Food and whine
Improving communications,
  processes, and more
Nursing shortage breeds innovation
Nursing gets biggest boost
Decoding risk
A better image of lung cancer?
Real-time defense against bioterrorism
Healthy execs=healthy companies


Moving Forward

Food and whine

    by Carol Pinto


Marilyn Warner transports trays to "smart"
retherm carts lined up on the right.




Cheryl Gaither removes a two-gallon bag
of grits from the chill tank.




The cook/chill process retains the quality
and safety of food before and after it is
assembled on trays by food service
employee Lucinda Webb.


When we finally got the grits right, we knew we had it made," says Lynne Ometer, director of Food and Nutrition Services at Emory Hospitals. "We had so many complaints at first, but now the grits are just as good as when we made them the old way."

Getting the grits to the right consistency was a benchmark in mastering the hospitals' new "cook/chill" system -- a revolution in cooking grits and lots more at the hospitals. It's part of a four-year recipe cooked up by Food and Nutrition Services to better serve more than 2 million patient and visitor meals a year.

Construction of the new $4.5-plus million kitchen at Emory University Hospital (EUH) began in February 2001, and 16 months later patients started getting "cook/chilled" meals at EUH as well as the Center for Rehabilitation Medicine and Emory Crawford Long Hospital (ECLH), where food is delivered daily in refrigerated trucks. Wesley Woods will become part of that mix in 2003.

Cook/chill, as opposed to "cook/serve," is a method used by chefs in kitchens ranging from four-star restaurants to schools. Take fresh ingredients, cook them precisely until they are just done, then rapidly chill. Later, finish the process by reheating slowly just before serving. Instead of food being overdone after being kept warm on steam tables, dishes are "rethermed" and served, with a goal of turning out consistently higher-quality food.

"When food is prepared traditionally, it really makes a difference if you are the first or the last person served from a large pan on a steam table because the food is held over high heat," says Ometer. "With cook/chill, quality is more consistent from serving to serving. The food is safer too."

The other big advantage is efficiency and cost-effectiveness. Large quantities - for instance, 700 pounds of meat - can be prepared all at once and rapidly chilled, saving time and energy, then heated and served as needed. Duplication of effort is avoided.

"We serve food such as vegetable soup and mashed potatoes every day," says Ometer. "It doesn't make sense to start from scratch every day, gathering the ingredients and washing all those pots each time we make the same dishes. We can make a week's worth of fresh vegetable soup - no preservatives or artificial ingredients - then vacuum seal it, chill it, and heat it as needed before serving. Nutrient retention is greater, and each person gets the same high-quality meal."

The kitchen's new 100-gallon kettles have paddles that stir the food constantly and pump out a uniform product mix into two-gallon heavy-duty plastic bags. Two cook/chill cooks guide the bags as they are filled, vacuum-sealed, and date-stamped, before the bags travel up a conveyor belt that drops them into an icy water bath. When full, the tank closes and starts the tumble chill that quickly drops the temperature from 165° F to 41° or below in 1.5 hours, a feat that would take nine hours under normal refrigeration. Food is kept at between 33° and 37° F in the "food bank." The rapid chilling, vacuum sealing, and low holding temperature keep the food safe for up to four weeks without deterioration in quality.

Implementing the new system was not easy. For one year, kitchen staff at EUH had to work around the construction. Although not enlarged, the kitchen had to be totally reconfigured and new equipment added to create a central food-production area. All the cooking equipment was relocated, and the tray assembly line was moved three times. Offices were gutted and renovated. The old bake shop was converted to a cold food preparation area. An ingredient control room was constructed, and five new walk-in refrigerators were installed. It took five months to dig a pit in the middle of the kitchen so the cook/chill kettles could be recessed into the floor. A hoist was constructed to move pasta in a large basket out of the kettle and over to an area where it is dumped to cool and be used in recipes.

"We were working in little hallways set aside around the sealed-off construction pit in the middle. Every day, food service employees would come in and find that things had been moved overnight. The fact that our employees survived all of this and never missed a meal is amazing!" says Ometer.

