Paris and 2015 Congress 2016 was another busy year for Stamford Health’s Connecticut of the International Society of Intensive Care and Emergency Center for Sleep Medicine (CCSM). For the fourth year in a row we Medicine, in Brussels. increased the number of patients being evaluated for sleep disorders and the number of home and in-center sleep studies performed In addition, the following manuscripts were published: despite the current climate of numerous challenges presented by Krinsley JS, Bruns D, Boyd J. The impact of monitoring frequency on federal regulations and private insurance companies. We continue the domains of glycemic control – a Monte Carlo Simulation. J Diab to strive meet the increasing demands of our patients and referring Sci Tech. 2015 9(2):1-9. physicians by adding Dr. Desh Nandekhar our third board-certified sleep specialist to the team that currently includes Dr. Dominic Roca, Krinsley JS, Preiser JC. Time in blood glucose range 70-140 mg/dL > Dr. Steven Thau, Dr. Michael Bernstein, Dr. Caroline Gulati, Diana 80% is strongly associated with increased survival in critically ill non- Bernal Messinger, APRN, Lance Dougherty, RN, RT, RSPGT, Dr. Alex diabetic patients. Crit Care 2015; 19:179. Ortega and Karolyn Chang PA-C. We also added Dr. Anna Moniodis, who joined us from Brigham & Women’s Pulmonary/Critical Care Wenerman J, Desaive T, Finfer S, Foubert L, Furnary A, Holzinger U, fellowship. Our goal remains to continue to provide outstanding Hovorka R, Joseph J, Kosiborod M, Krinsley JS, Mesotten D, Nasraway care for our sleep patients while decreasing the wait time for doctor S, Rooyackers O, Schulz M, Van Herpe T, Vigersky R, Preiser JC. visits and for studies. Dr. Hossein Sadeghi is board-certified in Continuous glucose control in the ICU: Report of a 2013 roundtable Sleep Medicine and, as a part the CCSM, makes us poised to treat our meeting. Crit Care 2014; 18:226. potential pediatric population. In addition to those achievements, Krinsley JS. Is glycemic control in the critically ill cost effective? Hosp PAS and the Sleep Centerventured into Greenwich in the second Prac. 2014, 42(4):53-58. half of the year, working with the Stamford Health Medical Group (SHMG) practice there to provide state-of-the-art sleep services for Krinsley JS. Glycemic control in the critically ill: What have we learned patients in Greenwich. This could not have happened without since NICE-SUGAR? Hosp Prac. 2015; 43(3):191-197. our close working relationship with Dr. Rod Acosta and

50 2016 Clinical Annual Report Dr. Gail Fennell, who spearheaded this endeavor. We are looking The technical aspects of the CCSM have always been outsourced forward to solidifying this relationship to a permanent one that will and we have been with our current company Persante, formerly benefit SHMG, the Sleep Center and the patients in Fairfield County. known as Sleep Care of New Jersey, for the past five-and-a-half years. They provided the CCSM flexibility in managing IT and Federal The program is a Stamford Hospital Center of Excellence and guideline challenges throughout the year. All of the technicians accredited by the American Academy of Sleep Medicine as a were supervised by lead sleep technicians and our board-certified sleep center to diagnose and treat all sleep disorders including sleep physicians, 24-hours-a-day. but not limited to sleep apnea, insomnia, restless legs, narcolepsy, delayed/advanced sleep phase, jet lag and all other conditions While sleep apnea was the most common diagnosis seen at our that cause sleepiness or difficulty sleeping. In FY16, we performed center, the CCSM also had significant experience in treating all over 1,400 sleep studies; 571 in-center studies, up from 454 last year, childhood and adult sleep disorders such as restless legs, insomnia, and 867 home studies, up from 615, making us one of the largest narcolepsy and REM behavior disorders. providers of home studies in Fairfield County. We are on pace to exceed those numbers next year with over 1,800 studies projected, The Connecticut Center for Sleep Medicine remained one of which is a very exciting challenge. We also welcome our new the premier sleep centers in the tri-state area and will continue scorers, Maggie Quintero and Ernestine Tillman. With their help, to provide state-of-the-art sleep medicine to the region. patients will get their tests and results more quickly.

New data continues to strengthen the link between sleep Rehabilitation Medicine apnea and cardiovascular disease, atrial fibrillation, other rhythm disturbances, stroke, thromboembolic events, psychological disorders, cognitive deficits, diabetes and other metabolic disorders, which can not only lead to obesity, but an increased risk of cancer Edwin F. Richter, MD as well. The literature also continued to demonstrate that treatment Director of Rehabilitation Medicine with CPAP reduces that risk. There is even more data suggesting that obstructive sleep apnea contributes to cognitive decline in dementia patients and CPAP can ameliorate those symptoms.

CPAP remains the most effective treatment for obstructive sleep apnea. For some patients, the adjustment period can be difficult Active Staff: and education has been shown to be the largest factor in improving • Aris Barbadimos, MD • Daniel Southern, MD patient adherence. To further facilitate the goal of CPAP compliance, • Carolyn Casino, MD • David Walshin, MD the CCSM continued to offer CPAP Management. For those who • Andrew Illig, DO • Jun Xu, MD ultimately could not tolerate CPAP or did not wish to continue with • Stephen Massimi, MD • Po Priscilla Xu, MD CPAP therapy we helped patients explore other options such as oral • Edwin F. Richter, MD appliances, positional therapy devices and/or surgery. The FDA has approved Inspire a hypoglossal nerve pulse generator controlled The physiatrists (doctors specializing in Physical Medicine and by a small handheld sleep remote. This provides another treatment Rehabilitation) of the Division of Rehabilitation Medicine provide available to help our patients maintain compliance. a broad range of services including musculoskeletal care, pain management, electrodiagnostic testing and rehabilitative services for Our 14th Annual Sleep Symposium featured Dr. Ana C. Krieger, patients with a wide variety of disabling conditions. Patient services Associate Professor of Clinical Medicine, Associate Professor of are provided in the physicians’ offices as well as at the Optimus Clinic. Medicine in Neurology and in Genetic Medicine, who spoke on Inpatient services are provided in the Van Munching Rehabilitation “OSA and Hypoventilation: Review and Treatment.” This is currently Unit as well as other areas of Stamford Hospital. a “hot topic” in the field of medicine, as different modalities are being used to treat different breathing patterns as a way to The Van Munching Rehabilitation Unit had an exceptionally busy improve outcomes and quality of life. year with over 365 discharges, and patient satisfaction ratings remain high. We continue to look for new opportunities to enhance

2016 Clinical Annual Report 51 Department of Medicine: Annual Report 2016

care such as the expansion of neuropsychological services for Van Dr. Karp is a graduate of Brown University and the Brown University Munching inpatients over the past year. Education programming for School of Medicine seven-year medical program. She completed her inpatients has also been enhanced. residency at Stamford Hospital and her fellowship in rheumatology at New York University (NYU) School of Medicine. She is board certified Outpatient rehabilitation services are provided at the Tully Health in both internal medicine and rheumatology. Dr. Karp is a member Center and its Darien satellite and at Chelsea Piers Connecticut. of the Shoreline Medical Group division of Westchester Health. She is Services provided at various locations within the system include a member of the Women’s Health Research at Yale Advisory Council, physical therapy, occupational therapy, speech therapy and a non-profit affiliate of the Yale School of Medicine dedicated to neurophysiology. Rehabilitation services are an important advancing knowledge about women’s health and medical gender component of the new Balance Center that was developed by differences, training researchers, and translating findings into practice Stamford Health this year. Specialized rehabilitation services are and national public policy. Dr. Karp serves on the Advisory Council provided for cancer survivors. Ongoing support groups are designed of the Warren Alpert Medical School of Brown University and as a to help patients with history of amputation as well as those with member of Brown’s Advisory Council on Biology and Medicine. history of stroke or brain injury. Dr. Hulinska is a full-time rheumatologist with private practice With our new facilities, we are looking forward to expanding offices in both Stamford and Westport. She received her medical opportunities for collaboration with colleagues across the degree from the University of Connecticut School of Medicine health system. and completed her residency and rheumatology fellowship at North Shore University Hospital in Manhasset and Long Island Rheumatology Jewish Hospital. She is board certified in internal medicine and rheumatology.

Dr. Mehta practices full-time rheumatology as a member of the Stamford Health Medical Group. She joined Stamford Health Tomas Vietorisz, MD in 2015 and works in partnership with Drs. Vietorisz and Beger. Director of Rheumatology Dr. Mehta received her medical degree from Maulana Azad College of Medicine in New Delhi, India. She completed her residency in internal medicine at Maimonides Medical Center in New York City and went on to complete a rheumatology fellowship at Westchester Medical Center in Valhalla, New York. She is board certified in Active Staff: internal medicine and rheumatology.

• Erik Beger, MD • Shikha Mehta, MD Dr. Beger received his medical degree at the Georg-August University • Hana Hulinska, MD • Donald Stangler, MD in Goettingen, Germany. He subsequently completed his residency • Sharon Karp, MD • Tomas Vietorisz, MD in internal medicine at Boston University and went on to complete a fellowship in rheumatology at Albert Einstein College of Medicine. The Department of Rheumatology is currently comprised of six Since 2000 he has served as attending rheumatologist in a variety members: Drs. Erik Beger, Hanna Hulinska, Sharon Karp, Shikha of hospitals including Nassau University Medical Center, Queens Mehta, Donald Stangler and Tomas Vietorisz. As Chairman of the Hospital Center, Catholic Medical Center, Flushing Hospital Center Department, Dr. Vietorisz continues to practice full-time as a member and most recently has been practicing locally as a member of of Stamford Health Medical Group. He received his medical Soundview Medical Associates in Norwalk, Connecticut. He joined degree from the Mount Sinai School of Medicine in 1988. After a Stamford Health Medical Group in September 2015 and is in residency in Internal Medicine at Boston University, he completed practice with Drs. Vietorisz and Mehta. Dr. Beger is board certified his fellowship in rheumatology at The Albert Einstein College of in both internal medicine and rheumatology. Medicine in 1994. He is board certified in both internal medicine and rheumatology. The Department is proud to announce that three of its members, Dr. Karp, Dr. Vietorisz and Dr. Beger, have all been selected as “Top Docs” in Connecticut magazine.

52 2016 Clinical Annual Report In addition to providing rheumatological care in the private Departmental Safety and Quality practice setting, the Drs. Vietorisz, Beger and Mehta continue to provide indigent care for members of the community suffering Under the leadership of Rohit Bhalla, MD, Vice President, Quality with rheumatological illnesses through the Optimus Clinic & Chief Quality Officer, the Department of Medicine actively system. The rheumatology clinic meets once a month, s staffed participates in Stamford Hospital’s many safety and quality initiatives. by house officers of the Stamford Hospital and is supervised by The following are year-to-date statistics (as of October 5, 2016) for Dr. Vietorisz, Dr. Mehta and Dr. Beger. These physicians also the measures in which the Department is actively involved provide indigent care to medical inpatients requiring more (numbers in parentheses represent the target values): urgent rheumatological interventions.

The field of rheumatology continues to be exciting and rapidly Clinical Effectiveness: developing. The use of biologic therapies has now become • VTE Prophylaxis – All Inpatients 99% (97%) firmly established as safe and effective, and has greatly expanded • Stroke Education 98% (97%) the number of patients with rheumatic diseases who can be • Early Elective Deliveries <39 Weeks 2.7% (0.8%) successfully treated. Biologic therapies currently approved for use (Elective deliveries<39 Weeks Gestation) include agents targeting TNF, IL-1, IL-6, T-cell receptor molecules • Outpatient Surgery Antibiotic Use Composite 100% (99%) CD-80/86, B-cell receptor CD-20, IL-12/23 as well as the newest biologic agent to be approved, sekukinumab (an IL-17a inhibitor). • Surgical — SCIP — Appropriate Care 97% (97%) Studies looking at biologic agents targeting IL-12, IL-23, CD-19 • Venous Thromboembolism – Appropriate Care 98% (95%) among others are currently in phase 2 and 3 studies and show • Stroke – Appropriate Care 96% (94%) promise as potential future options in treatment of autoimmune disease. In addition, the use of kinase inhibitors has become a reality in the treatment of rheumatic disease with the approval of Hospital-Acquired Infections: Tofacitinib for use in patients with rheumatoid arthritis. • Hand Hygiene 95% (95%) However, the cost of these agents continues to be prohibitive • Central Line-Associated Bloodstream 0.91 (0.70) for many patients particularly the uninsured and underinsured. Infections (Med/Surg + ICU) per 1,000 line days With the expiration of patent protection for biologic agents • Central Line-Associated Bloodstream 7 (8) etanercept and infliximab, the era of biosimilars is nearly upon Infections (Med/Surg + ICU Actual #) us. How these agents are to be regulated, priced and approved • Central Line-Associated Bloodstream 0 (1) by the FDA are questions that are yet to be answered. Hopefully, Infections (NICU Actual #) these products will reduce the cost of biologic therapies and • Catheter-Associated Urinary Tract 6 (9) make these highly effective treatments available to a wider Infections (ICU, CAUTI per 1,000 catheter days) number of individuals. • Catheter-Associated Urinary 6 (9) Tract Infections (ICU, Actual # of CAUTIs) • All Surgical Site Infections (per 100 Surgical Cases) 0.62 (0.7) Hospital Committee Participation • All Surgical Site Infections (Actual # of SSI) 34 (44) In addition to the broad participation of members of • Colon Surgical Site Infections (Actual #, all classes) 7 (8) various departments and divisions within the Department • MRSA (per 1,000 patient days) 0.06 (0.08) of Medicine (referred to in each department’s individual report), acknowledgment goes to Steven Thau, MD, who was elected by • VRE (per 1,000 patient days) his peers to be the at-large Department of Medicine representative 0.000 (0.06) to Stamford Hospital’s Medical Executive Committee, a position • C. Difficile (per 1,000 patient days) 0.708 (1.0) he has held, and ably served since January 1, 2016. • Resistant Infection Rate 0.768 (0.95) (MRSA, VRE, C. Diff per 1,000 patient days)

2016 Clinical Annual Report 53 Department of Medicine: Annual Report 2016

Teaching Activities The Fifth Annual “Residents as Teachers Day,” jointly sponsored by Columbia P&S and Stamford Hospital, was held on October 27, 2016. The keynote presentation was given by Lisa Mellman, MD, Senior Medical Student Education Associate Dean for Student Affairs and Clinical Professor of Psychiatry at Columbia University College of Physicians and Surgeons. This was Stamford Hospital’s affiliation with Columbia University College of followed by additional presentations along with individual meetings Physicians and Surgeons (Columbia P&S) is now in its eighteenth with department chairs, clerkship site directors, and Columbia P&S year. Currently, 98 physicians at Stamford Hospital hold major faculty residency program directors. appointments at Columbia University P&S, 83 within the Department of Medicine as follows: The Department of Medicine also provides a comprehensive course in the Foundations of Medicine; it is the first major experience in • Instructor in Clinical Medicine 34 clinical medicine for medical students. This course is under the • Assistant Clinical Professor of Medicine 36 exemplary leadership of Neil Boside, MD, with Drs. Peggy Geimer, • Associate Clinical Professor of Medicine 7 Alfred Wolfsohn and Richard Sheinbaum ably serving as educators. • Clinical Professor of Medicine 3 • Professor of Clinical Medicine 3

Columbia P&S students are assigned to our Department of Medicine in both the Inpatient Clinical Clerkship and in Primary Care Medicine, Residency Program as well as in Family Medicine, Surgery, Obstetrics and Gynecology in Internal Medicine and Pediatrics. At any given time there are as many as 24 Columbia students throughout all rotations. Stamford Hospital numerically Kirsten Hohmann, MD teaches the entire student body of Columbia P&S. Interim Program Director, Internal Within the Department, seven or eight third-year students are Medicine Residency Program assigned to Inpatient Medicine and one or two to Primary Care/ Medical Director of Ambulatory Education, Optimus HealthCare Ambulatory Medicine at any one time. The Department also regularly accommodates students who seek clinical electives at Stamford Associate Clinical Professor of Medicine, Columbia University College of Hospital. Since Critical Care Medicine is not a dedicated rotation Physicians and Surgeons during the third year at Columbia, this is an especially attractive and vital elective experience we can offer. Other clinical electives include Cardiology, Pulmonary Medicine, Infectious Disease Medicine, Stamford Hospital’s Residency Program in Internal Medicine had Hematology and Oncology and a fourth-year sub-internship in another productive and successful year, which was notable for Internal Medicine and Emergency Medicine. Columbia P&S medical a number of programmatic changes. students consistently laud the quality of their educational experience at Stamford Hospital and the personalized, role model education 1. Residents: The program welcomed the addition of six new they receive. These physicians are recognized as preceptors for the Categorical Interns in July 2016 (Drs. Brett Carroll, Pankil Desai, 10 clinical clerkship sessions of the academic year: Claire McCutcheon, Lovin Pappy, Theodora Vamvouris and Niurka Visconti) and two Preliminary Interns, Dr. Marco Russo (who will • Maria Asnis, MD • Ted Listokin, MD be completing a residency in Neurology) and Dr. Krutika Parasar • Revekka Babayev, MD • Scott Martin, MD (who will be completing a residency in Physical Medicine and • Salvatore Carbonaro, MD • Shikha Mehta, MD Rehabilitation). We proudly acknowledge the achievements • Joonun Choi, MD • Wayne Miller, MD of our recent graduates who have gone on to pursue competitive • Deena Ebright, MD • Bismruta Misra, MD fellowships in Cardiology, Gastroenterology, Pulmonary/Critical • Melissa Goldstein, MD • Craig Olin, MD Care and Endocrinology, as well as hospitalist positions at • Rebekah Gospin, MD • Noel Robin, MD respected academic institutions. We have already begun our • Anthony Gulati, MD • Paul Sachs, MD recruitment season for the 2017 intern class, and have received • William Hines, MD • Asha Shah, MD more than 2,000 applications for our eight resident positions • Sarah Kahn, MD • Brianna Siegel, MD in the 2017 NRMP match.

54 2016 Clinical Annual Report 2. Faculty: Regrettably, Dr. Maria Maldonado left the Internal vignette posters at the Stamford Hospital’s first Annual Medicine Program in July 2016 to pursue primary care practice Research Day in May. Four residents working under the direction in Yonkers. During her seven-year tenure as program director, of Dr. James Krinsley also presented abstracts or delivered an there were numerous programmatic improvements and oral presentation at the Society of Critical Care Medicine initiatives that have ensured an excellent education for our Meeting this year. residents. Dr. Kirsten Hohmann has assumed the role of Interim Program Director in addition to her continued role as Director 5. Clinical Learning Environment Review (CLER): The ACGME of Ambulatory Education, while a search is underway for a now ensures that residents are meaningfully engaged in their permanent replacement. institution’s quality strategy and patient safety initiatives through the Clinical Learning Environment Review process that occurs The inpatient teaching experience remains under the able every 18 months, and ours took place on November 1-2. Internal leadership of Drs. Maher Madhoun and Paul Huang, Co-Assistant Medicine residents are given multiple opportunities to work with Program Directors. In the ambulatory setting, Dr. Celeste Cox Hospital leadership and interprofessional teams to improve the has joined Optimus Health Care where she will be an Internal quality of patient care, and several sit on institutional committees Medicine preceptor as well as an independent practitioner as such as Sepsis, ED Throughput and Information Technology. part of a collaborative position between Optimus and All residents are required to engage in a longitudinal Quality Stamford Hospital Improvement project in either the inpatient or ambulatory setting with the purpose of implementing a lasting intervention 3. Curriculum Development/Program Evaluation: The Clinical to improve care. Competence Committee meets monthly for continued oversight of resident competency assessment. The Program Medical Student Education: Within the Department of Evaluation Committee meets annually for program evaluation Medicine, seven to eight third-year medical students are and improvement, and this year the focus has been on inpatient assigned to Inpatient Medicine and two are assigned to education with the consequent development of longer floor Primary Care Ambulatory Medicine for four- and five-week rotations and inpatient portfolios. A new required one-week blocks. The Department continues to accommodate rotation in Quality Improvement and in Primary Care offices has students for other clinical electives and a fourth-year medicine been instituted for the 2016-17 academic year. A comprehensive sub-internship in Internal Medicine and Emergency Medicine. internal review of the Internal Medicine Residency program was Our ICU faculty have also supported a dedicated Critical conducted from April through June 2016 by Drs. Frances Care Medicine rotation for students. Columbia P&S students Ginsburg and Setul Pardanani, and their review noted adequate consistently laud the quality of their educational experience resident supervision in inpatient and ambulatory venues. at Stamford Hospital and the personalize role model education they receive. Second- and third-year residents continue to participate in a two week rotation in Neurology at the renowned Neurologic Institute at Columbia University, as well as in Geriatrics at the Dorothy Adler Geriatric Assessment center at Yale-New Haven Hospital.

Dr. Maldonado along with the collaborative efforts of Dr. Steve Horowitz, Marc Brodsky, Joonun Choi, Joseph Connelly and Tzivia Moreen have developed a Planetree Curriculum for residents that focuses on our core value of patient-centered care as well as physician wellness.

4. Research/Scholarly Activity: All six senior Internal Medicine residents and two junior residents presented abstracts at the annual Connecticut Chapter Meeting Scientific Session of the American College of Physicians on October 28, 2016. Six residents presented either research abstracts or clinical

2016 Clinical Annual Report 55 Department of Medicine: Annual Report 2016

Continuing Education • The 38th Annual William H. Resnik Memorial Lecture — This year’s distinguished speaker was Lee Goldman, MD, Harold and Reflective of its commitment to continuing medical education, Margaret Hatch Professor, Executive Vice President and Dean Stamford Hospital was awarded in its most recent site visit in 2013 of the Faculties of Health Sciences and Medicine at Columbia an unprecedented six years of accreditation, with commendation, University Medical Center, who spoke on “Too Much of a Bad by the Committee on Continuing Medical Education (CME) of the Thing.” The program was followed by a Town Hall Meeting Connecticut State Medical Society. with all engaged participants in Medical Education.

The breadth of CME programs offered in 2016 illustrates • A special lecture provided by John Fitzgibbons, MD, Professor this commitment: of Clinical Medicine at Columbia University College of Physicians and Surgeons, on “Presidential Health Maladies: Mistakes • Medical Grand Rounds — Weekly diverse, educational and Cover-ups.” presentations, many emphasizing an integrative and multidisciplinary approach to care. Themes in 2016 included • Senior Resident Presentations — Seven senior resident “Biologic Bases for Human Obesity,” “Immunotherapy in Cancer presentations addressed a wide range of clinical topics. Management,” “Screening for Lipopathies,” “Breast Care for the Primary Care Provider” and “Domestic Violence.” • Schwartz Rounds — Although in the domain of all of Stamford Hospital, these important, reflective and poignant teaching • Dedicated lectures in Nephrology included “Classification experiences, held every two months, are meaningful and and Diagnosis of Renal Tubular Acidosis,” Pathophysiology and inspirational to our Department. Treatment of Metabolic Alkalosis” and “Resistant Hypertension.” • The 12th Annual Sleep Medicine Symposium — Sponsored by • Comprehensive Clinical Case Conference — This monthly the Connecticut Center for Sleep Medicine, under the leadership conference draws on the rich array of relevant clinical cases of Drs. Dominic Roca and Steven Thau. This year’s presentation requiring multidisciplinary involvement. was given by Ana C. Krieger, MD, Medical Director of the Weill-Cornell Center for Sleep Medicine, on “Obstructive • Yale University Seminars in Geriatric Medicine — Four timely, Sleep Apnea and Hypoventilation.” topical presentations regarding the care of older adults. Themes this year included “Medication Use in the Elderly” • The 34th Annual Pulmonary, Critical Care and Sleep Medicine and “Optimizing Medication in Older Adults with Multiple Symposium — Sponsored annually by the Department of Chronic Conditions.” A related Medical Grand Rounds was Pulmonary Medicine to enlighten physicians on current issues titled “Is it Parkinson’s Disease?” in Pulmonary Medicine, their pathophysiologic mechanisms and their clinical management. This year’s presentation • The 8th Annual Keith Landesman Memorial Lectureship — A was given by Gregory Pearson, MD, PhD, Cardiac and lasting tribute to a beloved colleague and the values that Thoracic Radiologist at Stamford Hospital, and Associate defined his life. This year’s lecture was given by Dr. Steven F. Professor of Radiology at Columbia University College of Horowitz, Clinical Professor of Medicine at Columbia University Physicians and Surgeons. College of Physicians and Surgeons. The title of Dr. Horowitz’s presentation was “Nutrigenomics, Epigenetics and the Future • The 23rd Annual Oncology Symposium —sponsored by the of Integrative Medicine.” Carl and Dorothy Bennett Cancer Center to provide physicians with the most current knowledge and understanding of cancer. • The Annual William F. Buckley, Jr. Memorial Lecture — Given This year’s theme was “Immune Checkpoint Inhibition and in memory of Mr. Buckley, whose gracious bequest allowed for Beyond” and was presented by Patrick A. Ott, MD, Clinical the creation of an ongoing lectureship in Infectious Diseases. Director of the Center for Immuno-Oncology at Dana-Farber This year’s lecture was given by Michael F. Simms, MD, Director Cancer Institute. of Infectious Diseases at Waterbury Hospital, on “Healthcare Associated Infections.”

