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Joanne's Journal - Thursday, February 8, 2018

Joanne's Journal - Thursday, February 8, 2018

Dear Colleagues:

Knowing your Numbers

People generally know that heart disease is the leading cause of death for men and women in the United States, causing 1 in 3 deaths each year. The warning signs for women aren’t the same as in men. When women have a heart attack, we stand a greater chance of dying.

I am speaking at the American Heart Association’s Go Red for Women luncheon this Friday, and in preparation, I began to wonder about the risks for women who work at Dartmouth- Hitchcock. Go Red for Women, is a passionate, emotional, social initiative designed to empower women to take charge of their cardiac (heart) health. For all the men reading this, please don’t tune out – this is important information for you to share with the women in your life – wives, mothers, daughters, etc.

First I want to educate you and then activate you.


Risk factors (80 percent of the women I am speaking to Friday will have at least one):

  • High blood pressure (over 130/80)
  • Smoking
  • High blood cholesterol (over 200)
  • Lack of regular activity and being overweight
  • Diabetes

The risk of stroke is also higher in women. High blood pressure is a risk factor, along with atrial fibrillation, diabetes, depression and emotional stress. Smoking and birth control pills boost the risk further. Women who experience migraine headaches with aura (visual disturbances) also have a greater likelihood of having a stroke. 

Last year, our employee health insurance recorded 13 heart attacks, 18 strokes, 18 cardiac cath lab tests and 6 heart surgeries for employees. And 85 percent of our employees are women!

My father had a long history of extremely high blood pressure…it was the cause of his disability. He used to boast that when he did a treadmill test for heart disease, he did so well that they had to pull him off the treadmill! Years later, I read the report and saw that he was throwing so many aberrant heart beats that he scared the physicians!

So, of course as young adults, my brothers and sisters and I were very aware of the importance of maintaining a normal blood pressure. I actually have 2 automatic blood pressure cuffs and take my own blood pressure about 3 times a week. I know my blood pressure is high if I wake up in the morning with a persistent headache. In fact, that is how I realized that I had developed high blood pressure. I also know that when I am stressed (after a tough day at work) or have too much coffee (2 cups is my max) my blood pressure will be higher. I actually write it down so I can follow the trends…because you don’t want to overreact to one high reading.

If my friends have visual changes, persistent headaches, rushing or pounding in their ears, fatigue or even a really red face, I ask if I can take their blood pressure. We have found quite a few that had high blood pressure that was undiagnosed. (Beware if you see me walking the halls with a blood pressure cuff!) Sometimes you can’t tell …so it is important to measure your blood pressure.

We did have an employee ask what happened to the self-monitoring blood pressure machine we used to have in Borwell. It disappeared a few years ago….so we purchased another one which will be located across from the outpatient pharmacy on the 3rd floor at DHMC. We also have them at our Heater Road location.


There are significant differences in heart disease in men and women. The most common heart attack symptom in women is some type of pain, pressure or vague discomfort in the chest. Women are more likely than men to have subtle symptoms such as:

  • Neck, jaw, shoulder, upper back or abdominal discomfort
  • Shortness of breath
  • Pain in one or both arms
  • Nausea or vomiting
  • Sweating
  • Lightheadedness or dizziness
  • Unusual fatigue

In men, a heart attack typically begins with the sudden rupture of a cholesterol-filled plaque in a coronary artery, which then precipitates a blood clot. In younger women in particular, a plaque is more likely to erode into the vessel wall rather than to burst.

Women are also more likely than men to develop small vessel disease, a condition where blockages occur in the tiny vessels within the heart muscle rather than in the large, surface arteries. Their major heart arteries look normal, so they are told it's not their heart.

Some of the diagnostic tests are just not as sensitive for women as they are for men. The standard run on the treadmill test hooked up to an EKG machine is less specific and sensitive in women. Better tests are stress echocardiography and cardiac perfusion tests. The problem is that most of what we know about diagnosis and treatment of heart disease comes from research done on middle-aged men resulting in the disease being under-recognized and under-investigated in women.

