A REPORT TO THE RIVER RAPIDS HEALTH CARE SYSTEM

1
A REPORT TO THE RIVER RAPIDS HEALTH CARE SYSTEM

• Prepared by Students of the
• Medical University of South Carolina
• for the CLARION INTERPROFESSIONAL CASE
  COMPETITION
• Fall 2006

2
INTRODUCTIONS

• AMANDA BARNHORST
• 1ST YEAR, MD PROGRAM
• MUSC COLLEGE OF MEDICINE
• CARYN HOANG
• 1ST YEAR, PA Program
• MUSC COLLEGE OF HEALTH PROFESSIONS
• JARRETT WALSH
• 4TH YEAR, MD/PhD PROGRAM
• MUSC COLLEGE OF GRADUATE STUDIES
• SETH ZEIGLER
• 3rd Year, PHARMD PROGRAM
• MUSC COLLEGE OF PHARMACY

3
PRESENTATION OVERVIEW

• CASE OVERVIEW
• METHODS OF ANALYSIS
• MAJOR FINDINGS
• SPECIFIC FINDINGS
• RECOMMENDATIONS/ACTION PLAN
• TRACKING INDICATORS
• COST ANALYSIS
• SYSTEMS ISSUES
• REFERENCES/ACKNOWLEDGEMENTS

4
CASE OVERVIEW RIVER RAPIDS

• RIVER RAPIDS COMMUNITY
• WISCONSIN TOWN OF 2,300 PEOPLE
• 98 WHITE NON-HISPANIC, 1.5 HISPANIC, 0.5 2
  RACES
• MEDIAN HOUSEHOLD INCOME OF 34,000
• RIVER RAPIDS HEALTH CARE SYSTEM
• 25-BED HOSPITAL WITH EMERGENCY DEPARTMENT
• ATTACHED CLINIC AND FIVE RURAL CLINICS
• NURSING HOME

5
CASE OVERVIEW RIVER RAPIDS

• RIVER RAPIDS FACILITIES
• 19 MEDICAL/SURGICAL BEDS, 3 CRITICAL CARE BEDS, 3
  OB SUITES
• CLIA-CERTIFIED LABORATORY
• SURGICAL SUITE WITH TWO OPERATING ROOMS
• RIVER RAPIDS HEALTH PROFESSIONALS
• EIGHT FAMILY MEDICINE/ONE INTERNAL MEDICINE
  PHYSICIANS
• SPECIALISTS COME FROM NEIGHBORING PLEASANTVILLE
• TWO STAFF PHARMACISTS RNS, LPNS, AND CNAS

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CASE OVERVIEW PASCO

• PASCO COMMUNITY
• WISCONSIN TOWN OF 900 PEOPLE
• 10 MILES EAST OF RIVER RAPIDS
• 92 WHITE, 4 HISPANIC, 4 SOMALI
• MEDIAN HOUSEHOLD INCOME OF 32,000
• PASCO CLINIC
• ONE OF FIVE CLINICS IN THE RIVER RAPIDS SYSTEM
• OPEN MONDAY, WEDNESDAY, AND FRIDAY
• NP ALL DAY, PHYSICIAN FROM 12-5.

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CASE OVERVIEW PATIENT

• FIVE-YEAR-OLD SOMALI BOY
• IMMIGRATED TO THE U.S. 20 MONTHS AGO
• IMMIGRATION INTERVIEW DIAGNOSED HIM WITH
  MILD/MODERATE PERSISTENT ASTHMA
• FAMILY SPEAKS LITTLE ENGLISH
• PARENTS WORK FOR MINIMUM WAGE WITH NO HEALTH
  INSURANCE

8
CASE OVERVIEW MEDICAL HISTORY

• MONTH 0-18
• MULTIPLE ASTHMA EXACERBATIONS
• FOUR TRIPS TO RIVER RAPIDS EMERGENCY DEPT
• TWO HOSPITALIZATIONS
• MONTH 19
• FIFTH TRIP TO RIVER RAPIDS EMERGENCY DEPT
• PRESCRIBED RESCUE ALBUTEROL INHALER