56 2016 Clinical Annual Report • Dedicated Summer Syllabus in Medicine — A comprehensive, to be represented in all components of medical education, and 12-week compendium aimed at new house staff and that community physicians feel a part of the clinical and intellectual medical students. stimulation that is part of their association with Stamford Hospital.

• Medical Grand Rounds during the Summer Syllabus — 12 weekly An important corollary is the need to maintain and foster sessions led by Department staff on clinical, medico-legal, and Stamford Hospital’s role as a major teaching campus. The Hospital quality and safety topics. has established a special relationship with Columbia University College of Physicians and Surgeons and is privileged to have the • Annual Medical Grand Rounds Lecture in Podiatry — The 2016 responsibility of educating so many future physicians. This privilege Speaker was Robert Fridman, MD, who spoke on “Common is cherished with pride, humility and unwavering commitment. Pediatric Problems Faced by Primary Care Physicians.” We are also very proud of our selection as the campus site for the Sacred Heart University Physician Assistant Program and the • “Art in Medicine” — a dedicated annual interactive program educational vibrancy that this contributes. given by Anna Willieme, MFA, on “The Development of Medical Observational Skills Through Fine Works of Art.” The responsibilities of the Department of Medicine are large and are shared by many. No single individual or group of individuals • Stamford Hospital and the Fairfield County Medical Association can possibly perform all the clinical, service and educational co-sponsored two special programs on “Medical Issues Relevant responsibilities. This annual report gives formal recognition to those to Returning Service-People in U.S. Armed Forces” and “Opiate members who have generously given of their time, energy, and Addiction.” These programs were relevant for Connecticut- above all, themselves. Our medical community is surely better as a required CME, but also covered two exceedingly important result of their kindness and good deeds. They have enriched all and medical and social issues of our times. have made our community and profession all the better. We may be very fortunate as a community to have facilities and technology, present and future, of extraordinary design and sophisticated Community Outreach capability. Nothing, however, is more important than the worth of our staff. They deserve our highest respect and appreciation. As part of the Department’s commitment to promoting a healthier Their beneficiaries and generosity must never be taken for granted. community through education, physician members participate in It is my deep hope that their generous and selfless contributions an array of forums and programs including the Mini Medical School, ennoble them and augment their pride and esteem in our health fairs, lectures, symposia and awareness days focused on beautiful profession. specific health conditions. To those good physicians who exemplify these ideals, who continue to make ours a profession of meaning and worth — for their Strategy/Future Direction dedication, kindness, friendship and collegiality, the Department of Medicine extends its heartfelt gratitude. 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. Emblematic of the clinical excellence to which we will always strive is the new Stamford Hospital tower, a metaphoric beacon of our departmental and institutional commitment.

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 that Hospitalist Medicine continue

2016 Clinical Annual Report 57 Care. Delivered.

Obstetrics & Gynecology

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

58 2016 Clinical Annual Report Department of Obstetrics & Gynecology: Annual Report 2016

Carol Fucigna, MD Interim Chair, Department of Obstetrics & Gynecology Vice Chair, Department of Obstetrics & Gynecology

A Message From The Chair The Year in Review

The Hugh K. Miller, MD, Department of Obstetrics & Gynecology I am proud to serve as Interim Chair of this Department and look works in collaboration with our obstetricians and gynecologists and forward to continued growth in the Women’s Health service line strives to provide the highest level of quality care to patients in our over the next fiscal year. community by offering the most up-to-date diagnostic testing and novel treatment modalities in a safe and nurturing atmosphere. The Department is proud to share its accomplishments and highlight Scope of Clinical Activities the areas in which we continue to work to assure that we are setting the highest standards for providing excellent patient care. The Department is pleased to report volume growth in Obstetrics, Gynecology and Gynecologic Oncology (with data provided in This was a productive year for the Department: Figures 1 and 2). In addition, our global quality program continued • Stamford Hospital was recognized for its outstanding to achieve results, demonstrating a Departmental focus on quality obstetric care and received the 2016 Women’s Choice and value. All Department members continue their commitment Award in Obstetrics for the third year in a row. to put patients first, and patient feedback affirms the success of these efforts. • We are pleased to announce that many of our attendings have received local, regional and national recognition, We are cognizant of the constantly evolving medical landscape including Fairfield Magazine Top Doctors, Connecticut and remain poised to change quickly to meet regulatory Magazine Top Doctors, Castle Connolly’s New York Metro requirements as well as implement cutting-edge technologies. Area Top Doctors in Obstetrics and Gynecology and the The Department is comprised of many members across several Path to Parenthood Family Building Award. disciplines. This multidisciplinary approach to patient care and our commitment to continually strive to improve that care • We would also like to congratulate our PGY III Resident, position us well for the future. Andrew Rausch, MD, for being awarded the Gold Humanism Award from Columbia University.

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

2016 Clinical Annual Report 59 Department of Obstetrics & Gynecology: Annual Report 2016

Included below are some of the highlights of the Department’s • The Gynecologic Oncology program, led by Elena Ratner, MD, activities in 2016: and comprised of three Gynecologic Oncologic surgeons, grew by 40% from 2015 to 2016. • As shown in Figure 1, our Obstetricians performed a total of 2,227 deliveries including 1,230 vaginal deliveries and • The Hospital’s Cesarean rate remained a focus for analysis 997 Cesarean sections. during fiscal year 2016. Data regarding the Cesarean rate in nulliparous patients presenting at term with a single fetus • As shown in Figure 2, there were a total of 1,492 gynecologic in vertex presentation was collected through the course of surgeries performed, which has increased from 1,429 the year and submitted to The Joint Commission as part performed during FY 2015. of the Perinatal Care Core Measures Project. During FY16, the NSTV Cesarean rate at Stamford Hospital was 40%, an Figure 1. Number of Babies Delivered increase from the 37% rate recorded in FY15. Efforts during

2450 the most recent fiscal year to address this measure included:

2400 – Transition of physician documentation of perinatal care from GE Centricity to MediTech. This required the 2350 2363 2367 development of documentation templates that would 2300 permit effective. documentation of the indications

2288 for Cesarean in individual cases to that quality data 2250 2285 may be effectively collected.

2200 FY13 FY14 FY15 FY16 – Collaboration with IT to develop a perinatal quality Number of Babies Delivered 2013-2016 “dashboard” using data extracted from these templates.

– Collaboration with the Departmental Peer Review Figure 2. Gynecologic Volume Committee to develop triggers for peer review in 1800 selected cases of Cesarean birth in this population. 1600

1400 • “One of the most highly effective preventive measures 1492 1200 1429 a mother can take to protect the health of her infant is to

800 breastfeed. However, in the United States, although most 600 mothers hope to breastfeed and 79% of babies start out 400 being breastfed, only 19% are exclusively breastfed six 200 months later. Additionally, rates are significantly lower 00 FY15 FY16 for Afican-American infants” (www.CDC.gov).

Gynecologic Volume 2015 vs 2016 According to the CDC 2013 Breastfeeding Report Card, 76.9 % of new mothers in Connecticut ever breastfed • The Minimally Invasive Surgery/Robotics Program is now in its (76.5% national average), 35.8 % were exclusively eighth year, and recently received a three-year reaccreditation breastfeeding at three months (37.7 % national average) as a Center of Excellence for Minimally Invasive Gynecologic and 15.5% were exclusively breastfeeding at six months Surgery. Gary Besser, MD, and Stephen Gallousis, MD, are (16.6 % national average). These rates fall woefully short Co-Directors of Minimally Invasive Gynecologic Surgery. of the AAP’s recommendation that new mothers provide • Our Minimally Invasive Gynecology (MIG) numbers continue exclusive breast milk for the first six months of a baby’s life. to be affected by the loss of uterine power morcellation We recognize and support each mother’s individual feeding in hysterectomy and myomectomy (April 17, 2014). Stamford choice, while ensuring that each patient has the necessary Hospital hasproactively prohibited the use of the morcellator information and knowledge about their feeding decision. in all gynecologiccases and we are constantly re-evaluating Our Hospital exclusive breastfeeding rates have gradually the literature on morcellation.

60 2016 Clinical Annual Report increased toward the 53% national benchmark. We recognize Medical Staff that there are instances when it is medically appropriate to support infant feeding with formula. Our goal is to provide The Department is comprised of 14 full-time physicians, 41 voluntary attending physicians, 12 resident physicians, four nurse practitioners optimum care to moms and babies, encourage and facilitate and one physician assistant. breastfeeding as a best practice for both mom and baby, and when necessary, intervene in a way that continues to support breastfeeding rather than interfere with it. Paul Bobby, MD • Under the direction of Tracy Shevell, MD, the Maternal Fetal Director, Perinatology Medicine Department has been working collaboratively Co-Director, OB Safety & Quality Committee with the Postpartum Support International’s CT Chapter to Medical Student Clerkship Director bring educational resources and training on mood and anxiety At-Large Member, Medical Executive disorders to the Department. Committee • In conjunction with the Connecticut Department of Public Health, Stamford Hospital and Optimus Health Center under the direction of Setul Pardanani, MD are now able to offer the CT Early Detection Program for breast and cervical cancer Frances Ginsburg, MD screenings to women who are uninsured/underinsured. Director, Reproductive Endocrinology & Additionally, the program offers women access to the Wise Infertility & Residency Program Director Women Program, which promotes additional preventative healthcare measures.

• The Department conducted an interdisciplinary campaign to promote teaching and awareness on the Zika Virus to physicians, clinical staff and patients. Setul Pardanani, MD • In an effort to streamline our EMR systems and to be in line Director of Ambulatory Care & with other Departments, we have transitioned from using Associate Residency Program Director GE Centricity to MediTech on Labor and Delivery.

• Planetree tenets continued to be integrated into daily patient care operations.

• The Department published a quarterly newsletter highlighting clinical and programmatic updates for the system, including information on our residency program Tracy Shevell, MD and recognition of physicians. Director, Perinatal Ultrasound

The Department’s gynecologic procedure numbers continue to be robust, however, we continue to be impacted by the ban on morcellation. The FDA ban on intraabdominal morcellation in April 2014 has led to a decrease in minimally invasive procedures.

The Gynecologic Oncology program experienced a 40% growth Brian Hines, MD in surgical volume in 2016. Our patients are cared for by three Director, Urogynecology & Pelvic board-certified Gynecologic Oncologists: Drs. Elena Ratner, Reconstructive Surgery Karen Nishida and Babak Litkouhi. Community physicians continue to support the program with an increase in referrals from all catchment areas.

2016 Clinical Annual Report 61 Department of Obstetrics & Gynecology: Annual Report 2016

New Staff: • Barry Whitt, MD Reproductive Endocrinology Elena Ratner, MD Director, Gynecologic Oncology Transitions: The following Department members resigned in 2016: • Mariel Focseneanu, MD • Emre Seli, MD

Gary Besser, MD Departmental Education and Co-Director, GYN Minimally Teaching Activities Invasive Surgery The Department serves as a clinical training site for a second- and third-year core clerkship in Obstetrics & Gynecology for medical students from Columbia University College of Physicians and Surgeons. The OB/GYN residency program received a three-year accreditation from the RRC/ACGME. The Maternal-Fetal Medicine Division is approved by the American Board of Genetic Counseling Stephen Gallousis, MD as a teaching site for senior genetic counseling students from Co-Director, GYN Minimally Invasive Surgery Sarah Lawrence College. Additionally, the Department continues its relationship with Planned Parenthood of New England as a second- and third-year resident rotation site for outpatient practice.

The Residency Program in Obstetrics & Gynecology is under the supervision of Director Frances Ginsburg, MD, and assisted by Setul Pardanani, MD. The program has a full complement of residents, which consists of three residents in each of the four years. Janine Popot, MD Chair, Peer Review Committee The current first-year residents are: • Valerie Curro, DO, Nova Southeastern University College of Osteopathic Medicine • Laura Gilroy, MD, Royal College of Surgeons in Ireland Donna Bowman, APRN School of Medicine Co-Director, OB Safety & Quality Committee • Jessica Li, MD, University of Miami Leonard M. Miller School of Medicine Kathy LiVolsi, RN, MHA The recent graduate residents are: Clinical Operations Director, Maternal & Child Health Services • Oluwakemi Adegoke, MD, Fellowship in Global Health, Massachusetts General Hospital Mary L. Henwood Director, Women’s Health & Pediatric Service Line • Daniel Cibulsky, MD, Private Practice, Stamford, Connecticut • Elizabeth Rodriguez, MD, Private Practice, Boston, Massachusetts

62 2016 Clinical Annual Report The Department also provides an active program • First Trimester Detection of the EEC Syndrome, Andrew C. of Continuing Medical Education: Rausch, MD; Paul Bobby, MD. State of Connecticut Resident Research Day, Hartford Hospital. September 2016. Poster • Faculty and Departmental Meeting Presentation. • Multidisciplinary M&M Conference • Multidisciplinary OB/PEDS Conference • An Observational Study of Obstetrics and Gynecological • Grand Rounds Graduate Medical Education in Nepal and the United States, • CoreCases for OB/GYN — Co-Developed by Kiger Lau, MD, MPH; Setul Pardanani, MD. State of Connecticut ACOG & CaseNetwork Resident Research Day, Hartford Hospital. September 2016. In addition, the Department sponsored the 22nd Annual Morton Poster Presentation. A. Schiffer Day Resident Research Symposium on June 3, 2016. • Spontaneous Orgasm with Movement after TOT Placement: A Case Report, Sarah Elliott, MD; Brian Hines MD. State of Connecticut Resident Research Day, Hartford Hospital. Departmental Research and September 2016. Poster Presentation. Scholarly Activities • Prolapse Recurrence after Partial Removal of Transvaginal Department members gave several presentations at regional and Mesh, Xibei Jia, MD; Katherine Sandhu, MD; Brian Hines, MD. national meetings in the past year: State of Connecticut Resident Research Day, Hartford Hospital. September 2016. Poster Presentation. • Retrospective Analysis of Transvaginal Hysterectomy vs. Supracervical Hysterectomy with Associated Sacrocolpopexy • Prolapse Recurrence after Partial Removal of Transvaginal Mesh, — Oluwakemi Adegoke, MD; Brian Hines, MD; Katherine Xibei Jia, MD; Katherine Sandhu, MD; Brian Hines, MD. ACOG Sandhu, MD. ACOG Annual Clinical and Scientific Conference, District 1 Annual Meeting. Toronto Canada. August 2016. Washington DC. May 2016. Poster Presentation. Poster Presentation.

• Intrahepatic Cholestasis of Pregnancy in Stamford, Ana • Intrahepatic Cholestasis of Pregnancy in Stamford, Ana Pantel, Pantel, MD. Annual State of Connecticut Resident Research MD. ACOG District 1 Annual Meeting. Toronto Canada. Day, Hartford Hospital. September 2016. Oral Presentation. August 2016. Poster Presentation.

• An Observational Study of Paternal Weight Gain During Pregnancy, Courtney Noonan, MD; Paul Bobby, MD. State Strategy/Future Direction of Connecticut Resident Research Day, Hartford Hospital. September 2016. Poster Presentation. The Department of Obstetrics & Gynecology had a strong year focused on collaborating with our Physician Relations leader, • Immediate Postpartum LARC in a Community Setting: Patient Lisa Rosato, to ensure that we visit most of our physicians at their Desires and Effectiveness, Kelly Fellows, MD, Setul Pardanani, offices and work together to strengthen and improve our clinical, MD. State of Connecticut Resident Research Day, Hartford nursing and administrative relationships. Over 30 physician office Hospital. September 2016. Poster Presentation. visits were conducted this year. We continue to refine plans to • Implementation of a Universal Perinatal Depression Screening improve physician and patient satisfaction for both our inpatient and Treatment Program in a Community Health Care Setting, and outpatient care. We have also worked on increasing our Kiger Lau, MD, MPH; Setul Pardanani, MD. State of Connecticut obstetric volume by increasing the number of obstetricians on Resident Research Day, Hartford Hospital. September 2016. our staff. The new daVinci robot was installed this past year and Poster Presentation. all our gynecologic physicians were delighted to be trained to utilize the new technology and enable us to provide the latest • An Observational Study of Paternal Weight Gain During robotic technology for our gynecologic patients. Pregnancy, Courtney Noonan, MD; Paul Bobby, MD. State of Connecticut Resident Research Day, Hartford Hospital. The Women’s Health service line continues to focus on developing September 2016. Poster Presentation. comprehensive services for women in the community.

2016 Clinical Annual Report 63 Department of Obstetrics & Gynecology: Annual Report 2016

Our Marketing team has collaborated with many of our physicians • Prolapse Recurrence after Partial Removal of Transvaginal to write and publish blogs on issues from breast-feeding to Mesh, Xibei Jia, MD; Katherine Sandhu, MD; Brian Hines, MD ovarian cancer. The use of social media is an important channel • Retrospective Analysis of Toxicity, Treatment Delays and of communication with women in our market 25-65 years of Recurrence-free Intervals for High-risk Endometrial age. Physicians who post blogs receive significant increased Adenocarcinoma of the Uterus Treated with Chemotherapy volume to their Hospital listing on our website and visits to their vs. Combined Modality Therapy — Elena Ratner, MD. own web pages. We will continue to work with our Marketing team to enhance our efforts to reach women who are thinking of becoming pregnant or are newly pregnant to introduce them Outcomes in the Department of OBGYN to the excellent physicians on staff and promote the wonderful services offered at Stamford Hospital. Departmental Safety and Quality Current and future projects for research include: Led by Co-Directors Paul Bobby, MD, and Donna Bowman, APRN, • Prevalence of Intrahepatic Cholestasis in Pregnancy the primary mission of the OB Safety and Quality Committee is is SW Connecticut — Ana Pantel, MD to develop evidence-based protocols for delivering obstetrical • An Observational Study of Paternal Weight Gain during care at the highest level of safety and quality. Compliance with Pregnancy — Courtney Noonan, MD; Paul Bobby, MD these protocols, along with the Department’s collaborative, • Has Use of Non-invasive Prenatal Testing Changed Practice multidisciplinary approach to care, has produced favorable in the Community Hospital Setting: A Retrospective Chart results on a variety of quality and safety measures. Review— Tracy Shevell, MD

• Safely Decreasing the Primary Cesarean Section Rate in Quality Metrics/Core Measures 201 a Community Hospital — Kezia Spence, MD • Joint Commission (year-to-date FY16) • Impact of a Quality Improvement Initiative on the Episiotomy »» Elective deliveries <39 weeks — 2% (Leapfrog & CMS Rate at a Community Hospital — Andrew C. Rausch, MD; benchmark <5%) Maureen Burke, MD; Donna Bowman, DNP, FNP-BC, RNC-OB; »» Cesarean in NSTV (Nullip, Term Singleton, Vertex) 39% Paul Bobby, MD; Daryl Wieland, MD, MSMI (no benchmark) • Resection of Vaginal Mesh and Recurrent Pelvic Most are for labor arrests and NRFH. We have referred select Organ Prolapse: A Retrospective Study — Xibei Jia, MD; indications for peer review. These include “arrest of dilation diagnosed prior to 6cm” and “failed induction.” Oluwakemi Adegoke- PGY 4; MD, Brian J. Hines, MD; Katherine S. Sandhu, MD • Antenatal steroid administration — 100% (no benchmark) • Transvaginal Resection of Sacrocolpopexy Mesh to Relieve Pelvic Pain — Xibei Jia, MD; Oluwakemi Adegoke, MD; • Exclusive breastfeeding has increased from 37% to 47% Brian J. Hines, MD; Katherine S. Sandhu, MD (no benchmark) • Spontaneous Orgasm with Movement after TOT Placement: • Leapfrog (publicly reported) A Case Report, Sarah Elliott, MD; Brian Hines MD »» Episiotomy 17% (benchmark <12%) • Implementation of a Universal Perinatal Depression Screening »» DVT prophylaxis for Cesarean — 97% (benchmark 80%) and Treatment Program in a Community Health Care Setting, Kiger Lau, MD, MPH; Setul Pardanani, MD Safety Program • First Trimester Detection of the EEC Syndrome, Andrew C. • 100% eligible residents passed Electronic Fetal Heart Rausch, MD; Paul Bobby, MD Monitoring Exam • An Observational Study of Obstetrics and Gynecological • 100% eligible nursing staff passed Electronic Fetal Heart Graduate Medical Education in Nepal and the United States, Monitoring Exam Kiger Lau, MD, MPH; Setul Pardanani, MD • Preeclampsia DTR compliance 95 % (internal target 90%)

64 2016 Clinical Annual Report 2016 ClinicalMain Annual Concourse Report 65 Testing. Expedited.

Pathology

We continue to expand our level of sophisticated testing by bringing in advanced clinical chemistry platforms and automation. We expanded our molecular diagnostics capability in microbiology — enabling us to identify a vast array of major human pathogens within hours. We continue to expand our ability to identify common molecular alterations in hematologic malignancies and solid tumors that can serve as targets for novel therapeutics.

66 2016 Clinical Annual Report Department of Pathology & Laboratory Medicine: Annual Report 2016

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

A Message From The Chair The Year in Review

In 2016, the Laboratory focused on enterprise growth and cost The Lab underwent a CAP inspection by a team from Montefiore containment. Following an intensive process we identified Abbott Medical Center, and we have received full 2 accreditation. as the manufacturer/vendor to install a new, fully automated clinical We continue to participate in the College of American Pathologists chemistry system to further upgrade our capabilities and achieve Laboratory Accreditation program, and CAP Performance significant annual savings. Our Siemens system was dismantled, Improvement Programs in Surgical Pathology, Cytopathology temporary Abbott equipment brought on-line and construction and Dermatopathology. of our new Abbott Architect Full-Line Automation is in progress. This type of line conversion is a highly disruptive process for any laboratory and has significant impact on operations. This conversion Scope of Clinical Activities will be complete by Q3 2017.

The Lab now has 2 Roche/Ventana H600 automated histology single- Division of Clinical Chemistry slide strainers, which allow for production of “best-in-class” histology slides and maximize patient safety. At Stamford Health, it is impossible We continue to review and enhance our daily workflow processes to have tissue contamination during the H&E staining process. These to ensure accurate test results and optimal TAT of patient results. instruments replaced our Symphony single-slide histology staining In 2015, we implemented Nova whole blood instruments for BMPs process. They eliminated Xylene (a known carcinogen), are cheaper to to reduce TATs in the Emergency Department and maintained our operate, have improved coverslipping and produce high-definition 60-minute goal throughout FY16. histology slides that increase our diagnostic accuracy. In 2016, we submitted a RFP for a full laboratory automation system We have also upgraded all our Ventana Immunostainers to improve and after extensive research, we decided on the Abbott integrated our turnaround time (TAT) and IHC results, and in anticipation of clinical chemistry and immunoassay platform. We are in the first expanding our in-house capability to identify tumor markers that phase of the Lab renovation and instrument implementation dictate therapy (such as ALK, PD1 and PDL1) in 2017. process. This five-phase project will take approximately 10 months to complete. Once fully operational, this system will perform front- We now have a Frozen Section Room in the new hospital with end processing, centrifugation, tests analysis and sample storage a complete pathologist workstation. This will improve our frozen for the majority of chemistry and routine coagulation. Abbott section TAT and assure best communication with surgeons during immunochemistry offers the highest quality testing for HIV and surgery. We are poised to deliver live video of tumor and surgical hepatitis that can be performed 24/7 for improved patient care. margin evaluation into the operating rooms, as well as live video We continue to offer vitamin D testing and procalcitonin testing of histologic evaluation. We will be the first hospital in Connecticut 24-hours-a-day, seven-days-a-week. These new instruments and to have this capability.

