From the category archives:

Ask the Expert

Constantine LyketsosTake a trip down memory lane with Constantine Lyketsos, director of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins Bayview Medical Center, who recently spoke at the A Woman’s Journey conference about how memory changes as we age. Read about his talk, which included the relationship between diet and memory, how unnecessary medications affect memory, and best practices for promoting brain health.

 

What is the relationship between diet and memory?

Diet is closely related to obesity and being overweight, and being overweight is bad for the brain. Even if you are overweight and follow a good diet, it still has a negative impact on the brain.

Research shows that following a Mediterranean diet has a positive impact on the brain. This type of diet limits certain kinds of fats and carbs while focusing on fresh fruits and foods, olive oils, fish, etc.

Antioxidants are great for brain health. A few of my favorites include blueberries, dark chocolate and red wine! The best way to consume antioxidants is through your food. Many foods in Mediterranean diets include antioxidants.

Alcohol intake is related to memory, but it is not always about the alcohol’s direct effect on the brain. Injuries that affect memory can occur because of incidents that happen due to alcohol use or abuse. Certain kinds of alcohol, such as red wine, have other substances in them that—when taken in moderation—are healthy for the brain.

Are all medications necessary as we age? How do they affect memory?

My main suggestion is to adapt medication to your age group. What is right for you at age 50 may not be right at age 70. Here are some thoughts on medications for blood pressure cholesterol and bladder control.

Blood Pressure Medications

The general rule for blood pressure is that you want top number below 140 and the bottom number below 90. But what many do not know is that these numbers have been generated for people in their middle ages, so they don’t necessarily apply to people in their 70s, 80s and 90s.

The elasticity of blood vessels lessens as we get older, resulting in our bodies not doing as good of a job at pushing blood flow to the brain. Therefore, regarding blood pressure management in older people, the top number can be as high as 150 or 160. Therefore, older people may not need to be on medication to control blood pressure that would keep it in the 140 range.

Statins

Statins can take up to five or even 10 years to make a real difference in health. Some evidence shows that it is acceptable to have cholesterol in the blood as you get older, into your 70s and 80s. Therefore, it may not be necessary to take statins as you age, especially with the length of time it takes them to really help.

Bladder Control Medications

Many medicines that do a great job of addressing bladder control can badly affect memory. While this is generally ok for younger people and may not cause as much of an effect, people who are 80 and 90 years old have a harder time controlling the medications’ effects on their memory.

Is there one exercise or activity you have found that prevents cognitive aging?

There is no “one thing” that can prevent cognitive aging. By doing just one thing, you only exercise that one part of your brain. For example, you can’t exercise your whole brain just by jogging.

The simple concept is to protect your brain as you age through variety. Variety is not only the spice of life, but it will also promote brain health. The concept of variety is tripartite, just like a three-legged stool.

  • Mental – keep as mentally active as you can
  • Physical – keep as physically active as you can
  • Social – keep as socially engaged as you can

Variety is a balance across these three areas, but also within the areas.

When you retire, you can change your brain health. Since you will no longer be in a consistent environment, you will need to replace the mental, physical and social engagement with something else. You don’t want to drop that high level of activity into something lower or nonexistent. For example, retiring and making no plans other than watching television or racing cars is not healthy for your brain.

Physical activity is important. I read about a study that looked at how exercise affected getting Alzheimer’s a half or full decade later. Results showed a few interesting things related to memory:

  • The more calories burned and the more frequently participants exercised, the lesser their chance of developing Alzheimer’s.
  • It made a big difference for participants to burn calories through a variety of activities.
  • For participants who carried a specific Alzheimer’s gene, exercise didn’t affect the chance of developing or not developing Alzheimer’s.

Mental activity is the second part of variety in keeping your brain healthy. Do things that are relatively challenging that you are interested in and that you can repeat to keep your brain stimulated. Websites like lumosity.com offer interesting brain challenges and puzzles that keep your brain engaged by increasing in difficulty over time.

Social activity is the third part of variety in keeping your brain healthy. This one is pretty obvious; be social!

What are some recommendations to stay brain healthy as we age?

Find a good doctor

Have a good primary care doctor who keeps track of your health over your lifespan and someone who is open to questions. Aside from monitoring weight, cholesterol and blood pressure, a good doctor can identify things that would predict if someone will develop dementia. Something like having a bad health event, such as heart attack, surgery or stroke, are all stress events on the brain, which are shown to be a predictor for developing dementia. Undergoing surgical procedures with limited or no anesthesia (when possible) is also better for the brain.

Focus on sleep

Sleeping well is key: how we live our lives is how we sleep. Invest in your sleep! Figure out a way to personally adjust your lifestyle to develop “good sleep hygiene” by doing things like going to bed and getting up same time every day, not doing other things in bed like reading or watching television, etc. Avoid taking medications to help you sleep, which are generally only meant for short-term use.

A Fitbit or something similar can help you keep track of your sleep patterns and the results may surprise you. I was amazed when I first started wearing the Fitbit of how little quality sleep I was actually getting. It was a wakeup call for me, so I changed my sleep patterns, which made a difference in energy level and interest level.

Good sleep is related to life expectancy; sleeping better attributes to living longer. I define quality sleep as when you feel rested when you wake up in the morning. Adjust your sleep depending on your own needs as you age.

Limit the effects of stress

We can’t avoid stress 100 percent, so limit the effects of stressors in your life by learning a strategy that works for you, such as meditation or yoga. Whatever you choose, choose something that you will actually do and will enjoy doing.

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Kristian Hayes

Kristian Henderson-Hayes, former assistant director of general services at The Johns Hopkins Hospital, shares insight and updates on sustainability measures, past and present, at The Johns Hopkins Hospital. Find out what is being done to win the race against waste and submit your questions for Henderson-Hayes to answer in today's Ask the Expert.

 

Why did sustainability become a focus for the hospital and health system? What influenced you to become involved?

The Johns Hopkins Sustainability Network is the network of students, staff and faculty who are committed to promoting sustainability in their operations and among the larger Johns Hopkins community. As a system, Johns Hopkins understands sustainability as the collection of smart and responsible actions that prioritize people, natural resources, and finances to safeguard the health of future generations. By following the ideals of “First Do No Harm,” we have fostered a culture change by implementing multi-disciplinary initiatives, communicating our success, and sharing best practices to help continue to reduce environmental impacts and to provide for our patients, employees, and local communities.

What has Johns Hopkins done over the past several years to be more environmentally friendly?

There are a variety of ways The Johns Hopkins Hospital has adopted more environmentally friendly initiatives based on reducing negative impacts to the environment and providing healthier options for patients, visitors, and staff. To name a few:

  • Implemented an integrated waste stream solution that focuses on increasing recycling and reducing regulated medical waste (since 2011, we reduced annual generation of regulated medical waste by 57 percent).
  • Introduced a variety of healthier food options for our patients and guests.
  • Implementing meatless Mondays and procuring antibiotic free meats in hospital eateries (currently 60 percent of total meat purchases are antibiotic free).
  • Collaborated with local farmers for our weekly farmers market to try to alleviate some negative impacts of the food industry.
  • Reduced overall sugar-sweetened beverages.
  • Utilized construction methods to build to LEED standards. The Nelson/Harvey building is currently under review by Baltimore City’s Green Stars program (the equivalent of LEED Silver).
  • Introduced a 65,000-square-foot green roof to help reduce effects of water runoff.
  • Invested in cogeneration technology to reduce overall CO2 emissions by 30,000 metric tons in FY14.

