November 2013 Emory Surgery newsletter Department of Surgery of the Emory University School of Medicine

 

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EUH ICU pilots new patient monitoring system

Dr. Tim Buchman in the ICU.
Timothy Buchman

In an effort to streamline the often-overwhelming barrage of data that has traditionally tracked patients’ conditions and vital signs in the ICU, and to be better equipped to use that data to foresee patient complications, the Emory University Hospital ICU is using a new patient monitoring system that could allow clinicians to acquire, analyze, and correlate medical data at a volume and velocity that has never before been possible.

The project falls into a major data movement in healthcare, with companies trying to make better use of the vast amounts of information in medical records, hospital monitors, and other sources.

The research application developed by Emory uses IBM's streaming analytics platform InfoSphere Streams with Excel Medical Electronics’ bedside monitor data-aggregation application to collect and analyze more than 100,000 real-time data points per patient per second. The software developed by Emory then produces patterns that create an overall picture of the patient's health, and identifies patterns that could indicate serious complications like sepsis, heart failure, or pneumonia, aiming to provide real-time medical insights to clinicians.

Dr. Timothy Buchman, director of the Emory Center for Critical Care, initiated the evaluation of this new system. He hopes that by creating a more coherent picture of patient readings, physicians will eventually not only be able to have a clearer understanding of how each patient is doing, but also detect possible complications and thereby prevent them.

One of the challenges of developing the system is to make it relatively simple to both learn and use. "We're just at the point of accessing the data. There's a lot of work to be done to develop that visualization. But that's the goal. We want to free up the minds of doctors, nurses, and other caregivers. We want them to be able to focus on the patient, not the computer," he says.

Dr. Buchman is aware that his work involves prototype technology. He acknowledges that the evaluation is in its early stages, and that it will probably be about two years before Emory can begin studying how well patients do under the new monitoring system compared to patients with more conventional care.

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WIG creates iPad app to teach patients how to "Come Clean"

Screen shot from Come Clean surgical site infections app.

Healthcare-related infections are the frontline of an ongoing battle that impacts both patient safety and cost effectiveness. Emory's Wound Infection Group (WIG) was formed in January of 2012 to reduce a major sub-set of this problem: surgical site infections, considered the second leading cause of nosocomial infections.

"The group's members include surgeons from general surgery, acute care surgery, surgical oncology, colorectal, vascular, plastics and urology; anesthesiologists; infectious disease and infection control specialists; preoperative nursing and floor nursing; coders, administration (coordinators), medical students, a CDC liaison, and residents," says WIG chair and general surgeon Dr. Joe Sharma.

Screen shot from Come Clean surgical site infections app.

WIG's agenda involves all aspects of patient care—from preoperative visits and perioperative counseling to intraoperative issues and post-op care, even to coordinating with facilities management to monitor and increase the operating room temperature.

"All of our collected data is fed into the National Surgical Quality Improvement Program (NSQIP) national database," says Dr. Sharma. NSQIP's prospective, peer reviewed database quantifies 30-day risk-adjusted surgical outcomes derived from data submitted by its enrolled hospitals, thereby allowing the hospitals to compare outcomes. "Then we get quarterly/semiannual report cards. From these we extract areas needing improvement and implement associated checklists. We are now seeing an improvement in surgical site infections due to the OR checklist and WIG-led protocols."

In addition to the checklist, WIG recently launched the educational iPad app Come Clean: Stop Surgical Infections Before They Start in pre-admissions testing. "The app is intended to educate patients on wound care, how to reduce their risks for surgical site infections, and to empower them to be their own 'champions'," adds Dr. Sharma.

The app addresses such imperatives of infection control as proper hygiene procedures prior to surgery. The risk for exogenous spread of infection to surgical wounds from the patient's own skin flora can be reduced radically through a preoperative whole body wash at home with chlorhexidine soap. The app gives clear, easy-to-follow instructions about the precise steps that must be followed for the wash to be effective. In addition to a properly-administered shower, the app instructs patients on how to "come clean" to surgery by eliminating smoking and controlling their blood sugar in the days leading up to entering the hospital.

