Clinical News

New precision CO2 laserenhances surgery safety 3

AHRQ survey results showimproving culture of safety 4

Secondhand smoke cancer screening program 8

General News

New voluntary benefit maybring insurance savings 12

Welcome new M-D Staff 13

Social networking policiesand guidelines 14

of 50 of the most common medica-tions—15 to 20 of them standard on allunits, and the others specific toindividual units. The department then designed the for-mat for the cards and generated thedata.Introducing Medication Task Force

Now, the Medication Task Force, aOne Voice subgroup led by 3E’sDeborah Dennison comprising RNIIsfrom each unit, works to furtherimprove and promote the process ofcommunicating medications’ purposeand side effects to patients. “Having Pharmacy involved in thisproject has been great,” says PaulaTomanovich, RN, BSN, ACE Unit,Wilmington. “Working together as ateam improves the experience for

This is another in a series of arti-cles about projects that aretransforming care delivery atChristiana Care.

W ilmington Hospital’sOne Voice project has

launched its neweststrategy to include patientsand their families in careplans: talking in detail withpatients about their medica-tions using handy new tipcards.

In response to patient surveydata showing that discussingmedications with patients and familiesis a strong component of patient satis-faction, the One Voice team developedthe medication tip cards to serve as areminder and a quick reference fornurses. Covering commonly prescribed drugs

The small laminated cards hang froma metal ring on every medication carton each unit. Covering the 30 mostcommonly prescribed drugs atWilmington Hospital, the cards con-tain both the generic and brand namesof each medication, what the medica-tion is used for, its most common sideeffects and any precautions.“Nurses like them because they don’thave to search the full medication lit-erature to get the information,” saysInpatient Pharmacy, Wilmington,Director Rob Thornton.Researching the drugs prescribed oneach unit, Pharmacy developed a list

F O C U S

Makaba Bakayoko, RN, reviews med-ications with a patient on the ACEUnit at Wilmington campus.

One Voice project launches innovative medication tip cards

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and instituting bedside shift reports.But according to Senior Vice-President, and Associate ChiefMedical Officer Janice Nevin, M.D.,MPH, the cards prompt nurses to dis-cuss the medications with patientsand families. “The cards are anotherexample of the structures ChristianaCare is creating to include patientsand families.”

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everyone, especially the patients.”One Voice is an interdisciplinary teamof a patient/family advisor, healthcare providers and representativesfrom Pharmacy, pastoral care, casemanagement, social work and patientrelations. Forging strong relationships

It focuses on improving the patientcare experience by forging better com-munication among patients, their fam-ilies and health care providers.

Using the Electronic AdministrationRecord (EMAR) computer on the cart,nurses print out the formulary infor-mation on the medication, highlightthe side effects, and put the printoutin the patient’s folder. Patients still receive full printed infor-mation about their medications. Implementing medication tip cardsfollows putting white boards withinformation about the plan of care ineach patient’s room on select units

C OV E R , M E D I CAT I O N T I P CA R D S , C O N T I N U E D

Junior Board volunteers JeanneCheckel (left) and Joanne Gioffre arehelping patients find their way duringconstruction on the Wilmingtoncampus.

During construction at ourWilmington campus, Christiana

Care’s Junior Board is leading theway—literally. Realizing that during constructionand renovation people might havedifficulty finding their way aroundthe hospital, the board created theGreeters Committee to help patientsand visitors through the potentialconfusion. “People will need direction andguidance,” says Janice Nevin, M.D.,MPH, senior vice-president andassociate chief medical officer, “par-ticularly at the new main entranceand at the bank of elevators thatreach the OR and floors 1 – 8.”During construction of the six-storyoffice building and the nine-storytower, the 17 members of the com-mittee, under the leadership of DottyFlynn and Mary Julian, will help vis-itors with directions and will escortpatients to appointments.“The Greeters Committee couldn’t

have come at a better time,” says Dr.Nevin. “The committee is just the lat-est example of this fantastic group’slong history of support.”During the summer, the committeeran a pilot program to determine thebest placement for greeter stations andto clarify responsibilities. On Oct. 5,the committee began work in earnest,with Junior Board members LindaDepfer and Karen Kelly serving aspioneers. “With the closing of the circle, thegreeters will be particularly helpful,”says Barbara Burd, Junior Board presi-dent. “The Junior Board sees this newcommittee as an excellent way to sup-port the hospital during this excitingtransformation.”After construction is completed, thecommittee intends to continue helpingpeople find their way, says Flynn.“Guiding lost people and offering asmile and kind word to someone indistress is what we’re all about.”

Junior Board volunteers greet, help patientsand visitors find their way at Wilmington Hospital

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Christiana Care surgeons are per-forming delicate otolaryngeal sur-

gery and neurosurgery less invasivelyand more accurately with the newOmniGuide Carbon Dioxide (CO2)Beam Path fiber laser system.What’s more, patients can be dis-charged usually within one or twodays instead of the seven to 10 daysrequired with external surgery.More precise excisions

“The new laser allows us to reachareas that were less accessible beforeand to make more precise excisions.Because we sacrifice less normal tis-sue, there’s less morbidity to patients,”says Robert Witt, M.D., FACS, chief ofHead and Neck Oncology at the HelenF. Graham Cancer Center.With the new laser system—two atChristiana Hospital and two atWilmington Hospital surgeons canremove tumors involving the larynxthrough endoscopic procedures ratherthan open surgery in selected cases.Because the new procedures requireno tracheotomy to open the windpipe,patients can talk immediately andoften can eat the next day, Dr. Wittsays.Allowing surgeons to control penetra-tion depth, CO2 lasers have alwaysbeen the safest and most accurate ofall lasers. Because water, 60-70 percentof cell composition, absorbs CO2 laserenergy more quickly and fully thanother types of laser energy, CO2 lasersproduce less heat spread through tis-sue—and therefore cause less trauma.