How have our sustainability efforts helped our patient care?

Sustainability is specifically aligned with the People and Performance pillars of the Johns Hopkins Medicine strategic plan. In order to reduce current and future health care costs, we focus on our patient, visitors, and employees. The Johns Hopkins Hospital strives to reduce unnecessary exposures by purchasing and applying less harmful chemicals through purchasing supplies and equipment. Some patients and staff are very sensitive to cleaning chemicals typically used in hospitals to clean and disinfect, which may trigger respiratory distress . By utilizing green seal-certified general purpose cleaners when able, we are reducing overall exposure to harmful chemicals. Additionally, use of UV disinfection equipment removes airborne bacteria and viruses, and microfiber mops have reduced overall chemical and water use.

Focusing on foods served in the hospital enables us to offer healthier options while reducing our overall environmental impacts. Reducing the amount of meat served in hospitals provides health, social, and environmental benefits that are consistent with prevention-based medicine. Hospitals can deliver an important preventive health message to patients, staff, and communities by reducing the amount of meat and poultry they serve and by purchasing more sustainably-produced, healthier meats as an alternative. The Johns Hopkins Hospital took a multi-tiered approach, examining all menus to see where meat options could be reduced, increasing vegetarian entrée offerings and implementing a meatless Monday program. The hospital has introduced new sustainable meat products, produced without the routine use of antibiotics. We are also collaborating with distributors and local producers and emphasizing the need for more sustainable meat products on a weekly delivery schedule. Over 60 percent of the meat served at is antibiotic-free, all eggs used are cage-free, and 100 percent of seafood is sustainably-produced.

Of the many measures taken by Johns Hopkins to improve sustainability, which do you think has been the most impactful or successful? Why?

The hospital's operating room (OR) has continued to excel in environmental excellence with the support of the OR Green Team, who has helped segregate recyclables, municipal solid waste and regulated medical waste. Specifically in the OR we collected 5 tons of OR devices for reprocessing. By utilizing a fluid management systems we saved $30,000 on one-time-use supplies such as canisters and solidifier last year alone. With this technology we avoided 10 tons of waste, which otherwise would have been sent as regulated medical waste, a waste stream that’s often 5 times more expensive to dispose of than municipal solid waste. In order to reduce energy consumption, more than 50 percent of our ORs are equipped with LED lighting and more than 85 percent of our ORs have HVAC setback that reduce air exchange per hour when rooms are unoccupied.

What are some ways employees can personally contribute to Johns Hopkins’ sustainability goals?

The first step for employees to personally contribute is to “know where to throw.”

  • All confidential and non-confidential paper should go into Nexcut bins to be shredded and then recycled.
  • All bottles and cans should go into green recycle bins.
  • For more information on our specialty recycling programs such as batteries, eye glasses, furniture, and writing utensils please contact sustainable@jhmi.edu.

The monthly Johns Hopkins Hospital Green Team meeting is held at 12 noon on the second Wednesday of each month. This meeting is open to any and all Johns Hopkins Medicine employees to discuss current and future sustainable programs specific at The Johns Hopkins Hospital. We coordinate guest speakers such as the sustainable partners, our own Wellnet group, Re-form, MD Farmers Market Association, and many more to continue building upon our already multi-disciplinary approach to sustainability.

Another recent program is the Green Office Certification program, a simple 10-minute questionnaire to highlight the sustainable programs currently in place in your individual office. This past week for Earth Week Mr. Peterson awarded the three certified offices. Click here to learn how your office could be the next certified office in November in celebration for America Recycles Day.

Dramatically reducing the amount of regulated medical waste was a huge achievement for the hospital. What are some other goals the hospital and health system is working toward?

A host of successful projects, including presenting at new employee orientation to highlight our organizational sustainability goals, implement regulated medical waste reduction program, recycling over 13 streams, Styrofoam reduction, spreading awareness of impacts of anesthetic gases, zip cars and a farmers market, has earned The Johns Hopkins Hospital their first award from Practice Greenhealth in 2014.

Our goals for FY2015 include applying for additional environmental excellence awards, finalizing our environmental sustainable policy, increase healthy beverages by 20 percent compared to FY14, and continue to spread awareness to continue to fuel the culture change of integrating sustainability into our daily operations throughout the hospital.

If you have any questions or interested to learn more about our sustainable programs, please contact sustainable@jhmi.edu.

 

 

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Donate LifeMore than 123,000 Americans are on the transplant waiting list for lifesaving organs, yet according to Donate Life America, only about one-half of the country’s population is registered as an organ donor. Johns Hopkins has been a leader in organ and tissue transplant innovation for decades and opened the Comprehensive Transplant Center in 1996 to provide patients with the best transplant experience possible. Learn more at hopkinsmedicine.org/transplant or call the center at 410-614-5700.

Read some commonly asked questions about organ donation and transplant, and find out ways you can help save a life, including through social media. Also, read through an interview with Johns Hopkins nurse Clint Burns and his lifesaving liver transplant 20 years ago.

 

Do I have to be a particular age, of a certain ethnic background or practice a specific religion to be an organ donor? What if I am not 100 percent healthy?

There are many common myths surrounding organ donations and what type of person qualifies to be an organ donor. Age, religion, ethnicity, finances and health concerns should never prevent someone from considering registering as an organ donor.

Age: No patient is ever too old or too young to give the gift of life. Newborn babies, great-great-great-grandparents and everyone in between may be able to become an organ or tissue donor. The decision to use a patient’s organs and tissue is based on strict medical criteria, not age.

Religion: All major religions support organ and tissue donation, seeing it as the ultimate act of charity. If you have questions about their faith’s views on donation, you can consult with your minister, pastor, rabbi or other religious leader.

Ethnicity: While transplants can and do cross racial and ethnic lines, donors are more likely to match with someone from their own racial or ethnic background due to genetic similarities. According to Donate Life America, nearly 58 percent of patients awaiting lifesaving transplants are minorities. Therefore, people of all ethnicities can—and should—register to be organ donors.

Finances: There is no cost to the donor or family for organ or tissue donation. Celebrity status and wealth are also never factors in determining organ donors and recipients, a decision based strictly on medical criteria to ensure the organ will go to the person who needs it the most.

Health: Even if you have health issues, your medical history will be thoroughly reviewed to determine if you are a suitable donor. Many people who have diabetes or heart disease have been able to donate organs or tissue. According to Donate Life America, a single tissue donor can save or heal up to 50 people, and one deceased organ donor can save eight lives. Additionally, nearly 50,000 patients have their sight restored each year through corneal transplants.

 

What does it mean to be a living organ donor? Can I live without certain organs?