Colorectal surgery pre-op protocol also includes a chlorhexidine shower the night before surgery, followed by another the next morning. "The app is shown to all colorectal surgical patients," says Rebecca Layson, nurse clinician at Emory University Hospital Same Day Surgery. "We are also showing it to some surgical oncology patients who are having large abdominal surgery. The patients initially view the app in the doctor's office and watch it again in pre-admit testing."

General surgeon Dr. Carla Haack led the creation of the app content and appears in the audio and video portion, and Michael Konomos, lead multimedia developer for the School of Medicine, designed the app and created the illustrations. Dr. Sharma and chief quality officer Dr. John Sweeney provided careful review and input. Stephen Wheat, chief information technology architect of the Emory IT Architecture Group, and members of his team helped to operationalize the app. "The Wound Infection Group was very supportive and provided great feedback along the way," says Mr. Konomos. "This was truly a cross-disciplinary effort."

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Dr. David Kooby
David Kooby
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Dr. Shishir Maithel
Shishir Maithel

Two Emory studies featured in Annals of Surgical Oncology

Emory surgical oncology faculty were coauthors of two high-profile studies published in the October 2013 edition of Annals of Surgical Oncology. Both studies examined the ability of controversial techniques to enhance patient survival.

"Impact of adjuvant radiotherapy on survival after pancreatic cancer resection: An appraisal of data from the national cancer data base," which was listed on the journal's cover, analyzed the impact of adjuvant radiotherapy on overall survival (OS) for pancreatic adenocarcinoma (PDAC). "We wanted to take steps towards resolving the issue of whether or not this treatment is effective," says first author Dr. David Kooby, associate professor of surgery at Emory and director of surgical oncology at Saint Joseph's Hospital. "Patients will clearly benefit from widening the options generally accepted by physicians for treating PDAC."

Dr. Kooby's coauthors included seasoned Emory oncology investigator Dr. Theresa Gillespie and members of the Rollins School of Public Health, Emory Transplant Center, and Department of Radiation Oncology.

Using the National Cancer Data Base (NCDB), the team queried 11,526 patients with resected PAC from 1998-2002 who had received either adjuvant chemotherapy (ChemoOnly), adjuvant chemoradiotherapy (ChemoRad), or no adjuvant treatment at all (NoAdjuvant). After applying a novel method of propensity score matching to analyze the data, the team found that ChemoRad had the best OS in comparison with ChemoOnly and NoAdjuvant, thereby concluding that radiotherapy should be a component of adjuvant therapy for PAC.

"Is it time to stop checking frozen section neck margins during pancreaticoduodenectomy?" weighed in on the debate concerning whether or not additional pancreatic neck margin should be removed at pancreaticoduodenectomy (PD) for PDAC when a tumor-positive frozen section (FS) has been detected.

"The utility of reacting to the presence of cancer in the margin by resecting even more of the neck has been deliberated by experienced surgeons for several years," says coauthor and Emory surgical oncologist Dr. Shishir Maithel; additional coauthors were senior author Dr. Kooby and other Emory cancer surgeons, pathologists, and postgraduates. "In terms of quality, patient welfare, and cost, it's important to know if removing additional pancreatic tissue at the time of Whipple surgery is appropriate, as it appears from these results to yield no benefit to the patient."

All patients (382) who underwent PD for PDAC at Emory from January 2000-August 2012 were identified and classified as negative (R0) or positive (R1) based on final neck margin. In addition to neck margin classification and removal of additional neck margin, the impact of factors such as tumor size and grade were considered on OS. The authors found that while positive margins were connected to poor survival, they also observed that extending neck resection did not appear to improve OS. A multicenter assessment of this finding is in progress.

