Smilow Cancer Hospital Town Hall | March 22, 2023

March 23, 2023

Hosted by Eric Winer, MD, and Lori Pickens, MHA

Smilow Updates and Clinical Announcements: Kevin Billingsley, MD, MBA, FACS, and Kim Slusser, RN, MSN.

The Center for Gastrointestinal Cancers: Pamela Kunz, MD, and Anne Mongiu, MD, PhD.

The Colon Cancer Screening Pathway: Xavier Llor, MD, PhD.

Information

ID: 9721
To Cite: DCA Citation Guide

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00:00All right. Well, welcome, everyone.
00:03I'm just going to go
00:05ahead and share my screen.
00:08Welcome to our. Just make sure I.
00:14For the panelists,
00:15is everyone seeing one screen?
00:17Hopefully, yes. So thank you.
00:19All right. Welcome, everyone,
00:21to our Smilo Cancer Hospital town hall.
00:26I'm Kim Slesser,
00:27vice president of patient services for
00:30Smilo and joined by my dyad partner,
00:33Doctor Kevin Billingsley.
00:34We have a few announcements to
00:37go over and a few highlights,
00:40but the majority of our town hall today
00:42will be our agenda as you see below.
00:45So we have with us Doctor Jensen
00:48Morris to go over some updates on
00:51code policies for the health system
00:53and then our program highlight.
00:56This evening is our Center for GI
00:59cancers and we are very fortunate to
01:02have doctors Pamela Kuntz and Manju
01:06and Chavier Lord with us this evening.
01:10So very excited for them to present.
01:13And then hopefully this month we will
01:15have time for questions and answers.
01:18So start to think about those
01:19questions that you might want to ask.
01:21We we have been trying to make
01:24the agenda a little lighter.
01:26So that we have more time for Q&amp;A.
01:28So there should be plenty of time to
01:30answer any questions that anybody has.
01:36So we always like to
01:37start out with making sure that we're
01:39highlighting things to celebrate and
01:41smilo and then the Yale Cancer Center.
01:44And so on March 19th of every year
01:47that is our day that we celebrate
01:50in the nursing profession,
01:52Certified Nurses Day.
01:53So this is a day where we really
01:56recognize our nurses who have
01:58achieved specialty certification.
02:00So in order to do that,
02:01a nurses generally have to work.
02:04At least two years in that specialty
02:06and then they have to study and
02:08sit for an exam that really
02:10demonstrates their competence and
02:12expertise within that specialty.
02:14So 35% of all of our smilo nurses
02:18are certified in a specialty.
02:20And again, we do have a, you know,
02:23a number of new graduate nurses.
02:25So our our rate of eligible nurses
02:28is even higher than that 35%.
02:30But we want to make sure that we
02:32recognize all of our certified nurses.
02:34Today during this town hall and
02:36we're proud of their commitment
02:38to nursing excellence.
02:39So this was the picture of some
02:41of our certified nurses that was
02:43on social media over the weekend
02:45to celebrate the event.
02:46So thank you to all of our certified nurses.
02:51And before I go on to the next slide,
02:55we don't really have a slide for this,
02:57but it just so happened that today
02:59was also a day that there was a change
03:02in the health system mask use here.
03:06So we thought we would just take a
03:08minute and go over those changes.
03:09So there really are no changes to
03:13patients or employees wearing masks
03:15and clinical or patient care areas.
03:19So we wanted to make sure that everybody.
03:21Knew about the the minor changes
03:24across the health system.
03:25So mass art remain a requirement in
03:27all clinical and patient care areas
03:30and that are accessible to visitors
03:32throughout the health system.
03:34So this obviously includes our lobbies,
03:37our reception areas and waiting rooms,
03:39our hallways and elevators and
03:43charting areas.
03:44Located in the hallways are cafes
03:47and obviously our patient rooms,
03:49exam rooms and treatment rooms.
03:51So masks are still.
03:53Required during all of those
03:55activities and environments,
03:57but masks are optional now when
03:59you are in an area not designated
04:01for patient or visitor use.
04:04And so in general this can
04:06include our auditoriums,
04:07our conference rooms and
04:09closed door charting rooms.
04:11It can also include our lunch or break rooms,
04:14office spaces,
04:15administrative offices and hospital
04:18inter campus and parking shuttles.
04:21This was really a change.
04:23By the health system due to the decreasing
04:26level of COVID-19 transmission in the
04:29Community and an increasing level
04:31of immunity across the population,
04:34we've had mandatory masking
04:36with no change since early 2020.
04:39And again just these minor changes in
04:43non clinical areas and our infection
04:46prevention team and infectious disease
04:48teams will continue to monitor rates
04:50of COVID-19 and if there are significant.
04:53Increases then mass may be
04:56reinstated in all areas.
04:58So we're happy to take any
05:00questions later about that.
05:02There are some nice FAQ's that are
05:07available on the COVID-19 intranet site
05:10for anybody that would that needs it
05:13for their staff or for their own use.
05:17And now I'm going to turn it over to Kevin.
05:23Thanks, Kim. You know,
05:24as many of you are aware,
05:26last week was national Patient
05:29Safety Week and I think we would
05:32be remiss if we had this gathering
05:35today and did not under score
05:38the importance of our collective
05:40commitment to safety for our patients,
05:44not only in our hospital environment,
05:46but in all of our care environments.
05:50And I just wanted to kind of
05:52take a moment to under score the
05:54importance of the work that many,
05:57many people are doing around the organization
05:59to help us make our patients safe every day.
06:03First off, I want to just give a really
06:08enthusiastic hats off and cheers for
06:11our team on NP11 hematologic oncology.
06:14As many of you know they have
06:18joined the thousand day.
06:21Bob, 1000 days without a caudy, so.
06:26Incredible work, you know,
06:29that's physicians, nurses.
06:32ACA's environmental services
06:34truly A-Team effort,
06:36so thank you very much.