While part of the end-of-life conversation includes deciding whether or not to become an organ donor, it is becoming more common to donate organs or parts of organs while living. A person who does this is called a living organ donor. Kidneys are the most common organs in a living organ donation. Other organs include a lobe of a lung, partial liver, partial pancreas and partial intestine.

There are several advantages to living organ donation:

  • Shorter wait time for a donor to become available
  • Takes place during a scheduled operation, rather than waiting “on call” for an organ to become available
  • Increased success rates; for example: a kidney from a living donor lasts twice as long as one from a deceased donor

In a video interview, Johns Hopkins transplant surgeon Dorry Segev talks about the science behind living with one kidney rather than two: “Living with one kidney, after donating a kidney, provided that someone is healthy and not destined to get any major diseases, is the same as living with two kidneys. In a study involving 90,000 patients, living with one kidney did not put anyone at excess risk of dying prematurely than with two kidneys.” View the full interview here.

 

If I know someone who needs an organ, can I donate mine directly to them?

This is only possible with living donations; organs from deceased donors will be matched with the national registry based on medical need. Living donors can choose to make a directed or nondirected donation.

Directed Donation: This is when a donor and recipient know each other, though they may not be related and may not be an exact match. The Johns Hopkins Comprehensive Transplant Center developed a method called plasmapheresis, which allows for “nonmatching” donors to provide kidneys to a recipient. Another option is to participate in a kidney swap, where a donor/recipient pair trade kidneys with another donor/recipient pair.

Nondirected Donation: Nondirected donors are also called altruistic donors and often choose to donate based on selfless motives to an unknown recipient.

Learn more about living organ donation at hopkinsmedicine.org/transplant/living_donors.

 

How can we make people more aware about the need to register as organ donors?

Every 10 minutes, another name is added to the national organ transplant waiting list, and each day, 18 people die from lack of transplant. In the United States, 90 percent of the population supports donation, but only about 30 percent know how to become a donor.

In 2012, Andrew Cameron, surgical director of liver transplantation at Johns Hopkins, teamed up with Facebook’s chief operating officer, Sheryl Sandberg, to change these numbers using social media.

A Facebook change in May 2012 allowed users to share their organ donor status with friends and use convenient links to make the status official through a state’s department of motor vehicles website, resulting in a twenty-onefold increase in organ donors in a single day. Read more about this success.

To change your personal Facebook status and show that you’re an organ donor, follow these easy steps:

  • On your personal Facebook page, click “Life Event” in the area where you’d post a photo, a status update, etc.
  • Choose “Health & Wellness,” and then choose “Organ Donor.”
  • Update your information and help spread the word!

 

I’m interested in registering as an organ donor. Do I have to go to a department of motor vehicles office to complete the process?

No, you can register as an organ donor in your state right now by visiting organdonor.gov/becomingdonor/stateregistries. As of April 5, 2015, more than 2.5 million Maryland residents were registered organ donors.

 

What are some recent achievements in organ donation and transplant at Johns Hopkins?

A number of milestones and groundbreaking discoveries have been achieved at Johns Hopkins since the first kidney transplant was performed in Maryland at The Johns Hopkins Hospital in 1968. Here are a few highlights:

  • Out of 48,000 corneal transplants performed each year in the U.S., about 10 percent of them end up being rejected. A recent study showed that tiny nanoparticles applied at the time of surgery can slowly release medicine and help reduce the risk of rejection after eye surgery.
  • A bill signed into law in November 2013 now allows HIV-infected people to donate their organs after death, offering hope to thousands of HIV patients on transplant waiting lists. The bill was based on Johns Hopkins research that showed a significant decrease in the amount of waiting time for both HIV-infected and nonHIV-infected patients on the transplant list.
  • In December 2012, Johns Hopkins physicians performed the first bilateral arm transplant at The Johns Hopkins Hospital and used an innovative treatment to prevent rejection of the new limbs.
  • The use of half-match bone marrow transplants—also called haploidentical—was effective in eliminating sickle cell disease in selected patients during a clinical trial. Read the press release or watch a video about a patient's success story thanks to this groundbreaking discovery.
  • In August 2012, Johns Hopkins established a facial transplant service to help transform the lives of people with severe facial injuries.

 

 

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LisaAllenLisa Allen, chief patient experience officer for Johns Hopkins Medicine since September 2014, speaks on one of the institution’s strategic priorities, delivering safe, quality patient- and family-centered care that that is compassionate and respectful.

Click on the red Leave a Comment to submit a question.

What kind of feedback do we get from our patients about their visit or hospital stay?

Patient experience is measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for inpatients and Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for outpatients. These surveys are mailed to a random sampling of patients after discharge or a visit. The HCAHPS survey covers patients’ perceptions of their hospital stay, such as communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment and care transitions. The results are posted on Medicare’s Hospital Compare website.

On April 15, the HCAHPS survey will switch from reporting the results as a top-box percentage to an easy-to-understand, consumer-friendly five-star rating system, similar to what is used for hospitals, movies and restaurants. Our goal is to always deliver a five-star patient experience. View a brief video about how the HCAHPS survey works.

What resources do we have to enhance the way we care for our patients?

The service excellence and patient experience departments at each hospital are a tremendous resource.  The staff members there are available to help walk you through the survey data and comments to gain a better understanding on what our patients are looking for in their experience.

Some of you may also remember the Language of Caring training that was introduced a few years ago. We are reinvigorating this module-based program that teaches patient-centered caring communication. The topics are: Practice of Presence, Showing Caring Non-Verbal, Explaining Positive Intent, Acknowledging Feelings, Gift of Appreciation, Blameless Apology, and Caring Broken Record.  These modules teach us that even though we are caring people, we can utilize specific tools to help us make our caring known to those we are caring for and working with each and every day.

What are some other simple, practical ways we can help our patients and their loved ones?

When people are in the hospital, they are anxious and scared, and they need to feel listened to and cared for. When you help them feel connected, you can resolve problems earlier or stop them before they even start. Some simple things you can do:

  • Use the 3 W’s
    • Who are you? Smile, introduce yourself (by name and role) to the patient and family members, be courteous and attentive.
    • What are you there to do? Explain what is about to happen and why you are doing what you are doing.
    • Why do you care? Show empathy and partnership.  I want to help reduce your pain level.  I know you want to get home. I am here to help you prepare for discharge.
    • Don’t interrupt. Most providers interrupt within 18 seconds. Listen attentively.
    • Confirm patients understand what you have said; explain using words appropriate to their health literacy; use teach back.
    • Work as a team, always. Talk UP about your colleagues.  “I see you have Dr. X as your surgeon. She is fantastic.”  “This is Joe, he is the nurse taking over your care for the next shift.  I have explained how you are doing and he is a great nurse.”

How can employees find out how our hospitals and other hospitals are rated?

You can visit medicare.gov/hospitalcompare/, type in the ZIP code or name of the hospital in the “Find a Hospital” search box, indicate the hospitals you would like to compare, and hit the “compare now” button.

Johns Hopkins hospitals’ overall ratings ranged from between four and two stars. These scores are based on responses/data collected between July 2013 and June 2014. Five of our hospitals received four stars in one or more of the 11 key areas, with all hospitals receiving four or five stars on patients’ willingness to recommend the hospital.

