Posted by: Duke Raleigh Hospital | May 6, 2014

Choosing Wisely; patients & physicians making smart decisions…together

Choosing Wisely website helps patients and physicians make a smart decision – together

By Carol Hahn, MD

Do I need cancer screening tests? Are Pap tests needed at every annual physical? If I have cancer, do I need to have treatment? What are my options and how long should it take? What about treatment for slow-growing prostate cancer … is it OK to watch and wait?

There is confusion – and there are sometimes contradictions – particularly in what one can find on

Dr. Carol Hahn

Carol Hahn, MD

the internet – when it comes to information about medical tests and treatments. Patients who wish to be active participants in their own health care – and I encourage all my patients to be – should spend time discussing suggested tests and treatments with their providers who have the most information about their health matters. But certainly there is much valuable information available online, and how can a consumer decide what is right to do when faced with contradictory information?

Fortunately for patients and doctors, there’s a new website with authoritative information from more than 50 different specialties. was begun as an initiative of the American Board of Internal Medicine (ABIM) Foundation to help patients and their doctors (and other health care stakeholders) start a conversation about which medical tests and procedures make good sense and which are unnecessary – and maybe even harmful.

Duke Raleigh is one of the hospitals leading the way in evidence-based medical care. There can be a fair amount of variance in health care, but when your quality of care is dictated by evidence, it means you’re getting the best care available. That was the thought behind the Choosing Wisely effort: Base treatment recommendations on scientific evidence.

For many years, more treatment or testing was considered the standard. But we now know that more isn’t always more. More can, frankly, be not helpful, costly and sometimes harmful.

So experts at the national level have come together to participate in the Choosing Wisely initiative and give the definitive word, based on evidence reviewed by experts, on recommendations for best care across a number of medical disciplines.

As a leader with the American Society for Radiation Oncology (ASTRO) and Chair of ASTRO’s Quality Council, I have been deeply involved in developing treatment guidelines for physicians in my specialty. I have also worked to develop my society’s items for Choosing Wisely. Our list of five items was put together to help patients choose care that is truly necessary, supported by evidence and free from harm.

An example of an area we clarified: radiation for patients with breast cancer – how many treatments do I need? For women with early stage breast cancer, radiation is an important portion of breast conserving therapy. This is the local treatment used for breast cancer that is as effective as mastectomy, but allows a woman to keep her breast. While older studies of breast radiotherapy generally used treatment courses of five to six weeks, more recent data has demonstrated that in many patients, three to four weeks of treatment are just as safe and effective. Women with early breast cancer should discuss this with their physicians to see if shorter treatment is right for them.

The Choosing Wisely effort is national in scope and is aimed at everyone with a stake in health – from patients and their families to health care providers to health insurance companies. The website has some resources aimed at physicians, but there are patient-friendly resources, as well.

Patients should always have all treatment options discussed with them. Knowing all the tests and treatments available is the only way to make an informed decision about your health. It’s what I’ve always tried to do in my practice. Now – thanks to this website and effort – doctors and patients across the country can begin (or continue) to have these informed discussions.

When it comes to your health, get the facts, have a candid discussion with your doctor and – together – choose your course of action wisely.

Carol Hahn, MD is a radiation oncologist at Duke Radiation Oncology. Learn more about guidelines on medical tests and treatments at

Posted by: Duke Raleigh Hospital | March 3, 2014

Healthy Lunch Recipe: chicken and avocado wrap

avocadoLooking for something healthy, fresh and quick for lunch? This chicken and avocado wrap goes great alongside our Awesome Orzo Salad featured in the Spring 2014 issue of Healthy Focus magazine.


1 avocado, peeled

1/2 cup tomato, chopped

4 lettuce leaves

4 fat-free flour tortillas,

2 cups cooked, shredded chicken

1/2 cup shredded four-blend Mexican cheese


1. Mash up avocado and spread evenly on tortillas.

2. Place one lettuce leaf per tortilla.

3. Evenly divide chicken, tomatoes and cheese among the four tortillas, and roll up.


Nutritional Information

Servings: 4

Calories: 315

Total fat: 17.1g

Cholesterol: 69mg

Sodium: 150mg

Carbohydrates: 12.3 g

Fiber: 5.2g

Sugars: 1g

Protein: 26.3g

Posted by: Duke Raleigh Hospital | January 16, 2014

Score a Family Planning Touchdown

by Aaron Lentz, MD

refereeIn sports, they say the best defense is a good offense. It applies to plenty of things off the field, too.

Take family planning, for instance. There are a number of ways to prevent unplanned pregnancies. But the safest, quickest and least expensive way, by far, is vasectomy. My medical partner, Dr. Charles Viviano, and I are hoping to raise awareness for this underutilized form of contraception with our Big Game Vasectomy Blitz clinic on Friday, Jan. 31.

When men get the procedure done on a Friday, our expectation is that they’ll return to work the following Monday. The recovery really is that quick. If you have the procedure on the Friday before pro football’s biggest event, you’ll have an exciting game to look forward to just two days later. We’ll even send everyone home with an ice pack and have a drawing for a prize pack featuring novelty items and snacks.