2016 Clinical Annual Report 67 Department of Pathology & Laboratory Medicine: Annual Report 2016

automation will improve our quality of results, specimen handling patient responsiveness to antiplatelet medications such as aspirin, and overall satisfaction. Plavix® (clopidogrel) and Brilinta® (ticagrelor). A memo will circulate to all physicians once the test system is live for patient evaluation. The Lab will be bringing Hgb, Serum Proteins and Immunofixation Electrophoresis in-house. This will improve TAT, increase patient and Urinalysis: physician satisfaction and decrease our reference testing costs. We acquired and implemented a new Arkray AU4050, which automates both dipstick and sediment analysis. Analyzer flags for The Department remains focused on the cost-efficiency of our pathogenic components including yeast, casts, crystals and flags reference testing, and we continue to review these tests with the for manual microscopic review for confirmation. intent of bringing more assays in-house as the criteria of order frequency and cost are met. Fertility: Semen analysis, post-vasectomy semen analysis and sperm wash We were successful in recruiting a new highly qualified and procedures have been transitioned from the Chemistry section experienced Clinical Chemistry Supervisor to complete our roster of to the Hematology section, as these technologists have better section supervisors. Patricia Linquist joined our team in October 2016. competency to accurately perform such analyses. These tests will continue to be offered by appointment only, Monday through Friday, from 8:00 a.m. to 2:00 p.m. Please call Hematology at Division of Hematology, Coagulation ext. 7600 to make appointments. and Urinalysis

Hematology/CBC Analysis: Stamford Hospital Coagulation Clinic We acquired and implemented new Sysmex XN technology for both the Bennett Cancer Center (BCC) as well as the main The Lab continues to closely support the Coagulation Clinic, which Laboratory. This technology upgrade to the BCC resulted in offering is administered by Isabelle Millet, PharmD, PhD, and is under the a six-part differential (as opposed to previous 3-part diff), nRBC medical directorship of Raymond Baer, MD. The site successfully enumeration (previously not available) and Immature Granulocyte passed all CAP survey samples during this past year with 100% (IG) enumeration (also previously not available). For the main accuracy. The Clinic accepts patients by physician referral only hospital Laboratory, this upgrade results in automatic repeat testing for those who wish to use it for anticoagulation initiation and/or when questionable results arise (thus improving quality of results), maintenance of their anticoagulated patients. decreased TAT, 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 patient chart in MediTech, which means previous result history from either testing The Blood Bank transitioned to the New York Blood Center (NYBC) location is integrated into a uniform patient record. services this year. The NYBC collects 2,000 blood product units per day and distributes to more than 20 million people in New York Coagulation: City, Long Island, Hudson Valley, NY, New Jersey, Connecticut and The Laboratory will be upgrading to a new coagulation analyzer, Pennsylvania. It has a web-based ordering system to expedite blood the ACL Top 750 by Instrumentation Laboratory, which is deliveries. The NYBC reference laboratories, under the direction compatible with the new Abbott track system. This new model of of Connie Westhoff, utilize state-of- the-art methods in serological coagulation analyzer has the capability to check for pre-analytical investigation and DNA blood group analysis to resolve complex factors such as short sampling, clotted samples and excessive cases, determine clinical significance and provide consultation for hemolysis and lipemia. Adding the ACL Top 750 to the track will the selection of proper blood for transfusion. The NYBC also performs provide a consistent TAT for all routine coagulation tests (PT/INR, RHD genotyping testing for cases where routine laboratory testing aPTT, D-dimer, and Fibrinogen) by automating the processing, for RHD results in discordant or weaker than expected results for centrifugation and sampling of each tube. pregnant women or potential transfusion recipients. This allows for The Laboratory is in the process of validating the VerifyNow® fewer unnecessary injections of Rh immune globulin and increased analyzer by Accumetrics. This system allows for a quick analysis of availability of Rh-negative red blood cells.

68 2016 Clinical Annual Report To allow for faster delivery, prothrombin complex Kcentra, for the Division of Microbiology rapid reversal of Coumadin, is now being stored and distributed by the Pharmacy. The Blood Bank continues to provide activated Cepheid continues to be our PCR platform of choice. We continue factor VII (Novo 7) for treatment of patients with life-threatening to perform PCR testing for Enterovirus in CSF, Nasal MRSA, Nasal bleeding. Both of these products still require consultation and MRSA/ MSSA, C. difficile (including the virulent NAP1 strain) and dose calculation by Blood Bank Director Raymond Baer, MD. Mycobacteria tuberculosis complex with gene mutations associated with Rifampin resistance. Our newest additions to the platform The Blood Bank maintains sufficient blood products for the include Influenzae A, B and RSV, and PCR capability to detect cardiac and trauma services, and has protocols to provide multiple carbapenamase activity. The carbapenamase assay will enable blood products quickly. These protocols are continually being us to determine the specific plasmid associated with resistance updated and modified to reflect the most current scientific data for these highly resistant organisms. Now that our facility has all available. The Blood Bank Director also serves as consultant for private rooms, the improved Influenza/RSV PCR assay will enable difficult patient coagulation issues. us to provide this highly sensitive testing methodology to all of our ED and inpatients. All of these assays provide real-time testing, It is anticipated that as soon as the pneumatic tube system improving TAT of results so that our patients can be treated as is validated, blood and blood products will be delivered from quickly as possible. the blood bank by pneumatic tube, decreasing transit time. BloodTrack® is also in the process of being implemented. The Lab uses the Hologic Panther system for amplified RNA detection This is a blood management system from Haemonetics that for chlamydia and gonorrhea testing, and HPV. The E6 and E7 genes combines software and hardware components to allow blood of high-risk HPV genotypes are known oncogenes. Fourteen HPV to be remotely stored and distributed. A dedicated smart genotypes are considered pathogenic or high-risk for cervical refrigerator will be located in the ED for quick dispensing of disease. Multiple studies have linked genotypes 16, 18, 31, 33, 35, 39, emergency blood products. A smart refrigerator will also be 45, 51, 52, 56, 58, 59, 66 and 68 to disease progression. Women with located in the OR to allow for blood to be stored and a persistent infection with one of these types have an increased risk distributed to the proper patients. for developing severe dysplasia or cervical carcinoma. The Transfusion Administration Record (TAR) computer module We have expanded our capability to identify respiratory pathogens was implemented by the Nursing Department and Blood Bank. with the introduction of the BioFire Microarray, an automated This allows for transfusion documentation to be directly entered in-vitro diagnostic system that utilizes nested multiplex PCR and in the computer, which increases transfusion safety. We continue high-resolution melting analysis to detect and identify multiple to review and update policies with the Nursing Department. nucleic acid targets from clinical specimens. The assay is capable Blood transfusion audits are reviewed and documented at the of identifying 20 of the most common viruses and bacteria Transfusion Committee and recorded by Nursing for National associated with infectious respiratory diseases. BioFire testing Patient Safety Goals. is now available 24/7/365 with an approval/order by Infectious In order to reduce data and clinical entry errors, the Blood Bank Diseases physicians or Pulmonary specialists. TAT for this assay is in the process of interfacing the automated analyzer (Tango) is approximately one hour. with the MediTech computer. In addition to the respiratory panel, we have added the BioFire Due to the collaborative efforts of the Blood Bank, Transfusion meningitis panel. This panel enables us to detect the most Committee and clinical departments, Stamford Hospital continues common viral agents associated with Viral meningitis, as well to have one of the lowest crossmatch-to-transfusion ratios in the as the most common bacterial agents. state. The Blood Bank continues to monitor transfusion practices, resulting in decreased utilization of blood and blood products Working with our Infectious Diseases physicians, we continue to throughout the Hospital. perform 100% daily clinical follow-up on all positive blood cultures. We generate drug-bug mismatch alerts that allow for the early detection of inappropriate drug selection, and we monitor BC growth 24/7 to enable early notification of positive results to the clinicians.

2016 Clinical Annual Report 69 Department of Pathology & Laboratory Medicine: Annual Report 2016

In 2015, we implemented the Bruker MALDI-TOF to improve our and where the additional molecular testing can better identify capability for microorganism identification. This mass spectrometry a neoplastic process. instrumentation enables us to perform same-day identification of

most organisms, drastically reducing our TAT. We have incorporated Thyroid, Colon & Lung Cancer the MALDI-TOF into our routine workflow and are looking forward to the implementation of the MALDI-TOF/MicroScan interface. Dr. Xu also evaluates EGFR, KRAS, BRAF, ROS, ALK and PDL1 mutations The interface will allow us to report the identification of organisms in lung, colon and thyroid cancers. The Lab continues to evaluate more quickly while waiting for the MIC to isolate. colon cancers for mismatch repair proteins (MMRP) using IHC with reflex positives to full-sequence analysis (microsatellite instability The Lab also implemented Alere™ isothermic PCR for rapid evaluation) is to identify patients with Lynch syndrome (hereditary molecular detection of influenza. This platform is more accurate non-polyposis cancer). We also continue to augment thyroid FNA than the classic immunoassay technology. We continue to offer cytology evaluation with molecular pathology testing, and promote this PCR technology for all of our outpatient influenza testing. a collaborative process to our referring endocrinologists and radiologists whereby indeterminate/suspicious category thyroid FNA Division of Point-of-Care Testing biopsy specimens are evaluated with molecular testing for various KRAS, NRAS and BRAF mutations. This process allows for judicious The advent of the new hospital resulted in significant growth in and cost-effective molecular testing. Point-of-Care Testing, and the program was expanded to include additional glucose and urine devices to support the opening of We successfully evaluated three platforms for thyroid molecular tests: several new patient testing sites within the new building. As one Thyroseq, ThyraMIR and Vericyte. We are currently using ThyraMIR example, the ED doubled the number of urine testing devices to platform which combines DNA mutational analysis with microRNA support its new footprint. testing to achieve a highly sensitive and specific result.

Activated Clotting Time (ACT) testing performed in CVOR and With cooperation from our Colorectal Surgeons and Medical Cardiac Cath Lab areas was standardized prior to the opening of Oncologists, we established that all Stage II and III colorectal cancer the new building. All patients will now have this testing performed tumors will be evaluated for Recurrence Score using Oncotype Colon on the ITC Hemochron Signature Elite device. Elimination of a RX assay. This independent variable, when combined with T stage secondary device previously used in CVOR also achieved requiring and MMRP status, allows for optimal patient selection for adjuvant less blood sampling from our patients. chemotherapy and benefit of Oxyplatin (at Stage III CRC).

Anatomic Pathology Laboratory Leukemia/Lymphoma Molecular Pathology Testing In conjunction with Neogenomics Laboratories, we continue to GYN: offer our clinicians an array of ancillary testing, the equivalent We utilize the Hologic Panther for HPV testing. This automated of which would be offered at any large academic institution or PCR DNA-detection method identifies 14 high-risk HPV types and specialty cancer hospital. All hematopathology cases are evaluated specifically identifies the most oncogenic types, HPV 16 and HPV 18. by either Raymond Baer, MD, or Tal Oren, MD, both board-certified Hematopathologists. In close collaboration with the treating Coagulation: Hematologists and/or Oncologists, Drs. Baer and Oren select The Lab utilizes the Cepheid GeneXpert platform to detect Factor II the most appropriate battery of ancillary tests to supplement and Factor V abnormalities. conventional morphologic evaluation and to ensure appropriate utilization in line with the most current guidelines. Bladder Cancer: For the detection of bladder cancer (urothelial neoplasia), Ongoing advances in molecular diagnostics enabled us to Fluorescent In Situ Hybridization (FISH) interpretation of the bring these advancements to Stamford Hospital. FISH panels UroVysion test is performed by Bo Xu, MD, PhD. We have successfully for myelodysplastic syndrome have been expanded to better implemented reflex UroVysion testing on those urine cytology capture the growing number of abnormalities that were recently specimens where determination of urothelial neoplasia is difficult incorporated into the revised IPSS scoring system. FISH panels for

70 2016 Clinical Annual Report acute myeloid leukemia have also been expanded to reflect the Melanoma growing number of distinct subtypes recognized in the latest World Health Organization classification schema. FISH panels for multiple We continue to offer BRAF testing for metastatic melanoma. myeloma can now be performed by enriching plasma cells, thereby BRAF mutation positive melanoma patients derive significant improving the sensitivity of this assay to identify prognostically benefit from medications targeting BRAF. As the panel of significant abnormalities in the neoplastic plasma cells. medications targeting key players of important molecular pathways has expanded, we now offer testing for N-RAS and C-KIT. In We continue to re-evaluate and to expand our offerings in the addition, a recent and exciting advance in the field of melanoma growing arena of Next Generation Sequencing (NGS) in an therapy has been the use of drugs to modulate the immune system effort to identify common molecular alterations in hematologic in fighting cancer cells. To this end, we are now offering PDL-1 malignancies that can serve as targets for novel therapeutics, testing in the setting of metastatic melanoma. particularly in those patients who are either too old to receive standard therapies or who have already failed conventional therapy. Melanoma FISH testing is also available through Neogenomics These expanding NGS offerings enable oncologists to better Laboratories for those lesions that fall under the provisional understand the exact biologic underpinnings of a given patient’s category of “MELTUMP” (melanocytic tumor of unknown malignant malignancy and tailor a treatment plan accordingly, permitting potential) or borderline lesions such as is the case with Atypical Stamford Hospital to remain at the forefront of this exciting and Spitz tumors. Elgida Volpicelli, MD, coordinates the ordering of this emerging technology. An additional development in the field of test and correlates results with the morphology of these difficult NGS is the ability to detect abnormalities in the patient’s peripheral melanocytic lesions in order to predict behavior. blood, a technique often referred to as a “liquid biopsy.” We have just begun to offer liquid biopsies to our patients, enabling our oncologists Division of Cytology the potential to follow molecular abnormalities in a patient’s blood without patients having to undergo a repeat biopsy. To stay at We continue our “push-cart service” with microscope and staining the forefront of these technologies, we recently partnered with equipment placed on a mobile cart. We provide on-site immediate Foundation One, an industry leader in this field, to become the assessment for deep-organ CT-guided biopsies, ultrasound-guided exclusive provider for NGS and Liquid Biopsies at Stamford Hospital. transbronchial biopsies of the lungs and mediastinum performed in the OR and endoscopic ultrasound-guided fine needle aspirations In summer 2016, Stamford Hospital oncologists began to (FNA) of the pancreas/stomach/duodenum performed in the special request that most of their bone marrow biopsies be performed procedure room. We work closely with Interventional Radiologists, by interventional radiologists. In response to this, the Laboratory Pulmonologists, Thoracic Surgeons and Gastroenterologists to make mandated that a cytotechnologist be present at all bone marrow sure diagnostic material is obtained and appropriate triage of each biopsies to ensure the appropriate procurement of material for specimen takes place. morphologic review and ancillary studies. At the beginning of this transition, a subset of the biopsies were below the quality necessary We now have five years of experience with the Celient cell for optimal review, necessitating a joint meeting between Pathology, block technology for creation of cell blocks from cytology material. Medical Oncology and Interventional Radiology to discuss strategies This technology enables us to create superior, concentrated for quality improvement. After this meeting, changes were samples from body fluids and FNA specimens for subsequent made to the process, the result of which has been a noticeable immunohistochemical testing to classify malignancies. improvement in the diagnostic yield for patients undergoing bone The direct patient benefit is that we can do more with less. marrow biopsy and a significant drop in the number of “marginally adequate” and “inadequate” specimens. In our community we are fortunate to have a number of Endocrinologists who are also skilled ultrasonographers and We continue to provide the professional interpretation for perform ultrasound-guided FNAs in their office. Thyroid lesions many of these tests, which allows us to better integrate all of that are difficult to sample and require Interventional Radiology the available data and generate a single, cohesive, comprehensive with immediate cytopathology assessment are performed at final diagnostic report for our clinicians. We feel that this approach Stamford Hospital. Our skilled Interventional Radiologists work not only improves patient care and but is also of significant hand-in-hand with our Cytopathologists in sampling value to our clinical colleagues. difficult lesions.

2016 Clinical Annual Report 71 Department of Pathology & Laboratory Medicine: Annual Report 2016

Due to the Hospital’s growing expertise, we have seen a significant Departmental Physician Activities amount of thyroid pathology, more than most academic medical centers. Stamford Hospital is the only institution in Connecticut Department members continue to actively participate in with two MD Anderson fellowship-trained Cytopathologists institutional tumor boards and conferences as follows: (Dr. Babkowski and Dr. Xu). At this point, we handle the majority of thyroid FNA cytology specimens in Fairfield County. • Weekly Breast Tumor Board — Dr. Robert Babkowski, Dr. Elgida Volpicelli 2015 was our first year of completely insourced gynecologic cytology. We hired three experienced Cytotechnologists and implemented • Weekly Radiology-Pathology Breast Biopsy Correlation Hologic computer-assisted screening. This has decreased our cost Conference — Dr. Robert Babkowski, Dr. Elgida Volpicelli of gynecologic cytology and improved our result TAT. Our first • Monthly GYN Oncology Tumor Board — Dr. Bo Xu CAP inspection took place 2016 and we passed inspection with no deficiencies. Given the brand new nature of this Laboratory • Monthly Genito-Urinary Tumor Board — Dr. Bo Xu expansion, we are very proud of that achievement. • Bi-Weekly Chest Tumor Board — Dr. Augusto Podesta

• Monthly General Tumor Board — Dr. Augusto Podesta, Division of Surgical Pathology Dr. Tal Oren

The Division of Anatomic/Surgical Pathology and the Histology • Monthly Hematology Tumor Board — Dr. Tal Oren Laboratory at Stamford Hospital has remained very active with Monthly GI Tumor Conference — Dr. Augusto Podesta over 22,000 surgical specimens processed during the fiscal year. • Our case complexity has also grown with increasing volume in • Bi-Weekly Complex Surgical Case dermatology/melanoma, breast and thoracic pathology. Conference —Dr. Robert Babkowski

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.

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

After serving as the beta test site for the HE600, the Histology lab welcomed its own HE600 in the spring of 2016 and a second unit in the summer.

The Pathology and Histology Department have started the build and implementation of Vantage, a barcoded specimen tracking system that will go live in January 2017. This fully automated system will allow the user to track a specimen’s location at any time and will eliminate specimen labeling errors.

A Frozen Section Room was opened in the new hospital, providing crucial service just steps away from the OR. This suite is fully automated with state-of-the-art audio-visual equipment, allowing the Surgeon and Pathologist to view gross and microscopic images in real-time.

72 2016 Clinical Annual Report Medical Staff Hospital Committee Participation

Department members participate in various Hospital committees, including:

Raymond A. Baer, MD, FCAP • Transfusion Committee — Dr. Raymond Baer Director of Clinical Pathology and Transfusion Services • Breast Center Steering Committee — Dr. Robert Babkowski

• Cancer Coordinating Committee — Dr. Robert Babkowski

• GI Tumor Steering Committee — Dr. Robert Babkowski

• Infectious Disease Committee — Dr. Raymond Baer

• Lung Cancer Steering Committee — Dr. Robert Babkowski Tal Oren, MD, PhD, FCAP Director of Hematopathology • Medical Executive Committee — Dr. Robert Babkowski • Patient Safety & Quality Committee — Dr. Robert Babkowski

Laboratory Outreach

The Lab expanded our in-office phlebotomy service to Glenville Medical Group in Greenwich. We also established Augusto H. Podesta, MD, FCAP relationships with several Urgent Care Centers, including Director of Surgical Pathology those on Frost Road in Waterbury, Chase Street in Waterbury and East Main Street in Stratford.

Additionally, we completed interfaces to Practice Fusion (Dr. Mayzlor); Athena (Pulmonary Associates, Gastroenterology Associates and Stamford Gastroenterology); Healthtronics (Drs. Nurzia and Santarosa); and Lab Soft (Dr. Goldberg).

Elgida Volpicelli, MD, FCAP Director of Dermatopathology

Bo Xu, MD, PhD, FCAP Director of Cytopathology and Molecular Pathology

2016 Clinical Annual Report 73 Dream. Realized.

Pediatrics

The new Steven and Alexandra Cohen Pediatric Emergency Department opened late in the year, fulfilling a dream of this Department. As the only specialized Pediatric Emergency Department in lower Fairfield County, it represents a significant enhancement in the delivery of healthcare to our youngest most vulnerable patients.

74 2016 Clinical Annual Report Department of Pediatrics: Annual Report 2016

Gerald B. Rakos, MD, FAAP Chair, Department of Pediatrics Director, Division of Neonatology Medical Director, Cohen Children’s Institute

A Message From The Chair The Year in Review

This past year was nothing short of historic for all of Stamford The Department continues to operate the Medical Home Initiative Health and 2017 looks to be equally notable for the Department of Southwest Connecticut, a program that has received grant funding of Pediatrics and the Cohen Children’s Institute. The new Steven from the Department of Public Health since 2005. The program, and Alexandra Cohen Pediatric Emergency Department opened which is in the last year of a three-year grant and covers Greenwich late in the year, fulfilling a dream of this Department. For over through Bridgeport, strives to help coordinate the complex care a decade, members of the Department recognized the need often required for children and youth with special healthcare needs. for such a facility and worked collaboratively with many others at Stamford Health to make it a reality. As the only specialized With construction of the new hospital complete, next year Pediatric Emergency Department in lower Fairfield County, promises to be both busy and exciting as we further develop it represents a significant enhancement in the delivery of the Cohen Pediatric Emergency Department and begin to healthcare to our youngest and most vulnerable patients. The next build our new inpatient facility, the Cohen Children’s Unit. major project for the Department will be construction of our new inpatient facility, the Cohen Children’s Unit in the Whittingham

Pavilion. The design and development phase is finished and work Scope of Clinical Services is set to begin early in the new fiscal year with completion by spring 2017. Whittingham will become a complete Mother–Child pavilion Cardiology when this unit opens. Pediatric cardiology at Stamford Hospital has been a well-utilized We continue to strive for strong alignment with our pediatric area of subspecialty care over the year, providing inpatient and colleagues in Stamford Health’s primary and secondary service outpatient evaluations and treatment to referring physicians and to areas. Towards this end a workgroup has begun to reach out to the community. There are three full-time pediatric cardiologists on practitioners who are not interested in an employment model staff. Drs. Allison Levey, Michael Monaco and Michael Snyder all but may want to explore other areas of strategic partnerships. hold academic appointments at Columbia University with admitting privileges at Morgan Stanley Children’s Hospital of New York, Kids’ FANS (Fitness and Nutrition Services) programs have taken facilitating the local delivery of academic-based subspecialty care. a major step forward this past year as our nutritional education has successfully been incorporated into the curriculum for all Hospital-based cardiology imaging and testing has continued to be third grade students throughout the Stamford Public Schools. active. During the past year, we performed an average of 20 pediatric Additional programs continue to run in many sites including and neonatal echocardiograms each month. Figure 1 details the schools, daycare centers and community centers in both non-invasive studies and pediatric stress tests performed over Stamford and Norwalk.

2016 Clinical Annual Report 75 Department of Pediatrics: Annual Report 2016

the course of the year. Both ECGs and echocardiograms are now Gastroenterology available for rapid review online, facilitating timely reporting. During the past year, the Division of Pediatric Gastroenterology Fetal imaging continues to be an important component of has continued to support the pediatric inpatient service, NICU our service. Working in close collaboration with the Division and Emergency Department, as well as providing specialty care to of Maternal-Fetal Medicine and community obstetrical practices, patients of the area’s primary care pediatricians and Family Medicine we have performed a significant number of fetal consultations physicians. Dr. Sarah Lusman remains part of the Cohen Children’s and echocardiographic studies over the past year. All fetal studies Specialty Center. are now integrated with the hospital EMR. Finalized reports are available for review by OB staff and referring physicians shortly after the studies have been completed. All three physicians are General Pediatrics part of the Cohen Children’s Specialty Center and evaluate clinic patients in their office as well. Pediatric hospitalists continue to expertly care for the vast majority of hospitalized children as nearly all of our community pediatricians Figure 1: Diagnostic Pediatric Cardiology Volume have elected to utilize their service. The entire staff is eagerly 2015 2016 Change awaiting the spring 2017 opening of the new Cohen Children’s Unit in the Whittingham Pavilion. This past year saw a slight decrease in Echocardiograms 254 234 -7.9% the number of admissions to the Pediatric Unit as shown in Figure 3. Electrocardiograms 418 428 +2.4%

24 Hour ECGs 43 49 +14% Figure 3: Inpatient Pediatrics — Discharges Pediatric Stress tests 24 22 -83% 2015 2016 Change Fetal Echocardiograms 213 228 +7% Inpatient 377 372 -1.3%

Observation 57 51 -10.5 %

Cohen Children’s Specialty Center Total 434 423 -2.5% at Tully Health Center

The Steven & Alexandra Cohen Children’s Specialty Center

continues its vital role as a center of highly specialized outpatient Connecticut Medical Home Initiative pediatric care for our region. In total, there are 27 providers in 18 specialties. Growing volume at the Cohen Children’s Specialty Madhu Mathur, MD, directs the Connecticut Medical Home Initiative Center is highlighted in Figure 2. for Children and Youth with Special Health Care Needs – Southwest. The program, which began in 2005, is in the last year of a three-year Figure 2: Cohen Children’s Specialty Center Volume grant from the State of Connecticut’s Department of Public Health. Emphasis continues to be on care coordination for un- and under- 5000 insured children with highly complex special healthcare needs. Figure 4 showcases patient volume for 2016 vs. 2015. 4000 Figure 4: Connecticut Medical Home Initiative for Children 3000 and Youth with Special Healthcare Needs — Southwest:

2000 2015 2016 Change Patients Served for Special 1000 Healthcare Needs 934 856 -8.4%

Patients Served With High 0 Complexity Needs 466 537 +15.2% 2009 2010 2011 2012 2013 2014 2015 2016

76 2016 Clinical Annual Report Kids’ FANS The newborn service saw a modest decline in FY16 as shown in Figure 5, while the NICU saw growth of just over two percent, Stamford Health’s Kids’ FANS (Fitness and Nutrition Services) as shown in Figure 6. program promotes childhood wellness, obesity prevention and physical activity using a hands-on curriculum that is designed to make learning about healthy eating and regular exercise Figure 5: Stamford Hospital Newborn Service engaging and interactive. 2015 2016 Change Under the leadership of Ilaria St. Florian MS, RD, the program has Births 2,426 2,377 -2% significantly grown since its inception in 2004 and has expanded its reach in the last two years from about 13 participating sites and 300 children enrolled to approximately 35 sites and over Figure 6: Neonatal Intensive Care Unit 2,200 children estimated for the 2016 – 2017 school year. This 2015 2016 Change initiative includes a community-wide program now being taught Admissions 308 315 +2.3% in schools from pre-K to high school, as well as in summer camps, after-school programs, childcare centers and health fairs. Kids’

FANS also provides one-on-one nutrition counseling to students at two School-Based Health Clinics in Stamford. Neurology

In March 2016, Kids’ FANS, along with the Stamford Obesity Task Drs. Murray Engel and Robert Fryer and Margot Laedlein, APRN, Force (since renamed Stamford Children’s Health Collaborative), as well as the non-clinical staff at Stamford Health Medical Group spearheaded the first city-wide nutrition awareness initiative for (Pediatric Neurology), have continued their mission to be the regional National Nutrition Month. center for Pediatric Neurology care. Their referral base remains quite broad drawing from Westchester and from both lower and upper Fairfield County. While currently located at the Cohen Children’s Neonatology Specialty Center in shared space, they are hoping to move to dedicated space, which will allow further expansion of the practice. The NICU continues its long tradition of providing outstanding There is also hope to add anotherpart-time Child Neurologist who care to neonates. Our team of neonatologists provides will help with coverage and allow for an increase in sessions to personalized care that not only includes high-quality technical ensure that the community’s needs are met. Drs. Engel and Fryer care but also Planetree patient-centered components like continue their involvement at the Concussion Center at Chelsea kangaroo care, infant massage and mentoring from the Tiny Piers Connecticut as well. Miracles Foundation. The NICU’s outstanding Press Ganey patient The Division continues its strong academic affiliation with satisfaction scores support the success of these initiatives. NewYork-Presbyterian at both the Cornell campus, where We continue to maintain membership in the Vermont Oxford Dr. Engel is Professor of Clinical Pediatrics and Clinical Neurology, Network, a voluntary collaboration of health professionals and Director of the Clinical Service, and at the Columbia campus, throughout the world working together to improve neonatal where Dr. Fryer is Assistant Professor of Clinical Neurology. care. Please note our outcomes in the Department Safety and Figure 7 highlights the Division’s EEG volume in 2016 vs. 2015. Quality section.