What can we do to improve our scores?

The only way the scores will improve is if we change the experience. We believe that the efforts we’re making today will improve our ratings in the future. Since the most recent reporting period concluded, our hospitals have implemented several programs to improve our patients’ experience.

Questions?

We will be sharing more information about patient- and family-centered care with you. In the meantime, contact service@jhmi.edu if you have questions.

 

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Andrew CosgareaWith the weather getting warmer and spring sports in full swing, it’s important to stay informed about injury prevention and treatment, especially for school-age athletes. Andrew Cosgarea is the head team physician for the Johns Hopkins University Department of Athletics and a professor of orthopaedic surgery at the Johns Hopkins University School of Medicine. As such, he has seen and treated his fair share of sports injuries.

As today’s expert on sports injury and prevention, Cosgarea invites you to submit your questions about sports injury and prevention in today’s Ask the Expert.

For more information on sports medicine, contact the Johns Hopkins Department of Orthopaedic Surgery at 443-997-2663 or hopkinsortho.org/hopkinssportsmedicine.

For more information on rehabilitation, contact the Department of Physical Medicine and Rehabilitation at Johns Hopkins at 410-583-2665 or hopkinsmedicine.org/physical_medicine_rehabilitation/.

 

In your opinion, what are some of the top causes of sports-related injuries?

Sports injuries generally occur for two different reasons: trauma and overuse. Traumatic sports injuries are usually obvious, dramatic scenes; for example, when we see a player fall down clutching a knee. One of the most recognized injuries is an anterior cruciate ligament, or ACL, tear. Overuse injuries, which are actually more common, are usually caused by pushing the body past its current physical limits or level of conditioning. Poor technique and training errors, like running excessive distances or performing inadequate warmups, often contribute.

What are the most common injuries seen related to the increase in spring activities?

With warmer spring weather, many people head outdoors to ramp up their exercise programs. Runners are prone to shin splints, patellofemoral (knee cap) pain, iliotibial band syndrome (pain on the outside of the knee) and tendinitis. The ankle is vulnerable to Achilles tendinitis. Upper-extremity injuries, such as tennis elbow (pain on the outside) and golfer’s elbow (pain on the inside), also occur frequently during the spring months. Traumatic injuries like ACL tears, ankle sprains and shoulder dislocations often happen in spring sports like lacrosse and baseball.

What preparation tips can you offer to people who plan to begin new activities?

I am a strong advocate for setting goals and working hard to achieve them, but it is crucial that our goals are realistic, achievable and sustainable. Most importantly, we need to allow for adequate time to gradually increase training levels so that our bodies have time to adjust to the stresses on our bones, joints and muscles. When running, increase mileage gradually and give yourself plenty of time to recover between workouts. Alternate running days with other cross-training activities like swimming and biking.

Preparation and planning are very important in staying healthy when choosing a new sport. Research the activity and learn the proper techniques. Classes are a safe and enjoyable way to get started. Most importantly, listen to your body and adjust your activities accordingly. While a mild and short-lived muscle ache is generally considered “good pain,” pain in your joints is not normal and is a sign that you should cut back. And if you have not exercised regularly in the past and are just starting a new program, make sure you discuss it with your primary care provider first.

Are there any nutritional guidelines pre- and post-exercise that you recommend?

Dietary recommendations vary greatly based on the specific needs of each individual. I generally recommend no more than a light snack prior to exercise, followed by a protein source like chocolate milk afterward. Adequate hydration is extremely important, especially as the spring days begin to warm up. As exercise programs become more intense, it makes sense to find a more formal nutritional program.

There are many resources available locally through your primary care provider, a nutritionist or online. One useful approach is the three-level concept developed by the U.S. Olympic team nutrition specialists. Recommended meals are matched to the level of workout intensity—easy, moderate or hard. On “easy” days, athletes eat a nutritious and balanced diet focused on maintaining a healthy weight and making smart food choices. On “hard” days, meals provide the fuel the body needs to perform at a peak level for a sustained period of time, primarily through higher levels of carbohydrates. The guidelines can be found on Team USA’s website.

What can be done to prevent and treat shin splints?

Shin splints are a common type of overuse injury in athletes involved in running sports. Pain is usually over the front and inside of the shin in a relatively broad area, closer to the ankle than the knee. The mainstay of shin splint prevention is gradual increase in training intensity, proper footwear, maintaining good Achilles tendon and ankle flexibility, and cross-training to allow for less continuous high-impact activity. Shin splints are primarily treated with ice, rest and gradual return to sports. Stretching exercises of the calf with the knee straightened and with the knee bent may play a role in prevention and treatment. Formal physical therapy and orthotics may be necessary in cases that are not responsive to initial treatment.

Should injury occur, when is it proper to see a doctor?

The appropriate time to see a clinician is ultimately up to each individual, but here are some good reasons for seeking medical care:

  • Inability to bear weight on the injured limb
  • Sharp pain, swelling or a sense of instability in any joint
  • Pain or swelling that does not improve with rest
  • Numbness, tingling or muscle weakness
  • Persistent pain or dysfunction that prevents you from participating in desired activities

If you have these symptoms, contact your primary care provider or schedule an appointment to see a clinician in the Division of Sports Medicine by calling 443-997-2663. Additional contact information can be obtained on the Department of Orthopaedic Surgery’s website.

What are the keys to the successful rehabilitation of a sports injury?

Patience, persistence and a disciplined rehabilitation plan are the keys to successful recovery. If your initial efforts don’t result in substantial improvement, seek advice from your primary care provider or physical therapist. Most rehabilitation programs will incorporate targeted muscle strengthening and flexibility exercises with gradual return to sports activity after initial pain, swelling and stiffness are addressed.

The Department of Physical Medicine and Rehabilitation at Johns Hopkins has physical therapy offices at several locations throughout the Baltimore area and can be reached at 410-583-2665. Additional information can be obtained on the department’s website.

 

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The Johns Hopkins Armstrong Institute for Patient Safety and Quality oversees, coordinates and supports patient safety and quality efforts across Johns Hopkins’ integrated health care system.

Our quality and safety goals are to reduce preventable harm, eliminate waste, and improve clinical outcomes and patient experiences. Alongside these goals, the Institute of Medicine—the national leader on health practices—has championed that quality improvement efforts should also be safe, timely, effective, efficient, equitable and patient-centered.

Johns Hopkins Medicine quality improvement teams work to ensure that our health system is providing care that aligns with these six aims, and they help us meet our quality and safety goals. This involves reporting progress on certain quality and safety measures and implementing improvement plans where we are providing less than excellent care.

Renee Demski, vice president of quality for The Johns Hopkins Hospital and Health System and the Armstrong Institute, focuses on the effective integration of quality services across the health care continuum for the Johns Hopkins Health System, with the goal of maximizing organizational improvement, efficiencies and the value of clinical services. Tiffany Callender is a quality and innovation project manager with the Armstrong Institute, working closely with hospitals across the Johns Hopkins Health System on quality improvement efforts. She also supports the organization in recognizing and preparing for trends in reporting quality and safety measures.