They essentially vaporize cells byboiling away the water.Until the OmniGuide, though, thelong wavelength of CO2 lasers limitedtheir use to line-of-sight procedures,and the equipment was large andunwieldy. The OmniGuide BeamPath systemdirects CO2 energy through a flexiblefiber optic tube that surgeons canmanipulate into previously impossi-ble-to-reach areas.

Adds flexibility duringbrain tumor resection

“Delivering the laser through fiberoptics provides more control of theenergy at the tumor surface, allowingfor more accurate and complete braintumor resection,” says Magdy Boulos,M.D., director of the Surgical Neuro-Oncology MultidisciplinaryCenter (MDC). “The newlaser is safer. We can goaround corners, resecting asmuch as possible of thetumor without damagingsurrounding eloquent neuraltissue.” Damaging eloquenttissue could cause loss of

sensory processing and minor or evencomplete paralysis.For patients with otosclerosis, MichaelTeixido, M.D., uses the OmniGuide toremove bone growth from the stapesin the inner ear, afterward inserting apiston prosthesis. The stapes transmitssound to the inner ear through vibra-tion, and the bone growth reduces thestapes’ ability to vibrate. Dr. Teixido isone of a handful of surgeons nation-wide OmniGuide’s manufacturer hasasked to help improve the technologyby providing feedback on his experi-ences with it.“With OmniGuide technology, we canuse the CO2 laser wavelength safely inhard-to-reach areas—somethingsurgeons have been waiting for fordecades,” says Dr. Teixido.

New precision CO2 laser system enhances safety

Robert Witt, M.D., FACS,chief of Head and NeckOncology at the Helen F.Graham Cancer Center, withSurgical TechnologistMichele Lloyd at WilmingtonHospital with theOmniGuide fiber optic lasersystem.

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aspects of the patient safety culture:n Reporting culture—the frequency ofreporting mistakesn Just culture—whether mistakes arehandled as individual problems orsystem problemsn Flexible culture—teamwork andrespect in unitsn Learning culture—assessment andevaluation procedures and opportuni-ties to learn from mistakesImproving teamwork and learningChristiana Care showed significantimprovement in all areas, especially inteamwork and organizational learn-ing. Many of Christiana Care’s trans-formation initiatives underlie this suc-cess:n Team Training—The team trainingcurriculum is designed to improvepatient outcomes by building commu-nication and other teamwork skills.n Storytelling—Sharing stories aboutactual errors or good catches in ablameless environment enables staffnot only to address systems-based fail-ures but also to realize the importantrole each staff member plays in active-ly preventing errors.n No Harm Intended: LessonsLearned in Patient Safety—These ses-sions increase visibility of errors, showthe human impact of errors, andinvolve staff actively in developingsolutions to enhance patient safety.The sessions allow for openly dis-cussing and analyzing errors in orderto learn from them.n Improved handoff communica-tion—To ensure that complete infor-mation is communicated to the nextprovider of care, Christiana Care hasdeveloped and implemented a num-ber of procedures for effective hand-offs:Round Trip Ticket—to report perti-nent information to other departments

Results from the Agency forHealthcare Research and Quality

(AHRQ) 2009 Hospital Survey onPatient Safety Culture attest toChristiana Care’s success in transform-ing its culture of patient safety. From 2006, the first year health careproviders at Christiana Care partici-pated in the survey, to 2009, the per-centage of respondents who gaveChristiana Care an overall patientsafety grade of either “A” or “B” rosesix percent to 75 percent, above thebenchmark for teaching hospitalsnationwide.The improvement in other scores isequally impressive:n Effectiveness of handoffs and transi-tions—15 percent improvementn Management support for patientsafety—11 percent improvement n Teamwork across units—8 percentimprovement n Organizational learning-continuousimprovement—7 percent improve-mentARHQ, the Federal agency establishedto improve the quality and safety ofhealth care for all Americans, releasedthe first Survey on Patient SafetyCulture in 2004 to establish a bench-marking database to help hospitalsevaluate themselves over time andagainst other hospitals. The 2009 data-base contains information on morethan 600 U.S. hospitals.“The survey is a valid, well estab-lished instrument that helps us trackchanges in our patient safety cultureand evaluate the impact of our patientsafety interventions,” says Senior VicePresident of Quality and Patient SafetySharon Anderson, RN, MS.Measuring patient safety culture at theunit/department level and the overallhospital level, the survey assesses four

when patients move from onedepartment to another.DATAS tool—to report patient condi-tion during handoffs. An electronicDATAS template is in development.SBAR—to report findings to a physi-cian or other members of the healthcare team. A progress note templatebased on SBAR is being piloted onseveral nursing unitsStandardized hand-offcommunication—a process using digi-tal dictation is in development.Enhanced WebPaging—A system toimprove RN/MD communicationsn Achieving Competency Today(ACT) course—In this 12-week course,interdisciplinary teams develop per-formance improvement projects—andenhance their team building skills.Just as the survey illuminates success-es, it also illuminates opportunities forimprovement. One opportunity is inmanagement response to error.Because 45 percent of the staff reportsfeeling as if “their mistakes are heldagainst them,” Christiana Care isfocusing on how to balance a fair andopen culture with system and individ-ual accountability. These are just a few examples ofChristiana Care’s determination tobecome an error-free hospital.Committing to the time and resourcesthe survey requires is another exam-ple—because transforming a culturerequires assessing it.“Health care has become so complex,so highly technical, so multidiscipli-nary that we must constantly assesswhere we are, how far we’ve come,and where we need to focus,” saysChief Medical Officer and PatientSafety Officer James Newman, M.D.“The AHRQ survey helps us under-stand how our organization is com-mitted to keeping our patients safe.”