06:39I also just want to give a quick shout out to
06:42our quality and safety team here in smilow.
06:44They work with all of us.
06:47They're part of the system,
06:49but they are an incredible group of
06:52professionals under the leadership
06:54of Michelle Kelvey Albert.
06:56I don't want to leave anyone off the list,
06:58but I do want to say a special
07:00thanks to Chloe Shevlin.
07:02Tom Collins,
07:03Maria Mora and I know there are others,
07:06but.
07:06I I just want to recognize the
07:09work that all of you do week in
07:12and week out with all of our teams
07:14to help us make our care safe.
07:19I think this slide is an important
07:22reminder because really being a high
07:25reliability organization is about
07:27creating a culture that supports that.
07:31And all of us continuing to learn,
07:34continuing to learn and our
07:36processes and operations,
07:38continuously examining,
07:39testing and refining,
07:42asking questions and then equally
07:45important is creating, sustaining.
07:47And nurturing a culture of high reliability.
07:51And I think this slide from that IHI
07:55really highlights the number of the key
07:58elements of what HRO culture is about.
08:01And I'm going to call out the 1st that I see,
08:03which is psychological safety.
08:05And that really is about creating an
08:09environment where any or all of us
08:11feels really good about speaking up or
08:14stopping the line when we see or feel
08:18something that we're concerned about.
08:20And I would encourage all of
08:22us to support that environment,
08:25whether you're a nurse,
08:26a nursing student, Med student,
08:28your opinion and your concerns are
08:31important and valuable. And please.
08:35Help us keep our patients safe.
08:40You know,
08:40it's a good time just to refresh all of
08:44our memory on what our champ behaviors are.
08:47You know, our importance,
08:50our emphasis on communication.
08:53Accurate, clear communication.
08:54Usually supported by an S bar.
08:58Effective handoffs.
08:59Meticulous attention to detail using
09:02star moments and star behavior.
09:06Mentoring,
09:06supporting each other to 200% accountability
09:10and that's certainly part of teamwork,
09:13communication,
09:14psychological safety and last but not least,
09:18practicing and accepting a questioning
09:21attitude against tying back to a
09:24sense of safety and accountability.
09:26So again,
09:28just a big note of thanks from Kim myself,
09:33the other Cancer Center in Smilo leaders.
09:36For the work that everyone does to
09:39support the safety of our patients.
09:42Next slide.
09:45So one of the things that I
09:47wanted to spend a few moments
09:50updating our community on is that.
09:54Our system is undergoing growth,
09:57change and development and as
10:00we adapt towards a specialty
10:03driven cancer care enterprise,
10:05we're going to have changes in our
10:08operations and the way we deploy our
10:11providers and our clinicians at different
10:13clinical sites around the enterprise.
10:16And one of the things that we're
10:18trying to do is to make high level
10:22expertise accessible to patients and
10:24families in a way that is close to home,
10:28yet also aggregates the key
10:32elements of specialty driven care.
10:35And to that end we have,
10:38we are we are going to be
10:41reconfiguring our smilo center in
10:44Orange to provide comprehensive care.
10:47For patients with benign
10:49hematology needs and diagnosis,
10:51this is a complex and growing group of
10:54patients and we have found that there
10:58are efficiencies as well as benefits
11:00and care coordination and expertise
11:03in clustering some of those things
11:05together in a centrally located site.
11:08Doctor Joe Lasala has practiced
11:10at this site and done broad based
11:13hematology and oncology for many years.
11:17We're transition will practice
11:19to Guildford on June 12th.
11:21Her hematology patients will either stay in
11:24orange or follow doctor Lasala to Guilford.
11:27Doctor Kelsey Martin will remain in Orange,
11:31where she has a predominantly benign
11:35or classical hematology practice.
11:38And we'll see some of her patients,
11:40particularly malignant hematology
11:41patients at our site in North Haven.
11:45Classical hematology that has
11:47previously been in North Haven
11:50will transition to orange.
11:52So like all change,
11:54there is some anxiety and concern.
11:58Associated with that,
12:00it does mean long established
12:02practices will be moving,
12:04but this is an enormous opportunity
12:07to leverage the collective expertise
12:09of our system and our collection of of
12:12sites and assets really to deliver the
12:14best possible care to our patients.
12:16So I would just ask for people to
12:19be supportive and understanding
12:20as we go through this,
12:22which will be probably one of many
12:24changes as we evolve to a more
12:27specialty driven and integrated.
12:28Organization.
12:31So a big, big round of enthusiastic
12:36congratulations to Doctor Pat Lorusso.
12:40As most of you know,
12:41Pat is our fearless leader of our
12:45phase one clinical trials unit.
12:47This is truly one of the resources that makes
12:50Smilo and the Yale Cancer Center a leader.
12:54This is the center where
12:56we bring truly innovative,
12:58cutting edge therapies into the clinic.
13:01And Pat has been elected to the Presidency of
13:05the American Association for Cancer Research.
13:08She's the president-elect for 2023 to 2024.
13:12The American Association for
13:15Cancer Research is probably.
13:17One of the most highly regarded international
13:21organizations for the oversight and
13:25support of cancer care research,
13:29it largely focuses on the translation
13:32of basic scientific discoveries into
13:35therapeutics, an area of which doctor
13:38Lorusso is clearly an expert.
13:39So it's a big.
13:43Endorsement for Pat's leadership
13:44in this space and a great feather
13:47in the cap for our organization.
13:49So well done, Pat.
13:54So with those updates out of the way.
13:58It gives me great pleasure to kick
14:00over to my friend and colleague, Dr.
14:03Pam Kunz and her team of GI Oncologists,
14:07who will be giving us a program update on
14:09the Center for Gastrointestinal cancers.
14:12So Pam and team, take it away. Thank you.
14:20Thank you, Kevin.
14:21And I hope everyone can see
14:23this slide to start with.
14:24So it's really my pleasure to
14:26represent the Center for GI cancers
14:28and we're going to focus a little
14:30bit on colorectal cancer tonight.