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Lisa Carlson
Lisa Carlson

Refurbished Surgery Research Administration Team ready for current funding climate

2013 Surgery Research Admin Team
Front row, left to right: Shundra Holcombe, Millicent Scott, Gina White, Tracey Obertone, Yasmin Ali. Second row, left to right: Caroline Clear, Kristin Onken, Blake Harrington (behind Kristin), Alex Bean, Wayne Morris.

"Today's research funding environment is more challenging than ever before. Low paylines require far more grant proposals than in the past to maintain a consistent level of funding," says Lisa Carlson, director of academic affairs for the Department of Surgery and leader of the Emory Surgery Research Administration Team. "To meet the challenge of keeping this pace, and to sustain the progress the Department has made in creating one of the most diverse and robust research portfolios in the country, the research admin team has restructured and retooled."

Completing the sequence of steps required to prepare a solid proposal can be overwhelming, and the pre-award component of the admin team is available to support any Emory Surgery faculty member with the intricate process of routing grant proposals. Senior research financial analyst Yasmin Ali, who came to the pre-award service in 2010 after nine years working in pre- and post-award areas for the Dean's Office of the School of Nursing, has been joined by new members Alex Bean, Tracy Obertone, and Millicent Scott. Alex received an undergraduate degree in finance from Howard University and has several years of healthcare-based accounting and finance experience; Millicent was an assistant director of finance with the Global Campus Division of TROY University; and Tracy, a 24-year Emory veteran, earned her PhD in genetics and molecular biology here and has managed labs in several departments including Neurology and Biochemistry.

To ensure an informed understanding of how funding issues and variables are affected by particular disciplines, the post-award staff are pre-assigned to specific divisions, programs, or faculty. Business manager Kristin Onken, who came to the Department in 2010 from Emory Dermatology and recently received CRA certification, focuses on grants in the division of transplantation and awards to Dr. Timothy Buchman and Dr. Linda Cendales. Joining the group after receiving his MPH in health services management from the Rollins School of Public Health, Blake Harrington works with the division of general and GI surgery and the Emory Surgery programs based at Grady Memorial Hospital. Shundra Holcombe does post-award management for the Cardiothoracic Research Laboratory (CTRL) and the divisions of cardiothoracic surgery, pediatric surgery, and plastic surgery. Shundra's Emory experience includes working for the departments of Dermatology and Neurology and doing financial reporting for The Emory Clinic. Pre-award member Alex Bean also has post award expertise and works with the divisions of vascular surgery and oral and maxillofacial surgery and the departments of Otolaryngology and Urology.

Caroline Clear, Wayne Morris, and Gina White work outside of the pre- and post-award team designations. With a resume that includes working in hospital finance solutions at The Advisory Board Company, Caroline focuses on the project implementation efforts associated with the Department's complex federal contracts with the Centers for Medicare & Medicaid Services and the Department of Defense. Gina and Wayne perform a variety of pre- and post-award functions, ranging from clinical trials invoicing and reconciliation to the various protocols required by the Institutional Animal Care and Use Committee (IACUC).

Any faculty member who has yet to initiate a relationship with the Research Admin Team and is uncertain of where to start is encouraged to contact Lisa at 404-712-4807, lisa.carlson@emory.edu.

Surgery Research Administration's intranet site at www.ourehc.org/departments/surgery/surgery_research_administration is also an excellent resource, containing such information as grant routing instructions, descriptions of the clinical trial submission process and IRB approval, and team contact information.

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Dr. Delman in the OR.
Keith Delman

Dr. Delman receives 2013 Dean’s Teaching Award

“We thank you for your service to the education mission of the School and know that you will continue your important work in educating society’s future physicians and health care providers.” – excerpt from the Dean’s Office letter congratulating Dr. Delman

Recipients of the Dean’s Teaching Award are nominated by colleagues and students and chosen by the Teaching Awards Committee for their superior teaching of medical and allied health professions students and their many contributions as course directors and mentors.