Survey shows success in transforming culture of patient safety

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vessels.The electrophysiologist automaticallycontrols the motion and targeting ofthe fully integrated catheter and digi-tal fluoroscopy mapping by using ajoystick, computer mouse or touchscreen. Reduced exposure to X-ray

What’s more, stereotaxis remotetechnology and less time required fordigital fluoroscopy potentially canreduces X-ray exposure significantlyfor patients and the electrophysiologyteam, as well as lead protective cloth-ing time for both physicians and staffduring the procedure.Using stereotaxis along with Dr. Sarterare Christiana Care electrophysiolo-gists Raymond Miller, M.D., associatedirector, Electrophysiology Lab,Piamsook Angkeow, M.D., StephenBlumberg, M.D., John Hynes, M.D.,Roger Kerzner, M.D., JosephPennington, M.D., and Henry Weiner,M.D.

TimothyGardner, M.D.,medical directorof the Center forHeart & VascularHealth (front,left) snips theribbon openingthe new Mr. andMrs. Gerret andTatianaCopelandArrhythmiaCenter.

E lectrophysiologists atChristiana Care now have the

latest technology at theirfingertips to treat complex heartrhythm disorders.

Physicians now treat patients with thenewest generation Stereotaxis Niobe®

Magnetic Navigation System in theMr. and Mrs. Gerret and TatianaCopeland Arrhythmia Center in theInterventional Suite at the Center forHeart & Vascular Health. The stereo-taxis system was made possiblethanks to a generous gift from theCopelands.“Introduction of the stereotaxis systemplaces us at the forefront of currenttechnology and significantly advancesour ability to provide highly special-ized cardiac care for our patients inDelaware and surrounding communi-ties,” says Medical Director Timothy J.Gardner, M.D. “Few centers surpassour capabilities in this area.”Easily recognized, challenging to treat

Atrial fibrillation is a common heartrhythm disorder easily recognized butchallenging to treat, prevent or cure.The complexity of previously availableablation techniques limited treatmentoptions to few patients by only a smallnumber of highly trained physicians.According to Brian Sarter, M.D., med-ical director of the Electrophysiology(EP) Lab, the new system represents amajor advance in catheter-based inter-ventional cardiology.“Stereotaxis technology allows us tomanipulate catheters inside the heartmore precisely and more consistentlywith a greater margin of safety andefficacy,” he says.

The added safety and expectation ofeasier and shorter procedures couldmake more patients eligible forcatheter ablation of episodic andchronic atrial fibrillation, possiblyeven tripling the number of proce-dures performed in the next two tothree years.The new EP stereotaxis lab in theInterventional Suite at the Center forHeart & Vascular Health initially willtreat arrhythmias and guide left ven-tricular lead placements for cardiacresynchronization therapy. Futureapplications may include the treat-ment of multi-vessel and other com-plex coronary artery diseases.Revolutionary technology

What makes stereotaxis technology sorevolutionary are magnetic fields thatallow physicians direct control of thetip of soft catheters. Unlike othercatheters used for radiofrequencyablation, stereotaxis catheters are moreflexible and easily manipulatedthrough the labyrinth of cardiac blood

Generous Copeland gift launches new Arrhythmia Center

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M.D., Christopher Casscells, M.D., andAlex B. Bodenstab, M.D., the seminarsfocused on operative and non-operativeremedies for hip and knee pain.

The consumer seminars and annual sympo-sium are repeated each October.

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More than 160 surgeons, primary carephysicians, physician assistants and

physical therapists turned out for the sec-ond annual Delaware OrthopaedicSymposium Oct. 9 hosted by ChristianaCare and the Delaware Society ofOrthopaedic Surgeons.

Keynote speaker and Senate FinanceCommittee member Sen. Tom Carperopened the conference with an addressabout shared responsibility in health carereform.

The symposium included three educationaltracks (orthopedic surgery, pediatric ortho-pedics and allied health) and featured 15speakers from ChristianaCare, A.I. duPont Hospitalfor Children and nationallyknown orthopedic surgeonsTodd Albert, M.D., andThomas Graham, M.D.

According to Brian Galinat,M.D., who organized theevent along with RandeepKahlon, M.D., "In just itssecond year, this conferencehas become a respectedregional event that bringsproviders together to dis-cuss issues related to oneand joint health."

The symposium was preced-ed by two consumer educa-tion seminars titled“Moving Freely WithoutPain.” Led by Delaware sur-geons William A. Newcomb,M.D., Steven M. Dellose,

Sen. Carper attends orthopedic surgeons’ second annual regional educational symposium

Fifteen orthopedic surgeons (below) taught atthe annual Delaware Orthopaedic SymposiumOct. 9 at the John H. Ammon Education Center.U.S. Sen. Tom Carper (front row, red necktie),keynote speaker, talked about shared responsi-bility in health care reform.

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Doriel Ward, Ph.D., has beennamed Christiana Care director

of Research, responsible for the over-all direction of the Research Office,strategic planning of research activi-ties, mentoring of young researchersand development of new programs.

Dr. Ward comes to us from MDAnderson in Houston, Texas, whereshe was in charge of CancerTherapeutics and Phase 1 trials for theDepartment of Cancer Medicine.Her research experience is in publichealth issues, including racial andethnic disparities in cancer care andAIDS. “She brings a wealth of experi-ence in grants management, whichshould improve both the quality andextent of grants for which we are suc-cessful,” says Brian W. Little, M.D.,Ph.D., vice president, AcademicAffairs & Research.Email dward@christianacare.org orcall the research office, 623-3830.

New education clinics are moreconvenient for chemotherapy patients

Doriel Ward, Ph.D.,named director ofResearch

Doriel Ward, Ph.D.