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CASE OVERVIEW SENTINEL EVENT

• MONTH 20
• SEVERE ASTHMA ATTACK AT SCHOOL
• AMBULANCE CALLED FROM RIVER RAPIDS
• INTUBATION AND VENTILATION WERE PERFORMED
  RESULTING IN A PNEUMOTHORAX
• TRANSPORTED BY AIR TO PLEASANTVILLE REGIONAL
  MEDICAL CENTER
• DIAGNOSIS OF ANOXIC BRAIN INJURY ON STABILIZATION

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METHODS

• INVESTIGATION
• IDENTIFICATION OF MAJOR EVENTS
• CAUSAL FLOW ANALYSIS
• ROOT-CAUSE ANALYSIS
• IDENTIFICATION OF CONTRIBUTING FACTORS
• REMEDIATION
• LITERATURE REVIEW
• DEVELOPMENT OF RECOMMENDATIONS
• TRACKING INDICATORS
• COST ANALYSIS
• CONCLUSIONS

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MAJOR FINDINGS

• DECREASED ACCESS TO QUALITY CARE
• MULTIPLE HOSPITALIZATIONS
• ANOXIC BRAIN INJURY

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DECREASED ACCESS TO QUALITY CARE
13
DECREASED ACCESS TO QUALITY CARE FLOW ANALYSIS
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DECREASED ACCESS TO QUALITY CARE ROOT CAUSE
ANALYSIS

• ROOT CAUSE STATEMENT
• IMPROPER DISEASE STATE MANAGEMENT LED TO
  UNCONTROLLED ASTHMA WHICH INCREASED THE PATIENTS
  RISK FOR AN ADVERSE EVENT.

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DECREASED ACCESS TO QUALITY CARE ROOT CAUSE
ANALYSIS

• THREE MAJOR FINDINGS
• INAPPROPRIATE DRUG THERAPY
• STAFF/PATIENT COMMUNICATION
• DISORGANIZATION

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INAPPROPRIATE DRUG THERAPY
INAPPROPRIATE DRUG THERAPY
DID NOT FOLLOW GUIDELINES
CONTINUOUS UNCONTROLLED ASTHMA
FINANCIAL CONSIDERATIONS
17
STAFF/PATIENT COMMUNICATION
NO COMMUNICATION WITH PARENTS
NO INTERPRETER
FAILURE TO EXPLAIN REFERRAL
STAFF/PATIENT COMMUNICATION
18
DISORGANIZATION
DISORGANIZATION
NO PHARMACY REVIEW
MISPLACED CHARTS
LACK OF RESPONSE TO COMMUNITY PHARMACIST
19
DECREASED ACCESS TO QUALITY CARE ISHIKAWA
INAPPROPRIATE DRUG THERAPY
FINANCIAL CONSIDERATIONS
CONTINUOUS UNCONTROLLED ASTHMA
DID NOT FOLLOW GUIDELINES
DECREASED ACCESS TO QUALITY CARE
NO INTERPRETER
NO PHARMACY REVIEW
LACK OF RESPONSE TO COMMUNITY PHARMACIST
NO COMMUNICATION WITH PARENTS
MISPLACED CHARTS
FAILURE TO EXPLAIN REFERRAL
DISORGANIZATION
STAFF/PATIENT COMMUNICATION
20
DECREASED ACCESS TO QUALITY CARE CONTRIBUTING
FACTORS

• INAPPROPRIATE DRUG THERAPY
• STAFF DID NOT FOLLOW PUBLISHED GUIDELINES
  RESULTING IN UNCONTROLLED ASTHMA AND PLACING A
  FINANCIAL BURDEN ON FAMILY
• STAFF/PATIENT COMMUNICATION
• STAFF FAILED TO COMMUNICATE WITH FAMILY AND
  INAPPROPRIATELY ADDRESSED CHILD NOT PARENTS
• DISORGANIZATION
• LACK OF ORGANIZATION LED TO SUBSTANDARD PATIENT
  CARE