14:32But I hope this slide just really shows
14:35how the breadth of multidisciplinary
14:37care really across across our network.
14:39And it's really been,
14:41I've been here now about 2 1/2 years and
14:43it's been a pleasure to direct this center.
14:46So our Center for GI cancers is
14:48organized in a leadership cabinet.
14:51I serve as the director and we've had some
14:53evolution over the last couple of years.
14:55And again I just want to demonstrate
14:58how this really has brought together
15:01stakeholders throughout multiple
15:02disciplines including medical oncology,
15:05surgical oncology,
15:07radiation oncology path,
15:10digestive diseases,
15:11cancer imaging and and you can see
15:14some other examples we have a.
15:16Mini cabinet that has recently
15:18formed that includes myself as
15:21the Director of Clinical Research,
15:23Mansky as the Director of clinical
15:26director for medical oncology,
15:28Mandar Muzumdar is our
15:30Translational Science director.
15:31In current Shiraga is the
15:33surgical oncology director.
15:35I won't go through all of the names
15:37of our ad hoc cabinet members,
15:38but really it's a fantastic
15:42group of individuals.
15:44Since my arrival,
15:45we have launched 4 key disease
15:47based programs that themselves have
15:49steering committees and these were
15:51really based on existing expertise.
15:54And we are going to focus tonight on
15:56the colorectal anal cancer program
15:58that is led by doctors Michael Cikini,
16:01Chavier your and Anne Manju has
16:03newly joined as a Co director
16:06representing colorectal surgery.
16:08Doctor Chikuni cannot be on tonight,
16:10so I am representing medical oncology.
16:14So I'll remind everybody that March
16:16is colorectal Cancer Awareness Month.
16:18These are some pictures from
16:20across our network and I think Joe
16:22Mendez for a few of these pictures.
16:24Dress in Blue Day was March 3rd
16:27and this was again a really cross
16:30health system effort led by Joe and
16:33the folks in digestive diseases and
16:36a really fun way to both increase
16:40awareness around colorectal cancer screening.
16:44I'm going to pass now to Doctor
16:46Ann Monjeau to talk a little bit
16:49about the national accreditation
16:50program for rectal cancer.
16:52Hi,
16:52thanks Pam.
16:54So
16:55as part of the ACS,
16:56we now have a pathway towards
16:58ex seeking excellence in rectal
17:00cancer care and that's the NPRC or
17:03National accreditation program.
17:04What we know is that cancer outcomes
17:06are better when patients are managed
17:08according to multidisciplinary team care.
17:10And in Europe, in fact when they've
17:13implemented similar programs,
17:14they have seen decreases in
17:16the rate of permanent stomas,
17:18reduce rates of local recurrence and
17:20basically greater delivery of evidence.
17:22Face care on the appropriate
17:24time scale and so that's sort of
17:26the goals of the NPRC program.
17:28They
17:28have sort of three elements that
17:30they look for and that's program
17:32management ensuring that you
17:34have an appropriately qualified
17:35rectal cancer program director.
17:37And we have a wonderful director
17:38in the our division Chief of Colon
17:40and rectal surgery, Doctor Reddy.
17:42They look at clinical services to
17:44make sure that patients receive,
17:46are presented appropriately at
17:47multidisciplinary care and also receive
17:49their treatments in a timely fashion
17:51according to the latest standards.
17:53Old standards of treatment for rectal
17:55cancer and finally quality improvement
17:56using data to improve our efficiency,
17:59looking at how we do and continuing to
18:01standardize our care and improve our
18:02outcomes as we go through the process.
18:04We are in the process of applying
18:06for any PRC accreditation and that
18:08is basically a multidisciplinary
18:10team that comes together to do this.
18:12And that's not only just surgery
18:14or surgical oncology,
18:15but that involves our colleagues
18:17in pathology, radiation oncology,
18:19radiology and medical oncology.
18:22It's a pretty large.
18:23Commitment and we all work together
18:26to create a program where patients
18:28have true multidisciplinary care and
18:30can progress smoothly through it.
18:32So that's
18:32just a little bit about the program.
18:34I'm going to
18:34pass it off now
18:35to Doctor Lord.
18:47Thank you very much and thank
18:48you for having me tonight.
18:49So we're going to talk a little bit
18:51about the colorectal cancer screening
18:53pathway as one of the tools that that
18:56that we've helped develop to really ramp
19:00up our screening efforts here at Yale.
19:04The first thing I wanted to
19:05show you is this, we've been,
19:07we've become accustomed to seeing this.
19:09Graph, that's always been
19:11so encouraging since then,
19:13um, 1980s, mid 1980s,
19:14where we've been seeing this a progressive
19:17decrease in both incidents and
19:19mortality related to colorectal cancer.
19:22So we've been always very happy about that.
19:25But the reality is that over
19:27the last few years,
19:28things have changed a little bit and
19:31now the declining incidence rates have
19:34become confined to the individuals
19:37who are 64 years old and older since.
19:40Rematch 2011 and when we look at individuals?
19:45Who are aged 50 to 64,
19:49these incidence rates have kind
19:51of stabilized,
19:51but looking at the 50 to 54 year olds,
19:54these incidents has started going up
19:57and and the more consistent level,
20:00the individuals that are younger
20:02than 50 have seen an increase
20:05of about an average 2% per year.
20:07So really worrisome trends here and
20:10in fact the diagnosis of people under
20:12age of people under age 55 have doubled.
20:16From 11% in 1995 to 20% in in 2019
20:20and this is very nicely visualized
20:22here in this slide from the uh,
20:25this uh recent publication from the
20:27ACS that looks at individuals by age,
20:31cancer diagnosis by age by per per
20:34100,000 population and in red the
20:37red bars is population between ages
20:40between the 1975 and 79 and the green
20:43ones between 2015 and 2019 the more recent.