This coming year, Drs. Jennifer Bragg and John Ciannella are Figure 7: Pediatric Neurology EEG Volume planning to join the Division of Neonatology at Yale-New Haven Hospital in an effort to further enhance communication and 2015 2016 Change relationships with our colleagues there. They intend to work as EEGs 174 161 -7% attendings several weeks per year in their busy Level IV NICU and also participate in educational conferences. Long-term EEGs 70 66 -6%

2016 Clinical Annual Report 77 Department of Pediatrics: Annual Report 2016

Pulmonology Medical Staff

Pediatric Pulmonology at Stamford Hospital continues to provide inpatient and outpatient consultations, RSV prophylaxis treatment and cystic fibrosis care. Pediatric sleep evaluation and management is also available at the Stamford Health Sleep Michael Snyder, MD Center. Hossein Sadeghi, MD, holds an academic appointment at Director, Division of Cardiology Columbia University as its Director of the Pediatric Cystic Fibrosis Program. Pediatric Pulmonary function test volumes are listed below in Figure 8.

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

2014 2016 Change Murray Engel, MD Director, Division of Child Neurology Spirometry 240 285 +18.8% Plethysmography 353 372 +5% Diffusion Capacity 12 6 -50% Bronchodilator Evaluations 175 166 -5.4%

Pulmonary Exercise Testing 68 18 -74%

Sweat Tests 68 23 - 66% Mark Glassman, MD Director, Division of Gastroenterology

Gerald B. Rakos, MD Director, Division of Neonatology

Hossein Sadeghi, MD Director, Division of Pulmonology

78 2016 Clinical Annual Report Honors and Recognition

Top Doctor Awards

• Alison Cass, MD – New York Metro Area and Fairfield County Letitia Borras, MD • Karen Beckman, MD – New York Metro Area and Fairfield County Co-Director, Hospitalist Medicine • Ora Burstein, MD – New York Metro Area and Fairfield County • Murray Engel, MD – New York Metro Area and Fairfield County • Robert Fryer, MD – New York Metro Area and Fairfield County • Mark Glassman, MD – New York Metro Area and Fairfield County • Jennifer Henkind, MD – New York Metro Area, Fairfield County and Connecticut Shahrzad Mohammadi, MD • Timothy Kenefick, MD – Connecticut Co-Director, Hospitalist Medicine • Rosemary Klenk , MD – New York Metro Area and Fairfield County • Arnold Korval, MD –New York Metro Area, Fairfield County, and Connecticut • Susan Lasky, DO – Connecticut • Allison Levey, MD – New York Metro Area and Fairfield County • Alan Morelli, MD – New York Metro Area and Fairfield County Madhu Mathur, MD, MPH Director, Medical Home Initiative • Todd Palker, MD – New York Metro Area and Fairfield County • Gerald B. Rakos, MD – New York Metro Area and Fairfield County • Henry Rascoff, MD – New York Metro Area and Fairfield County • Hossein Sadeghi, MD – New York Metro Area and Fairfield County • Michael Snyder, MD – New York Metro Area and Fairfield County New Staff: • Sanford Swidler, MD – Connecticut The Department of Pediatrics welcomed the following • George Tsimoyanis, MD – New York Metro Area and members this year: Fairfield County • Elisabeth Fishbein, MD (General Pediatrics)

• Beth Rosenberg, MD (General Pediatrics) Honors • Alejandro Mones, MD (General Pediatrics) • Sarah Lusman, MD was named to the editorial advisory board • Meltem Seli, MD (Neonatology) of PREP GI, an online self-assessment tool from the American • Shravani Vundavalli, MD (General Pediatrics) Academy of Pediatrics, and served as a peer reviewer for UpToDate and JAMA.

Transitions: • Jenifer Henkind, MD received the Outstanding Commitment The following members resigned this year: Volunteer Award from St. Joseph’s Parenting Center.

• Amy Cram, MD (General Pediatrics) • Paule Couture, MD received recognition from New York Medical • Catherine Ford, MD (General Pediatrics) College for 20 years of teaching and serving as a preceptor for • Nicholas Matarazzo, MD (General Pediatrics) medical students. • Michael Schessel, MD (General Pediatrics)

2016 Clinical Annual Report 79 Department of Pediatrics: Annual Report 2016

Honors (continued) Figure 9: Stamford Hospital Vermont Oxford Network NICU th • Center for Advanced Pediatrics received the International Outcomes in Top 25 Percentile Board Certified Lactation Consultant (IBCLC) Care Award and 1 1 All the Pinnacle Award from Cigna for highest quality pediatric VLBW VLBW Infants2 2015 2015 care in Connecticut. 2015

Pneumothorax Yes No Yes • Hossein Sadeghi, MD was honored by the CT chapter of the Cystic Fibrosis Foundation as a community champion. He was Periventricular Leukomalacia Yes Yes Yes also promoted to the rank of Associate Professor of Pediatrics Chronic Lung Disease Yes Yes Yes at Columbia University and named a Samberg Scholar at NewYork-Presbyterian Hospital. Necrotizing Enterocolitis No No No Severe Intraventricular Yes No No Hemorrhage Grants Severe Retinopathy Yes Yes Yes of Prematurity • Madhu Mathur, MD, and Gerald B. Rakos, MD received a

three-year grant (2015-2017) from the Connecticut Department Late Infections No Yes Yes

of Public Health for the Connecticut Medical Home Initiative for Mortality Excluding Early No Yes Yes Children and Youth with Special Health Care Needs — Southwest Deaths

in the amount of $808,000. Mortality Yes No No

• Jennifer Bragg, MD received a grant from the March of Dimes Death or Morbidity Yes Yes Yes for a study entitled “The impact of infant massage in the 1 Very Low Birth Weight (<1500 grams) 2 Neonatal Intensive Care Unit” in the amount of $5,000. Includes all NICU admissions beginning in 2015

• Hossein Sadeghi, MD - CF learning and leadership collaboration; Studies: CTBM100C2407 Novartis CF TOBI Podhaler study; OPTIMIZE study (effect of Azithromycin Patient Satisfaction on Tobramycin on children with CF newly diagnosed with The NICU once again achieved outstanding Press Ganey results Psuedomonas aeruginosa; TEACH study (effect of Azithromycin and this is highlighted in Figure 10. on Tobramycin in children with CF who have chronic Pseudomonas aeruginosa in their sputum). SENTINEL Figure 10: NICU Press Ganey Satisfaction FY16 (RSV) study was completed.

All Facility AHA Region 2 Raw Score Database Percentile Percentile NICU Overall 94.8 98 99 Departmental Safety and Quality NICU Nurses 97 98 99 Stamford Hospital’s NICU has been a member of the Vermont

Oxford Network (VON) since 1997. In 2015, the NICU joined the NICU Physicians 92.6 91 93

expanded VON database which includes all admissions, not just NICU Overall those whose birth weights are <1,500 grams. It is now possible Assessment 97.8 99 99 to benchmark outcomes of all infants admitted to the Stamford Hospital NICU with almost 1,000 NICUs worldwide. Over 185,000 Figure 11 outlines the Hospital performance for Maternal-Child infants are included in this database. Outcomes analysis is by the Health. Core measures include: elective delivery; Cesarean section; calendar year and the most recent data available is from 2015. antenatal steroids; Healthcare-associated bloodstream infections in Our goal is to be in the top 25th percentile for 10 major outcomes newborns; and exclusive breast milk feeding. and results are shown in Figure 9.

80 2016 Clinical Annual Report Departmental Education and Testing This has received very positive feedback from practitioners who otherwise would not have been able to attend. The Department continues to offer weekly continuing medical education conferences that are regularly attended by many Family Medicine residents continue to rotate through Pediatrics. pediatricians, Family Medicine physicians and residents, nurse Columbia University College of Physicians and Surgeons medical practitioners and school nurses. In addition to our staff, speakers students as well as Stamford Hospital OB/GYN residents rotate come from academic medical centers such as Columbia University through the NICU. Formal educational and multidisciplinary rounds College of Physicians and Surgeons, Albert Einstein College of are held daily on the Pediatric inpatient unit. Teaching is also Medicine, Yale-New Haven Children’s Hospital and community provided by Dr. Sadeghi to Family Medicine residents and genetic and state agencies. As part of our ongoing efforts to connect with counselors, and Dietary Department students who participate our primary as well as secondary community of health providers, in the Cystic Fibrosis program. All Pediatrics division directors we began to live stream our Grand Rounds lectures this past year. hold teaching appointments at major academic medical centers.

Figure 11: Maternal Child Health Quality Scorecard Including Joint Commission’s Perinatal Care Core Measures:

Maternal Child Health Scorecard FY 2016

Indicator Threshold Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep YTD

JC-PC01- Elective Delivery <39 wks LF & JC (All Cases) 1% 0/18 0/21 0/19 1/15 0/18 0/14 0/21 0/27 0/20 1/17 1/31 0/12 0.4%

JC-PC01- Elective Delivery <39 wks (CMS Sample) 1% 0/5 0/5 0/10 1/4 1/11 0/5 0/7 0/6 0/4 0/7 0/10 0/10 2% 35/73 22/57 20/46 26/66 21/49 28/69 20/63 24/66 25/66 36/84 32/77 21/62 JC-PC 2 - NSTV Cesarean (All Cases) Ntl 3% 48% 39% 43% 39% 43% 49% 32% 36% 38% 43% 41% 34% 40%

16/33 20/36 11/25 12/31 12/36 14/38 11/34 15/36 14/32 15/41 12/32 9/36 JC-PC-02 NSTV Cesarean (CMS cample) 48.5% 55.6% 44% 38.7% 33% 37% 32.4% 41% 44% 37% 38% 25% 39% No JC-PC 3 - Antenatal Steroids Ntl <95% 5/5 Cases 4/4 4/4 5/5 4/4 4/4 6/6 3/3 5/5 8/8 2/2 100% JC-PC 4 - Newborn Blood Stream Infections Ntl <5 0 0 0 1 0 0 0 0 0 0 0 0 1

16/37 13/40 12/32 41/85 11/32 15/30 21/36 21/39 21/35 20/39 16/39 17/34 JC-PC 5- Excl. Breastfeeding (CMS) Ntl 50% 43.2% 32.5% 37% 48.2% 34% 50% 58.6% 53.8% 60% 51% 41% 50% 47% 19/19 12/13 20/20 20/20 20/20 20/20 17/20 18/20 17/20 10/20 20/20 19/20 Skin to skin within 30 minutes of Del. NSI 90% 100% 92% 100% 100% 100% 100% 85% 90% 85% 90% 100% 95% 95% 13/19 13/19 14/40 15/20 9/20 17/20 13/20 15/20 14/20 12/20 17/20 15/20 BF - Attempt/ Latch 1hour NSI 80% 68% 69% 69% 75% 45% 85% 65% 75% 70% 60% 85% 75% 70% Pedi PIV Infiltrates NDNQI 0 0 0 0 0 0 0 0 0 0 0 0 5 45/48 46/48 20/20 22/22 20/20 20/20 20/20 20/20 20/20 20/20 19/20 20/20 NB Bilirubin Screening LF 90% 94% 96% 100% 100% 100% 100% 100% 100% 100% 100% 95% 100% 98% NICU CLABSI NDNQI Q 0 0 0 0 0%

18/19 10/11 16/17 10/11 11/11 10/13 9/12 13/13 13/13 11/11 20/21 10/10 <37 wk adm temp on NICU adm PI 90% 95% 91% 94% 91% 100% 77% 75% 100% 100% 100% 95% 100% 93%

VON 2/2 No 1/1 1/1 3/3 2/4 1/1 3/3 2/2 4/4 8/8 1/1 <1500 gm temp on NICU adm > 96F (36C) 25% tile 100% cases 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 93%

NSTV: Nulliparous singleton term vaginal, PIV: Peripheral Intravenous, NB: Newborn, CLABSI: Central Line Associated Blood Stream Infection, LF Leapfrog, JC: Joint Commission VON: Vermont Oxford Network, NDNQI: National Database of Nursing Quality Indicators

2016 Clinical Annual Report 81 Department of Pediatrics: Annual Report 2016

Departmental Research and Strategy/Future Direction Scholarly Activities This coming year promises to be memorable with the opening of the new Cohen Children’s Unit. Additionally, we will look to: Abstracts and Papers

Jennifer Bragg, MD – Annemarie Stroustrup, MD, MPH, Jennifer • Explore long-term strategic partnerships with prominent Bragg, MD, Syam Andra, PhD, Paul Curtin, PhD, and Chris academic medical centers. Gennings, PhD. NICU-Based Phthalate Exposure Impacts Early • In collaboration with the Department of Emergency Medicine, Neurodevelopmental Performance. continue recruiting for our new Pediatric Emergency Department. Sara Shrager Lusman, MD – Sarah Lusman, Jillian Sullivan. • Further recruit specialists for the Cohen Children’s Nutrition and growth in cystic fibrosis. Cystic Fibrosis. Pediatric Specialty Center, particularly in Pediatric Surgery. Clinics of North America. Elsevier; August 2016. • Continue to work with independent physicians on Served as the site principal investigator for a project entitled: enhancing alignment strategies. Assessing the Association Between EPAs, Competencies and Milestones in the Pediatric Subspecialties. • Further develop of a simulation testing program for all hospital-based physicians and nurses. Hossein Sadeghi, MD – Abstract accepted at this year’s North American CF conference titled: Patient perceptions on transition • Continue our collaboration with the Stamford Health and timing of transfer to adult care. Department in the Connecticut Hospital Association’s Statewide Asthma Initiative.

• Expand the NICU’s Infant Massage program. Community Outreach • Continue efforts to recruit un- and under-insured children The Department was represented at many events and health and youth with special healthcare needs for the Medical fairs including: Home Initiative.

• Health Wellness & Sports Expo at Chelsea Piers Connecticut • Continue philanthropic activities related to Pediatrics • Community Health Fairs in the Healing Reimagined campaign.

• Fairfield County Sports Commission • Explore research opportunities with the Vermont • March of Dimes March for Babies Oxford Network. • Early Childhood Fair School Readiness Council • Together with Physician Relations continue visiting • Fall Harvest at Fairgate Farms area practices to apprise them of ongoing and planned • Stamford Children’s Health Collaborative Departmental programs and initiatives. (formerly Stamford Obesity Task Force) • Cystic Fibrosis Foundation’s Great Strides Walk • Stamford Public School’s Teacher Orientation • March National Nutrition Month, Stamford city-wide initiative included 25 events • Rye Country Day School 1st Annual Wellness Day • Stamford STEMFEST at Mill River Park • Yerwood Center Family Fun Fair • HarborFest

82 2016 Clinical Annual Report Nursing Station2016 in Clinicalthe Patient Annual Report Tower83 Teamwork. Facilitated.

Psychiatry

We continue to see large numbers of individuals from the community who present to the Hospital’s Emergency Department in need of psychiatric and substance abuse services. There was a 7% increase in inpatient volume in the Psychiatry Unit compared to the previous year and the average length of stay increased from 7.52 days in FY14 to 9.29 days in FY16, reflecting the increased patient acuity and limited community residential resources for patients.

84 2016 Clinical Annual Report Department of Psychiatry: Annual Report 2016

Draupathi Nambudiri, MD, FAPA Chair, Department of Psychiatry

A Message From The Chair The Year in Review

In the past year, the Department of Psychiatry has accomplished • Maintained the program that began in July 2004 for provision a great deal in its role as the major provider of patient-centered of evening and weekend psychiatric house physician services mental health assessment and treatment services for patients in the ED to facilitate timely assessment of psychiatric patients with acute and serious psychiatric disorders in the greater Stamford community. Specifically, we: • Maintained a collaborative relationship with the Dorothy Bennett Behavioral Health Center at Optimus Health Care • Maintained a high-quality inpatient and consultation/liaison and Dubois Center in Stamford to provide continuity of service to meet the ever-increasing psychiatric care needs high-quality psychiatric care to patients of our patients The Department’s clinical services remained quite busy with • Met all requirements to maintain substantial grant funding significant activity. We continue to see large numbers of individuals through the Department of Mental Health & Addiction from the community who present to the Hospital’s Emergency Services in the amount of $289,000 per annum Department in need of psychiatric and substance abuse services. There was a 7% increase in inpatient volume in the Psychiatry Unit • Continued to reduce Emergency Department gridlock and compared to the previous year and 21% increase over FY14 (5,796 improve clinical services through our emergency psychiatric days in FY16 compared to 5,416 in FY15 and 4,766 in FY14). The hold program, providing four psychiatric ED hold beds located average length of stay increased from 7.52 days in FY14 to 9.29 on the Inpatient Psychiatry Unit days in FY16, reflecting the increased patient acuity and limited community residential resources for patients. • Modified the physical environment for psychiatric assessment in the ED to accommodate increasing demand and improve customer services and satisfaction; this was accomplished with the opening of designated Behavioral Health space in the new ED

2016 Clinical Annual Report 85 Department of Psychiatry: Annual Report 2016

Figure 1: Psychiatric Inpatient Service (South-1) FY12-FY16 Data on volume for the Inpatient Psychiatric Unit is presented in Figure 1. 6000 Compared to FY15, the Medical/Surgical and substance abuse 5000 consultation volume remained stable in FY16. There were 2,705 consults in FY16 compared with 2,710 consults in FY15. It is 4000 important to note that over the years the number of child and adolescent psychiatry cases seen by the consultation service has 3000 gone up from 109 cases in FY12 to 177 cases in FY16. Data for 2000 psychiatric consultations is presented in Figure 2.

1000

0 Scope of Clinical Services FY12 FY13 FY14 FY15 FY16

Inpatient Volume Inpatient Services

The Inpatient Psychiatry Unit at Stamford Hospital is the major provider of patient-centered mental health assessment and Figure 2: Consultation/Liaison Services Volume treatment services for patients with acute and serious psychiatric disorders in the greater Stamford community. The community has come to trust and rely upon the high quality of acute ED Floor Substance Total # of Change Abuse From Last care with rapid assessment and stabilization delivered on the Consults Consults Consults Consults Year inpatient service. As the only community hospital-based inpatient FY12 1,486 1,188 93 2,767 +10% psychiatric service between the New York/Connecticut border and Norwalk, Connecticut, this service provides a vital link in the FY13 1,541 1,984 126 3,651 +32% mental healthcare of those who reside in lower Fairfield County. We maintain a high caliber of service on this unit while exploring FY14 1,501 1,533 22 3,056 -16% how best to serve specialty populations in the area.

FY15 1,554 1,156 — 2,710 -11% The Department’s approach to mental health is multidisciplinary, and our care team is sensitive and compassionate to patients FY16 1,776 939 — 2,705 0% and their families. In addition to psychiatrists, psychiatry nurse practitioners and psychiatry physician assistants, nurses and technicians, patients may also work with social workers, a substance abuse counselor, a case manager, an activity therapist 250 and other support staff. 200 Treatment is highly individualized to the unique needs of each 150 patient. We offer dual-diagnosis behavioral health treatment services, group and individual behavioral therapy, medical 100 psychiatry and psychopharmacological interventions. Pet therapy, music therapy, spirituality and relaxation groups are also available. 50 Upon discharge, patients receive a carefully constructed discharge 0 plan and arrangements for aftercare. We invite involvement of a FY12 FY13 FY14 FY15 FY16 patient’s family or significant other (with patient permission) during this process. Child Adolescent Cases

86 2016 Clinical Annual Report

Consultation Liaison/Medical, Surgical & Emergency • Department Medical Peer Review Committee – Dr. Enenge Department Consultation Services A’Bodjedi (Chair), Dr. Rachit Patel, Dr. Gopal Upadhya • Medical Executive Committee – Dr. F. Carl Mueller, There is an ever-increasing demand for psychiatric evaluation services Dr. Draupathi Nambudiri in the Emergency Department. Disorders such as delirium, behavioral difficulties associated with dementia, acute anxiety, panic, psychotic • Graduate Medical Education Committee – Dr. Draupathi disorders, depressive states and alcohol and substance use disorders Nambudiri are but a few of the common difficulties which the Department • Continuing Medical Education Committee – Dr. Draupathi is called upon to address with the medical/surgical inpatient Nambudiri population. The Psychiatry Consultation/Liaison service plays a vital • Inpatient Psychiatry CQI Committee – Dr. Draupathi Nambudiri, role in the care of these patients. Dr. Rachit Patel

• Patient Safety & Quality Committee – Dr. Draupathi Nambudiri Medical Staff • Pharmacy & Therapeutic Committee – Dr. Rachit Patel, Nicole Feagin, PA-C

• Hospital Nominating Committee – Dr. Jeffrey Koffler

• Department QIC Committee – Dr. Gopal Upadhya (Chair) F. Carl Mueller, MD, FAPA • Medial Staff Credentials Committee – Dr. Kenneth Graham

Associate Chair • Core Measures Work Group – Dr. Draupathi Nambudiri (member)

• Dementia Work Group – Dr. Draupathi Nambudiri

New Staff Departmental Safety and Quality • Robert Feeley, MD • Taiye Ogundipe, MD • Nicole Feagin, PA-C Psychiatry Core Measures, HBIPS

Psychiatry Core Measures target patient safety, quality of care Transitions and timely transmission of clinical information to next level of • Farid Force, MD left the medical staff in April 2016 care. The Core Measures also include compliance with screening • Linda Pettei, APRN left the ancillary staff in May 2016 all admissions to the Inpatient Psychiatry Unit for alcohol and substance abuse using a special screening tool. HBIPS Appropriate • Rachit Patel, MD left the medical staff in June 2016 Care Measure Score for FY15 was 95% and for FY16 we achieved a score of 96%, above the target of 95%. Since January 2015, Hospital Committee Participation the Inpatient Psychiatry Unit has been participating in Tobacco Screening (TOB) Core Measures. For FY15, we achieved 99% Department members participate in various Hospital compliance and in FY16 at 100% compliance in screening patients committees, including: for tobacco use. Although we were 98% compliant with ordering • Department Executive Committee – Dr. Enenge nicotine replacement therapy, only about 80% of our patients A’Bodjedi, Dr. F. Carl Mueller, Draupathi Nambudiri (Chair), accepted the treatment. For Inpatient Psychiatry Alcohol Screening, Dr. Jeffrey Koffler, Dr. Gopal Upadhya the compliance score was 100% in both FY15 and FY16. • Outpatient Behavioral Health CQI Committee – Dr. Enenge HBIPS Immunization compliance score in FY16 was 99%, with the A’Bodjedi target set at 98%.

2016 Clinical Annual Report 87 Department of Psychiatry: Annual Report 2016

Patient Satisfaction Figure 4: Average Length of Stay (ALOS)

Patient satisfaction for the Inpatient Psychiatry Unit is tracked DAYS by distributing a survey to all patients who are discharged from 12 the unit. The score range is from 1-5, with 1 being the lowest and 5 the highest. For FY16, the score was 4.44, which was higher 10 than prior years (4.36) as shown in Figure 3.