In today’s Ask the Expert, Demski and Callender share some important information about quality measures across Johns Hopkins Medicine. Submit your questions for an interactive Q-and-A with the experts on patient quality.

 

What are the quality improvement priorities within Johns Hopkins Medicine?

The Johns Hopkins Medicine Strategic Plan incorporates six priorities: people, biomedical discovery, patient- and family-centered care, education, integration and performance. Delivering patient- and family-centered care is the priority under which the quality and safety goals fall.

Goals within the patient- and family-centered care domain change slightly each year to reflect new milestones to improve care and current evidence-based best practices. Some of our fiscal year 2015 patient- and family-centered care areas of focus include:

  • Reducing the occurrence of hospital-acquired conditions and Maryland hospital-acquired conditions, such as pressure ulcers
  • Reducing the number of catheter-associated urinary tract infections
  • Increasing the number of patients who are screened for and appropriately receive venous thromboembolism prophylaxis

Priorities for fiscal year 2016 will continue to reflect areas of focus where we are striving to improve care and meet our quality and safety goals. While improvement projects occur continuously across the health system, Johns Hopkins Medicine’s systemwide effort to strategically improve quality of care and safety measures is supported by the institution’s national leader strategy.

What is the national leader strategy?

In 2012, Johns Hopkins Medicine set the ambitious goal to demonstrate national leadership in patient safety and quality. This decision, made by the Johns Hopkins Medicine Patient Safety and Quality board of trustees and leaders from across Johns Hopkins Medicine, has resulted in a systemwide commitment to meet specific goals to ensure our patients always receive the excellent care they deserve.

The national leader strategy provides a framework by which performance improvement efforts are executed across the Johns Hopkins Health System. The components of the framework and examples of each are:

  • Identify and communicate clear goals.
    • Example: Issue memos from leadership to all staff communicating measures of focus and performance targets.
  • Create infrastructure/build capacity.
    • Example: Launch systemwide work groups to allow hospitals to share areas of challenge and lessons learned in an effort to improve care on a particular measure.
  • Practice data transparency and reporting.
    • Example: Create and distribute a monthly report to regularly communicate performance to frontline staff and leadership.
  • Exercise accountability.
    • Example: Implement a quality and safety accountability plan that tracks performance each month and triggers action where measures are below target. The plan escalates up and is reviewed by the Johns Hopkins Medicine board of trustees, ensuring all levels of the organization are aware of challenges and are involved in the solution—from the “boardroom to the bedside.”
  • Emphasize sustainability.
    • Example: Develop sustainability plans documenting processes that have resulted in sustained, improved performance.

While the national leader strategy initially focused on core measures, bloodstream infections and hand hygiene, the strategy has expanded to include other key measures like surgical site infections, patient experience and hospital throughput. Also, although initially focused on inpatient measures, the national strategy now includes efforts in our ambulatory, pediatric, home health, population health and international settings.

How do quality and safety measures link to patient outcomes?

Quality and safety measures inform us of how well we are meeting our goals and gauge how well we provide standardized best practices for care that minimizes harm.

Quality of care can impact patient outcomes in many ways. For example, a patient who develops a pressure ulcer may require additional treatment during and after hospitalization. This may result in increased cost, increased length of stay and decreased quality of life. Following our quality and safety goal to eliminate harm, the most effective and patient-centered way to address pressure ulcers is to ensure practices are followed that focus on prevention and minimize the initial occurrence of the pressure ulcer.

Tracking our quality metrics and developing improvement plans that target key areas help to reach this goal.

What happens if my Johns Hopkins institution does not meet the new targets set forth in these measures? What happens if Johns Hopkins Medicine overall does not meet the new targets?

Many of the quality and safety measures we track are also linked to programs that provide financial incentives and penalties for exceptional or poor performance. While our quality improvement efforts are first and foremost intended to provide excellent patient care, performance on these measures can impact hundreds of thousands—if not millions—of dollars in each hospital’s budget. Loss of this money further impacts patient care, because it limits the resources and services we are able to provide to our patients.

How can I track my unit’s progress?

Committing to the Johns Hopkins Medicine quality priorities and knowing where your unit stands are important, as external agencies are adding new measures in the coming months.

To view your unit’s performance, visit the internal, systemwide quality and safety dashboard at hopkinsmedicine.org/MeasureUp. Here, you can drill down to your unit or department to see how your area measures up against organizational targets and peers across the health system.

Employees can use the dashboard to access a library of resources to help them improve and reach the organization’s goal to reduce preventable harm and optimize patient outcomes and experience while reducing health care costs. The dashboard can also be used to find out how patients rate their experience and how often standardized best practices of care are used to prevent infections and other complications.

How can I become more involved in quality improvement initiatives at Johns Hopkins Medicine?

As employees of Johns Hopkins Medicine, we all have the ability and responsibility to ensure our patients receive the safest and highest quality of care possible. For Johns Hopkins Medicine and our patients to thrive, we all must commit to quality.

Here are a few suggestions to become more involved in quality improvement efforts:

  • Connect with your organization’s quality department to learn more about local efforts.
  • Join an existing group, such as a core measure work group or a clinical community, to help us develop and implement interventions and accountability plans and streamline processes to improve quality at the local and larger health system levels.

The Armstrong Institute also offers numerous opportunities, including trainings, workshops, fellowships and certificate programs, for the Johns Hopkins community to deepen its involvement in quality improvement initiatives. To learn about the institute’s programs and how you can become more involved in patient safety initiatives across Johns Hopkins Medicine, visit hopkinsmedicine.org/armstrong_institute/.

 

 

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One hospital, one cleaning team. That was the idea behind the transition of multiple cleaning teams into one single entity, the newly renamed Environmental Care Department, which is responsible for cleaning each and every inch of The Johns Hopkins Hospital.

Previously called environmental services as a part of General Services, the hospital’s cleaning team was outsourced through Broadway Services until a decision was made in July 2013 to bring all cleaning responsibilities in-house.

Boubacar Maiga

The result was a change in name to the Environmental Care Department and a shift in structure to become a department within the Johns Hopkins Health System’s Facilities Department. In addition to cleaning common areas, administrative offices and floors throughout the hospital, the Environmental Care Department most recently assumed responsibility for cleaning patient rooms, operating rooms and clinical areas that had previously been maintained by support associates and operating room associates within different areas of the hospital.

This transition has taken place under the watchful eye of today’s expert, Boubacar Maiga, director of environmental care, who invites you to submit questions you may have about the department’s recent changes and refocus.

 

What prompted the change in name from environmental services to environmental care?

For quite some time, environmental services was marginalized from taking care of the clinical areas. Because it had been so long, the cleaning crew felt excluded from patient care, which should be the primary responsibility of every department working within the hospital. By changing from environmental services to environmental care, we are trying to make that connection between our services and the strategic priority of patient- and family-centered care.

Some may not be aware of the Environmental Care Department’s responsibilities. How would you sum up the purpose of the department?

The Environmental Care Department plays a primary role in patient care and safety, acting as the liaison between both areas. We prevent healthy people from getting sick by properly sanitizing and disinfecting the areas they use, and we help sick people get better by providing them with a clean and sanitary environment. We serve as guides throughout the Johns Hopkins community, since we are the only group that works in every area every day of the week, 24 hours a day.