Social workers, dieticians, financialcounselors and coaches are avail-

able at any time for a consultation atthe Helen F. Graham Cancer Center.But a new approach for patientsreceiving chemotherapy may makecounseling more convenient andimprove awareness and use of themany support programs available forpatients and their caregivers.

Recently, the Cancer CareManagement Group at the centerestablished a schedule of miniclinics inthe Chemotherapy Infusion Suite toprovide daily patient support, includ-ing counseling on diet, wellness,finances, community resources andorganizing medications.

Therapy time: A good time for learning

“Patients and their families often havelittle to do while the patient is receiv-ing treatment,” says Tricia Strusowski,the group’s director. “During testingand diagnosis, patients and their fami-lies may be shocked and unable toconsume the amount of informationwe want to give them.“Once they have started treatment,they are more settled and able to hearabout support options, ask questionsand choose what’s appropriate fortheir situation.”“The idea to offer programs right inthe infusion suite came as a result offeedback from the year-old Patient/Caregiver Advisory Group,”Strusowski explains.The group noticed poor attendance atsimilar programs in the evening, butsince the time and place changedpatient and caregiver awareness anduse of support programs has grown.

Cancer patients and those whosupport them in their journey cannow attend one-hour daytime mini-clinics at the Helen F. GrahamCancer Center to gain valuableinformation about health, wellnessand more.

Here’s a daily schedule:

Mondays, 9:30-10:30 a.m.Ask Your Dietitian

Tuesdays, 10-11 a.m.Know Your Community Resources

Wednesdays, 10-11 a.m.Wellness Wednesday

Thursdays, 10-11 a.m.Meet Your Social Worker

Fridays, 10-11 a.m.Meet Your Money Coach orOrganizing Your Medicines

Strusowski expects patient satisfactionto so climb even higher as patients andtheir caregivers learn about the pro-gram. For more information about this pro-gram, contact Strusowski at 302-623-4710 or e-mail strusowski@chris-tianacare.org.

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well as Sullivan’s husband Danny.“They are advocates,”“ says BarbaraMarconi, RN, BSN, OCN, researchnurse and study coordinator. “Theyare dedicated to getting the word outabout secondhand smoke.”As FAMRI participants, the two sistersreceived a free, noninvasive, low-doseCT scan that can detect lung cancerwhen it is at Stage 1, before it hasspread and when it can be surgicallyremoved. At that stage, the survivalrate is about 90 percent, according topublished I-ELCAP data. “The test is easy and quick—andthere’s an immediate sense of relief,”Yeager says.Eligibility requirements

Programs participants must be 40 orolder, have smoked less than 100 ciga-rettes in their life times, and have asignificant history of being exposed tosecondhand smoke.The siblings have encouraged othersto participate in the program. Andthey have changed their behavior,avoiding secondhand smoke.“I don’t stay around smoke anymore,” Yeager says. “I feel it’s pollut-ing our lungs.”In addition to being a FAMRI partici-pant, Christiana Care is one of only 52institutions in the Early Lung CancerAction Project. ELCAP screens smok-ers and former smokers for lung can-cer in order to detect the disease atStage 1.That program is open to people whoare 40 and older who have smoked forat least one year. To learn more aboutthe FAMRI and ELCAP programs, call302-623-5227.

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Joe Hullinger was a fitness enthusi-ast, an active guy who enjoyed run-

ning and boating. Then Hullinger developed a cough hecouldn’t shake. He lost weight andcouldn’t figure out why.His doctor ordered a chest X-ray thatrevealed a tumor. In September 2001,Hullinger was diagnosed with Stage 4lung cancer, a small-cell type associat-ed with smoking.Was never a smoker

But Hullinger never smoked. “He atebroccoli every day,” recalls his sister,Cathy Sullivan. “Chicken, no redmeats.” His doctors believe his cancerwas caused by secondhand smoke,first in his parents’ home and then on

the job, where Hullinger worked longhours in confined spaces as a comput-er programmer.“The earlier the exposure and thegreater the exposure to secondhandsmoke the greater the prevalence ofcancer,” says Thomas Bauer, M.D.,chief of thoracic surgery at the HelenF. Graham Cancer Center. “We knowthat children who are exposed to sec-ondhand smoke develop many kindsof respiratory problems, from asthmato lung cancer.”Christiana Care is participating in aprogram to screen people who aren’tsmokers but have been exposed to sec-ondhand smoke. It is funded by theFlight Attendants Medical ResearchInstitute (FAMRI) established as part

of a settlementof a suitbroughtagainst thetobacco indus-try by flightattendantsseeking dam-ages for ill-nesses linkedto secondhandsmoke inplanes.Hullingerfought his can-cer coura-geously andaggressively,undergoing a

combination of chemotherapy treat-ments. But because the disease wasalready advanced, the cancer couldnot be contained. He died 15 monthsafter his diagnosis. Since then, two ofthe most dedicated participants in theprogram are Hullinger’s sisters,Bernadette Yeager and Sullivan, as

Cancer screening program focuses on secondhand smoke

From left, Daniel Sullivan,Cathrine Sullivan, BernadetteYeager and Tom Bauer, M.D.(Inset) Yeager and CathrineSullivan’s brother, Joe Hullinger(inset), who died at 41 in 2002.

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Jennifer Packard, M.D., receives prestigious Howard Schubiner Award

Thomas Bauer, M.D., chief ofThoracic Surgery at the Helen F.

Graham Cancer Center, is principalinvestigator (PI) overseeing a Phase IIclinical trial in Albuquerque, N.M., ofan early-stage diagnostic for lung andother cancers. He is working with Biomoda Inc. tohelp determine the usefulness of thecompany’s trademarked diagnostictest CyPath® to detect lung cancerearlier in the sputum of patients withlung cancer. Dr. Bauer’s role is tolead the study, which utilizes CTscans and other data on study partici-pants as part of the longitudinal com-ponent of the study.“In addition to his thoracic surgerypractice and his faculty positions, Dr.Bauer is widely recognized by hispeers as one of the top lung cancerresearchers in the field,” saysBiomoda President John Cousins.“Repeat screenings under the longi-tudinal part of the study will proba-bly save lives in our study cohort aswell as provide additional data criti-cal to FDA approval of the assay.”