8 Thirty-Day Readmission Rate 6 Our 30-day readmission rates decreased from 14% in FY13 to 8% in FY14. The rate for FY15 and FY16 remained at 10%. 4

2 Seven-Day Readmission Rate 0 Our seven-day readmission rate remained steady at 4% over the past FY10 FY11 FY12 FY13 FY14 FY15 FY16 three years compared to a rate of 5% in FY13. Total DRGs Depressive Neuroses Psychoses Alcohol/Drug Abuse/Dep.

Figure 3: Patient Satisfaction 4.45 Average Length of Stay (ALOS)

Our Inpatient Unit staff has worked hard to reduce the average 4.4 length of stay from 10.07 days in FY10 to eight days in FY14 as shown in Figure 4. In FY15, the ALOS increased to nine days. In FY16, the same trend continued with an ALOS of 9.29 days. This increase 4.35 in ALOS is due to increased patient acuity and limited community residential resources for patients.

4.3

Awards and Accolades

4.25 • Justin Schechter, MD continued his appointment on the Psychiatric Security Review Board (PSRB). This board monitors the treatment, safety and security of those individuals found not guilty by reason of insanity. This is Dr. Schechter’s third consecutive term FY14 FY15 FY16 on the board. Appointment to this board was made by Governor Malloy and the Connecticut State Legislature.

• Justin Schechter, MD serves as a Consultant for the Veterans Administration Compensation and Pension Division.

88 2016 Clinical Annual Report

Departmental Educational In addition: and Teaching Activities • S.K. Vyas, PhD is continuing as Assistant Clinical Professor of The Department’s academic activities continue to enhance the Psychiatry for the Icahn School of Medicine at Mount Sinai, quality of care rendered to patients, as well as the educational Mount Sinai St. Luke’s-Mount Sinai West Hospital Center. experience provided to physician assistant students from Quinnipiac • Gopal Upadhya, MD maintained a Clinical Adjunct Assistant College and nursing students from local universities. Academic Professor position at Quinnipiac University for his active experiences with these students keep the Department vibrant and participation in PA student education. provide the opportunity to teach and continue to learn. • Justin Schechter, MD was reappointed as Assistant Clinical Department members were involved in Grand Rounds Professor of Psychiatry at Yale University School of Medicine. presentations at Stamford Hospital. This year’s Grand Rounds presentations included: • Draupathi Nambudiri, MD was reappointed as Assistant Clinical Professor of Psychiatry at Weill Cornell Medical College TOPIC LECTURER

DSM-5 A Brief Overview Gopal Upadhya, MD for the Mental Health Unit Chief, Inpatient Psychiatry Departmental Research and Professional Stamford Hospital Scholarly Activitities

Emergent properties in JF. Carl Mueller, MD Complex Systems such as Assistant Clinical Professor, Presentations Psychiatry and Health Care: Yale School of Medicine Theoretical and Practical Associate Chair, Department of Clinical Lycanthropy Exacerbated by Cannabis Use Disorder: A Case Concerns Psychiatry Stamford Hospital Report: Rachit Patel, MD, APA Annual Meeting May 2016, Poster presentation. Richard Gallagher, MD Professor of Clinical Psychiatry Improved Treatment Acceptance and Adherence Following the Treating Patients in Crisis: and Behavioral Science, New York Theory and Practice Diagnosis of Multiple Malformations of Cortical Development in a Medical College Faculty, Columbia Patient with Psychosis: Rachit Patel, MD, Kathleen Stuart, MSN, APRN, Univ. Psychoanalytic Institute Draupathi Nambudiri, MD, 1st Annual Research Day, May 2016. Mood Disorders with Joseph Goldberg, MD Stamford Hospital, Stamford, CT, Poster session. mixed features in DSM-5: Clinical Professor of Psychiatry Icahn Diagnostic & Therapeutic School of Medicine at Mount Sinai, Clinical Lycanthropy Exacerbated by Comorbid Cannabis Use Implications New York, NY Disorder: Rachit Patel, MD, 1st Annual Research Day, May 2016. Stamford Hospital, Stamford, CT, Poster session. Sejal Vyas, PhD Sleep in Psychiatry; Pediatric & Adult Neuropsychologist S.K. Vyas, PhD. Grand Rounds held at the Stamford Hospital, Neuropsychological & Assistant Clinical Professor of Department of Psychiatry: Sleep in Psychiatry: From a Perspectives. Psychiatry, Icahn School of Medicine at Mount Sinai Neuropsychological Perspective, November 12, 2015. Concussion Update: Christina Kunec, PsyD S.K. Vyas, PhD. An Update: Sleep in ADHD. Grand Rounds held at the Evidence Based Neuropsychologist Stamford Hospital, Department of Pediatrics Stamford, CT. February Approach to Concussion Stamford Hospital Management 25, 2016.

Insomnia, Tips and Tools Christine Naungayan, MD S.K. Vyas, PhD. gave seminar to Psychiatry Residents at Mount Sinai on Assessing and Treating CEO and Founder of Awakenings St. Luke’s- Mount Sinai West Hospital Center on “Psychological Testing Patients with Insomnia & Forensic Psychiatric Consultant with a Focus on Neuropsychology.” April 26, 2016.

2016 Clinical Annual Report 89 Department of Psychiatry: Annual Report 2016

S.K. Vyas, PhD. gave seminar to Psychiatry Residents at Mount • Dual Diagnosis Treatment Services — As co-morbid psychiatric Sinai St. Luke’s-Mount Sinai West Hospital Center on “What is substance abuse disorders continue to rise, the Unit will continue Neuropsychology.” May 3, 2016. to adopt evidence-based practices in order to provide high-quality services for dually diagnosed patients. Christine Kunec, Psy.D gave Pediatric Grand Rounds on topic of Concussion, at Stamford Hospital on March 2016. • Behavioral Health Workgroup — Actively participate in the Behavioral Health Work Group-led projects to raise awareness and educate our communities about mental illness and impacts Publication of alcohol and substance abuse.

Improved Treatment Acceptance and Adherence Following the • Access to Care — Collaborate with community treatment providers Diagnosis of Multiple Malformations of Cortical Development in a to improve access to care for mentally ill substance abuse patients. Patient with Psychosis: Case Report, Rachit Patel, MD, Kathleen Stuart, MSN, APRN, Draupathi Nambudiri, MD. Brain Disorders and Therapy, • Community Care Coordination — Collaborate with Community Vol 4, issue 5. Case Managers to reduce preventable psychiatric readmissions and improve psychiatric care for patients in the community.

• PA Student Training — With the opening of Sacred Heart Community Outreach University PA School on-site, Department staff and the psychiatry clinical services will play an important role in clinical training of Christine Kunec, Psy.D, along with the Outpatient Rehab team, hosted PA students from this program. a workshop in March 2015 for athletic trainers in the area to learn the vestibular ocular motor screen and how to incorporate it into their concussion assessment protocol. A panel discussion also took place Consultation Liaison/Medical, Surgical and during the workshop. Emergency Department Consultation Services

• Continued strengthening of the psychiatric house physician program to meet the growing demand for psychiatric evaluation Strategy/Future Direction of patients presenting to the ED after hours and on weekends.

The Department’s focus in the next year and beyond is in these areas: • Increased collaboration in the care of patients admitted to general hospital floors with co-morbid alcohol and substance abuse disorders. Inpatient Services • Close collaboration with geriatric medicine to implement the • Geriatric Psychiatry — Expanding the geriatric psychiatry dementia and delirium identification and management program services will become increasingly important with the aging of at the Hospital. “baby boomers.” The Department of Psychiatry is committed to partnering with • Medical Psychiatry Service — Assessment and treatment of colleagues in all departments and providing the finest psychiatric co-morbid psychiatric/medical illnesses will have an increasingly and behavioral healthcare services available. pivotal role, particularly as we are the only community providers of these services in the area.

• With the opening of the new Hospital, there will be future opportunity to create specialized treatment programs to meet the needs of geriatric and medical psychiatric patients.

90 2016 Clinical Annual Report 2016 ClinicalWaiting Annual Report Area91 Treatment. Transformed.

Radiology

We are the ones finding the breast and lung cancers early enough to be cured. We are the ones who will, through radiation therapy, touch two of every three patients at some point in the cancer journey. We are the ones who can image the beating heart with such speed and clarity that invasive catheterization for diagnosis has become obsolete. And we are the ones who diagnose appendicitis before surgery, saving 80% of patients from a major operation they would have undergone just a few years ago. There is no disease state, no organ system and no specialty that has not benefited profoundly from imaging technology. Better yet, our solutions last year touched the lives of our patients in very consequential ways more than 216,000 times.

92 2016 Clinical Annual Report Department of Radiology: Annual Report 2016

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

A Message From The Chair The Year in Review

Imagine… a giant copper coil cooled to negative 442 degrees that has not benefited profoundly from imaging technology. Better Fahrenheit. Through this super-cooled coil, electric current yet, our solutions last year touched the lives of our patients in very pulses, without resistance, creating a magnet 20,000 times consequential ways more than 216,000 times. That’s more interaction greater than earth’s magnetic field. At a molecular level, this is than there are people living in Stamford. strong enough to cause every one of the seven billion, billion, billion (7,000,000,000,000,000,000) protons in your body to shift During the past year, we accelerated the process of reimagination from random orbits and align with the magnetic field. From for the Stamford Health community. We opened the most advanced there, we turn on a radio to FM frequency and listen. Why the radio CT imaging device in the region, giving us the ability to image most waves? Their wavelength makes your magnetized protons precess parts of the body in 0.25 seconds. In trauma, there is good data to or wiggle and emit sound that we can hear. Each proton’s signal show that survival is independently predicted by the distance from is influenced by its neighbors and, believe it or not, each is unique. the trauma bay to the CT scanner. So, we placed this robust tool We take this signal, plot it by wavelength, amplitude and pitch, right next to the trauma bay where it will tell us what is broken and and from there, with the help of a supercomputer, create images will direct treatment in the moments when it matters most. This tool of the human body. These images see in ways we humans cannot. will save lives. Imagine that. They see the body as a composition in temperature, motion, water In Interventional Radiology (IR), we witnessed a 20% growth in content, and of course pathology. When combined with some new 2016 and that’s just the beginning. We performed the first seven tracers, we can even see how you think. liver radio embolization procedures in southern Fairfield County Imagine MRI Imaging. this year. This breakthrough technique allows us to deliver high doses of radiation right into the tumor via the liver artery. We can There are days when each of us in this exciting field has to step back, deliver these high doses while reducing risk to surrounding tissues, and take in the view. In just over 100 years, we have gone from a thereby markedly reducing side effects. Radio embolization works profession that translated shadows to the most pivotal of services when chemotherapy fails and when surgery is not an option. It is in healthcare. We are the ones finding the breast and lung cancers transforming the management of cancers involving the liver. It is one early enough to be cured. We are the ones who will, through of a group of new age image-guided IR solutions that are rapidly radiation therapy, touch two of every three patients at some point rewriting the textbooks. And we are the only ones in the on their cancer journey. We are the ones who can image the beating area who do it. Imagine Interventional Oncology. heart with such speed and clarity that invasive catheterization for diagnosis has become obsolete. And we are the ones who The following pages will tell you how we have worked to create, diagnose appendicitis before surgery, saving 80% of patients from communicate and deliver value. We will tell the story of how a major operation they would have undergone just a few years we have strengthened our quality management systems and ago. There is no disease state, no organ system and no specialty expanded their scope to include everything from scheduling to IT

2016 Clinical Annual Report 93 Department of Radiology: Annual Report 2016

to patient comfort. We will tell the big story, compiled from the stories US: In our fleet, there are 14 dedicated Radiology US machines and of each of the people we cared for every minute of every day last year. 21 sonographers. In 2016, they performed 47,725 scans. Our staff serves the Breast Imaging division, Interventional and the ED, As we move forward, we will continue to offer the most advanced as well as our general diagnostic population. With the new imaging solutions available, while never losing touch with the reason Hospital, we became the first Department in the region to offer we are all here. Having the chance to care for you and those who trust all inpatients the option of bedside US examinations. their health to you is a privilege. Thanks. VIR: This year was the beginning of what we expect to be a strong growth trajectory for IR. In 2016, the program enjoyed 20% growth and that is only the start. We introduced new Scope of Clinical Services procedures to Stamford like radio embolization of the liver and cryoablation of the lung and kidney, and began to offer services Imaging is the applied science of creating realistic representations for peripheral arterial disease. Our new IR Clinic is open as is our of the living human in ways that no anatomist could ever have hospital-based consultation service. The staff in IR now consist entertained. The Department performed over 200,000 studies this of eight dedicated IR nurses, two IR technologists and one PA. past year, creating several million images. The interpretation of those In 2016, we began the planning process for a new IR suite to images will inform some of the most critical decisions we will ever be installed next summer. make. Beyond diagnosis, we use the same images to guide cutting- edge image-guided treatment. In the world of imaging, our vision General Diagnostics: This is where it all started and from a uses x-rays, gamma rays, electrons, beta rays, ultrasound waves and volume perspective, remains the busiest area of the Department, even FM radio waves. You see the finished products as 3-D Breast performing 73,798 examinations last year. In our fleet, we Tomosynthesis, Bone Densitometry, Computerized Tomography, maintain 13 dedicated digital radiography rooms and a dozen General Radiography, Magnetic Resonance Imaging, Nuclear Medicine, portable devices, all digital. The staff of 23 serves the needs of Positron Emission Tomography and Ultrasound. our busy ED, Hospital and outpatients at Tully, Darien, Chelsea Piers Connecticut and the imaging facility at Long Ridge Road. MRI: Our team of 13 MRI technicians operate our three 1.5T MRI We began an educational program this year where once a month scanners. In 2016, we completed 12,942 examinations. This year, our the Radiologist reviews cases with the staff in this division. focus was on developing new protocols and standardizing processes. We reimagined how we image the small intestines with MRI using a Breast Imaging: Stamford Hospital was the one of the first new and much more palatable contrast agent, and developed an early in the country to provide Digital Breast Tomosynthesis (3-D radiologist review process for these studies. Mammography) to all women because, compared with 2-D, the newer technology offers superior breast cancer detection and CT: Six scanners and 16 highly trained, certified CT technologists decreased rate of false positives. This reduces unnecessary return performed 32,487 examinations in 2016. We have scanners at Tully, visits for images and biopsies. Our cancer detection rate – an Darien and four at the Hospital where they run 24/7/365. Our newest important marker of accuracy – remains at the highest levels scanner is located in the new Hospital ED. This piece of equipment nationally, and we are proud that the vast majority of cancers is the most advanced in the county, able to scan an area of 8 cm. in we detect are at the smallest, most treatable stage. a quarter of a second. We also refined protocols especially in chest and cardiac imaging. Below the diaphragm, to speed care in the ED Radiation Oncology: Twenty-one staff members, from radiation and improve imaging quality, we moved away from requiring that all oncologists to physicists, technologists and support staff, serve patients drink two pints of chalky dilute barium and wait two hours our busy Radiation Therapy division. The division uses an before abdominal scans by replacing the barium with a cup of water, advanced Toshiba 64-slice large-bore CT for radiation therapy and a 20-minute delay. Same results, faster turnaround and no chalky simulation. For conventionally fractionated radiation therapy, aftertaste! CT staff is on-site 24/7/365. the Department has a Varian 21EX linear accelerator with dual energy photon and multiple energy electron capabilities. Our equipment allows for conformal 3-D treatments as well as image-guided radiation therapy (IGRT) and intensity-modulated radiation therapy (IMRT). Our Varian 600 C linear accelerator

94 2016 Clinical Annual Report has been replaced by a new state-of-the-art Varian True Beam side effects than conventional alternatives. It offers our patients an linear accelerator. This unit will treat using 6 MV x-rays to all sites option not available at other hospitals in the region. In addition to and be operational by December 2016. ablation and radioembolization, we serve the oncology community at Stamford with general interventional services including biopsy, chest port placement and palliative/pain management services.

Clinical Focus/Signature Services In the Diagnostic division, Dr. Gregory Pearson joined our Department this year after a 20-year career at Columbia Cancer Care: Radiation Oncology represents a pillar of University/NewYork-Presbyterian Hospital. He is a nationally Stamford Hospital’s comprehensive cancer program. Practicing known expert in imaging of the lungs and heart, and offers our from the Bennett Cancer Center and CyberKnife® Center at community a level of skill and experience unmatched in Fairfield the Tully Health Center, our two Radiation Oncologists offer County. With our expert pulmonologists and Dr. Michael Ebright state-of-the-art radiation therapy and stereotactic radiosurgery anchoring Thoracic Surgery, Stamford Health offers bench depth to approximately 400 new patients every year, mostly on an unmatched in the region for patients suffering from lung cancer outpatient basis. This year, Stamford Hospital began offering and other conditions affecting the lungs. As Radiology Director high-dose rate (HDR) remote implant therapy for use primarily of our Lung Cancer Screening program, Dr. Pearson has refined with gynecologic malignancies. This technology allows our our low-dose lung screening protocols and brought our collaborative patients to access all aspects of gynecologic radiation therapy Lung Cancer Screening program, already the strongest in southern at Stamford Hospital, thus eliminating the need for referrals Connecticut, to a new level of multidisciplinary excellence. to other institutions. Stroke Neurosciences: Stamford’s team of four on-site and Very proudly after an extensive review by the Dana-Farber/Brigham nine off-site board-certified neuroradiologists interpret over and Women’s Cancer Center clinicians and staff, our outpatient 90% of our routine and emergency imaging involving the brain Bennett Cancer Center radiation oncology and medical oncology and spine. This level of specialized care cannot be found in the services were selected to be a member of the Dana-Farber/Brigham region outside of large university hospitals that depend largely and Women’s Cancer Care Collaborative. This membership will on trainees for front-line care. enhance our visibility and services and participation will provide medical staff with increased educational opportunities and the Cardiac and Vascular Disease: Dr. Pearson’s extensive experience ability to consult with medical specialists at Dana-Farber/Brigham in imaging of the heart and great vessels, is an asset to Dr. David Hsi and Women’s Cancer Center regarding complex cases. In addition, and members of the Cardiology division with whom we collaborate. our patients will have greater access to the latest cancer research Dr. Pearson has helped refine our protocols for imaging of the and clinical trials. heart and imaging prior to transcatheter aortic valve replacement (TAVR). As we evolve our MRI platforms, he will bring his experience Vascular and Interventional Radiology (VIR) represents the other in cardiac imaging to Stamford, complementing the new adult therapeutic branch of Radiology. VIR is focused on delivering Structural Heart Program. solutions using imaging tools. In the oncology population, we have developed solutions to treat tumors in the liver, lung, kidney Orthopedics: Fellowship-trained at the Hospital for Special and pancreas in situ using cross-sectional imaging like CT and Surgery, Dr. Elizabeth Gaary now reads the majority of our MRI to guide specialized tools right to the tumor bed. From there advanced musculoskeletal imaging. She is supported by four we are able to destroy the tumor where it lives using thermal MSK-trained radiologists in the network. energy. These techniques open new possibilities for patients who cannot tolerate conventional operations or in an increasing Womens Health: The Breast Imaging division is a nationally number of cases, they offer an alternative. Similarly, for patients recognized leader in the delivery of comprehensive breast on chemotherapy, we can often provide a break in treatment or diagnostic care. Four fellowship-trained mammography experts a solution when one area of disease fails to respond. This year, at provide comprehensive “one-stop” services. We remain the Stamford, we introduced these techniques to our community and only site in the region that provides results to all patients who inaugurated a new one called radioembolization. This involves undergo breast imaging during regular business hours. Women treating liver tumors by delivering radiation through the tumor’s who choose to have their studies during the evening or over feeding arteries. Radioembolization is more precise, with fewer

2016 Clinical Annual Report 95 Department of Radiology: Annual Report 2016

the weekend receive results within one business day. With Radiologists who provide services from remote locations. General Connecticut having the highest incidence of breast cancer in Diagnostics includes the subspecialty fields of Abdominal Imaging, the country, we are proud to provide this incredibly high level of Chest Imaging, Musculoskeletal Imaging, Neuroimaging, Nuclear accuracy and timely service to the women in our community. We Medicine and Interventional Radiology. We provide the full scope are equally proud to have installed the latest generation of breast of services 24/7 with 100% final reports in the major disciplines of MRI computer-aided detection software, which is used for all Radiology. Breast Imaging is served by a specialized group of four breast MRI studies, as we strive to find the smallest tumors at the mammographers who work in a center of excellence model with earliest stage. our breast surgeons. Finally, our two Radiation Oncologist serve as key members of Stamford Hospital’s Bennett Cancer Center Pediatrics: Stamford Hospital has 14 board-certified Pediatric Radiologists reading over 90% of the imaging for patients under the age of 18. Commensurate with the growing portfolio of Pediatric Chairman services in our system, we have worked to improve our services, Brian Stainken, MD (On-Site Hospital ext. 7881) particularly in the areas of pediatric ultrasound and MRI imaging. [email protected] Our annual Radiology volume by location is shown in Figure 1. Specialty: Vascular and Interventional Radiology Medical School: Georgetown University Residency: Diagnostic Radiology, San Diego Naval Hospital Figure 1: Yearly Volume by Location Fellowship: Vascular & Interventional Radiology, University of California, Los Angeles Yearly Volume by Location Board Certification: Diagnostic Radiology, CAQ Vascular and 100,000 Interventional Radiology

80,000

FY13 Thoracic Imaging 60,000 FY14 Gregory Pearson, MD (On-Site Hospital ext. 7789) 40,000 Director of Cardiothoracic Imaging FY15 Specialty: Diagnostic Radiology, Cardiac and Thoracic Radiology 20,000 FY16 Medical School: Harvard Medical School Residency: Diagnostic Radiology, Brigham & Women’s Hospital 0 Radiology Radiology Radiology Radiology Radiology Fellowship: Thoracic Imaging, Brigham & Women’s Hospital Chelsea Darien Long Ridge Stamford Tully Health Board Certification: Diagnostic Radiology Piers Road Hospital Center

Body Imaging Medical Staff Elizabeth Gaary, MD (On-Site Tully ext. 7799) Director of Musculoskeletal Imaging Stamford Hospital Radiology physicians complete five years of post- Specialty: Diagnostic Radiology, MSK/MRI Radiology doctoral training as well as one to two years of fellowship training Medical School: Georgetown University prior to obtaining subspecialty board certification in Body Imaging, Residency: Diagnostic Radiology, Dartmouth-Hitchcock Breast Imaging, Pediatric Imaging, Musculoskeletal Imaging, Medical Center Neuroimaging, Nuclear Medicine, Vascular/Interventional Radiology Fellowship: MSK/MRI Radiology, Cornell University, and Radiation Oncology. Hospital for Special Surgery Board Certification: Diagnostic Radiology The Department is organized into three divisions. The largest is the General Diagnosis and Interventional Radiology group. These services are currently anchored by a group of six on-site specialized Radiologists as well as a network of 24 additional

96 2016 Clinical Annual Report Mary L. Grebenc, MD (Off-Site 2747) William Caragol, MD (On-Site Tully ext. 7782) Office Location: San Diego, California Office Location: Stamford, Connecticut Specialty: Diagnostic Radiology, Body Imaging Specialty: Breast Imaging Medical School: University of New Mexico School of Medicine Medical School: New Jersey College of Medicine Residency: Diagnostic Radiology, Naval Medical Center Residency: New York Hospital, Cornell Medical Center Fellowship: Body Imaging, National Naval Medical Center Board Certification: Diagnostic Radiology Board Certification: Diagnostic Radiology Lily Kernagis, MD (On-Site Tully ext. 7710) Jeffrey D. Kleinman, MD (Off-Site 2747) Office Location: Stamford, Connecticut Office Location: Solon, Ohio Specialty: Breast Imaging Specialty: Diagnostic Radiology, Body Imaging Medical School: University of Pennsylvania School of Medicine Medical School: Wright State University School of Medicine Residency: Hospital University of Pennsylvania, Radiology, Residency: Diagnostic Radiology, MetroHealth Medical Presbyterian Medical Center, Center Case Western Reserve University Philadelphia Transitional Internship Fellowship: Body Imaging, MetroHealth Medical Fellowship: University of Pennsylvania Women’s Imaging Center Case Western Reserve University Board Certification: Diagnostic Radiology Board Certification: Diagnostic Radiology Valencia King, MD (On-Site Tully ext. 7710) Anthony J. Minotti, MD (Off-Site 2747) Office Location: Stamford, Connecticut Office Location: Olmsted Township, Ohio Specialty: Breast Imaging, Diagnostic Radiology Specialty: Diagnostic Radiology, Body Imaging Medical School: Cornell University Medical College, New York Medical School: Wright State University School of Medicine Residency: New York Presbyterian Hospital/Cornell Medical Residency: Diagnostic Radiology, MetroHealth Medical Center Center, Diagnostic Radiology Fellowship: Body Imaging, MetroHealth Medical CenterBoard Fellowship: Memorial Sloan Kettering Cancer Center, Certification: Diagnostic Radiology, CAQ Nuclear Radiology Breast & Oncologic Imaging, New York Board Certification: Diagnostic Radiology, General Certification Christopher Sidden, MD (Off-Site 2747) Office Location: Greenville, South Carolina Specialty: Diagnostic Radiology, Abdominal Imaging Musculoskeletal Imaging Medical School: Eastern Virginia Medical School Elizabeth Gaary, MD (On-Site Tully ext. 7799) Residency: Diagnostic Radiology, McGill University Health Centre Director of Musculoskeletal Imaging Fellowship: Abdominal Imaging, Brigham and Women’s Specialty: MSK/MRI Radiology Hospital Board Certification: Diagnostic Radiology Medical School: Georgetown University Residency: Diagnostic Radiology, Dartmouth-Hitchcock Breast Imaging Medical Center Fellowship: MSK/MRI Radiology, Cornell University, David Gruen, MD (On-Site Tully ext. 4152) Hospital for Special Surgery Office Location: Stamford, Connecticut Board Certification: Diagnostic Radiology Specialty: Breast Imaging Medical School: Cornell University Medical College Chad Calendine, MD (Off-Site 2747) Residency: New York Hospital Cornell, New York Chief Medical Officer of ARIS Fellowship: Memorial Sloan Kettering Office Location: Nashville, Tennessee Board Certification: Diagnostic Radiology Specialty: Diagnostic Radiology, Musculoskeletal Radiology Medical School: University of Tennessee Residency: Diagnostic Radiology, Emory University Hospital Fellowship: Musculoskeletal Radiology, Emory University Hospital Board Certification: Diagnostic Radiology