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DECREASED ACCESS TO QUALITY CARE RECOMMENDATIONS

• INAPPROPRIATE DRUG THERAPY
• ESTABLISH POLICY TO FOLLOW UP-TO-DATE STANDARD OF
  CARE GUIDELINES
• EDUCATE STAFF ON EVIDENCE-BASED MEDICINE
  RESOURCES
• STAFF/PATIENT COMMUNICATION
• PROVIDE INTERPRETER SERVICES - LANGUAGE LINE -
  FOR DIRECT COMMUNICATION WITH PARENTS
• DISORGANIZATION
• REQUIRE CLINICAL PHARMACIST PARTICIPATION IN
  REVIEW OF CHARTS AND PATIENT DRUG THERAPY
• COUNSEL PRESCIBERS ON IMPORTANCE OF FOLLOW-UP
  COMMUNICATION WITH OTHER HEALTHCARE PROVIDERS
  REGARDING MEDICATION THERAPY

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DECREASED ACCESS TO QUALITY CARE TRACKING
INDICATORS

• CLINICAL STAFF TRAINED IN EVIDENCE-BASED MEDICINE
  (100)
• INTERPRETER SERVICE PROVIDED FOR ALL
  LIMITED-ENGLISH PROFICIENT (LEP) PATIENTS
• DETERMINE FUTURE LEP NEEDS - USE ADMISSION DATA
  TO TREND THE INFLUX OF SPANISH, SOMALI, AND OTHER
  PATIENT POPULATIONS
• INPATIENT CHARTS REVIEWED BY CLINICAL PHARMACISTS
  (gt75)
• ALL INDICATORS ARE PERCENTAGE-BASED GOALS
  FOR IMPLEMENTATION ARE TO BE SET AT 100
  COMPLIANCE

23
DECREASED ACCESS TO QUALITY CARE

• EXPLANATION OF COST SAVINGS
• HOSPITALS MUST PROVIDE LIMITED ENGLISH SPEAKING
  PATIENTS (LEP) WITH THE SAME ACCESS TO QUALITY
  HEALTHCARE AS ENGLISH-SPEAKING PATIENTS
• TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
• OMH CLAS standards, HIPAA, NCQA and JCAHO
  accreditation standards.
• NONCOMPLIANCE MAY LEAD TO LOSS OF REIMBURSEMENT
  VIA FEDERAL FUNDS (MEDICARE)

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LACK OF APPROPRIATE MEDICATIONSCOST ANALYSIS
25
LACK OF APPROPRIATE MEDICATIONSCOST ANALYSIS
26
LACK OF APPROPRIATE MEDICATIONSCOST ANALYSIS
27
MULTIPLE HOSPITAL ENCOUNTERS
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MULTIPLE HOSPITAL ENCOUNTERS FLOW ANALYSIS
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MULTIPLE HOSPITAL ENCOUNTERS ROOT CAUSE ANALYSIS

• ROOT CAUSE STATEMENT
• LACK OF COMMUNICATION AND SOCIAL SERVICES
  RESULTED IN INCREASED LIKELIHOOD OF MULTIPLE
  HOSPITAL ENCOUNTERS.

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MULTIPLE HOSPITAL ENCOUNTERS ROOT CAUSE ANALYSIS

• THREE CONTRIBUTING FACTOR DOMAINS WERE
  IDENTIFIED
• STAFF COMMUNICATION
• STAFF/PATIENT COMMUNICATION
• INADEQUATE SOCIAL SERVICES