Women tend to show up in emergency rooms after heart damage has already occurred because their symptoms are not those usually associated with a heart attack, and because women may downplay their symptoms. The risk of heart disease in women is often underestimated due to the misperception that females are ‘protected’ by estrogen against cardiovascular disease. The differences in clinical presentation in women lead to less aggressive treatment strategies. The absence of chest pain is associated with a delay in diagnosis and treatment which increases the incidence of death after a heart attack.

Here are some staggering disparities:

  • Women age 45 and younger are more likely than men to die within a year of their first heart attack.
  • Only 65 percent of women said the first thing they would do if they thought they were having a heart attack was to call 9-1-1.
  • Men are 2 to 3 times more likely than women to receive an implantable defibrillator for the prevention of sudden cardiac death. 
  • Previous studies and clinical trials have often been done with inadequate numbers of women in the study population, representing just 38 percent of subjects.

So what am I asking you to do?

Look at your risk factors…find one that you want to change. Walk more, eat healthier, control your blood pressure, identify and manage stress, stop smoking…there are many options.

Be an advocate… knowledge is power, and when you have all of the facts you can become an activist, advocate and educator. 

What You Should Know About the Flu

flu image


This flu season is a particularly intense one. For three weeks straight in January, 49 states reported widespread flu activity, with 48 states still reporting such activity in the final week of that month. According to the Centers for Disease Control and Prevention (CDC), this is a first since its Influenza Division began tracking the flu.

For health care organizations like Dartmouth-Hitchcock – including our affiliate organizations – it is particularly important for clinical and non-clinical employees to adhere to best practices and take precautions to take care of themselves.

“We have seen a much higher number of influenza cases this year than in the prior two years,” says Michael Calderwood, MD, MPH, regional hospital epidemiologist. “Overall, the trends suggest that this season will be at least as bad as the 2014-2015 influenza season when 34 million people in the U.S. fell ill from influenza and close to 710,000 were hospitalized.”

Here are a few important reminders to help prevent the transmission of the flu:

  • Make a point to wash your hands regularly. Hand hygiene is the single best way to reduce the transmission of flu and other viruses. In particular, you should wash your hands after being out in public or around those with a respiratory illness.
  • Keep it covered. Cover your nose and mouth when you cough or sneeze with your elbow (not your hand). Throw away used tissues in the trash after you use them and don’t forget to wash your hands.
  • Avoid touching your face. Germs can be spread by touching your eyes, nose and mouth. Try to avoid touching these areas.
  • Clean, clean and more clean. Clean and disinfect surfaces and objects – such as desks, computer stations, telephones, doors and elevators – that may be contaminated with germs like the flu.
  • If you are sick, stay home! To stop the risk of spreading infection, you should stay home if you are sick. Remember that you cannot come to work if you have a fever and must stay out work until your fever has resolved for 24 hours without the use of fever-reducing medicines.
  • Wear a Mask. If you have a new cough or a runny nose, you must wear a mask when you are in the hospital until these symptoms have completely resolved. This includes on return to work after being out sick. In addition, all patients who present to the hospital with a new cough which is suspected to be infectious must be placed on Droplet Precautions immediately, which means anyone entering their room must wear a mask.
  • If you do get the flu, stay home and follow your health care provider’s recommendations. For D-H and Cheshire Medical Center employees who are diagnosed with influenza, the anti-viral treatment, oseltamivir (Tamiflu) is available through Occupational Medicine free-of-charge. Visit Flu.gov for tips on help to recover from the flu.

For more information, please visit the D-H flu website.