2016 Clinical Annual Report 97 Department of Radiology: Annual Report 2016

Eric K. Lizerbram, MD (Off-Site 2747) Mark J. Halsted, MD (Off-Site 2747) Office Location: Carlsbad, California Office Location: Cincinnati, Ohio Specialty: Musculoskeletal Imaging Specialty: Neuroradiology Medical School: USC Keck School of Medicine Medical School: Yale University School of Medicine Residency: Diagnostic Radiology, Cedars Sinai Medical Residency: Diagnostic Radiology, University of California San Diego Center Program School of Medicine Fellowship: MRI, University of California San Diego Fellowship: Magnetic Resonance Imaging, UCSD; Pediatric Board Certification: Diagnostic Radiology Radiology, Cincinnati Children’s Hospital; Pediatric Neuroradiology, Cincinnati Children’s Hospital Michael A. Mahlon, DO (Off-Site 2747) Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology, Office Location: Olympia, Washington CAQ Neuroradiology Specialty: Musculoskeletal Imaging Medical School: Philadelphia College of Osteopathic Medicine Tony Y. Maung, MD (Off-Site 2747) Residency: Diagnostic Radiology, Tripler Army Medical Office Location: San Diego, California Center Program Specialty: Neuroradiology Fellowship: Musculoskeletal Radiology, Penn State Medical School: New York Medical College University/Milton S. Hershey Medical Center Residency: Diagnostic Radiology, Harbor UCLA Medical Center Board Certification: Diagnostic Radiology Fellowship: Neuroradiology, Harbor UCLA Medical Center Board Certification: Diagnostic Radiology

Neuro Imaging John R. Wohlwend, MD (Off-Site 2747) Office Location: Henderson, Nevada Howard Liu, MD (On-Site Hospital ext. 7790) Specialty: Neuroradiology Director of Neuroradiology Medical School: Ohio State University College of Medicine Specialty: Neuroradiology Residency: Diagnostic Radiology, Henry Ford Hospital Medical School: The Chicago Medical School Fellowship: Neuroradiology, Northwestern University Program/ Residency: Diagnostic Radiology, Columbia University College of McGaw Medical Center Physicians & Surgeons, St Luke’s Roosevelt Hospital Center Board Certification: Diagnostic Radiology Fellowship: Neuroradiology, Yale University School of Medicine Board Certification: Diagnostic Radiology, CAQ Neuroradiology Lorraine M. Ash, DO (Off-Site 2747) Nuclear Medicine/PET Office Location: Bakersfield, California Harvey Hecht, MD (On-Site Hospital ext. 7783) Specialty: Neuroradiology Director of Nuclear Medicine and PET Imaging Medical School: Kirksville College of Osteopathic Medicine Specialty: Diagnostic Radiology, Nuclear Imaging Residency: Diagnostic Radiology, Cleveland Clinic Foundation Medical School: Albert Einstein College of Medicine Fellowship: Neuroradiology, University of Michigan Residency: Diagnostic Radiology, Columbia Presbyterian Hospital, Board Certification: Diagnostic Radiology, CAQ Neuroradiology NY; Montefiore Hospital, NY Board Certification: Diagnostic Radiology, Nuclear Medicine John D. Grimme, MD (Off-Site 2747) Office Location: Eugene, Oregon Josef Noga, MD (On-Site Hospital ext. 7787) Specialty: Neuroradiology Director of Interventional Radiology Medical School: University of Cincinnati College of Medicine Specialty: Diagnostic Radiology, Nuclear Imaging Residency: Diagnostic Radiology, University of North Carolina Medical School: Eastern Virginia Medical School Fellowship: Neuroradiology, University of North Carolina Residency: Diagnostic Radiology, Eastern Virginia Medical School Board Certification: Diagnostic Radiology, CAQ Neuroradiology Fellowship: Vascular & Interventional Radiology, Columbia University Medical Center Board Certification: Diagnostic Radiology

98 2016 Clinical Annual Report Anthony J. Minotti, MD (Off-Site 2747) Michelle A. Hercher-Galvez, MD (Off-Site 2747) Office Location: Olmsted Township, Ohio Office Location: Portland, Oregon Specialty: Diagnostic Radiology, Nuclear Imaging Specialty: Pediatric Radiology Medical School: Wright State University School of Medicine Medical School: Oregon Health Sciences University School Residency: Diagnostic Radiology, MetroHealth Medical Center of Medicine Fellowship: Body Imaging, MetroHealth Medical Center Residency: Diagnostic Radiology, University of New Mexico Board Certification: Diagnostic Radiology, CAQ Nuclear Radiology Medical Center Fellowship: Pediatric Radiology, Stanford University Medical Center Pediatric Board Certification: Diagnostic Radiology Terry L. Levin, MD (On-Site 2663) Office Location: Mamaroneck, New York Michael E. Katz, MD (Off-Site 2747) Specialty: Pediatric Radiology Pediatric Medical Director Medical School: Cornell University Medical College Office Location: Boca Raton, Florida Residency: Diagnostic Radiology, New York Presbyterian Hospital Specialty: Pediatric Radiology Fellowship: Pediatric Radiology, Columbia Presbyterian Hospital Medical School: Yale University School of Medicine Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology Residency: Diagnostic Radiology, Mallinckrodt Institute of Radiology Geoffrey A. Agrons, MD (Off-Site 2747) Fellowship: Pediatric Radiology, Mallinckrodt Institute of Radiology Office Location: Kensington, California Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology Specialty: Pediatric Radiology Medical School: University of Medicine and Dentistry of New Jersey Sandra G. Machado, MD (Off-Site 2747) Residency: Diagnostic Radiology, University of Pennsylvania Office Location: Lincoln, Nebraska Health System Specialty: Pediatric Radiology Fellowship: Pediatric Radiology, Children’s Hospital of Philadelphia Medical School: River Plate Adventist University Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology Residency: Diagnostic Radiology, Loma Linda University Fellowship: Pediatric Radiology, Loma Linda University Katherine M. Gyves-Ray, MD (Off-Site 2747) Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology Office Location: Kansas City, Missouri

Specialty: Pediatric Radiology Medical School: New York Medical College Radiation Oncology Residency: Diagnostic Radiology, University of Michigan Frank A. Masino, MD (On-Site Hospital ext. 6230) Fellowship: Pediatric Radiology, University of Michigan Hospitals, Office Location: Stamford, Connecticut C.S. Mott Children’s Hospital Specialty: Radiation Oncology Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology Medical School: Albert Einstein College of Medicine Residency: Radiation Oncology, Yale New Haven Hospital Laura J. Hanahan, MD (Off-Site 2747) Board Certification: Radiation Oncology Office Location: Columbia, Missouri Specialty: Pediatric Radiology Sean W. Dowling, MD (On-Site Hospital ext. 6630) Medical School: Leland Stamford Junior University Office Location: Stamford, Connecticut Residency: Pediatrics, University of New Mexico Program Specialty: Radiation Oncology Residency: Diagnostic Radiology, George Washington University Medical School: Yale University School of Medicine School of Medicine & Health Science Residency: Radiation Oncology, Yale New Haven Hospital Fellowship: Pediatric Radiology, Children’s National Medical Center Board Certification: Radiation Oncology Board Certification: Diagnostic Radiology, CAQ Pediatric Radiology

2016 Clinical Annual Report 99 Department of Radiology: Annual Report 2016

Vascular Interventional Departmental Safety and Quality

Bryan Lazzara, MD (On-Site Hospital ext. 7791) The radiological specialties span almost every aspect of inpatient Specialty: Vascular and Interventional Radiology and outpatient healthcare. We offer care to well over people every Medical School: New York Medical College year, and are involved in every organ system and disease state. We Residency: Diagnostic Radiology, Winthrop University Hospital serve your patients as well as your practices, and many of us also Fellowship: Neuroradiology, Northwestern University, Chicago; maintain our own active clinical practices. The definition of quality Vascular & Interventional Radiology, Columbia University in each of these domains is different but unified by a common goal Medical Center of striving to deliver the best. Board Certification: Diagnostic Radiology

Josef Noga, MD (On-Site Hospital ext. 7787) Radiation & Patient Safety Director of Interventional Radiology Specialty: Vascular and Interventional Radiology Radiology began in the 1930s in response to the growing Medical School: Eastern Virginia Medical School recognition that x-rays could cause harm. Our roots as a specialty Residency: Diagnostic Radiology, Eastern Virginia Medical School are invested in the protecting the patient. During training, Fellowship: Vascular & Interventional Radiology, Columbia Radiologists and Radiation Oncologists, Radiation Physicists and University Medical Center Technologists are all educated and certified in the physics of radiation Board Certification: Diagnostic Radiology and the science of radiation safety. There is growing interest from the public as well as regulators on the topic of radiation safety and Brian Stainken, MD (On-Site Hospital ext. 7881) medical applications. This year we installed a radiation monitoring Chairman, Department of Radiology and tracking software for quality and patient safety which allow us Specialty: Vascular and Interventional Radiology to review all CTs performed at all locations, along with the ability to Medical School: Georgetown University review the amount of cumulative dose for every patient having a Residency: Diagnostic Radiology, San Diego Naval Hospital CT within the organization. Statewide we continue being a part of Fellowship: Vascular & Interventional Radiology, University of the Connecticut Hospital Association’s Radiation Dose Management California, Los Angeles Collaborative committee. Sarah Bull, our Radiation Safety Officer, Dr. Board Certification: Diagnostic Radiology, CAQ Vascular and David Gruen, Co-Director of the Women’s Breast Center, and Jory Interventional Radiology Vidulich Savino, Quality Imaging Manager, are part of a subgroup that has decided on what will be captured and sent to CHA for state benchmarking. By April 2017 all participating hospitals will be receiving benchmark reports on dose. This is a step closer to being able to share cumulative dose statewide.

The Department also initiated the Radiology Continuous Quality Improvement Committee (RCQIC) with three subcommittees. Radiation Oncology was first and is going strong, while Radiology and Women’s Imaging are in the beginning stages. These subcommittees are modality specific and promote teamwork, transparency and standardization system-wide. The purpose of the RCQIC is to review protocols, policies and process improvement.

We continue to be committed to the two important radiation safety initiatives, Image Gently (alliance for radiation safety in pediatric imaging — “child-sized” radiation) and Image Wisely

100 2016 Clinical Annual Report (radiation safety in adult medical imaging) programs. In the Department, we track accuracy in a variety of ways. When At Stamford Hospital, we are committed to: we hear about a possible error in a report or a problem with a patient, we look at where we fell short and assess in the context of • Communicating openly with parents about imaging the clinical significance of the event for the patient. This year we doses (“child-sized” imaging). created a technical variance program where challenges related to image creation, everything from scheduling, to protocols, to • Putting patients’ safety, health and welfare first by optimizing positioning, to our IT systems are tracked, reconciled and reviewed. imaging examinations to use only the radiation necessary to Trends are shown in Figure 2. produce diagnostic quality images.

Conveying the principles of the Image Gently and Image • Figure 2: Technical Variances Trending Wisely programs to the Imaging team to ensure that our facility optimizes its use of radiation when imaging patients. Technical Variances Trending • Communicating optimal patient imaging strategies to referring physicians and having Radiologists available for consultation.

• Routinely reviewing imaging protocols to ensure that the least radiation exposure or dose necessary to acquire a diagnostic quality image is used for each examination.

• Initiating a “time out” in all procedural areas. Feb Mar Apr May Jun Jul Aug Sept

• Providing on-site education for our staff. In 2016, we provided History/Documentation Image Quality Protocol CT/MR education along with MRI Safety & Musculoskeletal MRI for staff growth.

On the image interpretation side of the Department, we also Accuracy carefully review any time there is a question about a report, generating about half the queries internally. Every time a question Making all of the findings on an imaging study can be a daunting is raised, it is independently evaluated, graded and, as necessary task. What was one to four images per patient in the era of plain the report is amended, process changed and feedback provided to film radiology is now easily 250–400 for a CT and up to 1,000 the person raising the query. Most of the time we accomplish this for many MRI examinations. We know that the average radiologist within 24 hours of the query. In 2016, we reviewed and reconciled misses between two and 20% of the findings on based on second 127 variances, and this is less than half the number submitted for reviews. The more images, the more information, the higher review two years ago. the chance something will be missed. Importantly, and perhaps not as well understood, is that this error rate is roughly identical In addition to variances, we randomly select 3% of the studies for colonoscopy and missed major diagnoses at autopsy for peer review. These cases are submitted to a national registry (Ulster Med J. 2012 Jan; 81(1): 3 – 9. Discrepancy and Error in where normalized data is provided. Led by Howard Liu, MD, our Radiology: Concepts, Causes and Consequences Adrian Brady, departmental Peer Review Committee reviews this data as well as Risteárd Ó Laoide, Peter McCarthy, and Ronan McDermott). internal quality related reports to the administration quarterly. Once We also know that we can impact our error rate through vigilance, a month, we also have an internal conference to review cases with education and, perhaps most importantly, communication. teaching value. The fundamental importance of communicating up front about presentation, examination and suspected diagnosis, and as Radiology pathology correlation is a cornerstone for any imaging importantly, communicating when exam findings and clinical quality system. The Breast Imaging division is constantly monitoring metrics are discrepant, cannot be overstated. their results and comparing them to national best practices. As an example, in Breast Imaging, the sensitivity is well over 95% every quarter and cancer detection rate remains at or above 5%.

2016 Clinical Annual Report 101 Department of Radiology: Annual Report 2016

This detection rate is well above the national average and achieved outpatient diagnostic imaging sites. Darien led the way with over without having patients return for additional views most of the 27% of patients completing an evaluation. At all three sites for 2016, time. In Breast Imaging, the recall rate is consistently less than the annualized patient reported satisfaction grade was over 95%. 5%, which is well below the national average. At Stamford, cases presented to the breast tumor board as well as all organ biopsy data are reviewed for concordance. Certification There are multiple organizations involved in assessing quality

and program certification. The Stamford Radiology practices are Timeliness accredited by The Joint Commission and the imaging modalities of A report that is not available when decisions must be made has CT, MRI and Ultrasound and Breast Imaging are also accredited by the no value. We are proud to note that our reporting turnaround American College of Radiology (ACR). Nuclear Medicine is accredited time is on average 20 minutes or less for a STAT request, less than by IAC. We have been inspected by the Nuclear Regulatory 27 minutes for an urgent request and less than four hours for Commission (NRC), ACR, State of Connecticut and Mammography routine requests as shown in Figure 3. Quality Standards Act (MQSA), all with excellent results.

In Breast Imaging, Stamford Hospital was one of the first in the nation Figure 3: Diagnostic Imaging Turn-Around-Time Complete to Final to become accredited by the National Accreditation Program for 120 Breast Centers and, more recently, was one of the first to receive 110 100 accreditation for the third consecutive time. The Breast Center 90 was cited on its most recent accreditation visit for numerous best 80 practices. In addition, it once again was designated as an American 70 College of Radiology Breast Imaging Center of Excellence. 60 TIME 50 40 30 20 Honors and Recognition 10 0 Jul Oct Jan Jun Apr Feb Dec Sep Nov

Mar Awards: Breast Imaging Aug May

ED: 30 Mins. Outpatient: 24 Hrs. • Dr. David Gruen, Director of Women’s Imaging, became the

Inpatient: 4 Hrs. Stroke CT head W/O: 20 Mins. first diagnostic radiologist in the country to serve as an inspector

for the National Accreditation Program for Breast Centers.

• The Breast Imaging group is first in the world to be NAPBC Patient Satisfaction accredited with a third accreditation where we were cited for The Breast Imaging division enjoys high satisfaction rates every five best practices. month. This is driven by a nationally recognized best practice wherein • The Breast Center again received the Women’s Choice Award as patients receive their breast imaging and results at the same visit. an America’s Best Breast Center. In 2015, overall, our patients rated their satisfaction on a 100-point scale between 90% and 97% (Press Ganey and customer feedback • The Breast Center became a participant in the National Quality survey results). Another way that Breast Imaging is reimagining Metrics Program for Breast Centers, one of only a few in the state. imaging is the team’s approach to patients needing breast interventions such as a biopsy. Every patient who needs a biopsy • We also achieved ACR reaccreditation for MRI, CT, US meets with our Breast Center navigator and is offered their biopsy and Mammography. at the soonest convenience, often the same day.

In 2016, we made a decision to increase the utilization of point-of- service evaluation tools at our Tully, Darien, and Chelsea Piers CT

102 2016 Clinical Annual Report Departmental Education Research and Scholarly Activity and Teaching Activities • Gruen, DR. Benign Intra parenchymal Scarring in the DBT • Harvey Hecht, MD, an Associate Clinical Professor in the Era (White Paper). Department of Radiology at NewYork-Presbyterian Hospital • Pass, A. Gruen, D. Breast Biopsy Can Be Avoided for Masses and a 46-year Stamford Hospital physician, continues to lecture without Suspicious Features in Women 25 and Younger. and teach medical students and Radiology residents at Abstract presented NCBC, 2016. monthly conferences. • Pass, A. Bishop J., Gruen D. Benefits of a Personalized Breast Cancer • Dr. Gregory Pearson, our new Chief of Cardiac and Thoracic Risk Assessment in a Community Mammography Screening Imaging, presented Stamford Hospital Medical Program. Abstract and Poster Presented, NCBC, 2016. Grand Rounds on Management of Lung Nodules; lectured on Emphesematous Endocarditis at the Society of Thoracic • Stainken, B. Trauma. Handbook of Interventional Radiology Radiology Meeting; and spoke at the New York Roentgen Procedures. April 2016. Wolters Kluwer. Ray Society on Transcatheter Aortic Valve Replacement.

• Dr. Brian Stainken spoke at the following meetings: - Y-90 “The Complete Course” San Francisco, January Community Outreach - Indian Society for Interventional Radiology, Bangalore, February Participated in the Paint the Town Pink Fashion Show; Stamford - Society of Interventional Radiology, Vancouver, March Health, Health Sports and Wellness Expo at Chelsea Piers CT; - Asia Pacific Society of Interventional Radiology, American Cancer Society Making Strides Cancer Walk; and The Susan Suzhou China, April G. Komen Breast Cancer Walk. - Society of Radiologia Interventionista, Sao Paulo, Brazil, July The physicians and staff at the Bennett Cancer Center work • A breast care symposium was organized by the nurses in the collaboratively with the City of Stamford Department of Health, Breast Imaging division, and featured Dr. David Gruen, Dr. Helen American Cancer Society and other physicians on the medical staff to Pass, director of breast surgery, Michele Speer, RN, breast center provide community outreach throughout the year. nurse navigator, and Mary Navins, BSN, RN, OCN, who oversees Dr. David Gruen and Dr. Helen Pass wrote blogs for Stamford Health’s survivorship. More than 100 members of the medical community social media program to promote breast health in the community. participated in the four-hour, CME– and CEU-accredited program.

• Dr. David Gruen was the featured speaker at the annual New England Radiation Division of the Department of Energy and the Strategy/Future Direction Environment annual conference in Norwich, Conn. He presented a lecture entitled, “Breast Health 2016: Prevention, Detection, It has been a busy first year at Stamford. We have achieved many Treatment and Controversies.” of our initial goals and established a strong platform for the future. We will continue to reimagine imaging, delivering the best in high • Drs. Frank Masino and Sean Dowling organize and chair more tech for the benefit of those practicing in the Stamford Health than 150 oncology-related conferences annually. system and, most importantly, those who benefit from our care.

• Diagnostic Radiologists and Interventional Radiologists participate and present imaging studies at the following weekly multispecialty tumor boards: Breast, Gastrointestinal, Lung, Neuro-Oncology, Gynecology, Hematology and Genito-Urinary.

• The Diagnostic Radiologists presented with Surgical house staff at the weekly Trauma Conference.

2016 Clinical Annual Report 103 Expertise. Elevated.

Surgery

We now have the premier operating services in Fairfield and Westchester County. We have tripled the size of many of our operating rooms and these include: the latest technology and integrated systems; state-of-the-art lighting; operating tables that keep the patient warm; the most advanced systems for video and laparoscopic surgery; and the newest version of the daVinci robot.

1042016 Clinical Annual Report Department of Surgery: Annual Report 2016

Kevin M. Dwyer, MD, FACS, FACC Interim Chair, Department of Surgery

A Message From The Chair The Year in Review

On September 23, 2016, we moved all the surgical inpatients from dedication of our Operating Services staff. Throughout the summer the “old” surgical floor to the “penthouse” 10th floor of the new they moved the equipment and materials to the new hospital. hospital. It was an exciting day for many; patients, transporters, They had countless education sessions to learn the new technology volunteers, housekeeping, maintenance, engineering, lab and and orient the surgeons and other staff to the new operating radiology technicians, physician assistants, resident and attending rooms. The dedication of the operating room technicians, materials physicians, and all the dedicated nurses and Hospital leadership. management, and operating room nurses under the leadership This gorgeous state-of-the-art facility that we have seen rising like of Faith Dorio, Alyson Essenmacher and Sandy Swiatek, was truly a beacon for the past four years was now ready for our surgical inspiring. Together with the effort of our Anesthesia colleagues, patients. The first reviews were that the patients loved their spacious under the leadership of Dr. Betty Ann Robustelli, we performed new rooms with the spectacular view of Long Island Sound or the our first surgical cases on September 26 in the same safe and caring Connecticut countryside. But what they appreciated most was the manner as always. By the next day, we were up to a full caseload care and attention they received from all those mentioned who were and the Operating Services team has been busy ever since. dedicated to moving the patients safely and joyfully. The move of the surgical floor was completed without a problem due to the countless Over the past the past several years, the Division of Orthopedic dedicated hours of preparation by the Hospital staff, the Hospital Surgery has consistently worked toward enhanced quality care, “family,” that is core of greatness for our Hospital, both old and now notably through achieving Joint Commission – Disease Specific new. The rest of the Hospital patients moved over the weekend and, Certification for Hip Replacement, Knee Replacement and Spine at 7:00 a.m. on September 26, the new Stamford Hospital opened Fusion. This year, Stamford Hospital has entered into a collaborative its Emergency Room and operating rooms for business. relationship with Hospital for Special Surgery (HSS) to further advance our orthopedic services. It is expected that volume will increase, In the new Stamford Hospital, we now have the premier operating resulting in the need for expansion of our operating room services services in Fairfield and Westchester County. We have tripled the for orthopedic surgery at both the Tully Outpatient Surgery Center size of many of our operating rooms and these include: the latest in early calendar year 2017, and at the new Stamford Hospital in fall technology and integrated systems; state-of-the-art lighting; 2017. With this increase of our orthopedic service and volume, the operating tables that keep the patient warm; the most advanced Hospital Board of Directors has determined that orthopedic surgery systems for video and laparoscopic surgery; and the newest version will no longer be a division of the Department of Surgery, but will of the daVinci robot. We have specialized rooms for Cardiovascular become a separate Department of Orthopedic Surgery. We look Surgery, Neurosurgery, Orthopedic Surgery and a hybrid room with forward to the partnership we will have with the new department to the latest technology for Vascular and Endovascular Surgery. provide the latest in surgical care at Stamford Hospital.

Despite the latest in technologic advances to meet the needs of our This year we have added new surgeons to our team in General surgical patients at Stamford Hospital, what makes us special is the Surgery, Surgical Oncology, Breast Surgery, Vascular Surgery,

2016 Clinical Annual Report 105 Department of Surgery: Annual Report 2016

Plastic Surgery, Hand Surgery, Colorectal Surgery, Orthopedics and Scope of Clinical Services Neurosurgery. Our specialists come from the top programs of the country and we have matched the best and most advanced hospital in the state with the expertise of our gifted surgical specialists. Medical Staff The leadership of the Department of Surgery is also in transition. The following is an overview of the Department’s divisions and This annual report is my final report as the Interim Chair of Surgery. active staff: It has been a very busy year and I am grateful to all the countless professionals that have helped me and the Department through this transition. I am particularly grateful for the support of Dr. Michael Ebright, who stepped into an Associate Vice Chair General Surgery role and helped with his medical staff oversight to the Perioperative Services, along with Executive Director Faith Dorio and Chair Division Leadership of Anesthesia Dr. Betty Ann Robustelli. We have a great team.