20:46As you'll see there's a big difference
20:49in in the earlier years we would
20:53see this progressive increase in
20:55incidence as we are getting older.
20:57Yet when we're looking at the
20:59more recent studies,
21:00more recent population we see is
21:02that this is pretty much similar,
21:04all these bars are similar.
21:05So really seeing this this disproportionate
21:08increase among the younger individuals.
21:10So definitely that's been that
21:12is being a concern and that again
21:15has changed the narrative.
21:17That we the the very optimistic
21:19narrative that we had been seeing
21:21over the last 30 years or so.
21:23And on top of that we've also seen an
21:26increase on the percentage of cancers
21:29that are regional or distant we've come.
21:32We've moved from 52% in the mid
21:352000s to a 60% in 2019 and that's
21:39mostly due to these in individuals
21:43ages 20 to 49 and the 50 to 64.
21:47So again,
21:48more on that worrisome trend
21:50of younger individuals and more
21:52advanced stages at diagnosis.
21:54So with some of these data that we've
21:57been seeing for a while already,
21:59the the American Cancer Society
22:02Commission Modeling Group to really
22:05try to figure out if that would warrant
22:08to increase to start colorectal
22:11cancer screening at an earlier age
22:13and the through the modeling they
22:16really have concluded that actually.
22:18Screening or average risk persons between
22:20the ages of 45 and 75 would reduce
22:23mortality from colorectal cancer with
22:25an acceptable risk as measured by number
22:28of colonoscopies for life years gained.
22:30So that kind of like that was the
22:33first group that really positioned
22:35themselves to really move the screening
22:38for average risk individuals to a 45,
22:41the USPSTF Commission that pretty much
22:43the same modeling and again it's it's the
22:46modeling that they've used in the past.
22:48But what they did is they updated the
22:51information on the recent trends of the
22:53earlier onset colorectal cancer and
22:55they came up with the same conclusion.
22:57And in 2021, May 2021,
23:00they came up with this great B
23:02recommendation of starting screening
23:05rate screening for average average
23:08risk individuals at 45.
23:10And all other societies have
23:13really endorsed these.
23:14And I think that we're all pretty
23:16much on the same page regarding this.
23:18Move to a earlier screening age.
23:22So where are we standing in terms
23:24of screening?
23:24This is national data and I'm
23:27going to show our own data here and
23:30basically looking at the national
23:31data by 2021 what we had is.
23:34That.
23:3758% of the population ages 45 to 75 are
23:42up-to-date with colorectal cancer screening.
23:45Only 20% are up to date on the
23:4845 to 49 age group, which is not
23:50surprising provided that we basically,
23:52it's been only a couple of years since
23:55this has been widely recommended.
23:58But what's really should be a little bit
24:01more surprising and not so nice to say is
24:03that only 50% and that's pretty consistent.
24:06Only 50% of the 50 to 54 are up to
24:09date with screening and this has been a
24:12recommendation for the last 30 years, so.
24:15That for 30 years we've
24:16recommended to start at 50,
24:18but we are not able to to really get
24:21to those levels in this population.
24:24And probably there's been a lot of
24:27wondering about what the fact is.
24:29But there's this described like if effect
24:31which is that we start talking to people
24:34at age 50 and by the time they really
24:36make the the decision getting screened,
24:39we're getting already too
24:41old and older than 50 to 54.
24:44And as we've seen by that time,
24:47many of those patients may have already
24:50have developed colorectal cancer.
24:51So we really have to make a push here.
24:53When we look at our own data,
24:55not extremely different.
24:56This is data from February 28th,
24:583 day, several days ago.
25:0158.4 of our patients are up
25:03to date with screening.
25:04And among the youngest individuals,
25:0833% among among the 45 to 49
25:12and 51.8% among the 50 to 54.
25:15So certainly a lot of work to
25:18be done particularly with this
25:19worrisome trend and and our very
25:22still very low levels of screening
25:24among the younger individuals.
25:26And beyond these younger individuals
25:30there are other groups that are have
25:32screening rates that are less than 50%,
25:34particularly Asians and Hispanics,
25:36people with less than high school
25:39diploma education levels are very
25:42well related to screening rates,
25:44Medicaid and uninsured patients.
25:45Have the lowest levels of screening
25:48to individuals who migrated to the US
25:50less than 10 years ago and individuals
25:52with lower income levels in general.
25:54Those all have levels that are below
25:5750% and those will really require our.
26:01Special efforts to really try to
26:04get them to a more palatable level.
26:07And as we've seen with with the need,
26:11the growing need for more colorectal
26:14cancer screening,
26:15here I'm just showing up the newly
26:18eligible population 45 to 4049 and
26:20what that would represent if we were
26:22to do colonoscopies for all of them,
26:24that would increase that to close
26:26to 18 million extra colonoscopies.
26:29So certainly it's extremely doubtful.
26:31The US is prepared to handle screening
26:35in the way that we've been handling
26:37it which which is through colonoscopy.
26:39And so I think we all realize about
26:42that and on top of that data is strong
26:45enough that there are other options
26:47that are being endorsed that do have a
26:50good data regarding their effectiveness.
26:53And beyond colonoscopy we have
26:55CT colonography we and we
26:57have stool based test speed and and multi
27:00target stool DNA and we also know that.
27:02Multiple screening options,
27:04having the possibility to have more
27:07options does increase the screening rates,
27:10but at the end of the day we'll really
27:12what we really have to learn is to
27:14figure out how we manage all these
27:17possibilities with these options for
27:19screening and how we better utilize
27:21our resources and so how do we
27:24choose among these different options.
27:26And and how do we make those shared decision,
27:29shared decision making with our patients.
27:33I think that's going to be critical
27:35and and part of that will rely
27:37also on risk stratification.
27:39And I think we are all in agreement
27:41that we would really make sure
27:43that screening happens among the
27:44highest risk through colonoscopy.
27:46But then we do have options for
27:49the other tests that have also been
27:51shown to be a very useful test.