Our Journey to High-Reliability: Deference to Expertise

As Sam Casella, MD, MSc, associate chief quality officer and co-chair of the Dartmouth-Hitchcock (D-H) Safety Committee, noted in this article “2018 Safety Goals Point D-H Toward Continued Improvement,” D-H is embracing a new high reliability theme—deference to expertise—as part of its 2018 safety goals. Casella says, “People on the front lines of care know the most about their areas, and we count on them to apply that expertise.”

D-H Today recently spoke with Casella to learn more about this theme, and how it is helping to improve safety at D-H.

What is meant by “deference to expertise”?

Deference to expertise is one of the five principles that characterize the culture within high-reliability organizations. Simply stated, these organizations make a conscious effort to ensure that the people who are most knowledgeable about the situation are empowered to make the decisions. They recognize that the employees closest to the work are often in the best position to resolve problems, and it is critical to obtain their perspective on any proposed solutions.

When was it rolled out?

D-H Chief Nursing Executive Susan Reeves, EdD, RN, launched the program at the fall Team Care learning sessions. She addressed unit managers, medical directors, and various Team Care members representing every inpatient unit, and used practical examples to illustrate the way we can incorporate this principle into our microsystems.

Can you give us an example of this kind of front-line expertise?

I recently met with staff from Environmental Services, and they raised their concern about frequently finding sharp objects in the regular trash, which sometimes injure them when they remove the plastic bags. Environmental Services Technician Jim Courtney pointed out that in many D-H locations the regular trash bin is positioned directly under the sharps container. So, if the container is too full or the employee is rushing, the sharps may fall into the regular trash and create a safety hazard. We walked down to the unit where he demonstrated this problem in multiple locations. Now we are working to eliminate this risk. If we hadn’t listened to his concerns, I don’t think we would have realized that this was a problem in several locations throughout the hospital.

What were some of the key takeaways from the Team Care learning sessions that you would like to share?

We talked about how expertise can be often be:

  • Ignored
  • Dismissed
  • Conditioned by rank
  • Minimized because of self-interest
  • Rendered secondary because of prevailing routines
  • Hidden
  • Wisdom and expertise are present in both the person doing the deferring and the person being deferred to.

What does the “deference to expertise” initiative entail?

We will carry this theme through the various Team Care presentations throughout the academic year, demonstrating ways in which we can incorporate this principle into our decisions. Senior leaders will also be rounding to frame this work in a way that is relevant each unit, to recognize the expertise of every member of the team and to solicit ways in which we can improve the care we provide. It is important for all D-H employees to understand that every voice matters, which is obviously the same theme as our employee engagement survey.

CHaD’s Newly Renovated Inpatient Space

From left: Didi Sheets, Keith Loud and Lisa Mitchell

From left: Didi Sheets, Keith Loud and Lisa Mitchell.

On March 6, Children’s Hospital at Dartmouth-Hitchcock’s (CHaD) will open a redesigned CHaD Inpatient Unit on 5 East, which will house both the Pediatric Critical Care Unit (PICU) and the Pediatric & Adolescent Unit (Pedi). This newly renovated space will include critical care, intermediate care, and standard medical-surgical care for children and adolescents, all in one integrated unit. It will eventually have 21 beds encircling its new central therapeutic play space, with nursing stations located closer to patient rooms. The project has been funded largely by generous donations from individuals, corporations and the CHaD HERO

Combining these two units will free up space for much-needed critical care beds for Dartmouth-Hitchcock Medical Center’s (DHMC) aging patient population, while also providing an opportunity to further improve CHaD patient care, says CHaD Director and Pediatrics Chair Keith J. Loud, MD, MSc, FAAP.  

“Combining the Pediatric and Adolescent Unit with the PICU creates an opportunity to pilot new care models that can increase patient safety and family satisfaction by decreasing transitions from space to space,” says Loud. “Flexibly cross-training much of the nursing staff can enhance continuity of patient assignments, also improving the patient experience and hopefully professional satisfaction and retention of the nurses, in addition to achieving efficiencies. We plan to adopt and combine the best practices from each unit to optimize care for all.”

Read the full story here.