Besides the name change, what are some of the major modifications the department has undergone over the last year?

The department has undergone a fundamental transformation over the last year.

  • The contract management team has been replaced by an in-house management team, working for The Johns Hopkins Hospital.
  • We have centralized all of the cleaning under one umbrella and one leadership team. By doing so, we have moved The Johns Hopkins Hospital from using nine different cleaning models to just one.
  • We have standardized cleaning protocol, including cleaning materials.
  • We have moved to more efficient and effective cleaning methods by introducing microfiber cleaning.
  • We have established a clear service-level agreement.
  • We are moving from a culture of underachievement and unaccountability to one of high achievement and accountability.

What is in store for the department in 2015?

We implemented the single cleaning model on Feb. 22, 2015, and are working toward cleaning and improving the appearance of the hospital. We will work to improve our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) number, which is our patient satisfaction rating, by enhancing our customer service. We have a patient advocate group for the Environmental Care Department whose goal is to speak to every patient about his or her experience.

As of April 15, hospitals will be rated like hotels; the higher the star, the better the overall service and care provided. The Environmental Care Department plays an essential role in hospital ratings—we have to make sure that the hospital is clean and presentable, and that each and every area is disinfected properly. In this country, there are still 100,000 people that die every year from hospital-acquired infections, and we would like to do our part to minimize that risk every day.

What is the department’s overall mission in regard to the recent changes?

The department’s overall mission is to provide patients, their families and visitors with a clean, sanitized and client-friendly environment. We are one the best care-giving institutions, so the Environmental Care Department strives to make The Johns Hopkins Hospital the cleanest and most sanitized health care institution.

We are working with other departments to increase safety and reduce infection by tying our cleaning and disinfecting methods to infection rates. Fighting and reducing infection in health care remains a big challenge, and the Environmental Care Department has the responsibility to help find the solution. We are trying several innovative approaches, such as using floor finishes that makes the floors resistant to bacteria by applying a coating that sterilizes the surface. This is a fairly new technology that could revolutionize the whole industry if successful.

 

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Each day in a hospital, staff members undertake complicated daily tasks caring for the critically ill, which can include ensuring nearly 200 steps for each patient. At Johns Hopkins Medicine, our quality and safety efforts aim to ensure that all of these steps work together to provide safer care for our patients.

The Johns Hopkins Armstrong Institute for Patient Safety and Quality works to eliminate preventable harm to patients and to achieve the best patient outcomes at the lowest cost possible. The institute also oversees, coordinates and supports patient safety and quality efforts across Johns Hopkins’ integrated health care system.

Lori Paine, director of patient safety at The Johns Hopkins Hospital and at the Armstrong Institute, is responsible for the strategic and tactical oversight of the patient safety program across Johns Hopkins Medicine. Lori’s role is designed to meet the Armstrong Institute’s values and work collaboratively and respectfully with all Johns Hopkins Health System entities to eliminate harm, improve outcomes the patient experience and value. Renee Demski is vice president of quality for The Johns Hopkins Hospital and Health System and the Armstrong Institute. Her main focus is the effective integration of quality services across the health care continuum for the Johns Hopkins Health System, with the goal of maximizing organizational improvement, efficiencies and the value of clinical services.

In today’s Ask the Expert, Paine and Demski will answer some important and meaningful questions about patient safety risk and how you can reduce it as an employee of Johns Hopkins Medicine.

 

What are the patient safety and quality goals of Johns Hopkins Medicine?

Johns Hopkins Medicine’s goals for patient safety and quality are to:

  • Reduce preventable harm.
  • Eliminate waste.
  • Improve clinical outcomes and patient experiences.

Who oversees and manages patient safety and quality for Johns Hopkins Medicine?

The Johns Hopkins Medicine Patient Safety and Quality board of trustees provides oversight for the patient safety and quality efforts across the organization. This committee meets quarterly and provides guidance and accountability over the progress and improvement efforts that are targeted to provide safe, high-quality care.

While the board of trustees provides the highest level of oversight, affiliates across the health system have quality and safety departments, improvement committees, and individual board committees that ensure we are also working toward our goals at the local level. Monthly systemwide quality and safety meetings bring together stakeholders at each of our affiliates. During these meetings, we discuss priorities, areas of concern and ways to continuously improve care.

The Armstrong Institute also supports the coordination of safety and quality improvement efforts across the health system by managing programs to reduce preventable complications and infections. Specifically, the Armstrong Institute:

  • Develops and delivers training programs and other educational resources that increase the ability of Johns Hopkins Medicine faculty and staff to carry out work that prevents errors and complications, improves patient outcomes, and enhances value.
  • Supports the scholarly activity of faculty in improving safety and quality and provides consultative services and technical support to our hospitals and departments.
  • Measures, tracks and broadly reports performance on safety and quality measures within Johns Hopkins Medicine.
  • Supports improvement programs across Johns Hopkins Medicine. Examples of these programs include adverse event reporting, the Safety Culture Assessment and the Comprehensive Unit-based Safety Program (CUSP).

The Armstrong Institute works closely with each affiliate to coordinate care through the entity’s designated quality and patient safety committees. These committees oversee the local improvement efforts.

How is patient safety and quality work structured?

To ensure we’re reaching our goals, Johns Hopkins Medicine approaches patient safety and quality through four domains:

  • Reducing patient safety risk
  • Improving patients clinical outcomes
  • Enhancing patient-centered care initiatives and improving the patient experience
  • Enhancing value

Safety and quality meetings across the health system build agendas and discussions around these four domains to keep us focused on our goals. While these areas govern our quality and safety work, they also fall under Johns Hopkins Medicine’s patient- and family-centered care strategic priority.

How does Johns Hopkins Medicine define patient safety?

Patient safety is the creation of safe systems and processes that lead to the elimination of preventable harm. Harm can be prevented by a series of steps, such as washing hands before entering a patient’s room or revising institutional policies to be more in line with best safety practices.

To prevent harm from occurring, Johns Hopkins Medicine designs and implements systems and protocols to help our care providers identify hazards, defend against errors, anticipate where our safety procedures could fail to prevent harms and ultimately keep errors from occurring.

How does patient safety affect me in my daily work?

Every staff and faculty member across Johns Hopkins Medicine is responsible for ensuring patients receive safe care.

To provide the safest care possible, you should practice these steps in your daily work:

  • Know your unit’s quality and safety performance data. You can check your unit’s progress on the internal Johns Hopkins Medicine Dashboard at hopkinsmedicine.org/measureup.
  • Speak up if you see a real or potential problem. We need a culture in which every employee feels comfortable raising concerns—whether you are a nurse, patient transporter, physician or an environmental services worker. We each play an important role in creating a strong safety culture that fosters open communication and supports a learning environment.
  • Use your chain of command and/or adverse event reporting system to report near misses and defects in care that could lead to a potential patient harm.
  • Participate in your unit’s safety activities through the CUSP teams.

What is my role in patient safety?

As employees of Johns Hopkins Medicine, we all have the ability and responsibility to ensure our patients receive the safest and highest quality of care possible. We know the most powerful and effective way to ensure quality of care is to hold our peers accountable for performing best safety practices, every day, in every interaction.