Dr. Keith Delman began serving as associate program director of the general surgery residency in 2006, and was appointed full program director in 2011. He has presided over a highly productive period for the program and such accomplishments as the American Board of Surgery’s approval of the department’s Global Surgery Program for resident rotations in Ethiopia; the initiation of the Emory residency's participation in the national Flexibility in Surgical Training pilot; and the implementation of the Quality In Training Initiative (QITI), a multi-institutional effort to create the first formalized curriculum for teaching residents to apply quality data to their clinical performances.

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Call for abstracts: 13th Annual Surgery Research Symposium

Dr. Allan Kirk with resident Steven Kim.
Dr. Allan Kirk, vice chair of research for the Department of Surgery (left), with resident Steven Kim (right).

The 13th installment of the Annual Surgery Research Symposium of the Department of Surgery will be held on April 17, 2014. The symposium showcases the basic and clinical science work of our students, postdocs, residents, and fellows.

While all trainees in a dedicated laboratory rotation should submit their research, the call for abstracts in both basic and clinical science categories is open to all trainees. All submissions will be considered for both oral and poster presentation. The submission deadline is midnight, January 16, 2014. Notifications will be sent on or before February 27, 2014.

Since the symposium is not a national or regional meeting, previously presented talks are admissible. However, previously published work must fall within the past two years.

The highest scoring abstracts in each category will be selected for a 10 minute oral presentation. Additional highly ranked abstracts will be allotted slots for poster presentation. Cash awards for first and second place in oral presentations in both clinical and basic science categories will be given, as well as awards for the top poster in each category. All winners will be invited to dinner with faculty immediately following the symposium.

Download the official symposium announcement for abstract and submission requirements. Questions or concerns should be addressed to Griselda McCorquodale at gmccorq@emory.edu.

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Dr. Shelly Abramowicz
Shelly Abramowicz

Welcome our new faculty member: Dr. Shelly Abramowicz

Division of Oral and Maxillofacial Surgery

(Assistant Professor of Surgery) Shelly Abramowicz, DMD, MPH, obtained her dental degree and her MPH in 2002 from the University of Pittsburgh, and completed her oral and maxillofacial surgery residency at the University of Florida in 2008. She was board certified in 2012.

After completing her training, Dr. Abramowicz joined Boston Children’s Hospital as a full time attending surgeon. She also served at Massachusetts General Hospital from 2008-2009 and Brigham and Women’s Hospital from 2009-2011.

While serving on the resident selection committee and DMD admissions committee of the Harvard School of Dental Medicine, Dr. Abramowicz received the 2010 Faculty Educator Development Award of the American Association of Oral and Maxillofacial Surgeons.

Dr. Abramowicz will direct the oral and maxillofacial surgery clinic at Grady Memorial Hospital, and will have a secondary appointment in the Department of Pediatrics. Her clinical specialties include pediatric oral and maxillofacial surgery, TMJ dysfunction in children with juvenile idiopathic arthritis, orthognathic surgery, and maxillofacial trauma.

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Upcoming events

EVENT DATE/TIME LOCATION
Departments of Surgery, Urology, and Otolaryngology Faculty Development Seminar Series:
Revenue Cycle and Billing Workshop

Presenters:
Babs Decatur
– Reimbursement Manager, TEC General Surgery Administration
Donna Beaulieu
– Assistant Director, Patient Financial Services, TEC PFS Revenue Management
5:00-6:30 p.m., November 19, 2013 EUH H Wing Education Classroom
Inflammation and Cancer-Associated Alterations in Drug Clearance
Presented by Edward T. Morgan, PhD
– Professor of Pharmacology, Emory University School of Medicine
– Member, Winship Cancer Institute of Emory University
7:30-8:30 a.m., November 20, 2013 C5012, 5th Floor Conference Room,
Winship Cancer Institute of Emory University
Department of Surgery Division Chiefs Meeting 5:30-7:00 p.m., November 26, 2013 EUH Whitehead Room
UNOS Region 3 Meeting Registration 9:30 a.m., Meeting 10:00 a.m.-3:00 p.m., December 6, 2013 Hilton Garden Inn, Atlanta
     
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