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STAFF COMMUNICATION
STAFF COMMUNICATION
LACK OF THOROUGH MEDICAL HISTORY REVIEW
DISORGANIZED RECORDS
UNMETHODICAL COMMUNICATION ABOUT PATIENT
32
STAFF/PATIENT COMMUNICATION
FAILURE TO EDUCATE PROPERLY
LACK OF INTERPRETER
LACK OF EMPATHY WITH PARENTS
STAFF/PATIENT COMMUNICATION
33
INADEQUATE SOCIAL SERVICES
INADEQUATE SOCIAL SERVICES
NO ASSISTANCE FINDING HEALTH INSURANCE
LACK OF COUNSELING FOR THE FAMILY
NEGLECT OF HOUSING SITUATION
34
MULTIPLE HOSPITAL ENCOUNTERS ISHIKAWA
INADEQUATE SOCIAL SERVICES
STAFF COMMUNICATION
DISORGANIZED RECORDS
LACK OF COUNSELING FOR THE FAMILY
NO ASSISTANCE FINDING HEALTH INSURANCE
UNMETHODICAL COMMUNICATION ABOUT PATIENT
LACK OF THOROUGH MEDICAL HISTORY REVIEW
NEGLECT OF HOUSING SITUATION
MULTIPLE HOSPITAL ENCOUNTERS
LACK OF EMPATHY WITH PARENTS
LACK OF INTERPRETER
FAILURE TO EDUCATE PROPERLY
STAFF/PATIENT COMMUNICATION
35
MULTIPLE HOSPITAL ENCOUNTERS CONTRIBUTING FACTORS

• STAFF COMMUNICATION
• DISORGANIZED STAFF FAILED TO INTEGRATE THEIR
  INDIVIDUAL AREAS OF PATIENT CONTACT, LEADING TO A
  BREAKDOWN IN CONTINUITY OF CARE
• STAFF/PARENT COMMUNICATION
• STAFF FAILED TO COMMUNICATE WITH THE PARENTS DUE
  TO LANGUAGE BARRIERS AND A LACK OF EMPATHY
• INADEQUATE SOCIAL SERVICES
• LACK OF POLICIES FOR SOCIAL ASSISTANCE LED TO
  NEGLECT OF ENVIRONMENTAL FACTORS CONTRIBUTING TO
  THE DECLINE IN THE PATIENTS HEALTH

36
MULTIPLE HOSPITAL ENCOUNTERS RECOMMENDATIONS

• STAFF COMMUNICATION
• ORGANIZED PROCEDURE FOR CHART STORAGE, TRANSFER,
  AND RETRIEVAL
• FULLY-INTEGRATED MULTIDISCIPLINARY TEAMS
• CASE MANAGER TO ENSURE APPROPRIATE PATIENT CARE
• STAFF/PARENT COMMUNICATION
• MAKE PROVISION FOR INTERPRETER SERVICES, EITHER
  PRE-PRINTED OR OVER THE TELEPHONE
• ORGANIZE DISCHARGE PROCEDURES TO GUARANTEE
  PATIENT EDUCATION
• TRAIN STAFF ON COMPASSIONATE CARE
• INADEQUATE SOCIAL SERVICES
• SOCIAL WORKER TO INTEGRATE EXTERNAL ASPECTS OF
  PATIENT CARE

37
MULTIPLE HOSPITAL ENCOUNTERS TRACKING INDICATORS

• REDUCTION IN NUMBER OF CHARTS NOT FOUND BY 50
• CASE MANAGER/PHARMACIST REVIEW OF CHARTS (gt75)
• PATIENTS RECEIVING DISCHARGE EDUCATION (100)
• SOCIAL WORKER INVOLVED IN EVERY CASE MEETING
  MINIMUM REQUIREMENTS

38
MULTIPLE HOSPITAL ENCOUNTERS

• EXPLANATION OF COST SAVINGS
• ADDING INTERDISCIPLINARY ROUNDS CAN LEAD TO A
  17.4 DECREASE IN INPATIENT COST PER PATIENT
• INTERDISCIPLINARY ROUNDING TEAMS WOULD INCLUDE AN
  MD, RN, PharmD, CASE WORKER AND SOCIAL WORKER

39
MULTIPLE HOSPITAL ENCOUNTERS COST ANALYSIS
40
MULTIPLE HOSPITAL ENCOUNTERS COST ANALYSIS
41
ANOXIC BRAIN INJURY
42
ANOXIC BRAIN INJURY FLOW ANALYSIS
43
ANOXIC BRAIN INJURY ROOT CAUSE ANALYSIS

• ROOT CAUSE STATEMENT
• INSUFFICIENT TRAINING AND LACK OF ORGANIZATION
  RESULTED IN INCREASED RISK OF HARM TO THE
  PATIENT.