Thomas Bauer, M.D.,leads New Mexicocancer trial

Jennifer Packard, M.D., received theHoward Schubiner Award, a pres-

tigious annual honor offered by theNational Med-Peds ResidencyAssociation (NMPRA).Dr. Packard, a fourth-year resident inChristiana Care’s Medicine-PediatricsResidency Program, accepted theaward Oct. 17 in Washington, D.C.The NMPRA presents the award toresident physicians who makeextraordinary, lasting contributions tothe organization’s success and/orMed-Peds at the local or state level.“It is such an honor to receive thisaward," says Dr. Packard. “It trulyspeaks to the support I had from theMed-Peds Residency Program’s fac-ulty, administration and fellow resi-dents, Academic Affairs andPhysician Relations. Christiana Carehelped to make the NortheastRegional Med-Peds meeting a successthrough resources provided byPhysician Relations. The John H.Ammon Medical Education Centerwas the perfect venue to host such anevent.”Allen Friedland, M.D., FACP, FAAP,director of Christiana Care’sMedicine-Pediatrics ResidencyProgram, who nominated Dr.Packard, says, “She worked so hardon developing and organizing thebest-attended regional med-pedsmeeting to date for medical students,residents and attending physicians.Attendees came from all over thecountry and included people from asfar away as California, Texas, Florida,New Hampshire and Wisconsin. I am

so proud of Jen.” According to the award’s namesake,Howard Schubiner, M.D., the honorgoes to a resident who “exemplifies thehighest standards for excellence in Med-Peds, including exemplary clinical careof patients, compassion and humanismin relationships with patients and withcolleagues in medicine and hospital co-workers, involvement in communityactivities, and contributions to the fieldof Medicine-Pediatrics.”“Jen’s successful template is being used

as the model for other regional med-peds meetings. This year, there will bean unprecedented three regional meet-ings across the country, and all areusing her template. She spent countlesshours for about a year to organize theevent in addition to her busy residencyresponsibilities.”Dr. Packard is graduate of JeffersonMedical College.

Jennifer Packard, M.D.

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Therapeutic Notes

Lisa Kletter Pharm.D

The triazole antifungals (fluconazole, voriconazole, itraconazole and posaconazole) havenumerous clinically significant drug interactions. The majority of these interactions involveoxidative metabolism via the cytochrome P450 enzyme system. To varying degrees, the tria-zoles are both metabolized by and affect the hepatic cytochrome P450 enzyme system. Theenzymes mainly affected are CYP3A4, 2C9 and 2C19. The drug interaction profiles of each ofthese agents vary slightly due to the different affinities for these isoenzymes. For example, flu-conazole is a much weaker CYP3A4 inhibitor and interactions with CYP3A4 substrates (i.e.,cyclosporine, tacrolimus, some of the statins, calcium channel blockers) are generally onlyobserved with doses > or = 200mg.

Some of the most significant and common drug interactions of the triazoles are elevated con-centrations of cyclosporine, tacrolimus, sirolimus, warfarin, most calcium channel blockers,steroids, most benzodiazepines, protease inhibitors and many of the statins due to inhibition ofthe CYP enzymes. Phenytoin metabolism is also inhibited by the triazole antifungals, leadingto increased phenytoin levels. Monitoring of serum phenytoin concentrations during concomi-tant therapy is suggested. Additionally, phenytoin, carbamazepine, phenobarbital, rifampin,and rifabutin induce the CYP enzymes that metabolize the triazoles, resulting in significantlydecreased azole concentrations. Rifampin has the greatest effect and has been associated withundetectable levels of itraconazole, significantly reduced levels of fluconazole and voricona-zole. Concomitant therapy with rifampin is contraindicated with voriconazole, not recom-mended with itraconazole and may require increased fluconazole dosing. These enzymeinductions can take up to two weeks to achieve maximum effect and persist for up to twoweeks after discontinuing the interacting medication, leading to potential treatment failures ordelayed response.

There are also P glycoprotein (P-GP) interactions. P-GP is a drug efflux transporter found in thegastrointestinal tract that limits exposure to drugs. P-GP substrates are structurally similar toCYP3A4 and so many 3A4 inhibitors will also inhibit P-GP. Fluconazole, itraconazole andposaconazole are known P-GP substrates, and itraconazole is a P-GP inhibitor. One of thebest-understood interactions with P-GP and triazole antifungals is increased exposure to digox-in when given concomitantly with itraconazole.

Alterations in gastric PH can affect ketoconazole, posiconazole and itraconazole (capsules butnot liquid formulation), which require gastric acidity for absorption. Drugs that increase gastricPH such as histamine-2 antagonists, proton pump inhibitors and antacids can decrease serumlevels of ketoconazole, posiconazole and the capsule formulation of itraconazole.The triazole antifungals have numerous drug-drug interactions. The major drug-drug interac-tions are associated with the P450 enzyme system. Particular attention needs to be paid tothose interactions involving drugs with narrow therapeutic indexes since there is the potentialfor therapeutic failure or toxicity. Serum drug concentration monitoring may be useful for someof the drugs with narrow therapeutic indexes. A more extensive list of these drug interactionscan be found in UpToDate, Micromedex and the hospital formulary.

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and Joseph J. Bennett, M.D., moderateda discussion on “Cancer SurvivorFollow-up: Is Your Clinical PracticeEvidence-based?”, at the AmericanCollege of Surgeons’ 95th AnnualClinical Conference in Chicago.