Kitchen staff adapted and came out better trained and working as a team, she says. "Preparing the food in advance has almost eliminated crisis management. We're less likely to run out of food now because more product can be pulled quickly from inventory. Since we aren't cooking to the clock, we don't have to have it all come out at the same time."

The patient breakfast tray assembly line starts at 5:30 am and is done two hours later, when the carts are taken to serve the patients. Assembly for lunch starts at 9:30 am, and all trays are ready by 11:30. The dinner assembly line starts at noon and finishes at 2 pm, but the "smart carts" are programmed to keep everything cold until about 4:30 pm. The carts begin slowly retherming the food about an hour before it will be served. The hot chamber is even hot enough to bake cookies right on the trays, while the cold foods are chilled on the other side.

A major difference is that the food is now plated cold, instead of hot. "We all had to learn new ways to check for quality, consistency, and doneness when the food is cold," says Ometer. "Before, we could taste-test hot food immediately before serving. Now we taste-test using sample trays that have been rethermed."

Emory Hospital has followed Emory Crawford Long in offering more "comfort" foods on its patient menu, which now is the same for the two hospitals. "We've found that when people are sick and in the hospital, they want the meatloaf and mashed potatoes rather than the Cornish game hen," says Ometer. "We provide healthy meals, but you have to give people what they want to eat. For example, with the new method, we had the green beans coming out beautifully green and tender/crisp. But many patients complained that the beans were too hard, so we gradually cooked them more and more until the complaints stopped."

Currently, most cook/chill food is used for patient meals, but more dishes will be prepared for the hospital dining rooms using the new method as food service staff test more recipes.

"As any cook knows, cooking in quantity requires experimentation. You can't just double or triple a recipe," Ometer says. "Seasonings and other ingredients need to be adjusted when preparing several thousand servings. We also have to consider that flavors become more intense as food is held in a cold environment."

Food and Nutrition Services serves about 196,000 meals a month -- an average of 6,530 a day. A third are patient meals, about 60% are served in hospital dining areas, and the rest is catering. Patient meals served will increase by another 8% when the EUH kitchen starts providing meals to Wesley Woods in 2003. The hospital cafeterias don't make a profit, but are set up to cover their costs. Ometer expects a 2.5-year payback on the cook/chill portion of the project.

"It's too early to fully measure results," she adds. "But we are reducing the required hours worked per meal. Without cook/chill we would need 21 more full-time employees to produce the meals projected for 2003."

Other ingredients in Emory's new approach to food include ECLH's new bake shop which soon will provide baked goods to Bishop's Pantry at EUH and also to Wesley Woods.

And Seasonings, the new "dining experience" at ECLH, is already proving its worth. Built on the "fresh market" concept, food is made to order there at tempting stations. The number of cafeteria meals served at Emory Crawford Long are up about 40% since Seasonings opened in July, with many customers coming from outside the hospital. But cafeteria - a word used less and less - hardly applies to Seasoning. "People say it's like an upscale restaurant instead of eating in a hospital," says Ometer. "It's become the place to eat."


Improving communication, processes, and more


Patients have been singing our praises for years. We're compassionate. We provide high-quality care. Yet while lauding our good graces, patients let us know that they were fed up with long wait times and a lack of communication. In a competitive market, it was time for a change. So more than two years ago, Emory Healthcare (EHC) formed the service performance initiative.

It began June 2000 with a benchmark patient satisfaction survey conducted by Press Ganey, a national satisfaction measurement company specializing in health care. Unlike in years past, EHC surveyed patients systemwide at Emory University, Emory Crawford Long, and Wesley Woods hospitals as well as The Emory Clinic and the Emory Children's Center. "We wanted to be sure that patients receive the same excellent service, whether they are an inpatient, an outpatient, or someone seeking a cardiology exam at our clinic in Hiawassee," says Redge Hanna, director for service performance at Emory Healthcare.

The 46,000 surveys returned by patients revealed that we needed to improve our communication skills and customer service. As a result, more than 8,000 new and existing Emory Healthcare employees and physicians are completing customer service sessions here as a refresher on how to communicate better with patients and co-workers, how to value them as people, and how listen to them more.