44
ANOXIC BRAIN INJURY ROOT CAUSE ANALYSIS

• TWO CONTRIBUTING FACTOR DOMAINS WERE ESTABLISHED
• POOR AIRWAY MANAGEMENT
• DISORGANIZATION

45
POOR AIRWAY MANAGEMENT
POOR AIRWAY MANAGEMENT
LACK OF APPROPRIATE DRUG THERAPY
INSUFFICIENT TRAINING
INADEQUATE EXPERIENCE
46
DISORGANIZATION
NO CENTRAL LOCATION FOR PEDIATRIC EMERGENCY
EQUIPMENT
INSUFFICIENT PREPARATION
DISORGANIZATION
47
ANOXIC BRAIN INJURYISHIKAWA
POOR AIRWAY MANAGEMENT
LACK OF APPROPRIATE DRUG THERAPY
INADEQUATE EXPERIENCE
INSUFFICIENT TRAINING
ANOXIC BRAIN INJURY
INSUFFICIENT PREPARATION
NO CENTRAL LOCATION FOR PEDIATRIC EMERGENCY
EQUIPMENT
DISORGANIZATION
48
ANOXIC BRAIN INJURY CONTRIBUTING FACTORS

• POOR AIRWAY MANAGEMENT
• LACK OF APPROPRIATE CHOICE IN DRUG THERAPY
  CONTRIBUTED TO ANOXIC BRAIN INJURY
• INSUFFICIENT TRAINING AND EXPERIENCE LED TO
  TRAUMATIC AIRWAY MANAGEMENT
• DISORGANIZATION
• INSUFFICIENT PREPARATION FOR EMERGENCIES LED TO
  DELAYED RESPONSE AND A HIGHER LIKELIHOOD OF A
  POOR OUTCOME
• LACK OF A CENTRAL LOCATION FOR PEDIATRIC
  EMERGENCY EQUIPMENT WASTED VALUABLE TIME AND
  CONTRIBUTED TO THE ANOXIC BRAIN INJURY

49
ANOXIC BRAIN INJURY RECOMMENDATIONS

• POOR AIRWAY MANAGEMENT
• CURRENT ALCS/PALS/ATLS CERTIFICATION FOR ALL
  CLINICAL STAFF
• REQUIRED YEARLY CME IN PEDIATRIC EMERGENCY
  MEDICINE
• MULTIDISCIPLINARY GRAND ROUNDS MONTHLY TO ADDRESS
  APPROPRIATE MANAGEMENT OF DISEASES
• DISORGANIZATION
• QUARTERLY DRILLS FOR EMERGENCY PREPAREDNESS
• ESTABLISHMENT OF A CENTRALLY LOCATED PEDIATRIC
  CODE CART WITH ALL RELEVANT EQUIPMENT

50
ANOXIC BRAIN INJURY TRACKING INDICATORS

• CURRENT CERTIFICATION OF CLINICAL STAFF IN
  ACLS/PALS/ATLS (100)
• PARTICIPATION IN MULTIDISCIPLINARY GRAND ROUNDS
  (gt90)
• DECREASE IN MEAN NUMBER OF ATTEMPTS TO
  SUCCESSFULLY INTUBATE (lt3 ATTEMPTS)
• TRACK AND INVESTIGATE ADVERSE EVENTS IN THE
  EMERGENCY ROOM (100)
• IMPROVEMENT IN RESPONSE TIME OVER EACH QUARTERLY
  RESUSCITATION DRILL

51
ANOXIC BRAIN INJURY

• THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT
  (EMTALA) STATES THAT MEDICARE-PARTICIPATING
  HOSPITALS MUST PROVIDE STABILIZING TREATMENT
  REGARDLESS OF ABILITY TO PAY
• SINCE RIVER RAPIDS ADVERTISES ITSELF AS AN
  EMERGENCY DEPARTMENT IT MUST FOLLOW THESE
  GUIDELINES OR RISK LOSING ITS MEDICARE FUNDING
• BROSELOW KITS ARE DESIGNED TO ALLOW THE
  PRACTIONER TO QUICKLY ESTIMATE THE CHILDS
  WEIGHT, DETERMINE WEIGHT-BASED DRUG DOSES, AND
  SELECT THE CORRECT SIZE EMERGENCY OR
  RESUSCITATION EQUIPMENT