At the 25th National Association ofNeonatal Nurses Annual EducationalConference, Sept. 23-26 in Austin,Texas:n NICU’S Barbara Dean, BSN, RNC,and L&D’s Melanie Chichester, BSN,RNC presented “Now and at the Hourof Our Death: MulticulturalDimensions in Palliative and End-of-LifeCare.”n NICU’s Barbara Dean, BSN, RNC,and Laure Maruszczak, BSN, RNC,presented a poster titled “A Few Cents Can Make a Lot of Sense:How Two Staff Nurses Organized aReview Course with Minimal Expenseand Motivated Their Peers to BecomeCertified.”Vascular specialist Ralph P. Ierardi,M.D., will appear Nov.12 at 7 p.m. oncable channel 21’s "Matters of theHeart Series," sponsored by Medtronics.Dr. Ierardi’s discussion will focus onvascular diseaseAppointments, Awards

Nicholas J. Petrelli, M.D., Bank ofAmerica endowed medical director ofthe Helen F. Graham Cancer Center,was a featured speaker at the AmericanCollege of Surgeons 95th AnnualClinical Conference. He shared infor-mation about the cancer center’s role inreducing Delaware’s cancer rate.Senior Social Worker Danielle Brownreceived the Leukemia and LymphomaSociety Patient Service Award for theDelaware Chapter, recognizing herdedicated support for helping theSociety fill its mission.

PublishingDarcy Burbage, RN, MSN, AOCN,CBCN, clinical nurse specialist at theChristiana Care Breast Center, Helen F.Graham Cancer Center, published achapter about body image in the sec-ond edition of a new OncologyNursing Society book titled"Psychosocial Dimensions of OncologyNursing Care."

Nicholas J. Petrelli, M.D., et al., Bankof America endowed medical directorof the Helen F. Graham Cancer Center,published “Preoperative MultimodalityTherapy Improves Disease-Free Survivalin Patients With Carcinoma of theRectum: NSABP R-03,” online ahead ofprint in the Sep 21 2009 Journal ofClinical Oncology,10.1200/JCO.2009.22.0467

PresentationsPaula Stillman, M.D., Christiana Caresenior vice president of Special Projects/ president of Health Initiatives, LisaNellius, RN, Cardiac Rehab Manager,Toni McMillen, RN, Cardiac Rehab,and John Shreve, senior systems ana-lyst, Cardiac Services, conducted aWeb-based seminar, “AchievingCardiac Rehab Excellence,” to tell theiraudience how Christiana Care clini-cians and IT work together to deliverevidence-based, patient-centric care.

Denise Lyons, MSN, GCNS, BC andPatricia M. Curtin, M.D., FACP, CMDpresented a poster “Implementation ofa Constipation Protocol,” at theGerontological Advanced PracticeNurses Association Annual EducationalConference in Savannah, Georgia. Theposter won first place in the posterproject category.

Diana Dickson-Witmer, M.D., associ-ate director of the Christiana CareBreast Center, and surgical oncologist

Publishing, Presentations, Appointments, Awards

Thank youTo our friends and coworkers for yourprayers and expressions of sympathywhen our daughter, ElizabethColmorgen, died in June. We can't ade-quately express how much comfort theygave us. God bless each of you. MarthaZazzarino and Garrett Colmorgen,M.D.

CongratulationsTo Jamie Bailey, BSN, RN, CCRN, onher recent promotion to RNII.To Carol Slijepcevic, BSN, RN, on herrecent certification from the AmericanNurses Credentialing Center. To Robert Cortez, Judy Pantalino andElaine Sherman, for graduating fromWilmington University.To Renee Collins and Porcia Jeffreys forreceiving a Certificate of Completionfor the ECHO Program. To Tina Fisher, RN, bariatric case coor-dinator for successfully passing theCertified Bariatric Nurse (CBN) exam.To Syreeta Davis for completing theSchool at Work (SAW) program, onAug. 5, 2009. To Leslie Harvell and Tameka Woods,winners of the employee essay conteston fitness. They shared inspirational sto-ries that highlighted their summer phys-ical activity experiences with their fami-lies. Look for their essays in an upcom-ing issue of Focus.

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The Office of Quality and Patient Safetyinvites Christiana Care leadership,departmental chairs, staff and othercolleagues and clinicians to jointhe Institute for HealthcareImprovement’s 21st Annual NationalForum on Quality Improvement inHealth Care Satellite Conference, fromOrlando, Fla., via satellite at ChristianaHospital, Room 1100 and theWilmington Conference Center. Thisconference is free to all employees. Thisreal-time broadcast will include fourkeynote sessions, plus four minikeynote sessions.For more information or registration,contact Jean Davis at (302) 733-2462or jeadavis@christianacare.org.For more information on the forum,visit http://www.ihi.org/IHI/.

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During National MedicalLibrarians Month, our libraries areplanning these events: Monday, Oct. 26 and Thursday,Oct. 29, a librarian from the GailGill Consumer Health Library willdemonstrate online consumerhealth databases in the HeartCenter Lobby at ChristianaHospital. Tuesday, Oct. 27 from 11 a.m.-3p.m. “Pop Into the Library” at theLewis B. Flinn Medical Library’sReference Office in the John H.Ammon Education Center atChristiana Hospital for popcornand brief demonstrations of libraryresources you can use to save timeand maximize your productivity. Wednesday, Oct. 28 and Friday,Oct. 30 from 11 a.m.-1 p.m. stopby the West End Café at ChristianaHospital to learn about theMedical Libraries’ resources. Thursday, Oct. 29 a ScavengerHunt starts at 9 a.m. at the LewisB. Flinn Medical Library atChristiana Hospital and ends whenthe final answer is found. Prize forwinner: $50 certificate toward abook purchase of your choice. Buck-a-Book sale all week (Oct.26-30) at the Lewis B. FlinnMedical Library at ChristianaHospital.For more information e-mail EllenJustice, Medical Librarian, at ejus-tice@christianacare.org or call733-1179.