This can mean reminding individuals to wash their hands before entering a patient’s room or speaking up if we see a potential harm. This can be challenging and even uncomfortable for us to do. But these acts of leadership and courage help us prevent harm. It only takes one individual to inspire an entire group to actively participate in patient safety.

How can I become more involved in patient safety and quality improvement initiatives?

Connect with your institution’s quality and safety departments to learn more about efforts most relevant to you.

You can also use the Armstrong Institute’s website to learn about the numerous opportunities available to the Johns Hopkins community to deepen their involvement in patient safety and quality improvement initiatives. These include:

  • Training and education opportunities, including workshops, team training programs, e-learning, Grand Rounds presentations, fellowships and certificate programs.
  • Support for patient safety and quality work through such efforts as a small grants program.

Learn more about your organization’s CUSP program and get involved.

You can also join or start a clinical community. These are peer-driven groups that collaborate across Johns Hopkins Medicine to improve care in focused areas.

 

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Johns Hopkins Medicine faculty and staff are often asked to participate in surveys throughout the year. This year, JHM is administering three important surveys over a consolidated time frame to assess a variety of criteria about employees’ satisfaction at work: the Johns Hopkins Medicine Employee Engagement Survey, the Safety Culture Assessment and the Johns Hopkins Hospital Registered Nurse Satisfaction Survey. What’s the purpose of each survey, and which survey are you supposed to take?  Our experts Carol Woodward, human resources consultant for The Johns Hopkins Hospital, Lori Paine, director of patient safety for The Johns Hopkins Hospital and Armstrong Institute for Patient Safety and Quality, and Patty Dawson, assistant director of central nursing for The Johns Hopkins Hospital, answer your most frequently asked questions in this week’s Hopkins Happening Ask the Expert.

1.      What’s the purpose of each survey?

The Employee Engagement Survey uses 12 highly researched and reliable questions to gauge the engagement of Johns Hopkins Medicine faculty and staff.  Employee engagement is the relationship between an organization and its employees.  Engaged employees are fully committed to their organization, loyal and willing to give discretionary effort to help the organization achieve its goals and further its reputation.  Organizations with high levels of employee engagement are generally more productive, efficient, safe, customer friendly and financially successful.

The Safety Culture Assessment is intended to measure caregiver attitudes related to the climate or culture of safety throughout the organization. We know that local culture can have an impact on the delivery of safe care. The information collected through this survey provides a snapshot of the overall safety culture in a given work area or within a team.

The NDNQI RN Satisfaction Survey assesses the frontline nurses’ satisfaction with the professional practice environment.  The tool provides valuable unit-level information about 11 areas of nursing practice including interactions with colleagues, autonomy, professional development opportunities and nursing leadership support.

2.      How will the surveys be administered?

The Employee Engagement Survey will be available March 9 to March 29. On March 9, you will receive a formal invitation from Gallup to take the survey along with a unique, randomly selected code you will use to access the survey online. This code will ensure your confidentiality. Visit the Gallup’s secure survey site to participate.

The Safety Culture Assessment will be available from March 9 to April 10 through your unit. Eligible staff will receive survey instructions from their unit's predetermined safety coordinator. For questions about the Safety Culture Assessment, please contact your manager.

Eligible RNs will receive an email invitation for participation that will include the hyperlink and website address, along with The Johns Hopkins Hospital survey code.  The survey is open from April 6 to 26.  For questions, ask your manager or visit the nursing intranet for full details.

3.      I think I just took a similar survey. How do these surveys differ from the other job satisfaction surveys that are done on an organizational level?

Johns Hopkins Medicine faculty and staff are often asked to participate in surveys that evaluate many areas. These three particular surveys have been identified by Johns Hopkins Medicine as critical to evaluating different aspects of our work environment, including how we take care of ourselves and others, the culture of safety at our institution, and perceptions of direct care and professional practice environment.

4.      How do these surveys support Johns Hopkins Medicine’s strategic priorities?

A primary measure of the people priority in Johns Hopkins Medicine’s Strategic Plan is engagement. These three surveys provide important feedback that helps us succeed in attracting and retaining the world’s best people. In addition, the safety culture assessment supports JHM’s patient-and family-centered care priority, while NDNQI RN Satisfaction is key to supporting our designation of excellence in the Magnet Recognition Program, which is also tied to the patient-and family-centered care priority.

5.      How will these surveys help improve my unit/department?

Surveys results will help us identify strengths that exist within our teams. Each of these surveys provides a unique perspective on the work environment.  When taken together, the surveys can provide managers and team members with a more complete, holistic view of their workgroups.  Each team can then identify strengths and opportunities for improvement, and create an integrated plan to make the workplace better for patients and employees.

6.      Which surveys do I need to take?

All Johns Hopkins Medicine and Johns Hopkins University faculty and staff should participate in the Employee Engagement Survey.

All Johns Hopkins Medicine staff members who directly affect patient care at any Johns Hopkins Medicine entity are asked to complete both the Safety Culture Assessment and the Employee Engagement Survey. This includes nurses, physicians, clinical associates, unit associates, technicians, pharmacists, respiratory therapists, social workers and others.

A nurse working in direct patient care at The Johns Hopkins Hospital is asked to provide their thoughts on all three surveys—NDNQI RN Satisfaction survey, Safety Culture Assessment and Employee Engagement Survey.

7.      Are the survey results confidential? Who will see the survey results?

Confidentiality of results is very important to Johns Hopkins Medicine and to the vendors we partner with in administering the surveys. Responses to all three surveys are confidential.

For the Employee Engagement Survey, faculty and staff will receive an email invitation to take it with a unique survey code.  Results are only published if there are at least five responses. Gallup maintains the survey data in a secure server.

Results from the Safety Culture Assessment are not tied to any unique identifiable information about you. Information is only made available to managers for groups/sub-groups with more than five respondents.

Completed responses to the NDNQI questionnaire are submitted directly to NDNQI. Your responses cannot be linked to you. Personal characteristics, such as age, sex, education, are not reported to individual units. Units with fewer than four participants will not receive NDNQI survey results.

8.      Any hints on how to maximize the response rate?

The best way to maximize the response rate is to commit to sharing the results and using the information to guide plans for your unit after the survey’s completion. This can be sharing progress toward the survey goal on a daily basis during the survey administration period.

The surveys are not time-consuming, with most individuals able to complete each survey in 10 to 20 minutes. Some managers schedule “survey time” into the daily routine, or provide a dedicated workstation on the unit where staff can complete the surveys.  Others offer a unit incentive, such as a pizza party or free Daily Grind gift cards, to the unit that achieves the highest completion rate.

For the NDNQI RN Satisfaction survey, a daily announcement will be made about the completion rate.

9.      How will the survey data be used?

The surveys are intended to help us create a better Johns Hopkins Medicine.  The survey data will be used to analyze strengths and identify areas for improvements among departments and units, as well as help guide manager’s in their plans to address the strategic priorities.