27:53So I'm going to stop here and and.
27:55Yeah.
27:56We'll run the short 2 minute video
27:58that kind of summarizes the colorectal
28:01cancer screening pathway that's been
28:03built along with primary care providers
28:05and and a lot of different people.
28:08The basically what he's trying
28:10to do is really help people walk
28:12through the process on who,
28:14who better qualifies for the
28:16different tests and what,
28:17who's better suited for everyone.
28:19And also from there the capability to
28:22really place the orders and have all
28:24the information from the pathway directly.
28:27Without having to go to anything,
28:28any other places to really go
28:30through that whole process.
28:31So it will show you the video
28:33and then we can talk about it.
28:41The care signature colorectal cancer
28:43screening pathways were created by
28:45Yale New Haven Health system experts
28:47in alignment with the most recently
28:49released guidelines and evidence
28:51to provide a resource tool for
28:54providing best practice care while
28:56discussing screening with patients.
28:58You can find the care signature
29:01pathways by going to the pathways tab
29:04while within a patient's encounter.
29:06To get to the colorectal cancer
29:09screening pathways,
29:09you can scroll or simply type in
29:12a ski search term including CRC or
29:14colorectal to find the pathways.
29:23The initial screening pathway
29:25is for patients who have not
29:27had colorectal cancer screening
29:30previously and identifies patients
29:32who should be offered screening.
29:35And those who should not
29:37be offered screening,
29:39and also populations where screening
29:40should include a discussion
29:42of the risks and benefits.
29:47Patients who are at high risk for
29:49colorectal cancer are identified and
29:51specific screening guidance is provided.
30:01For average risk patients,
30:03the focus is on a shared decision
30:05making model where the best
30:07screening test for that patient is
30:09the one that they will complete.
30:11Advantages and disadvantages are noted.
30:18As well as sensitivity and
30:20specificity of the available tests.
30:25A smart phrase has also been created
30:27that can be used to document your
30:30shared decision making conversation.
30:32There are also some various educational
30:34tools available to provide to patients
30:36which may aid in your discussion
30:38and in their decision making.
30:46Once a shared decision has been made.
30:49Simply click on the link for
30:51the preferred test to place the
30:53order for that test in Epic.
31:00You'll notice that some of the
31:02information has been prefilled to
31:04aid and efficiency whenever possible.
31:15We have also created pathways to help
31:17with clinical decision making for
31:19patients who had who have had previous
31:21negative colorectal cancer screening.
31:31And also a pathway to help guide and
31:35set expectations and next steps for
31:37patients who have had abnormal screening.
31:52If you have feedback about these pathways,
31:54including suggestions on how to improve them,
31:57click the feedback button and
31:58send you to send your suggestions
32:00directly to the care signature team.
32:03All feedback is appreciated.
32:17So Pam and team, thank you for this
32:21overview of what is really one of our
32:26our outstanding programs and it is,
32:28it's terrific to see the disciplines
32:31coming together to deliver these services
32:33and I know that this presentation
32:36just barely scratched the surface.
32:39I think we will see if there are any
32:43questions from from our our virtual
32:46audience before we go on to doctor
32:49Morris's update on code status and
32:52while we're waiting for some to come in.
32:55I'm going to take a little bit of
32:58moderators privilege and kind of kind
33:00of ask this question and and it's
33:03it's not an easy question so I I don't
33:06expect a straightforward answer but.
33:09And maybe I'm Javier.
33:11This is probably mainly for you,
33:13but I I'm struck by the fact that.
33:18Colonoscopy remains a uniquely
33:21effective and significant tool because
33:25it is not only early detection,
33:29but it is a powerful prevention modality.
33:34And as much as I would love to see deeper
33:38penetration of the other screening
33:41tools because I think they will be
33:44more accessible and they are probably
33:47our pathway forward in terms of.
33:49Broadening the access for early detection,
33:53how do we,
33:54how do we as clinicians reconcile
33:57what I think is a is a as is a bit
33:59of a disparity in the benefit that
34:02patients get colonoscopy versus
34:04other screening modalities.
34:06Does that make sense?
34:08Yeah, yeah, I think we all
34:11struggle with this concept.
34:12I think that at the end of the day where
34:15we have to go to back to is the data and
34:17the data has been very consistent that.
34:19We've decreased mortality with all
34:21these other options and that's
34:23why they are being endorsed.
34:25So and and there are a lot, a lot of aspects.
34:29Some people just don't want to go
34:31for a colonoscopy and we've been
34:33for the longest time ignoring them.
34:35It's like you're due for colonoscopy,
34:36boom ordered and then they don't show
34:39up because some people have fear,
34:41some people think this is
34:42way too overwhelming.
34:43So having none.
34:46Says that are not colonoscopy
34:48based is really able to just get
34:51a population to to to really get
34:53tested otherwise they would not
34:55be getting getting that tested.
34:58It's no small thing also to identify
35:00early lesions versus more advanced
35:02lesions and stool based tests and
35:05and cynical and ography have shown
35:07capacity to the to do that to again I
35:10think that it's when we take things
35:14to a population level that's when
35:16you really see the role of all these.
35:18Things,
35:19but I think it's also honest to say
35:22that we have to look at resources
35:24and colonoscopy is not an infinite
35:27resource in our environment.
35:29And with this new huge amount
35:31of new patients who are going to
35:34be eligible for screening,
35:36there's been no way that with our
35:38current environment will be able to
35:40screen everyone through colonoscopy,
35:41even if they were enthusiastic,
35:44all of them enthusiastic about
35:45having colonoscopies.
35:46So I think it's just looking at
35:48reality having a population.
35:50Have that level based approach
35:51and we really have to like try to
35:54reconcile all these thoughts that
35:56I think we're all sharing.
36:00Kevin, can I add just one thing that
36:02sort of ties if some of this together.
36:05I'll just mention that there are broad
36:07coordinated efforts to try to educate both
36:11our physician community and our patients.