Medical Grand Rounds on Thursday,Oct. 29, from 8-9 a.m. features PeterGreen, M.D., noted expert fromColumbia speaking on celiac disease,which he describes as a silent epidem-ic.

2009 Wilmington Walk for Life &Breath is Saturday, Nov. 14 at 10 a.m.at the Chase Center on the Riverfront,Wilmington, with registration open at8:30 a.m. For information, call 302-655-7258.

The next topic in Respiratory Care’sCOPD Lecture Series is “COPD andAlpha 1 Antitrypsin,” Tuesday, Nov. 17,10 a.m.-noon. Albert Rizzo, M.D., willdiscuss treatment options. Testing forAlpha 1 will be done at this session inRoom 1100, Christiana Hospital. CallDebbie Wood, 733-2562, to register.

Christiana Care Volunteers’ annualReading is Fun Book Fairs are a greatopportunity to buy books at a discount-ed price as holiday gifts for everyonefrom the newest grandchild to that spe-cial teacher. A portion of the proceedsfrom the book fairs will help such vol-unteer programs as the Video DoctorProgram, NetLink and the adult daycare centers. The book fairs will beopen:In Room 1100, Christiana Hospital:n Nov. 8, 3-8 p.m.n Nov. 9. 7 a.m.-8 p.m.n Nov.10, 7 a.m.- 7 p.m.On the 1st Floor at VNA, One ReadsWay:n Friday, Dec. 4, 9 a.m.-2 p.m.

Upcoming events

Beginning Nov. 1 employees cantake advantage of group discountsrelating to auto, home and petinsurance. The new voluntary benefit offeringis administered by Marsh, a world'sleading insurance broker and riskadvisor.The program provides employeeswith a Website and toll free numberto request free quotes that couldlead to lower premiums and bettercoverage In addition, if employeeswhose scheduled hours are 40 ormore per pay period are eligible topay the premiums via payrolldeductions.To get more information or to enrollon or after Nov. 1 call 1-866-796-6291 or visitwww.cchsvoluntarybenefits.com.

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Anesthesiology Manivanh Keobounnam,M.D. 2 Reads Way New Castle, DE 19720 Phone: 302-709-4709

Family & CommunityMedicine Hema Gouru, M.D. Westside Healthcare 404 Fox Hunt Drive Bear, DE 19701 Phone: 302-655-5822Mary M. Hagee, D.O.Loughran Medical Group 3411 Silverside Rd. Wilmington, DE 19810 Phone: 302-479-8464Gerry A. Rosales Jr., M.D. 1021 Gilpin Avenue, Ste. 104 Wilmington, DE 19806 Phone: 302-421-8282Brooke E. Sheffler, M.D. Family Medicine Center 1401 Foulk Road, Ste. 100 Wilmington, DE 19803 Phone: 302-477-3300

Medicine/Cardiology Michael J. Kostal, M.D. 252 Chapman Road, Ste. 150Newark, DE 19702 Phone: 302-366-1929

Medicine/Gastroenterology Jared Hossack, M.D., MBA537 Stanton-ChristianaRoad, Suite 203 Newark, DE 19713 Phone: 302-225-2380

Medicine/Neurology Camilo A. Gutierrez, M.D. 774 Christiana RoadSte. 201 Newark, DE 19713 Phone: 302-731-3017

Medicine/OccupationalMedicine Douglas B. Allen Jr., D.O.Smyrna Medical Aid Unit 100 S. Main Street, Ste. 101 Smyrna, DE 19977 Phone: 302-659-4545Christina Bovelsky, M.D. Smyrna Health & WellnessCenter 100 S. Main St., Ste. 101 Smyrna, DE 19977 Phone: 302-659-4545

Medicine/Physical Medicine& Rehabilitation

Vaishali S. Vora, D.O.Center for Rehabilitation Wilmington HospitalPhone: 302-428-6744

Medicine/Pulmonary& Critical Care Medicine

Michael T. McCurdy, M.D. eCare Telemedicine 200 Hygeia Drive Newark, DE 19713 Phone: 302-623-0600

Medicine/InternalMedicine Soon M. Chung, M.D. 131 Continental Drive, Ste.200 Newark, DE 19713 Phone: 302-366-1868Patricia A. Clancy, M.D. 131 Continental Drive, Ste 200Newark, DE 19713 Phone: 302-366-1868Kevin A. Copeland, D.O.Dept. of Medicine 6A39, Christiana HospitalPhone: 302-733-6342

Morgan E. Leafe, M.D. duPont Hospital for Children Pediatric Department 1600 Rockland Road Wilmington, DE 19803 Phone: 302-651-5863

Pediatrics/Neurology Sanjai C. Rao, D.O.3521 Silverside Road Wilmington, DE 19810 Phone: 302-477-0121

Psychiatry/Psychology Scott D. Siegel, Ph.D.Helen F. Graham CancerCenter 4701 Ogletown-StantonRoad S-1209 Newark, DE 19713 Phone: 302-623-4890

RadiologyVinay Kandula, M.D. Department of Radiology 1600 Rockland Road Wilmington, DE 19803 Phone: 302-651-4646Cyril Milunsky, M.D. 5936 Limestone Road, Ste 301 Hockessin, DE 19707 Phone: 302-234-5800Boris Reznikov, M.D. 5936 Limestone Road, Ste 301 Hockessin, DE 19707 Phone: 302-234-5800

Surgery/Podiatric Surgical Service

Rachel H. Tuer, D.P.M.Suite 303, Metroform 620 Stanton-Christiana Rd. Newark, DE 19713 Phone: 302-999-8511