The outpatient procedure takes just 20 to 25 minutes and is performed with a local anesthetic. The technique we use is minimally invasive and heals very quickly. We offer a low-dose sedative, and the patient remains awake during the procedure. We’re generally carrying on a conversation during the brief time it takes. Patients can expect a full recovery in just 48 to 72 hours.

Aaron Lentz, MD

Aaron Lentz, MD

Charles Viviano, MD

Charles Viviano, MD

Men generally feel so good immediately after the procedure that we have to caution them not to overdo it. They shouldn’t head for the gym for a game of hoops. We recommend taking it easy for two days. Use an ice pack (or a bag of frozen peas or corn) and Tylenol as needed. Compression underwear or a jock strap helps reduce any swelling. Post-vasectomy, men shouldn’t engage in any real strenuous activity for a week or so. But after that, it’s back to normal with no restrictions.

One caveat, though. It’s important for men and their partners to know the procedure does not render them immediately sterile. We have patients come back eight to 16 weeks after a vasectomy for a follow-up semen analysis. Once we confirm the results, the patient is considered sterile.

Around 500,000 vasectomies are performed in the United States each year, making it one of the most common non-diagnostic procedures in the country.

We always begin with a consultation – either one-on-one or with a group of men – and their spouses or partners – considering it. In fact, we encourage spouses to attend. It should be a joint decision, and I’m sure men appreciate the support from their significant other. During the consultation, we review all the benefits and talk about the (minimal) risks.

Downsides? Very few, really. The procedure should be considered permanent, so you need to be certain about your decision. But other than that, a vasectomy should not impact a man’s libido, his ability to have and maintain an erection or the amount of ejaculate.

The average age patient we see is between 35 and 50 years old, although we do see both younger and older men. Sometimes the younger men have had wives who have endured difficult or even dangerous pregnancies. They choose to get sterilized rather than risk another tough pregnancy. One recent patient has one child, but his wife was on bed rest for most of her pregnancy. They’d like to have more kids, but they decided adopting would be the best way to go.

A vasectomy is clearly a great defensive move. Its effectiveness in preventing unplanned pregnancies is second only to abstinence.

This football season, consider being a family planning MVP. Ice up, and be ready for a restful weekend – and the kickoff on Sunday, Feb. 2


Want to learn more, or schedule your consultation appointment? Call Duke Urology of Raleigh at 919-862-5600.


Aaron C. Lentz, MD is a urologist at Duke Urology of Raleigh. Check out these patient education resources to learn more about the procedure, and other services.

Posted by: Duke Raleigh Hospital | January 6, 2014

Our ICU Patients are Walking Out on Us; and, we couldn’t be happier

Rick Gannotta, president of Duke Raleigh HospitalBy Rick Gannotta, NP, DHA, FACHE, Duke Raleigh Hospital President

The secret to getting out of intensive care quickly turns out to be something pretty elementary: Walking.

While that may sound obvious, it wasn’t always. Not so long ago, prevailing wisdom held that patients in the ICU should be heavily sedated. Now we know the best way to get a patient well and on his or her way home is minimal sedation. When we help patients become ambulatory as soon as safely possible, we can pave the way for better patient outcomes, shorter hospital stays and fewer days on a ventilator.

A multidisciplinary team led by Kristin Merritt, nurse manager in the ICU and Mimi Matthys, ICU Clinical Team Lead have done inspirational work on early progressive mobility (EPM). The team has created a protocol that gets ICU patients who are on a ventilator up and walking much earlier than ever before. They’ve also created an entire education campaign to promote the effort.

The EPM project started in October 2012 with a $10,000 grant from the American Association of Critical Care Nurses (AACN) Clinical Scene Investigator (CSI) Academy. This grant awarded four nurses – Katherine Geyer, BSN, RN, CCRN; Craig Sibbach, BSN, RN, CCRN; Kerrie Klepfer, BSN, BSN; Jennifer LeBlanc, BSN, RN, CCRN along with CSI Coaches Connie Clark, RN and Brittain Wood, RN – a 16-month long nursing excellence and leadership training program to improve outcomes for ICU patients. This idea wasn’t dictated by CSI; the staff identified early ambulation as an important area of focus and one they wanted to investigate.

The concept for EPM begins with the once-radical idea that rehab starts from day one. The ICU staff is never going to push a patient to do something he or she isn’t ready for, but the staff now has the mindset that early ambulation is the ultimate goal. As Kristin Merritt has said, “Early ambulation saves lives.”

The CSI team conducted an ICU staff pre-survey to assess staff perceptions regarding ambulating patients. Then, a nurse-driven EPM protocol was created and vetted. In March, the CSI team launched the “Walk This Way” EPM campaign with two full days of education for staff.

Getting ambulatory starts small. A patient may dangle his feet off the side of the bed one day, and that may be enough. Then the next day, he may move from his bed to a chair. The next day, he may be ready for a walk down the hall. All of this is happening under the careful supervision of our ICU staff.

And the staff is helping patients celebrate every milestone. They’ve made it fun by using an Olympic theme in the ICU. Patients get medals for each step they take in their recovery.