We look forward to working with our new Chair, Dr. David Yuh,

the former Chief of Cardiothoracic Surgery at Yale, who started

here on November 1. We welcome him with great enthusiasm

and look to his leadership and fresh ideas to continue our

exponential growth as a top Department grounded in safety, Kevin M. Dwyer, MD, FACS, FACC

quality and expertise.

Figure 1. Department of Surgery - 2016 by the Numbers: Active Staff: Divisions/Sections: 19 James Bonheur, MD Staff (active, courtesy, honorary and provisional): 168 • • Marissa De Freese, MD Surgical Residents: 17 • Kevin Dwyer, MD Physician Assistants & Nurse Practitioners: 19 • Csaba Gajdos, MD

Kevin Miller, MD OR Procedures: • • Harold Neyra, DO (No longer here as of October 31, 2016) Total cases: 18,720 6.6% increase +5.2% vs. target • Joey Papa, MD Tully: 6,109 6.1% increase +3.8% vs. target • William Symons, MD Main OR: 5,488 9.4% increase +12.0% vs. target

Endoscopy: 7,123 4.9% increase +0.5% vs. target The Division of General Surgery continues to expand its expertise in surgical care with emphasis on high-quality minimally invasive surgery. We have excellent outcomes and high patient satisfaction. Members of the Division are highly skilled in minimally invasive approaches to hernia repair, endocrine surgery and bariatric surgery. Our newest member is Dr. Will Symons who comes to us from Washington University. Dr. Symons practices the full gambit of general surgery, particularly laparoscopic surgery, and has special interest in complex hernia repair. He is also fellowship trained in trauma and surgical critical care. We welcome him to our experienced and dedicated General Surgery medical staff.

106 2016 Clinical Annual Report Bariatric Surgery As the Division continues to grow we continued to identify and recruit surgeons with expertise in minimally invasive/laparoscopic bariatric surgery. In November, Dr. Neyra relocated to Orlando to Section Leadership be closer to family. With this in mind, we are currently interviewing qualified surgeons interested in joining our team

Bariatric Surgery James Bonheur, MD

Medical Director

Division Leadership

Active Staff:

• James Bonheur, MD Helen A. Pass, MD Director of Breast Surgery • Harold Neyra, DO (No longer here as of October 31, 2016) Co-Director, Stamford Health Breast Center

The Stamford Health Center for Surgical Weight loss (CSWL) offers a comprehensive program to meet the surgical, medical and emotional needs of patients regarding weight loss. Our surgeons have extensive training in minimally invasive/laparoscopic bariatric Active Staff: surgery and offer the most advance surgical procedures available. • Valerie Brutus, MD Procedures include the gastric bypass, sleeve gastrectomy, lap band, gastric balloon and revisional weight loss surgery as well as • Mandy Greenburg, MD endoscopic (incisionless) surgery. Using endoscopic techniques, • Helen Pass, MD we are able to treat individuals who are regaining weight despite previous weight loss surgery without undergoing an extensive The Section of Breast Surgery saw significant change in personnel. abdominal procedure. The endoscopic procedures are painless Dr. Valerie Brutus was recruited to replace Dr. Zandra Cheng, and and recovery is almost immediate. recruitment is ongoing to find a replacement for Dr. Jennifer Bishop. Both surgeons left Stamford Hospital to relocate closer I am proud to announce that the CSWL has been designated a to their families. Fully Accredited Metabolic and Bariatric Surgery Accredited Quality Improvement Program (MBSAQIP) by the American Society for During her time at Stamford, Dr. Jennifer Bishop was appointed Metabolic and Bariatric Surgery (ASMBS) and the American College Program Chair of the Connecticut Chapter of the American College of Surgeons (ACS). The MBSAQIP Accreditation recognizes surgical of Surgeons, while continuing to serve on the Education programs with a demonstrated track record of favorable outcomes Committee of the American Society of Breast Surgeons and the and low complication rates. Product Committee of Stamford Hospital.

MBSAQIP works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers. A bariatric surgical center achieves accreditation following a rigorous review process during which it proves that it can maintain certain physical resources, human resources, and standards of practice. All accredited centers report their outcomes to the MBSAQIP database.

2016 Clinical Annual Report 107 Department of Surgery: Annual Report 2016

Dr. Pass continues to serve as: Intramural Invited Presentations:

Extramural Activities: 1. “Best Breast Papers of the Past Decade” General Surgery Grand • Governor of the American College of Surgeons (ACS) Rounds, Stamford Hospital, Stamford, CT, October 29, 2015. • Member of the Committee on Applicants of the Connecticut 2. “What’s in Your Genes?” Rockrimmon Country Club, Stamford, CT, Chapter of the ACS May 12, 2016. • Member of the Executive Committee of the Commission on Cancer 3. “Breast Care: Current and Future Directions” Annual Nursing • Chairman of the Bylaws Committee of The American Society Symposium, Stamford, CT, September 9, 2016. of Breast Surgeons • Member of the American College of Surgeons Committee on Surgical Volunteerism and Humanitarian Awards Posters • Member of the International Committee of the National 1. “Benefits of a Personalized Breast Cancer Risk Assessment Accreditation Program for Breast Centers (NAPBC) in a Community Mammography Screening Program.” Pass AR, Intramural Activities: Hammarquist S, Gruen D. Poster Presentation 26th Annual Meeting • Co-Chair: Breast Steering Committee, of the National Consortium of Breast Centers. Las Vegas, NV. Stamford Hospital April 9-13, 2016. • Co-Chair: Breast Operations Committee, 2. “Breast Biopsy Can Be Avoided for Masses Without Suspicious Stamford Hospital Features in Women 25 and Younger.” Pass AR, Bishop J, Volpicelli E, • Co-Chair: Breast Program Leadership Committee, Gruen D. Poster Presentation 26th Annual Meeting of the National Stamford Hospital Consortium of Breast Centers. Las Vegas, NV. April 9-13, 2016. • Member and Physician Representative: STAR (Survivorship, Training and Rehabilitation) Committee, Stamford Hospital 3. “Dr. Mary Walker, Changing the Face of Surgery.” Pass AR, Bishop J. • Member: Cancer Coordinating Committee, Stamford Hospital Poster Presentation The Annual Meeting of the American College • Member: Chairman of Surgery Search Committee of Surgeons. Washington, DC. October 16-20, 2016.

4. “The History of Clinical Trials.” Pass AR, Bishop J. Poster Presentation Presentations The Annual Meeting of the American College of Surgeons. Washington, DC. October 16-20, 2016. Members of the Section presented at numerous national, regional, and community lectures on breast health and care over the course of the year. Papers

Extramural Invited Presentations: 1. Chafe S, Moughan J, McCormick B, Wong J, Pass HA, 1. “What You Need to Know about Breast Health” Invited Lunch Rabinovitch R, Arthur DW, Petersen I, White J, Vicini FA. Long-term and Learn First County Bank, Stamford, CT, October 23, 2015. Update of NRG Oncology/RTOG 0319: A Phase I/II Trial to Evaluate Three-Dimensional Conformal Radiation Therapy (3D-CRT) 2. “Neoadjuvant Treatment of HER-2 Positive Breast Cancer” invited Confined to the Region of the Lumpectomy Cavity for lecture Society of Surgical Oncology Conference, Boston, MA, March 3, 2016. Stage I and II Breast Carcinoma. Submitted Int J Radiat Oncol. 3. “What’s in Your Genes? How Family History Affects Your Risk of 2. Pass AR, Bishop J. Dr. Mary Walker: Trailblazing Feminist, Breast Cancer” invited lecture JCC, Stamford, CT, March 28, 2016. Surgeon, and War Veteran. Submitted Surgical History Journal. 4. “The ‘Best” Breast Papers of 2015” invited lecture for the American Society of Breast Surgeons 17th Annual Conference, Dallas, TX, April 15, 2016. 5. “The Best Papers, Benign and Malignant of 2015” invited lecture Winthrop’s 1st Annual Breast Health Symposium, Mineola, NY, September 30, 2016.

108 2016 Clinical Annual Report Blog Posts Honors and Awards

The Section also increased its social media presence with blog posts Dr. Pass was named to: throughout the year. Top Doctors: New York Metro Area: 2015 and 2016 1. “Don’t Survive….Thrive” Top Doctor of Fairfield County: 2015 and 2016 https://stamfordhospital.org/Blogs/DontSurviveThrive.aspx America’s Top Surgeons: 2016 October 2015 Best Doctors in America: 2015 and 2016 2. “Addressing the Confusion about Mammograms” https://stamfordhospital.org/Blogs/Addressing-Confusion- about-Mammograms.aspx October 2015 Cardiovascular Surgery

3. “Thanksgiving Day is National Family History Day” https://www.stamfordhospital.org/Blogs/Thanksgiving-Day-is- Division Leadership National-Family-History-Day.aspx

November 2015

4. “Top 5 Tips for a Healthier New Year” Michael A. Coady, MD, MPH, MBA https://stamfordhospital.org/Blogs/Dr-Katie’s-Top-5-Tips-for- Chief of Cardiac Surgery a-Healthier-New-Year.aspx Co-Director, Stamford Health December 2015 Heart & Vascular Institute

5. “Heart Health Affects Breast Cancer Risk” https://stamfordhospital.org/Blogs/Heart-Health-Affects-Breast- Cancer-Risk.aspx Active Staff: February 2016 • Michael A. Coady, MD, MPH, MBA 6. “Detection is Protection: Mammograms Save Lives” • William C. Feng, MD, ScD https://stamfordhospital.org/Blogs/Detection-is-Protection.aspx March 2016 • David D. Yuh, MD

7. “Sleep and Breast Cancer: What’s the Link?” Stamford Hospital offers patients the full spectrum of surgical https://www.stamfordhealth.org/healthflash-blog/cancer/sleep- procedures within the field of Cardiac Surgery, ranging from elective and-breast-cancer/ through immediate and life-saving. Clinical growth within the April 2016 Division of Cardiac Surgery rose by 37% for FY16, with 117 open heart surgeries, and 20 TAVR procedures. This clinical growth 8. “Breast Cancer in Men: Risk Factors and More” spanned all procedures within Cardiac Surgery, including CABG, https://www.stamfordhealth.org/healthflash-blog/ aortic and mitral valves, and thoracic aortic aneurysms. The surgical cancer/mens-breast/ team has continued to achieve outstanding clinical outcomes, June 2016 with a zero percent 30-day mortality rate for FY16. 9. “In Breast Cancer Care, as In All Things, Choose Wisely” In addition to conventional Cardiac Surgical procedures, the Division https://www.stamfordhealth.org/healthflash-blog/cancer/ also provides the Convergent Ablation Procedure for patients with choose-wisely/ long-standing atrial fibrillation, and actively participates with the July 2016 Division of Cardiology to support our growing TAVR program for 10. “New Guidelines for Patients with DCIS” patients with severe aortic stenosis at high or intermediate risk. https://www.stamfordhealth.org/healthflash-blog/cancer/ Unlike other institutions offering similar programs, the Stamford margin-guidelines/ Hospital surgical team is very focused on making each individual August 2016 patient experience extraordinary. We have a full-time, dedicated

2016 Clinical Annual Report 109 Department of Surgery: Annual Report 2016

patient navigator who coordinates care and guides patients anal manometry program to provide better care for patients through the process from pre-surgery through surgery and with pelvic floor problems. A member of the Hospital’s Robotic beyond. This Planetree approach to patient-centered care makes Committee, Dr. Shahzad Zafar’s has advanced the use of the Stamford Hospital a very special place to practice medicine. robot for colonic surgery at Stamford Hospital.

Dr. Coady is a reviewer for the Annals of Thoracic Surgery, Journal The Division implemented the use of one of the first 3-D of Thoracic and Cardiovascular Surgery, Circulation and Aorta. laparoscopes in the state to enhance visualization in patients having minimally invasive colon and rectal surgery. Dr. Feng published a new manuscript in the Annals of Thoracic Surgery. Feng W, Coady M. “Epicardial Tachosil patch repair of ventricular rupture in a 90-year-old following mitral valve Presentations: replacement.” Ann Thoracic Surg 2016;101:2361-3. Littlejohn, Charles. Presidential Address at the American Society Dr. Yuh joined Stamford Hospital on November 1 as the new of Colon and Rectal Surgeons, May 2, 2016; Los Angeles, CA. Chief of Surgery, and an active cardiac surgeon who specializes in minimally invasive cardiac surgery, particularly with respect to Bakes D, Calhoun J, Novack M, Frenk V, Littlejohn C. Effectiveness mitral valve disease and hybrid procedures for atrial fibrillation. of Adding Transverse Abdominus Plane (TAP) Catheters to Patient- As a nationally respected leader in cardiac surgery, Dr. Yuh serves Controlled Analgesia (PCA) in Laparoscopic Colon Resections: a as a frequent reviewer for the Annals of Thoracic Surgery, Journal retrospective chart review. Poster presentation. American Society of Thoracic and Cardiovascular Surgery and Circulation. of Colon and Rectal Surgeons, May 1, 2016, Los Angeles. CA.

Colon and Rectal Surgery Hand Surgery

Section Leadership Section Leadership

Charles E. Littlejohn, MD John D. Dowdle, MD

Director of Colon and Rectal Surgery Director of Hand Surgery

Active Staff: Active Staff:

• Ryan Bendl, DO • James McClane, MD • Jeffrey Brooks, MD • Haik Kavookjian, MD • Marilee Freitas, MD • Shahzad Zafar, MD • John D. Dowdle, MD • Richard Magill, MD • Charles E. Littlejohn, MD • Harold Gewirtz, MD • Emily Slate, MD

Dr. Charles Littlejohn is immediate Past President of the American The Hand Surgery section has grown with the addition of Dr. Richard Society of Colorectal Surgeons (ASCRS). This is the highest and Magill and Dr. Emily Slate. All hand abnormalities as well as hand and most prestigious position in the world’s premier society of wrist injuries are managed at Stamford Hospital. surgeons dedicated to the practice of colorectal surgery. Only the top colorectal surgeons in the country can achieve this. Dr. Marilee Freitas has led the Division’s efforts in starting up an

110 2016 Clinical Annual Report Neurosurgery Opthamology

Section Leadership Division Leadership

Andrea Douglas, MD Glenn E. Ostriker, MD Chief of Neurosurgery Director of Ophthalmology

Active Staff: Active Staff: • Paul Apostolides, MD • Avinash Mohan, MD • Robert J. Fucigna, MD • Lauren Schneider, MD • Mark Camel, MD • Marc Otten, MD • Gregory Gallousis, MD • Elizabeth Siderides, MD • Alain De Lotbiniere, MD • C. Cory Rosenstein, MD • Joan Gewirtz, MD • Esteban C. Vietorisz, MD • Andrea Douglas, MD • Scott Simon, MD • Peter Libre, MD • Eric L. Wasserman, MD • Amory Fiore, MD • Jacqueline J. Littzi, MD • Richard B. Weber, MD • Glenn E. Ostriker, MD • Andrew B. Wolf, MD The Division of Neurosurgery continues to grow the depth and breadth of neurosurgical services offered to our community. • Philip A. Piro, MD • James Wong, MD With the adoption of new intraoperative stereotactic guidance The Division of Ophthalmology is one of the largest subspecialty technologies, spinal neurosurgery remains the greater volume divisions in the Department of Surgery at Stamford Hospital. of neurosurgical cases performed in the Division. Continued While the majority of procedures are performed at the Wilton collaboration with our Oncology and Endocrine colleagues Surgery Center, which is affiliated with Stamford Hospital, we will provide sustained focus on strategies aimed at increasing continue to provide laser and other surgical procedures at the Tully the volume of cranial neurosurgical cases that can remain in Health Center and retinal surgery procedures at Stamford Hospital. the community for comprehensive care at our new hospital. Our deep and very well-trained Division includes subspecialists Two new neurosurgeons, Dr. Alain De Lotbiniere and in the fields of cornea, glaucoma, pediatric ophthalmology and Dr. Avinash Mohan, joined the Neurosurgical staff a year ago. retina. Members of our staff have been recognized many times on Dr. De Lotbiniere has been practicing in Fairfield and Westchester Best Doctors lists and include medical school faculty members at counties for the last 10 years, after spending 17 years specializing Columbia, Mount Sinai and New York University Medical Center. in Functional and Stereotactic Neurosurgery at Yale University. Drs. Robert Fucigna, Gregory Gallousis, Peter Libre, Jacqueline His practice focuses on stereotactic radiosurgery of cranial and Littzi, Glenn Ostriker, Lauren Schneider, Esteban Vietorisz and spinal pathologies, pituitary surgery and functional treatment Andrew Wolf provide emergency services for Stamford Hospital’s of facial pain and other chronic pain syndromes. Dr. Mohan is Emergency Room and inpatients, along with the Immediate Care a Pediatric Neurosurgeon who has been practicing in Fairfield Center at Tully. and Westchester counties for the last seven years. He treats both children and adults with neurosurgical abnormalities.

2016 Clinical Annual Report 111 Department of Surgery: Annual Report 2016

Oral and Maxillofacial Surgery • Benjamin D. Roye, MD • Corinne VanBeek, MD • William T. Schmidt, MD • Avi Weiner, MD Division Leadership • Krishn M. Sharma, MD • Daniel Zelazny, MD • Marc D. Silver, MD • Craig D. Tifford, MD • Allen I. Troy, MD

Robert M. Yudell, DDS, MD In 2016, the Division of Orthopedic Surgery continued to hold Director of Oral and steady in terms of medical staff. Overall orthopedic surgery volume Maxillofacial Surgery declined 11% from the prior year. Inpatient surgical volume held steady with the decline being seen in outpatient sports medicine surgeries. This is attributable to the outmigration of orthopedic surgery volume to one of several new area ambulatory surgery Active Staff: centers that have opened this year in Stamford. Figure 2 shows the • Donald Case, DMD total volume of orthopedic surgery patients by patient type.

• Christine Hamilton-Hall, MD, DMD Figure 2: Yearly Volume by Location • Robert M. Yudell, MD Total Volume by Patient Type

Inpatient or Outpatient FY2016 FY2015 FY2014

Orthopedic Surgery I 823 827 758

O 1,845 2,143 2,025 Division Leadership Grand Total 2,668 2,970 2,783

The Orthopedic & Spine Institute (OSI) at the Chelsea Piers CT (CPCT) campus has enjoyed continued growth in the number of physicians Rudolph F. Taddonio, MD seeing patients at that location. As a result, imaging at that location Director of Orthopedic Surgery has also increased. The space is home to Orthopedic Surgery, Neurosurgery, Integrative Care, Pain Management, Podiatry and the Concussion Center.

The Rehabilitation Department is an important ancillary service for

orthopedics and the new Sports Rehab location at CPCT opened Active Staff: in January. The program has been successful in exceeding budget • David Asprinio, MD • Alex Gitelman, MD within the first few months of operation. The services offered at this • Theodore A. Blaine, MD • Andrew Grose, MD location are targeted to musculoskeletal patients. • Adam R. Brodsky, MD • Andrew L. Haas, MD The Orthopedic Service line continues to function with an • Jeffrey J. Brooks, MD • Margaret Harvey, DO infrastructure that includes three subcommittees that are essential to Russell J. Cavallo, MD Peter W. Hughes, MD • • monitoring performance of programs from an operational, financial • Robert Cristofaro, MD • Richard Magill, MD and clinical standpoint. The subcommittees include Joint and Spine, • Joseph M. D’Amico, MD • John Nelson, MD Hip Fracture and Sports Medicine. Each committee works in a • Frank A. DiFazio, MD • Adam Lazzarini, MD collaborative and interdisciplinary fashion to advance that program.

• John D. Dowdle, MD • Haik G. Kavookjian, MD The Hip and Knee Replacement Programs achieved initial • Edward Feliciano, MD • Kevin D. Plancher, MD certification from The Joint Commission in 2009 and was recertified • Filip Findling, MD • Charles Popkin, MD in 2015. The Spine Fusion Program achieved initial Certification

112 2016 Clinical Annual Report in 2010 and was also recertified in 2015. Performance measures grow surgical volume for the organization. The Division of are monitored and discussed monthly at the Joint and Spine Orthopedic Surgery will be re-established as the Department Subcommittee meetings. The data is reported to The Joint of Orthopedic Surgery. Commission monthly, with periodic updates given to the surgeons at Division meetings. The measures currently monitored for the programs are as follows: Hip and Knee Replacement: Otolaryngology and Head DVT Assessment Neurovascular Check and Neck Surgery Care Partner Discharge to Home Division Leadership

Spine Fusion:

Care Partner Incentive Spirometer Early Mobilization Pain Control

Members of the Division continue to bring advanced technologies Bruce H. Klenoff, MD to the organization and the community including advanced 3-D Director of Otolaryngology navigation technology continues to be utilized in spinal surgery, especially in complex scoliosis and spinal deformity correction.

The spine surgeons in the Orthopedic and Neurosurgery specialties continue to work collaboratively through combined spine peer Active Staff: review as well as partnering at times in the OR. • Steven A. Bramwit, MD • Jason R. Klenoff, MD Orthopedic residents from Westchester Medical Center-New • Jacquelyn M. Brewer, MD • Biana G. Lanson, MD York Medical College continue to rotate through the orthopedic • Bruce H. Klenoff, MD program at Stamford Hospital. The rotation consists of four residents (PGY 2, 3 and 4) rotating on a four-month block. The Division of Otolaryngology and Head and Neck Surgery has This includes an academic schedule for education through case continued to increase the number of minimally invasive approaches reviews, peer review presentations as well as Journal Club. to surgery and now have 99% or our surgeries as outpatient surgery. Overall case volume has increased by 5% this year. The Division’s The surgeons in the Division participated in various activities on volume at Tully has increased by 1.5% while Hospital volumes have the educational calendar this year including general community increased by over 24%. We have continued to grow our balloon talks as well as CME lunch-and-learns provided to primary care sinuplasty program and most of our sinus surgery is now done physicians. with image guidance for increased safety. We collaborate with Looking ahead to 2017, growth is anticipated in various programs. our Neurosurgery and our Thoracic Surgery colleagues for complex We expect to add physicians to the CPCT Orthopedic & Spine oncologic procedures including minimally invasive skull base surgery. Institute offices. The Concussion Center recruited an additional We have optimized our sinus surgery anesthesia protocols and neuropsychologist to increase its capacity to see patients. have worked with the Pediatric team to improve the pediatric Also in partnership with the Outpatient Rehab department, perioperative experience. Members of the Division have also been specialty rehabilitation will be opening at the OSI offices to actively involved in the treatment of balance, hearing, taste and support Concussion Center patients with vestibular, ocular smell disorders, and have been an integral part of the new Stamford and physical therapy. Hospital Balance Center. The most widely anticipated opportunity to grow orthopedics Members of the Division teach residents and medical students, is expected to come by way of a new collaborative agreement provide lectures at the Hospital and to community groups, and are developed with Hospital for Special Surgery. This management on the faculty of both Columbia and Yale medical schools. services agreement will strengthen the existing program and

2016 Clinical Annual Report 113 Department of Surgery: Annual Report 2016

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

Plastic and Reconstructive Surgery Jeremy A. Bier, DPM Division Leadership Director of Podiatry

Active Staff: Harold S. Gewirtz, MD Director of Plastic and • Jeremy A. Bier, DPM • Mary Reilly, DPM Reconstructive Surgery • Rui De Melo, DPM • David Rosenzweig, DPM • Marissa Girolamo, DPM • Steven Shindler, DPM • Ellen Golden, DPM • Peter Siroka, DPM

• Matthew Juriga, DPM • Josephine Velasquez, DPM Active Staff: • Chris Kassaris, DPM • Robert Weiss, DPM • Harold S. Gewirtz, MD • David Passaretti, MD • Francisco Lago, DPM • Scott Weiss, DPM • Chang Soo Kim, MD • Arthur R. Rosenstock, MD • Kelly Powers, DPM, MS • Gregory Latrenta, MD • Alfred Sofer, MD • Rafael Magana, MD • Mrudangi Thakur, MD Dr. Kelly Powers joined Associated Podiatrists in Fairfield and • Sandra L. Margoles, MD • Julie V. Vasile, MD Greenwich. She was a resident in Podiatry at Boston University and • Leif O. Nordberg, MD completed a fellowship in Plastic Reconstruction at Georgetown University Medical Center. The Division of Plastic Surgery continues to provide excellent and current plastic surgical expertise to the Hospital. Members Drs. Robert and Scott Weiss have added a third associate, Dr. Matthew provide a variety of reconstructive procedures including tissue Juriga. Dr. Juriga was trained at the Beth Israel Deaconess Medical flaps and closure of complex wounds, as well as an array of Center where the Podiatry Department works closely with vascular cosmetic procedures. The Division is dedicated to complete and medical physicians from the Joslin Diabetes Center to produce coverage of the Emergency Department and other urgent consults some of the highest rates of limb salvage in the country. at all times. Drs. Bier, Weiss and Juriga provide Podiatric Surgery Emergency Department call services at Stamford Hospital to ensure high-quality care to our patients with podiatric emergencies.