Now collaborative teams are focusing on fixing the problems that patients identify. The initiative has formed 22 "waits and delays" collaborative teams, each comprised of department leaders, staff, physicians, and a facilitator from a different area.

"Areas that have employees and physicians committed to improving service performance are showing real progress," reports Peg Bloomquist, associate administrator at Emory Hospitals and chair of the EHC service performance team.

Emory University Hospital's 4G cardiology unit is a good example of putting data into action. Due to the high volume of patients needing cardiology beds, staff decided to work on reducing delays in the discharge process. In six months, the unit decreased by half the average time patients wait to leave after their discharge order is written, says Deborah Wright, department director.

How did they do it? Staff evaluated every possible reason for a delay and tried new approaches to speed up the process. New cardiology residents now complete a 4G orientation that emphasizes how efficient discharges can speed the admission process for new patients waiting for beds. Night shift nurses evaluate all patients for potential discharge the next day. If a patient is a candidate, the nurses begin the discharge paperwork, order an early breakfast tray, and encourage transportation to arrive by 11 am.

"These changes couldn't have happened without the commitment of the entire staff and physicians like Dr. Steve Clements, who admits many patients to 4G. He was our physician champion and with his staff, worked hard to improve our discharge flow," says Wright.

Positive feedback from patients makes the time spent planning and implementing a customer service performance plan worth it. Word is getting around. "Please accept my warm thanks for the care and attention extended to our good friend during his hospitalization," one patient visitor wrote, saying he and his wife are singing Emory's praises in this community. "It is so important that people have the best possible experience in the health care system. . ." That says it all.


Nursing shortage breeds innovation



Angelique Davenport is following in her mother's footsteps, courtesy of a new partnership between Emory Hospitals and Georgia Perimeter College (GPC). When Davenport, whose mother is a cardiac nurse in Ohio, completes the Emory Scholars program, she will have gained valuable on-the-job training, tons of wisdom from her nursing mentors, and a full-time job as a registered nurse.

Nursing colleagues around the nation will be happy to have her join their ranks in a profession that is caught up in a staffing crisis. Last summer, the Joint Commission on Accreditation of Healthcare Organizations reported that US hospitals had 126,000 vacant RN positions. By 2020, 400,000 fewer nurses are expected to be on the job, though the number of elderly patients will continue to mount.

Fortunately, top government leaders have been paying attention. In June, the Health Resources and Services Administration began awarding a series of grants totaling $30 million for nursing education and faculty development. Among the recipients was the Nell Hodgson Woodruff School of Nursing, which received close to $25,000 to train nursing undergraduates in hands-on geriatrics. In August, President Bush signed the Nurse Reinvestment Act to establish more scholarships, grants, and other incentives to attract and retain top-notch nurses. Congress has yet to appropriate funds under the new law.

There has been no shortage of creativity when it comes to nursing recruitment. Nationally, Johnson & Johnson's "Discover Nursing" campaign promotes nursing as a career and provides an extensive list of nursing schools and scholarship opportunities on its website (www.discovernursing.com). Closer to home, Emory Healthcare has reintroduced the RN flex pool to create its own internal agency and eventually fill 150 new RN positions at Emory Crawford Long Hospital. Employees can recruit nurses too by referring qualified applicants to human resources via the "Find an Original" campaign. If an RN candidate is hired successfully, the referring employee receives $500.

Already, Emory Scholars is gaining recognition for addressing the nursing shortage. Last fall, Emory Hospitals and GPC officials presented the program as a recruitment model at the National League for Nursing Summit in California. It is one of many nurse recruitment efforts Emory Hospitals has used successfully.

Interestingly, Emory Scholars is attractive to older students who want to make a career change. Davenport worked several years before returning to school to become a nurse and was enrolled at GPC when Emory Scholars was introduced in January 2002. As of fall, 50 students were enrolled in the program, which pays all tuition costs and provides a book allowance. After students graduate, they will pay back their scholarships by working as registered nurses at Emory Crawford Long, Emory University, or Wesley Woods hospitals for one to two years, depending on how long they were an Emory Scholar. Hopefully, many will continue their careers with Emory Hospitals beyond their scholarship obligation.