52
ANOXIC BRAIN INJURY COST ANALYSIS
53
CONCLUSION
54
RECOMMENDATION SUMMARY

• IMPROVED INTERPROFESSIONAL COMMUNICATION
• PROVIDE INTERPRETER SERVICES
• MULTI-DISCIPLINARY TEAMS
• MONTHLY GRAND ROUNDS TO ENSURE ADHERENCE TO
  STANDARD OF CARE GUIDELINES
• PROPER ORGANIZATION OF CHARTS AND EQUIPMENT
• REQUIRED CURRENT CERTIFICATION IN ACLS/PALS/ATLS
• YEARLY CME IN PEDIATRIC EMERGENCY MEDICINE
• PROVIDE A SOCIAL WORKER FOR ALL CASES THAT MEET
  THE MINIMUM REQUIREMENTS

55
IN AN IDEAL WORLD

• AN INTERPRETER WOULD HAVE BEEN UTILIZED
• THE INTERPRETER WOULD HAVE BEEN ABLE TO
  COMMUNICATE WITH THE FAMILY OPENLY, PROVIDE A
  BETTER PATIENT HISTORY, AND EDUCATE THE FAMILY
  APPROPRIATELY ABOUT ASTHMA, ALLERGIES, AND
  TRIGGERS, AS WELL AS PROVIDE INFORMATION ABOUT
  MEDICATIONS
• A CLINICAL PHARMACIST WOULD HAVE BEEN INVOLVED
• THE PHARMACIST WOULD HAVE PROVIDED CURRENT
  GUIDELINES FOR APPROPRIATE ASTHMA MEDICATIONS AND
  ASSISTED IN DEVELOPING A PLAN FOR OUTPATIENT CARE

56
IN AN IDEAL WORLD

• A SOCIAL WORKER WOULD HAVE MET WITH THE FAMILY
• THE SOCIAL WORKER WOULD HAVE HELPED THE FAMILY
  WITH SETTING UP MEDICAID, LESSENING THE FINANCIAL
  STRAIN ON THE FAMILY
• THE SOCIAL WORKER WOULD HAVE ASSISTED THE FAMILY
  WITH FINDING BETTER HOUSING AND BEEN ABLE TO
  PROVIDE SMOKING CESSATION COUNSELING TO THE
  FAMILY
• A CARE MANAGER WOULD HAVE REVIEWED THE CASE
• THE CARE MANAGER WOULD HAVE ENSURED COMPREHENSIVE
  PATIENT CARE AND ASSISTED IN SPECIALIST FOLLOW UP

57
FUTURE DIRECTIONS

• IMPROVE CRISIS MANAGEMENT SKILLS BY COLLABORATING
  WITH THE UNIVERSITY OF WISCONSIN MEDICAL
  SIMULATION PROGRAM
• INVITE SPECIALTY CARE PHYSICIANS TO GUEST
  LECTURE/TRAIN PHYSICIANS PRACTICING IN RIVER
  RAPIDS
• ACTIVELY PARTICIPATE IN PERFORMANCE MEASURES
  INCLUDING THE CHILDRENS ASTHMA CARE (CAC) JCAHO
  MEASURE SET
• TRACK HIGH VOLUME DIAGNOSES AND TRANSLATE
  TEACHING MATERIALS IN THOSE AREAS FOR LEP
  PATIENTS
• PURCHASE VIDEOS IN SPANISH AND SOMALI TO PLAY IN
  THE CLINICS