In addition to the nurses who developed the EPM project, our gratitude goes to the critical care team, surgeons, rehab staff, CSI coaches from Infection Prevention, ICU nursing leadership, the respiratory therapy team, who fully embraced the concept and have made it standard practice in the ICU.

The EPM work is so significant that it’s even going beyond Duke Raleigh Hospital. Other hospitals have asked to review our protocol, and the team has been chosen to present at AACN National Teaching Institute Critical Care conference in Denver this May. So, the team’s work is influencing healthcare outside our own walls.

The faster ICU patients can get up and get moving, the sooner they can get home. Nothing is more gratifying than seeing an ICU patient get up and walk out on us.

Posted by: Duke Raleigh Hospital | November 27, 2013

Order Up: mashed potatoes to the ICU

By Kristin Merritt, MSN, MBA/HCM, RN, NE-BC, CCRN

Mashed potatoes probably don’t seem like they have much to do with the Intensive Care Unit (ICU). But some patients in the ICU have a simple wish – they just want to eat mashed potatoes. No matter how simple (or big) the request, we try our best to honor it.

We ask patients during the admission process: “What is important to you during your stay?” We’re so serious about making sure patients get what they need that we write the question – and the patient’s answer – on what we call a “care board” in their room. Each day, the patient, his or her family, physicians and staff look at the request and try to ensure they’re taking care of it.

The answer to the question, “What’s important to you?” is very personal. Some people tell us, “I just want to go home,” and we think of that request each time we’re in their room. One patient asked simply, “Please let me know what you are doing to me and why.”

Consider it done.

Our focus in the ICU is on making sick patients well enough to go home. But we never forget their humanity and that they have wants and needs beyond the medical ones. We ask – and listen.

We also understand that a person is at his or her most vulnerable when being cared for in the ICU. He or she needs loved ones around. So we have an open visitation policy. That’s different from some other ICUs and certainly an improvement over where ICUs were even a few years ago.

It used to be that family members could visit in 15-minute increments four times a day. In some cases, people had traveled a great distance to be near their loved one, and seeing their son or daughter, mother, father or friend in 15-minute spurts just wasn’t acceptable. There were lots of limitations back in the old days, and we’ve done our best to lift those, while still keeping a patient’s physical well being top of mind. Just recently, we had a seven-month-old baby among an ICU patient’s visitors.

We’re proud to offer care that’s focused on the patient and his family and friends.

Hospitals also used to have a narrow definition of “family.” Only immediate family could visit an ICU patient. We understand, though, that patients may have a different definition of what constitutes family. We refer to visitors as “loved ones” or “patient support,” because they may not be related by blood or marriage. They may be friends or neighbors. But their presence is just as valid – and just as needed – as any sibling or parent.

Honors and awards

Our team has been honored for our accomplishments several times over the past couple of years. June 2012 marked two-and-a-half years without having a patient develop a central line associated bloodstream infection (CLABSI).  About half of all ICU patients need a central line during their hospital stay. Usually, it’s because the patient needs multiple antibiotics – more than we can administer through an ordinary IV.

A central line catheter infection happens when a patient develops an infection in the bloodstream that is unrelated to an infection at another site. The infection may be accompanied by fever, chills or decreased blood pressure. Until 2010, the medical community thought central line infections were an unfortunate, but frequent, risk. Now, we know they are avoidable. And, we’re doing all we can to prevent them. Our enhanced process, called Central Line Insertion Bundle Compliance, is a strict protocol that involves proper dressing, line maintenance and scrubbing the hub of IV line access ports with isopropyl alcohol (70 percent) for 15 seconds prior to each use.

Most recently, we won the N.C. Nurses Association Best Practice Award for preventing CLABSI. Maki Gallano-Massey, RN; Robin Fichuk, RN; Kim Bagley, RN; and Brittain Wood, RN accepted the award at the Oct. 2013 conference.

In October 2012, we were awarded a $10,000 grant from the American Association of Critical Care Nurses (AACN) to participate in the Clinical Scene Investigator (CSI) Academy. Our project is focused on ambulating ICU patients, including ventilated patients.

We’ve also assisted Community Health Systems Hospital in Franklin, Tenn. In July 2013, the hospital’s director of infection prevention contacted our team to learn more about our challenges and how the team overcame them.  Maki Gallano-Massey, RN; Robin Fichuk, RN, Kim Bagley, RN and Brittain Wood, RN led the way in sharing our knowledge and best practices with the ICU staff in Franklin.

In September, we presented at UNC/Rex Research Symposium on how to reduce visitor anxiety in the ICU. The ICU nurses involved in that presentation were Robin Fichuk, BSN, RN, CCRN; Susan Smith, MSN, RN; and IJ Anen, MSN, ACNP, CCRN.

We love getting industry recognition for our efforts to make our ICU care among the best in the region and the country. But not as much as we love being able to serve a patient mashed potatoes once he or she is able to eat them. That’s what really makes us proud.

Kristin Merritt is Nurse Manager, Operations in Duke Raleigh Hospital’s Intensive Care Unit and Neuroscience Step Down.

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