36:13And we've done a number of those
36:16this month through CME one,
36:18I know CHAVIER has been participating in
36:21many of them, but through partnership
36:23with our primary care physicians,
36:25I participated in one of those and
36:28in addition with kind of a patient.
36:31Related SMILO shares so I think some
36:33of this is getting the message out
36:35about all of these different screening
36:38modalities and my a disclosure my
36:40husband's a gastroenterologist so I
36:42sort of drink the kool-aid and and he
36:44says you know any screening is better
36:47than no screening and and I think
36:49that that's really the take away as
36:51we try to really advocate for them.
36:58So Doctor Manju,
37:00you were a gifted communicator.
37:03Do you have any tips for this audience,
37:06who all have families, friends,
37:09loved ones and community contacts?
37:13Any talking points to help
37:15get people in for screening,
37:17particularly as we know younger
37:19people are at more risk than
37:21we ever think and that can
37:23be a hard audience to reach.
37:25How do we get over the ick factor?
37:29And your and
37:29you're asking the colorectal surgeon
37:31who chose this as a profession?
37:37I mean I think one of the things I I talked
37:39to my own patients about is that I have
37:42done a colonoscopy and it's not awful.
37:44And you know I think one of the things
37:46that we do need to highlight before
37:48people in their head think about their
37:50parents and that four leader thing
37:52of go lightly which is horrible and
37:54we have so many alternatives to prep now,
37:58some that are tablets, some that are
38:00so much better than anything we had
38:02before and I think actually telling
38:03them that you know. Helps a lot,
38:06but also saying we lead by example as
38:08physicians ourselves that we have gotten
38:11age appropriate screening and that
38:13you know we have information for them
38:15about alternatives to colonoscopy.
38:18Just so again any screening and I
38:19think that's the most important thing.
38:21If that's the foot in the door
38:23that they are scared and we know
38:24that we have a lot of patients
38:26who are scared and they don't,
38:27they'd rather look the other way
38:29because they're worried about something
38:30rather than get invasive tests while
38:31this might be a foot in the door.
38:32And so I always say try to get
38:34them to do something.
38:35If we start with fit or Cologuard
38:36just to get them tested so we can
38:38maybe catch something that was
38:40already quite large in a young patient
38:42that no one would have screened.
38:43You know that 37 year old or 27 year old
38:46medical student who's having some bleeding,
38:48you know,
38:48we might be able to catch something
38:50there when no one would be looking
38:51for something and we have all
38:53seen that patient before.
38:57Thank you, doctor Manchu.
39:01I think why don't I,
39:03I think I'm going to have us go on
39:06to doctor Morris's presentation and
39:08then we'll have a bit of a Q&amp;A at
39:11the end that will be broad based.
39:14Doctor Morris needs no further introduction.
39:16She's our esteemed director of
39:19our Smilo hospitalist service and
39:21our go to person for all updates
39:24related to inpatient policy,
39:26procedure and clinical management.
39:28So thank you, Doctor Morris.
39:31Thanks, Kevin. You guys can hear me
39:34and see slides, OK, getting the nod.
39:36That was such impressive
39:38work from the GI Group.
39:40I learned a lot in that short presentation.
39:42Thank you. I am going to speak briefly
39:45about the new code status order set.
39:49This all went live yesterday.
39:53This is critically important,
39:54not just for our inpatient clinicians,
39:57but our outpatient staff as well,
39:59because we know that a lot of advanced
40:02care planning happens on the outpatient
40:05side and we do need it to translate
40:08into the inpatient side and vice versa.
40:11The reason we are we changed code status
40:15orders is that every hospital in the Yale
40:19New Haven system until yesterday had a
40:22different way of documenting code status.
40:25And as all of you know,
40:27we frequently accept transfers
40:29from other hospitals within our
40:32system and there can be confusion.
40:34And unfortunately, there have been
40:37errors in providing the wrong code.
40:40Treatment ACLS,
40:41treatment for patients based on some
40:43of the differences in how we document.
40:46So this is a standardization.
40:49Now, there are essentially
40:512 important code statuses.
40:53There is no longer a menu of choices.
40:56You can be full code or you can be no code.
41:01You may remember if you've worked
41:03on the inpatient service before,
41:04that it used to come up with a menu.
41:07You could have pressors,
41:08you could be intubated or not intubated.
41:11You could go to the ICU or not.
41:12You could have Bipap or CPAP or not.
41:16And it was not only confusing.
41:19But impractical and unsafe,
41:21you can now be full code or no code.
41:25Now this is really important.
41:27When you go into the code status order,
41:28there is a code status that
41:31says Defibrillation only.
41:32This only applies to the Cath
41:35lab and the cardiac ICU.
41:37These are for patients who have
41:39essentially frequent runs of Vt and they
41:42actually are getting shocked frequently.
41:44And they might choose to be Defibrillation
41:46only for the rest of the hospital,
41:48which means all of us.
41:50It's full code or no code.
41:53And this code status comes into effect the
41:56moment you are in cardio pulmonary arrest.
41:59So the moment your patient is pulseless,
42:02this code status is either full or no code.
42:06So this is what the order now looks like.
42:09You you can choose full code,
42:12discussed with the patient,
42:14verified with the attending,
42:16and you would accept that.
42:18You'll see there's no menu, simply full code.
42:22No code.
42:24Same thing.
42:25With whom was this discussed?
42:27Umm, code, status verified,
42:30full documentation and medical record.
42:32Again, no choices.
42:34Full code or no code except enter.
42:38Defibrillation only as I mentioned,
42:41only in bright red you will
42:44see Cath lab or cardiac ICU.
42:46In fact there if you are a resident at Yale,
42:50New Haven Hospital or when other
42:53hospitals within our system,
42:54you cannot even enter this order.
42:56This can only be ordered by an
42:59attending or designated APRN.
43:01So truly I bring this to your
43:03attention for awareness.
43:04You will never use it.
43:07Here are code status indicators.