Joseph M. Deutsch, M.D. Christiana Care HospitalistPartners 200 Hygeia Drive, Ste. 2100 Newark, DE 19713 Phone: 302-623-0188Ashwani K. Garg, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868Tamar Y. Jackson, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868Lisa M. Jones, M.D., MPH111 Continental Dr., Ste. 406 Newark, DE 19713 Phone: 302-984-2577Jonathan Kaufmann, D.O.111 Continental Drive, Ste. 406 Newark, DE 19713 Phone: 302-984-2577Janis Lawrence-Jackson, D.O.131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868Erin M. Meyer, D.O.Christiana Care

Hospitalist Partners 200 Hygeia Drive, Ste. 2100 Newark, DE 19713 Phone: 302-623-0188Priya R. Patel, M.D. 131 Continental Drive, Ste. 200 Newark, DE 19713 Phone: 302-366-1868

Pediatrics/GeneralPediatrics Mary Bove, M.D. duPont Hospital forChildren Pediatric Department 1600 Rockland Road Wilmington, DE 19803 Phone: 302-651-5863Ember L. Crevar, M.D. MAP I, Suite 136 Christiana HospitalPhone: 302-733-4206

Welcome New Medical-Dental Staff

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While Christiana Care employeesmay freely to participate in

social networking on the Internet,employees should adhere to all com-pany policies outlined within theEmployee Handbook and systemwidepolicies located on all internal portalsif they choose to be identified onlineas a Christiana Care employee.The guidelines are as follows: n Limit participation in public com-munications to not unduly interferewith the timely completion of your jobresponsibilities. n Avoid communicating any materialthat violates the privacy or confiden-tiality of any employee, patient, or ofChristiana Care. n Avoid disclosing any sensitive, pro-prietary, confidential, private and pro-tected health information or financialinformation about Christiana Care. n Refrain from posting any materialthat is obscene, defamatory, profane,libelous, threatening, harassing, abu-sive, hateful or embarrassing to anoth-er person or any other person or enti-ty. This includes, but is not limited to,comments regarding Christiana Care,its employees or affiliates. n Do not offer to buy or sell goods,operate a business or use ChristianaCare communication tools for person-al financial gain. n Do not endorse or appear toendorse a product or service withoutexpress written permission. n Do not use profanity or make

derogatory comments toward theChristiana Care. n Be aware that you may be heldresponsible for any personal legal lia-bility imposed for any content pub-lish. Use this disclaimer

Employees must include the followingdisclaimer on published public com-munications identifying themselves asa Christiana Care employee (dis-claimer may appear in your personalprofile on each site):

“The opinions expressed here are thepersonal opinions of [your name].Content published here is not read orapproved by Christiana Care before itis posted and does not necessarilyrepresent the views and opinions ofChristiana Care.”

Personal Internet conversations, blog-ging and posting updates should notbe done during work hours or whileusing Christiana Care property.Violations of Christiana Care commu-nications standards may result in dis-ciplinary action up to and includingtermination of employment.Additional information on publiccommunication, including tips andguidelines for your own protection,are in the Employee Handbook on theemployee portal, under Standards ofConduct. Questions regarding or furtherclarification of this policy may bereferred to Christiana Care EmployeeRelations at 302-733-1121.

Employee Handbook, systemwide policieshelp guide social networking activities

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John Emberger, BS, RRT, critical carecoordinator, has been appointed a

fellow in the American Associationfor Respiratory Care (AARC).Of the approximately 150,000 respira-tory therapists nationally, only 200 areAARC fellows. Emberger is the onlyDelawarean ever to be awarded thishonor.Emberger was elected president of theDelaware Society for Respiratory Carein January.“The FAARC credential, earnedthrough actions and not a result of anexam, is a high honor recognizingleadership in respiratory care that hasmade profound and lasting contribu-tions to the profession,” according to Christiana Care Respiratory CareDirector Lori Killian MBA, RRT-NPS,RPFT, AE-C. He joined Christiana Care in 1997.

John Emberger, RRTreceives prestigiousprofessional honor

John Emberger, BS, RRT, FAARC

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Employees from Skanska construction company paida visit recently to students at the First State School

to speak about the transformation underway on theWilmington Campus and the extraordinary safetymeasures the company uses.Students asked many questions about the project tak-ing shape outside the windows of their school. Theylearned how the hospital—and the school—will remainfully operational during construction and about suchthings as wearing a hard hat on the construction siteand harness safety belts the workers use.Skanska employees stressed the importance of onlyusing designated walkways on the campus.When completed in 2012, the project will include a newEmergency Department, operating rooms, a nine-storypatient tower and a medical office building.

Skanska construction experts visit First State School

Stefan Zablocki, safety manager (top photo) and Lyle Frederick, project executive (above, right),presented a variety of safety products to students at First State School on Wilmington Campus.

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This summer, more than 200 stu-dents from more than 40 area high

schools participated in the SummerVolunTEEN Program sponsored byVolunteer and Student Administrationstaff.

The VolunTEENS contributed morethan 11,000 hours of service atChristiana Hospital, WilmingtonHospital and the Preventive Medicine& Rehabilitation Institute, as well asvarious Physical Therapy PLUS loca-tions and Imaging Services locations.

Many teens performed clerical tasksusing their computer skills and

Summer VolunTEENScontribute 11,000hours of service

enthusiasm to tackle special officeprojects. Others volunteered moredirectly with patients, assisting onpatient care floors, delivering flowersand serving meal trays.

The 2010 Summer VolunTEEN

Program runs from June 14 throughAug.13. Interested high school stu-dents should check online at www.christianacare.org/volunteer byearly January or contact the VolunteerOffices at 302-428-2206.

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