114 2016 Clinical Annual Report Surgical Oncology Over the past year, two of Dr. Michael Ebright’s partners from the Columbia group have been added to the active medical Section Leadership staff — Dr. Joshua Sonett and Dr. Mark Ginsburg. The program is augmented by our dedicated nurse practitioner, Lauren Drysdale, and thoracic nurse navigator, Melissa Ronk.

The Lung Cancer Screening Program continues to progress Csaba Gajdos and is one of the largest and most successful in the area. Section Chief, Surgical Oncology It has been designated as a Center of Excellence by both the American College of Radiology and the Lung Cancer Alliance. This is a truly evidence-based program which has been studied as a model for other regional programs to emulate. Highlights include standardized reporting, a HIPAA-compliant computerized Dr. Gajdos has just joined the medical staff at Stamford Hospital database and the ability to provide real-time results to patients after enjoying an extensive and successful practice in surgical and their physicians. It is coupled with our one-to-one smoking oncology at the University of Colorado in Denver. Dr. Gajdos cessation program, Commit to Quit. This year we have recruited specializes particularly in hepato-biliary and gastrointestinal cancers a dedicated chest radiologist with a special interest in lung as well as cancer of the esophagus. He also has vast experience screening and cardiac imaging, bolstering several Hospital with melanoma and soft tissue sarcomas. We welcome Dr. Gajdos programs. Since 2014, we have detected 14 patients with lung to Stamford Hospital, and look forward to his leadership in cancer, all treated with curative intent (Stage IA-IIIB). re-establishing a first-rate surgical oncology program. The heart of our program is the multidisciplinary thoracic tumor board conference, which is consistently well attended. Our thoracic nurse navigator ensures efficient evaluation of every Thoracic Surgery patient with seamless care. Evidence-based protocols are followed and available clinical trials are reviewed. We utilize Division Leadership surgical and endoscopic diagnostic and staging techniques such as navigational bronchoscopy, endobronchial ultrasound (EBUS), esophageal ultrasound (EUS) and mediastinoscopy.

Stamford Hospital is on the forefront of minimally-invasive Michael Ebright, MD pulmonary surgery, using all available techniques including Section Chief, Thoracic Surgery video-assisted resection (VATS), robotic surgery and traditional open surgery to perform lobectomy, segmentectomy and non-anatomic resections. Roughly 90% of our operations are performed in a minimally-invasive format. All outcomes are entered into the Society of Thoracic Surgeons (STS) General Active Staff: Thoracic Surgery Database, a voluntary prospective databank • Michael Ebright, MD • Mark E. Ginsburg, MD utilized mainly by academic medical centers, allowing us to measure our surgical results against national standards. We • William C. Feng, MD • Joshua R. Sonett, MD are currently below STS average for length of stay, major The Thoracic Surgery Division continues to grow in volume and complications and mortality rates for pulmonary lobectomy. breadth. It is truly a multidisciplinary enterprise, intersecting with Case volume has quadrupled over the past four years. colleagues from Pulmonology, Gastroenterology, Radiology, Medical Our center recently began to accrue patients to a landmark Oncology, Radiation Oncology and Pathology. Although the majority national randomized controlled trial comparing lobar and of our cases are oncologic in nature, a growing number deals with sublobar resection for early stage lung cancer. benign disease as well.

2016 Clinical Annual Report 115 Department of Surgery: Annual Report 2016

New initiatives include increasing awareness of surgical options Muñoz-Largacha JA, Ebright MI, Litle VR, Fernando HC. for the treatment of gastroesophageal reflux disease including Electromagnetic navigational bronchoscopy with dye marking for laparoscopic fundoplication and the novel LINX procedure. identification of small peripheral lung nodules during minimally invasive Stamford Hospital became the first center in Connecticut to treat surgical resection. Submitted. an esophageal cancer patient with photodynamic therapy, an endoscopic treatment using a photosensitizing agent to fulgurate Narsule CK, Nair D, Gupta A, Oommen RG, Ebright MI, Litle VR, malignant tissue. Fernando HC. Percutaneous thermal ablation for Stage IA non-small cell lung cancer: long-term follow-up. Submitted. Dr. Ebright is an ad hoc reviewer for the Journal of Thoracic and Cardiovascular Surgery, Annals of Thoracic Surgery, Annals of Surgical Hewes PD, Jachey KJ, Zhang X, Tripodis Y, Rosenkranz P, Ebright MI, Oncology, Journal of Surgical Oncology, Journal of Thoracic Oncology McAneny D, Fernando HC, Litle VR. Evaluation of the Caprini model for and Diseases of the Esophagus. He is editor of the International venothromboembolism in esophagectomy patients. Annals of Thoracic Thymic Malignancy Interest Group Newsletter. Surgery. 2015; 100(6): 2072-8.

Several local seminars to primary care physicians and specialists were delivered over the course of the year on a variety of topics. Trauma Surgery and Critical Care Dr. Ebright gave following lectures and presentations: Division Leadership Muñoz-Largacha JA, Ebright MI, Litle VR, Fernando HC. Electromagnetic navigational bronchoscopy with dye marking for identification of small peripheral lung nodules during minimally invasive surgical resection. Presented by Dr. Ebright at the International Society for Minimally Invasive Cardiothoracic Kevin M. Dwyer, MD Surgery 2016 Annual Meeting, Montreal, Canada, June 2016. Director of Trauma and Critical Care

Ebright MI. Moderator, Live Thoracic Surgery Session, Poster Presentation, and Video Session, International Society for Minimally Invasive Cardiothoracic Surgery 2016 Annual Meeting, Montreal, Canada, June 2016. Active Staff:

Addagatla K, Ebright MI. Solitary fibrous tumor masquerading as • Marissa De Freese, MD • Joey Papa, MD pulmonary sequestration. Presented at the Connecticut Chapter • Kevin M. Dwyer, MD • William Symons, MD of the American College of Surgeons, Farmington, Connecticut, • Kevin Miller, MD November 2015. Stamford Hospital is a Level II Trauma Center designated by the Ebright MI. Keynote, Shine a Light on Lung Cancer, Lung Cancer Office of Emergency Medicine of the State of Connecticut and Alliance, Stamford, Connecticut, November 2015. verified by the American College of Surgeons (ACS) to care for acutely injured trauma patients. The Trauma Center has three The following manuscripts were published or in process: fellowship-trained Trauma and Critical Care surgeons and is the Ebright MI, Sridhar P, Litle VR, Narsule CK, Daly BDT, Fernando HC. regional leader for outreach, injury prevention, education and Endoscopic fundoplication: effectiveness for controlling symptoms of research. The American College of Surgeons visited in November gastroesophageal reflux disease. Submitted. 2015 and re-verified the Hospital for three additional years.

Addagatla K, Mamtani R, Babkowski R, Ebright MI. Solitary Fibrous In FY16, Stamford Hospital’s Emergency Department saw 917 Tumor of the Pleura with Abdominal Aortic Blood Supply. Annals of trauma activations and an additional 222 patients who required Thoracic Surgery. In press. admission for isolated fractures and hip fractures for a total of 1,139 patients seen and treated in the Emergency Department for moderate to severe traumatic injuries. Of these patients, 760 were admitted to the Hospital.

116 2016 Clinical Annual Report The Division hosted the Southwestern Connecticut Trauma Urology Symposium for trauma professional staff in November 2016. The symposium included presentations on recognizing signs of child Division Leadership abuse, pulmonary arterial hypertension, treatment of traumatic brain injuries for EMS providers, an epidemiological review of non-fatal firearm injuries and updates on pediatric trauma surgery.

The Trauma Center is engaged in public and professional education, Richard P. Santarosa, MD and offers a dedicated referral and access line to Trauma Center Director of Urology resources. Prevention activities center on priorities based on local injury data. For example, injury prevention activities include an Annual Trauma Fair that focuses on falls in the elderly. The Trauma Center collaborates with national, regional and state programs, including the Trauma Quality Improvement Program (TQIP). TPM Active Staff: participates in senior and family health fairs where information • Jonathan Bernie, MD • Eric J. Moskowitz, MD is provided on falls, helmet use, concussion and trauma safety in • Lori Dyer, MD • Michael J. Nurzia, MD general, as well as the Hospital’s ongoing Fall Prevention Program. • Ronnie Fine, MD • Richard P. Santarosa, MD The Hospital’s outreach programs include teaching pedestrian • Michael E. Karellas, MD • Vincent J. Tumminello, MD and bike safety at the elementary school level, the Annual Trauma • Robert H. Lovegrove, MD • Paul Zelkovic, MD Symposium, roundtable sessions provided for pre-hospital providers, an annual injury prevention fair, programs for local high school 2016 was an exciting year for the Division of Urology. Coverage students interested in healthcare careers, participation in a large for all aspects of urgent urology issues remained strong under annual mock trauma disaster drill and presentations on injury the leadership of Dr. Richard Santarosa. In April, we welcomed the prevention throughout the spectrum of pediatrics for the local addition of Dr. Michael Karellas to our medical staff. Dr. Karellas has school system’s health and physical education educators. quickly made an impact on the Division and has enhanced coverage of the Urology service with his general practice and his particular Dr. Dwyer is a member of the Eastern Association of Trauma (EAST) interest and expertise in urologic oncology. He has also been well- and the American Association of Trauma (AAST). Additionally, he is a received by the Operating Room staff and enjoys educating the staff member of the military liaison committee of the AAST. as well as the surgical residents. In August 2016, Dr. Eric Moskowitz Dr. De Freese was inducted into the American College of Surgeons joined the Division after completing his fellowship in robotic and (ACS) this past October. She is a member of EAST and on the Program minimally invasive urology at the Icahn School of Medicine at Mount Committee for the annual CT Trauma Conference presented by the Sinai. For 2017, we expect to grow our center as a premier provider CT Committee on Trauma of the ACS. for surgical and non-surgical treatment of prostate cancer.

Dr. De Freese is also a reviewer for the World Journal of Surgery.

Presentations:

Kramer, Kristina; Krinsley, James; Dwyer, Kevin: Time in Target Blood Glucose Range is Associated with Survival in Trauma ICU Patients. Region 1 Trauma paper competition, Boston, MA; November, 2015.

De Freese, Marissa. Ultrasound: The Wave of the Future. CT Trauma ’16 18th Annual Conference. Ledyard, CT; April, 2016.

2016 Clinical Annual Report 117 Department of Surgery: Annual Report 2016

Vascular Surgery demanding well-educated clientele of lower Fairfield County and will continue to strive to maintain the high standard of care for the treatment of vascular disease at Stamford Hospital. Division Leadership

Department of Surgery

Timothy Manoni, MD New Staff in 2016 Director of Vascular Surgery

Surgeons:

Joseph Ajdinovich, MD – Orthopedic Surgery

Ryan Bendl, DO – Colon and Rectal Surgery Active Staff: Jonathan Bernie, MD – Urologic Surgery Valerie Brutus, MD – Breast Surgery • Stephen M. Bauer, MD • Taras V. Kucher, MD Filip Findling, MD – Orthopedic Surgery • Jonathan N. Bowman, MD • Timothy Manoni, MD Ronnie Fine, MD – Pediatric Urology • Paul J. Gagne, MD • Ben U. Marsan, MD Mark Ginsburg, MD – Cardiothoracic Surgery • Lee Goldstein, MD • Bart Muhs, MD PhD Shareef Jandali, MD – Plastic and Reconstructive Surgery In welcoming Dr. Bart Muhs in 2015, the Vascular Surgery Division Michael Karellas, MD – Urologic Surgery developed an Aortic Center of Excellence and 2016 saw a growth Peter Libre, MD – Ophthalmology in the number of complex aortic aneurysm treated at Stamford Eric Moskowitz, MD – Urologic Surgery Hospital. In 2017, the Division plans to build on this trend with the William Symons, MD – General Surgery, Trauma & Critical Care opening of our beautiful state-of-the-art new hospital. Mrudangi Thakur, MD – Plastic and Reconstructive Surgery

In 2016, the Division continued to serve as a vital member of the Physician Assistants: Heart & Vascular Institute. The vascular surgeons continue to be assist the TAVR team with peripheral artery support for these sometimes- Genie Ball, PA-C – Cardiac Surgery challenging cases. In addition, Division members in collaboration Elizabeth Bubbico, PA-C – Surgery Subspecialties with the HVI and Columbia Presbyterian Hospital, have participated Dean Rivers, PA-C – Cardiac Surgery in the education of visiting physicians from China. Janine Tedesco, PA-C – Vascular Surgery Bridget Ward, PA-C – Surgery Subspecialties We also remain a vital member in the surgical residency program. This year Dr. Stephen Bauer initiated an endovascular training The following staff members have lab. Here the residents get hands-on endovascular experience on departed from Stamford Hospital: a “real-life” computer simulator in the treatment of aortic disease. We also continued to support the residency Journal club and Jennifer Bishop, MD – Breast Surgery Lecture Series conferences. Zandra Cheng, MD – Breast Surgery Diane Goodwin, PA-C – Surgery Subspecialties In research activity, surgical resident Kostantino Poulikidis worked with Dr. Paul Gagne on two clinical trials. One on the treatment of Peter Liebert, MD – Pediatric Surgery lower extremity venous hypertension and another on the patency Jennifer McDermott, PA-C – Surgery Subspecialties of drug eluting stents for peripheral artery disease. The trials plan to David McKee, MD – Otolaryngology finish in 2017 with results published soon after. Henry Rubinstein, MD – Orthopedic Surgery Sarah Russel, DPM – Podiatry Overall, we are quite pleased with the state of our Division in this Michael Stone, MD – Surgical Oncology competitive healthcare market. We are prepared with our current Paul Travlos, PA-C – Cardiac Surgery resources and expertise to meet the challenges posed to us by this

118 2016 Clinical Annual Report Stamford Hospital surgeons were listed among the Our efforts to develop a culture of safety are bearing fruit as Castle Connolly’s, Connecticut magazine and New York evidenced by the reduction in our surgical site infections overall, Magazine’s Top Doctors in 2016. They are: and in colorectal surgery patients specifically as shown in Figure 3. We continue to review our outcomes through reports from the • Paul Apostolides • Michael Nurzia Infection Prevention and Control team and the National Healthcare • Stephen Bauer • Glenn Ostriker Safety Network (NHSN, a subsection of the CDC) and through NSQIP. • Jeremy Bier • Helen Pass In 2016, we continued with our efforts of decreasing surgical site • Mark Camel • David Passaretti infections with our overall rate of infection dropping form 0.65% in • Russell Cavallo • Philip Piro 2015 to 0.61%. In the beginning of the fiscal year we saw a rise in • Michael Coady • Kevin Plancher colon soft tissue infection and so we established our Skin and Soft • Joseph D’Amico • Cory Rosenstein Tissue Infection (SSI) multidisciplinary committee. We refocused our efforts on our colon surgery protocol and we have not had a single • John Dowdle • Arthur Rosenstock colon SSI in the past six months. Also in 2016, we have decreased our • Kevin Dwyer • Stephen Salzer post-surgical pulmonary complications as monitored by NSQIP. • Michael Ebright • Richard Santarosa • William Feng • William Schmidt Through our SSI committee and the leadership of Perioperative • Jay Fleischman • Elizabeth Siderides Services, our goal is to establish the principles of the Enhanced • Joan Gewirtz • Marc Silver Recovery after Surgery for all our abdominal surgery to improve our • Harold Gewirtz • Peter Siroka outcomes in all aspects as recorded by NSQIP. This is in keeping with the goals of the Connecticut Surgical Quality Collaborative, of which • Andrew Haas • Scott Simon Stamford Hospital is a member. • Peter Hughes • Craig Tifford • Haik Kavookjian • Allen Troy Figure 3: Colorectal Surgery Standardized Infection Ratio • Bruce Klenoff • Esteban Vietorisz • Jason Klenoff • Eric Wasserman Stamford Hospital Colorectal Surgery • Charles Littlejohn • Richard Weber Standardized Infection Ratio • James McClane • Andrew Wolf 5.00 4.77 • Kevin Miller • David Zelazny 4.00

3.00 Departmental Safety and Quality 2.87 2.42 2.00 The American College of Surgeons National Surgical Quality

1.31 Improvement Program (ACS NSQIP®) is the first nationally validated, 1.00 1.16 1.13 0.92 risk-adjusted, outcomes-based program to measure and improve the 0.55 quality of surgical care. The Department of Surgery has participated 0.00 Q1Q2 Q3Q4 Q1Q2 Q3Q4 Q1Q2 Q3Q4 CT USA since 2012 and participates in the Connecticut Surgical Quality 2012 2012 2013 2013 2014 2014 State 2013

Collaborative, a NSQIP subgroup. Entering data to compare our 2013 performance to others, and the opportunity to learn from our We are enhancing our methods of data collection, review and colleagues across the state and country are key components assessment to better understand the costs of surgical care to improve of the program. our financial performance while maintaining quality and safety. Our first outcomes report showed that our mortality rate, adjusted for the severity of illness of our patients, put us in the top 10% nationally. Importantly, the report identified areas for improvement: reducing surgical site infections, especially in colorectal surgery, and pulmonary complications across all subspecialties.

2016 Clinical Annual Report 119 Department of Surgery: Annual Report 2016

Departmental Education and Current Residents

Teaching Activities PGY 2:

• James Clarke, MD, Georgetown University School of Medicine Student Education • Diane Durgan, MD, St. George’s University • Kristin McCoy, MD, American University of the Caribbean Dr. Marissa De Freese has been the surgical site clerkship School of Medicine director for the past year. Her duties include providing orientation (which includes expectations, responsibilities, key paperwork for submission, and technical skills); coordinating PGY 3: daily student activities (including bedside rounds, didactic • John Calhoun, MD, University of Central Florida College teaching sessions with attending faculty and residents, and other of Medicine similarly related educational activities); developing and revising • Elise McKenna, MD, New York Medical College curriculum; providing ongoing formative feedback to students; • Hebroon Obaid, MD, St. George’s University objectively assessing core competencies; reviewing summative evaluation for mid-clerkship feedback; and conducting exit PGY 4: interviews. In addition, Dr. De Freese provides weekly lectures for the medical students while on rotation. • Kamal Addagatla, MD, State University of New York, Buffalo, School of Medicine and Biomedical Sciences • Basil Nwaoz, MD, Tufts University School of Medicine Surgical Residency Program • Kostantinos Poulikidis, MD, New York Medical College

Program Director Kevin Dwyer, MD, FACS PGY 5: • Christian Cain, MD, University of Illinois College of Medicine The Surgical Residency Program continues to attract bright students • Mohamad Zanbrakji, MD, Ross University School of Medicine from much of the East Coast with over 700 applicants this past year. Our graduates leave with a deep and broad comprehension of • Kristina Kramer, MD, University of Connecticut School of Medicine surgical care and technique. Almost all go on to highly competitive

fellowships in subspecialties. This year, our graduates went on to 2016 Graduates and Positions Taken fellowships in colorectal surgery at the University of Miami, transplant surgery at New York University and surgical oncology at City of Hope. • Debbie Bakes, MD, Colorectal – Fellowship at Jackson Memorial Hospital/ University of Miami Our goal is to develop excellent clinical surgeons with a broad range of knowledge, with focus on areas such as quality, safety and team • Elijah Min, MD – Fellowship at Transplant, NYU Medical Center approaches to healthcare delivery. If our chief residents did not want • Heather Player, MD – Fellowship at Surgical Oncology, City of Hope to go onto a fellowship, we have given them a good basis to join a general surgery practice after graduation. Congratulations to our Chief Residents who have already been accepted to fellowships in Trauma, Acute Care and Critical Care Surgery. Dr. Christian Cain will be attending Maryland Shock Trauma New Interns (PGY-1) in Baltimore; Dr. Kristina Kramer will be attending Cook County Medical Center in Chicago; and Dr. Mohamad Zanbrakji will be • Rami Al-Aref, MD, Wayne State University School of Medicine attending Yale Medical Center in New Haven. • Borna Dabiri, MD, University of California, Irvine, School of Medicine (Prelim) • Ryan Duggan, MD, University of Connecticut School of Medicine (Prelim) • Marissa Novack, MD, Ross University School of Medicine • John Tedesco, MD, St. George’s University School of Medicine, Grenada

120 2016 Clinical Annual Report Residency Program: Scholarly Activity In November 2015, Dr. Kramer represented Stamford Hospital with An absolute requirement of a complete education is the her winning presentation on “Time in Target Blood Glucose Range development of critical thinking skills through the intellectual is Associated with Survival in Trauma ICU Patients” in Boston at stimulation of research, which is highly encouraged in the Region I, New England trauma paper competition and placed the Department. second.

Residents were highly visible as presenters at state and national Dr. Debbie Bakes presented Effectiveness of Adding Transverse conferences over the past year, including nine presentations at the Abdominus Plan (TAP) Catheters to Patient-Controlled Analgesia 2016 Connecticut Annual and Scientific Meeting (CT-ACS). (PCA) in Laparoscopic Colon Resections: A Retrospective Chart Review” as a poster on May 1, 2016 in Los Angeles at the American Society of Colon and Rectal Surgeons. This was also presented as an Resident Abstract oral presentation at the 1st Annual Research Day at Stamford Hospital on May 19, 2016. The Stamford Hospital resident team, Drs. Kristina Kramer, John Calhoun, and Marissa Novack, won second place in the 8th Annual Surgical Skills Competition at the Connecticut CT-ACS meeting.

RESIDENT ABSTRACT

Hebroon Obaid, MD Endoscopic Revision of Lap Sleeve Gastrectomy: A Novel Approach

Multiple Xanthogranulomas in the Setting of a Retropectoral Silicone Breast Implant. Borna E. Dabiri, MD Faculty Mentors: Zandra H. Cheng, MD, Leif O. Nordberg MD, Elgida R. Volpicelli, MD, FCAP Elise McKenna, MD A Contemporary Review of Firearm Fatalities in Connecticut

Diagnosing Muir-Torre Syndrome in a Patient with Non-Hodgkin’s Lymphoma and Sebaceous Marissa Novack, MD Carcinoma

John Tedesco, MD Phaeohyphomycosis Presenting as a Right Index Finger Mass in a Renal Transplant Patient

Basil Nwaoz, MD A Novel Technique for Spinal Wound closure

Differing methods of peritoneal flap closure in Laparoscopic trans-abdominal Kristin McCoy, MD* preperitoneal hernia repair affects post- operative pain and narcotic usage

Intrathoracic Malignant Peripheral Nerve Sheath Tumor Compressing the Trachea in an John Calhoun, MD 18-Year-Old Male with a History of Neuroblastoma Status Post Resection, Bone Marrow Transplant and Chemotherapy

Rami Al-Aref, MD Basal Cell Carcinoma: A case report on a unique presentation

*Kristin McCoy, MD – 2nd Place

2016 Clinical Annual Report 121 Department of Surgery: Annual Report 2016

Resident Awards 2015-2016 Strategy and Future Direction Research Award: Debbie Bakes, MD • Technology, healthcare delivery and financing are changing • Patient Care Award: Kristina Kramer, MD rapidly. We heed the rejoinder from Satchel Paige: “Don’t look back. • Teaching Award: Mohamad Zanbrakji, MD Something might be gaining on you.” We will continue to bring that newest and most advanced care to the people of Fairfield County, but we will also remember to bring the most personal care. We are Departmental Lectures/Visiting Professors looking ahead, toward, and with a plan to be, the future of surgical healthcare in Fairfield County. • “Is Halsted’s Model Still Relevant? Surgical Training Then and Now,” David Daiho Yuh, MD, FACS, FACC, Surgical Director, Heart and Vascular Center, Thoracic Surgery Residency Program Director, Yale-New Haven Hospital, New Haven, CT.

• “Surgical Rescue: The Fifth Pillar of Acute Care Surgery,” Andrew B. Peitzman, MD, Vice President for Trauma and Surgical Services, the Mark M. Ravitch Professor of Surgery and Vice Chairman, University of Pittsburgh Medical Center and Chief, Division of General Surgery - Stewart King Lecture.

• “An Introduction to Skilled Nursing Facilities and Palliative Care,” Christianne Bishop, Clinical Faculty, Geriatric Medicine.

• “Melanoma: A Case-Based Review and Update,” Laura Sowerby, MD, Dermatologist, Harvard University Fellowship in Mohs Surgery.

Other Educational and Scholarly Activities The Division of Trauma Surgery and Critical Care hosted the 5th Annual Community Safety & Injury Prevention Fair in October 2016.

The Division of Trauma Surgery and Critical Care hosted the 11th Annual Southwest Connecticut Trauma Symposium in November 2016.

122 2016 Clinical Annual Report Surgery2016 Clinical Family Annual ReportLounge123 Photograph: © Anton Grassl/Esto

StamfordHealth.org