43:09This is a change.
43:11So as of yesterday on the patient storyboard,
43:14that's the left side of your epic screen.
43:17Green bar, full code purple bar,
43:21no code pink bar, defib only.
43:25No bracelet. Full code.
43:29Purple bracelet, no code.
43:31Striped bracelet.
43:32That's sort of stripe that think
43:34of all the Vt that's happening.
43:36That's defib only.
43:37We will never see that.
43:39So it's either no bracelet or purple
43:42bracelet for your code status indicators.
43:45Alright, now you say,
43:47but what about the patient who
43:50does have some preferences?
43:52So this is so important for
43:56everyone to understand.
43:58You can be full code or no code
44:01and that is when your heart stops.
44:03You can have a CLS or no ACL S we
44:06know that if you have any version of
44:09modified AC LS you will not survive.
44:12You need to have full ACL S for
44:14your best chance of survival.
44:16So that is all we are offering
44:18full ACL or no ACS.
44:19However we know that there
44:22are critical conditions,
44:24urgent non cardiac arrest conditions.
44:26This is your typical RT situation.
44:29Where there are actually some advanced
44:32care planning decisions patients
44:34might want to have on their record.
44:36For example,
44:37if they have been intubated and they
44:39would like to say no I would not,
44:40I do not want to be re intubated or I
44:44do not want to be intubated primarily.
44:48I will accept cardioversion,
44:50but not Defibrillation,
44:52vasoactive medications, IV fluids,
44:54blood products, etcetera.
44:55Please note that if a patient
44:58agrees to blood products,
45:01they still need a formal consent
45:03even though they've already agreed
45:04in their code status order,
45:06we still consent them just as always now.
45:09If a patient says I do not want
45:12to be intubated,
45:14they cannot on their record have a full code.
45:17It will not allow you to make this
45:20person full code if they've have
45:22a ACL S if they have an urgent
45:25non cardiac arrest treatment
45:26preferences says no intubation,
45:28so epic will not allow a full
45:31code in that situation.
45:33Note that the code status order.
45:36Is a unique order in and of
45:38itself the urgent non cardiac
45:41arrest treatment preferences.
45:43Is a separate order and you would
45:45just type in urgent or non cardiac
45:48arrest and that would populate.
45:50Umm.
45:52And so here in your epic storyboard,
45:54you're here on the left of
45:56your patients chart.
45:57You're hovering over,
45:58you see full code,
45:59but then you also see this yellow banner
46:01that says that there's an advanced care plan.
46:04You hover over it and you can see what the
46:06patient has put in their advanced care plan.
46:08Patients do not need to have an
46:11advanced care plan.
46:12They need to have a code status
46:14if they're hospitalized.
46:15If my colleagues in the outpatient
46:17setting do an advanced care plan,
46:20they enter it into Epic and they
46:21put in a code status,
46:23what will populate when the
46:24patient arrives in the Ed
46:26is it will say code,
46:28it'll say review prior,
46:29which will tell me that
46:31somebody has already entered it.
46:33I need to review it, review it with
46:36the patient and agree to it and it'll
46:38then populate on the inpatient side.
46:41If it says no prior,
46:43then I need to establish a code status de
46:45Novo when they arrive here in the hospital.
46:49This has been done with really
46:51careful thought with multidisciplinary
46:53committee led by ethics.
46:56I am really pleased to see that
46:59we have simplified this and in
47:01all my conversations as I walked
47:03the hospital yesterday,
47:05sort of helping people to
47:07understand the new process.
47:09Universally,
47:10people are thrilled to see the
47:12menu go away and to see it.
47:14Very simple, full code or no code,
47:17and I'm happy to answer questions because
47:19it I know this could be complicated,
47:21I'm going to stop sharing.
47:33So, John, so thank you very much
47:36for this really important overview.
47:43Can you give us any?
47:46Early feedback on and maybe it's too,
47:49too early for these conversations, but.
47:54Um, how have patients and
47:57families been responding to this?
48:01Do do do we have any early read on this?
48:05So it is too early the the first step
48:08yesterday morning was all the code statuses
48:10in the hospital had to be re entered so
48:13all the old code statuses disappeared.
48:15We had to re enter all of the code statuses.
48:21I do not think it will change the
48:24discussions that are experienced
48:26clinicians are having with patients,
48:28are experienced clinicians talk about
48:31goals of care in a much more global way.
48:36Let's talk about your disease,
48:37your prognosis. How do you see?
48:41How would you best?
48:42See your life going forward
48:44in a much more global way.
48:46Our very junior providers had a
48:48habit of walking into the room
48:51and saying when your heart stops,
48:53Missus Jones, what would you like done?
48:56Which clearly is not the right approach,
48:58but many of our trainees approach
49:01code status in that way.
49:03And I'm sure you've all witnessed it.
49:06What would happen is our trainees would
49:08get bogged down in the details of,
49:10well, we have CPAP and we have
49:13Bipap and we have pressers.
49:15And it's lovely to remove all
49:17of that from the conversation
49:19because it was never an appropriate
49:21conversation to start with.
49:22And I think those who have these
49:25conversations in a skillful manner
49:26probably address code status at
49:28the very end of the conversation
49:30almost as an afterthought after
49:32we have established patients,
49:34true goals, what they really want.
49:42Thank you.
49:51We just want to remind people
49:52that if you have any questions
49:55about the code order changes or
49:58any of the topics that we brought
50:00up today during the town hall,
50:02please put it in the chat so
50:03we can answer them.
50:14Well, we're waiting.
50:16I'll just make make the comment
50:19that and and amplify a bit on
50:24your point chansa which is.
50:26Well, there are really two points.
50:28One is that I think this underscores
50:32the importance of all of us.
50:34Who are caring for patients throughout
50:36the spectrum of the disease?
50:38Including surgeons such as myself
50:42to begin to have conversations
50:46early and often about framing.
50:49Goals of care choices.