58
REFERENCES
American Society of Anesthesiologists Task Force
on Management of the Difficult Airway. (2003).
Practice guidelines for management of the
difficult airway an updated report by the
American Society of Anesthesiologists Task Force
on Management of the Difficult Airway.
Anesthesiology,98(5) 1269-77. Broselow/Hinkle
Pediatric Resuscitation System (2006) Retrieved
October 30, 2006 from the World Wide web
http//www.armstrongmedical.com
/ami/item.cfm?itemid755sction3sbsection14. Ce
nters for Medicare and Medicaid Services (id and
State Operations Manual Appendix V Interpretive
Guidelines Responsibilities of Medicare
Participating Hospitals in Emergency Cases (Rev.
1, 05-21-04). Retrieved October 30, 2006 from
the World Wide Web http//www.cms.hhs.gov/manuals
/Downloads/som107ap_v_emerg.pdf. Curley, C.,
McEachern, K. E., Speroff, T. (1998). A Firm
Trial of Interdisciplinary Rounds on Impatient
Medical Wards An Intervention designed using
continuous quality improvement. Med Care, 36(8),
AS4-AS12. National Institutes of Health National
Heart Lung and Blood Institute (1997). Guidelines
for the Diagnosis and Management of Asthma
(National Asthma Education and Prevention Program
Publication No. 97-4051)
59
REFERENCES

• The Joint Commission on the Accreditation of
  Healthcare Organizations (2006) Children's Asthma
  Care (CAC) Performance Measure Set. Retrieved
  October 30, 2006 from the World Wide Web
  http//www.childrenshospitals.net/AM/Template.cfm?
  template/CM/ContentDisplay.cfmContentID23183
• The Joint Commission on the Accreditation of
  Healthcare Organizations (2006) Joint Commission
  2006 Requirements Related to the Provision of
  Culturally and Linguistically Appropriate Health
  Care January 2006. Retrieved October 30, 2006
  from the World Wide Web http//www.joint
  commission.org/NR/rdonlyres/1401C2EF-62F0-4715-B28
  A-7CE7F0F20E2D/0/hlc_jc_stds.pdf
• The Kaiser Family Foundation StateHealthFacts.Org
  (2005) Wisconsin Medicare Enrollment as a
  Percent of Total Population, 2005. Retrieved
  October 30, 2006, from the World Wide Web
  http//www.statehealthfacts.org/cgi-
  bin/healthfacts.cgi?actionprofileareaWisconsin
  category MedicaresubcategoryMedicareEnrollment
  topicMedicareEnrollmentasa25ofTotalPop.

60
REFERENCES

• The Kaiser Family Foundation StateHealthFacts.Org
  (2005) Wisconsin Health Insurance Coverage of
  the Total Population, states (2004-2005), U.S.
  (2005). Retrieved October 30, 2006, from the
  World Wide Web http//www.statehealthfacts.org/cg
  i-bin/healthfacts.cgi?actionprofilearea
  WisconsincategoryHealthCoverage26Uninsureds
  ubcategoryHealthInsuranceStatustopicTotalPop
  ulation.

61
Acknowledgements

• Reamer Bushardt, PharmD, PA-C, Physician
  Assistant Program Director, College of Health
  Professions, Medical University of South
  Carolina, Charleston, SC
• Sandra Garner, PharmD, Associate Professor,
  College of Pharmacy / Pharmacy Clinical
  Sciences, Medical University of South Carolina,
  Charleston, SC.
• Jeana Havidich, MD, Associate Professor,
  Department of Anesthesia and Perioperative
  Medicine, Medical University of South Carolina,
  Charleston, SC.
• Matthew McEvoy, MD, Assistant Professor,
  Department of Anesthesia and Perioperative
  Medicine, Medical University of South Carolina,
  Charleston, SC.
• Karen Rankine, RN, Coordinator of Patient/Family
  Education and Interpreter Services, Medical
  University of South Carolina, Charleston, SC.
• Jason Roberson, MA, BA, Cultural Competency
  Coordinator, Interpreter services, Medical
  University of South Carolina, Charleston, SC.
• Robert Rodrigues, RN, Clinical Instructor,
  Emergency Services, Medical University of South
  Carolina, Charleston, SC.
• Stephen Saef, MD, Associate Instructor, Emergency
  Services, Medical University of South Carolina,
  Charleston, SC.
• Patricia Wagstaff, RN, MSN, Outcomes Manager,
  Medical University of South Carolina, Charleston,
  SC.