10.  What happens with the results after I complete the survey(s)?

For the Employee Engagement Survey, the responses are tabulated by the Gallup Organization and within six to eight weeks workgroup reports are generated and disseminated to managers.

The Safety Culture Assessment data will be analyzed by Pascal Metrics at the end of the survey period.  Results will be made available within six weeks.

The results of all NDNQI RN Satisfaction surveys will be available by early-to mid-June.  More information about how to obtain the data and access tools to conduct debriefings with your unit staff/care team will be made available to you closer to that time.

Offer to be a part of the discussion of the results and make your recommendations about how you take advantage of your strengths or make improvements.

 

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Angela GuardaEating disorders are serious complex illnesses that stem from a mix of biological, psychological and social factors. The Eating Disorders Program at Johns Hopkins, established in 1976, offers comprehensive evaluation, treatment planning and ongoing care for patients with eating disorders. It was the first behavioral specialty program for eating disorders in the United States.

Located at The Johns Hopkins Hospital, the program aims to restore the functional capacity, normalize the eating patterns and improve the quality of life of its patients.

Dr. Angela Guarda, Director of the Johns Hopkins Eating Disorders Program since 1997, is a Board Certified Psychiatrist and Associate Professor at the Johns Hopkins School of Medicine. She talks about what makes the Eating Disorders Program at Johns Hopkins stand out and what we know about eating disorders today in this edition of Ask the Expert.

To make an appointment with the Eating Disorders Program, call 410-955-3863 or visit hopkinsmedicine.org/psychiatry/specialty_areas/eating_disorders/ for more information.

 

What separates the program at Johns Hopkins from any other program or center that treats similar disorders?

Several characteristics set us apart.

First we are located within The Johns Hopkins Hospital and have access to experts in all fields of medicine, allowing us to treat patients with a wide range of concurrent medical or psychiatric conditions and disease severity, including those patients with unusual or atypical presentations. We additionally treat both adolescents and adults and both males and females.

Second, the Hopkins Program has superior rates of weight gain and weight restoration for anorexia nervosa that are nearly double those reported by most programs. As described in a recent study currently published online* in the International Journal of Eating Disorders, our average inpatient rate of weight gain for anorexia nervosa is 1.98 kg (4.4 lbs) per week and the majority of our patients leave the program weight restored to a BMI of 19 or above. This is very important as weight restoration is necessary for recovery from anorexia nervosa.

Third, our focus is on much more than weight gain -- we provide a comprehensive continuum of care, including Outpatient, Partial Hospitalization and Inpatient Programs focused on relapse prevention and long term recovery. Our goal is to help our patients return to a full life and healthy function and to reach their potential. Patients requiring hospital-based care are admitted to the Inpatient Program and once stable, transition to the Partial Hospitalization Program. While in hospital-based treatment, the multidisciplinary psychiatrist-led team meets daily with each patient to assess progress and individually tailor treatment plans.

How does the program help its patients?

In the Inpatient Program, the initial approach is to help patients change their behavior, block urges to engage in familiar unhealthy habits and eat a wide range of foods of differing calorie densities in healthy combinations and amounts. Once patients progress to the Partial Hospitalization Program, the focus shifts to practicing social eating skills in real-world settings—eating in the cafeteria, in restaurants, with family, preparing meals, grocery shopping —and mastering relapse prevention tools that will help maintain recovery once patients return home. The Partial Program has affiliated, supervised housing and can accommodate patients from out of state.

In treating anorexia nervosa, weight restoration to a normal, healthy weight and eating a wide range of foods are both important to recovery. Due to limited insurance coverage and the high cost of inpatient treatment, severely underweight patients may not be able to reach this goal if they are gaining weight too slowly or do not receive help in broadening their food repertoire. There is no evidence that partial weight restoration improves long-term prognosis in anorexia and we have shown that when carefully monitored, a faster rate of weight restoration is not associated with elevated medical risk of refeeding syndrome.

What are some factors that increase risk for eating disorders?

We know that genetic vulnerability to eating disorders is significant, especially in the case of anorexia nervosa, and that having a first-degree relative with the disorder increases risk tenfold.

Ninety percent of cases of anorexia and bulimia occur in females. It is likely that estrogen somehow facilitates onset of the disorder in vulnerable individuals, as it is rare to see these disorders before early puberty, when estrogen levels start to rise.

Dieting appears to increase risk for eating disorders, as can stressors or anything that causes the first 5 to 10 pounds of weight loss. For example, it is not unusual for anorexia to develop following a bad bout of gastroenteritis or mononucleosis in a teenage girl.

Are there any exact causes of eating disorders? 

We don’t know what the exact causes of eating disorders are, but we believe a combination of genetic vulnerability and environmental stressors interact to trigger their onset. Once an eating disorder develops, however, other factors may come into play that maintain disordered eating much like in substance dependence, where the original reasons for taking the substance become overshadowed by physical dependence and habit as the disorder advances.

Have there been any recent findings in research that have led to advancements or changes in treatment in the program in the last few years?

The most important advance in the treatment of anorexia nervosa has been the recognition that family therapy is the best intervention for adolescent anorexia nervosa. In particular, this approach focuses on helping parents re-feed their child, rather than searching for root causes or explanations for his or her behavior. For bulimia, cognitive behavioral therapy remains the best approach. For severely ill patients who do not respond to outpatient interventions, inpatient admission to a behavioral specialty unit, such as the one at Johns Hopkins, can be lifesaving. Anorexia nervosa in particular has the highest lethality of any psychiatric condition, yet full recovery is always possible.

How will someone know if he or she needs treatment for an eating disorder?

Once an eating disorder is impairing physical or psychological health or social function, it is time to seek professional help. Typical physical signs are loss of periods, cold intolerance, feeling faint or gastrointestinal complaints. Psychological signs can include depressed mood, anxiety, poor concentration, and a consuming preoccupation with food and weight/shape. Social consequences include avoiding social meals and activities that involve food, due to anxiety about either overeating or undereating, along with others commenting on one’s eating behavior.

As an issue that carries psychological consequences, what are some of the most important things for patients to keep in mind as they go through the treatment process?

Ambivalence toward treatment is typical of both anorexia nervosa and bulimia, especially treatment that focuses on normalizing eating behavior, yet behavior change is necessary for recovery. This is a disorder that, in a sense, you act yourself into, and you cannot talk yourself out of it. Talk therapy alone may help you understand your eating disorder, but only changing your behavior and practicing healthy eating will correct the thoughts and feelings that sustain disordered eating over time.

What is considered a full recovery for eating disorder patients?

A full recovery constitutes eating a wide range of foods at regular meals and in social settings, and not being continuously preoccupied with thoughts of food and weight. If underweight, this also means reaching a healthy weight, as starvation maintains anorectic thinking patterns and behaviors.

 

 

*Refeeding and weight restoration outcomes in anorexia nervosa: Challenging current guidelines. Redgrave GW, Coughlin JW, Schreyer CC, Martin LM, Leonpacher AK, Seide M, Verdi AM, Pletch A, Guarda AS. Int J Eat Disord. 2015 Jan 27. doi: 10.1002/eat.22390. [Epub ahead of print] PMID: 25625572 [PubMed - as supplied by publisher]

 

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