50:52Options and helping patients and families
50:57identify the limitations of these
51:01heroic end of life interventions and the.
51:05Are limited abilities to return people
51:09to a good quality of life if they
51:13have a significant cardiorespiratory
51:16event in the hospital setting.
51:19So lots of ongoing work to do and a lot of
51:26need for us as professionals to continue to.
51:31Develop our own skills,
51:32and I think you alluded to this,
51:35is something that requires
51:37learning and coaching.
51:39These are not straightforward conversations
51:42and I think those of us who have.
51:46Have.
51:47Some years of experience in this arena do
51:51have an obligation to mentor and share.
51:55Some of our lived experience in this regard.
52:02There's a question.
52:05Thank you, bill. And the question is,
52:07is there any concern that the
52:09language no code sounds like the
52:11patient does not have a code status?
52:16Folks on there? Yeah.
52:21I I suppose it could be misinterpreted.
52:28Yeah, so full code means we do full ACL S
52:32and no code means no ACL SI suppose that
52:36is why we need to get this message out.
52:42I think it is a great point.
52:45Maybe it's even something we could
52:47bring back to that to our code.
52:50You know that that multidisciplinary
52:51code team just to because they
52:54might have discussed this jensa,
52:55right and there might be.
52:58This might have been something.
53:00So I think we could bring that back
53:02to them just for feedback to see.
53:03I know sometimes we'll make
53:05when something new comes out in
53:06Epic and we get some feedback,
53:08sometimes we'll change some of
53:09the language based on feedback.
53:11It's very interesting.
53:12I mean it's so new, it just yesterday,
53:15right, just like the master today,
53:17so very new.
53:19So I think I can tell you the reason why
53:23is that different patient populations
53:25have different code protocols,
53:27so we couldn't simply say no.
53:29ACS because it turns out that Pediatrics
53:33does something called pals and then
53:36neonatal has something different.
53:38And so I think that is why they instead
53:41of saying no ALS, they simply said
53:44no code to simplify that language.
53:46But. Yes, I will let our director,
53:50Ben Tulchin know that this was brought up.
53:52Thank you.
53:57Evan, can I ask Jensa question?
54:01So, umm, jensa, you mentioned trainees.
54:04I'm wondering if you can speak
54:06to kind of efforts around kind
54:09of educating our trainees across
54:11the system about this and perhaps
54:14using it as an opportunity to do
54:16some additional teaching around
54:17how to talk about code status?
54:23Such a great question.
54:26So yes, the trainees have been presented
54:30with the new code status changes.
54:34Umm, I am meeting with Mark Siegel,
54:38who you know only has a small oversight.
54:41He has just internal medicine,
54:44but I think I could bring that up
54:46with him just to ask about what
54:49their training is, because I'm not.
54:51I don't know what process they go through.
54:54Most of the feedback we get
54:56is that on oncology is where
54:58they learn that they haven't.
54:59It isn't something they learn on geriatrics.
55:02It isn't something that
55:03you learn on the other.
55:04Rotations.
55:05It's really on oncology that that is.
55:09When they learn
55:10about goals of care conversations.
55:14What are your thoughts, Pam,
55:15in terms of how we can do a better job
55:17when we're on service with the trainees?
55:20Because if, if the primary place
55:22they're learning is on oncology,
55:24then how can we do a better job?
55:28I mean it's, it's a great question
55:30and I think they're really trainees
55:32across multiple specialties.
55:33I think as Kevin was alluding to earlier,
55:37really surgical oncology,
55:38radiation oncology,
55:39madong internal medicine that I think could,
55:43I think this is a really great opportunity.
55:45Anytime you change something,
55:46I think it's a nice time to
55:48really highlight best practices.
55:50I think partnering with our palliative care
55:53teams and Tara Sanft and Communication,
55:55I think this is like a really
55:58great opportunity.
55:59So I I don't the the logistics in
56:01terms of speaking to leaders across
56:03some of these programs I think is a
56:07step but then taking advantage of we
56:09have great expertise in the Cancer
56:11Center and and in palliative care.
56:14I'm going to follow up on that.
56:16I I like this is a great opportunity.
56:18Change is a great opportunity.
56:20I'm going to write that down.
56:27Right. Well, I don't see any other questions.
56:29And it's 2 minutes to the top of the hour.
56:32So I think we could close
56:34for the evening unless Kevin,
56:36do you have any other words?
56:38I, I do want to remind before I turn
56:40it over to you for final words that if
56:43you have topics that you want to see in
56:45town halls or if you have questions that
56:48you want us to discuss during a town hall,
56:52please send your questions
56:54to cancer answers at Yale.
56:55Edu whether it's a topic you
56:57want to see come here,
56:59whether it's a question you want
57:00addressed in a town hall, please do so.
57:03And I also want to remind people that
57:06our distribution lists are always,
57:08ever changing.
57:08So if you get an invitation to a town
57:11hall and you know your colleague or
57:14your staff have not gotten that,
57:16please feel free to forward those
57:19on it is it is so difficult to make
57:21sure that we're reaching everyone
57:23about our town hall, so.
57:25Please ask your ask your colleague
57:28that you that you talked to every
57:32day talk to your staff,
57:33make sure that if they are not getting
57:35these communications about our town
57:37hall like Kevin or myself or Renee know,
57:40we can make sure they get added
57:41to the list and then always feel
57:43free to forward them.
57:45So Kevin,
57:45I'll turn it over to you for any last
57:47words. Thank you.
57:49Thanks to all of our presenters.
57:52Really appreciate the work that
57:54Pam and her team have done.
57:56I know that this was just a narrow.
58:00Tidbit of the very impressive work
58:03that you're doing when all of across
58:06all of our missions and I I I can't
58:11emphasize enough, as I said early,
58:14the importance of bringing.
58:16All of ourselves to our patient
58:19safety work and thank you to
58:21our leaders there and Jensen,
58:23really appreciate your update.
58:24So everyone have a great evening.