Nursing gets biggest boost



The Nell Hodgson Woodruff School of Nursing will receive $5 million over the next five years toward an endowment that will fund scholarships for nursing students who already have bachelor's degrees in other fields. The $5 million from the Helene Fuld Health Trust - the largest single gift in the nursing school's history - will support the Nursing Segue Program. Graduates of the three-year-long program will earn both bachelor's and master's of science degrees in nursing.

"Most students who enter school for a second baccalaureate degree have exhausted their eligibility for federal loans during their first undergraduate program," says Anne Bavier, assistant dean for development in the nursing school. "Because they've usually been employed and have income after their first undergraduate degree, their eligibility for student loans from any source is jeopardized. These endowment funds will help insure the participation of dedicated students."


Decoding risk


The patients at Emory hospitals and clinics are a microcosm of the world, with nearly every race, faith, and nationality represented. Unlike, say, Iceland.

But there's a connection. The diversity of patients at Emory, when compared with the relative homogeneity of the small nation in the North Sea, may provide a unique opportunity to identify genetic factors that signal common diseases and disorders.

That's why Emory School of Medicine formed a strategic alliance with deCODE genetics, a Reykjavik-based genomics company that has used Iceland's largely static population as a giant gene-mapping laboratory. It is the first such alliance between deCODE and a university.

Here's how it works: Because of its isolation from the rest of Europe and the world, the population of Iceland has changed little over the years. Most of the approximately 290,000 people descend from small groups of settlers who arrived from Norway and what is now Great Britain nearly 1,200 years ago, with little immigration in the intervening centuries.

Add to that a nation that takes genealogy very seriously - family lineages are extensively recorded, and residents still use a surname system that denotes a parent's first name - and researchers have an unparalleled chance to identify genetic differences.

Normally, it can be difficult when looking at the genetic makeup of a group of people to determine which gene causes one to be predisposed to, say, having a stroke. But when the group is relatively homogenous and researchers have a detailed diagram of each person's ancestry, isolating the variation in question is much easier.

But while that may help the people in Iceland, the partnership with Emory will allow deCODE's research to aid people in the United States and the rest of the world. Using the maps that deCODE's scientists have developed to point them in the general direction, Emory researchers will conduct studies on patients here to identify other versions of the gene present in more diverse populations, like Atlanta's.

"The information deCODE provides is equivalent to telling us how to get to the stadium when we know that the Superbowl is being played," says Emory neurologist David Rye. "The relationship with Emory will allow the alliance to find the section, row, and seat more efficiently."

Eventually, the partnership could produce new information about everything from diabetes and autism to Parkinson's disease and Alzheimer's to sleep disorders and depression.


A better image of lung cancer?

A"re CT scans or X-rays better in helping reduce lung cancer deaths?

Emory researchers are now recruiting more than 1,500 current or former smokers to help find the answer. They will be part of the National Lung Screening Trial (NLST), which over the next eight years will compare the two methods of detecting lung cancer in more than 50,000 healthy older adults. Emory has received a $5 million grant from the American College of Radiology Imaging Network, which is sponsoring the study along with the National Cancer Institute.

Participants randomly selected to receive either CT scans or X-rays once a year for three years and then will be followed for another five years to monitor their health and help determine the long-term benefits of these two detection methods.

Lung cancer, the leading cause of cancer deaths, is hard to detect in its earliest, most treatable stage, says Emory radiologist Kay Vydareny, principal investigator of NLST at Emory. CT scans can pick up tumors under 1 cm, while X-rays - the primary means of lung cancer diagnosis for more than 100 years - can detect most tumors larger than one cm.

CT scans sometimes detect abnormalities such as scars from smoking, inflamed areas, or other noncancerous conditions that may require additional testing to determine that they are not harmful. These tests can cause undue anxiety for patients and may sometimes lead to biopsies or surgeries.

"Still, in some screening cases using CT, true cancers have been detected, many of which are in an early stage," Vydareny says. "If there are positive findings, we will contact participants and their primary care physicians and encourage a consultation with a cancer specialist so that there can be appropriate follow-up."

Current or former smokers between the ages of 55 and 74 may be eligible for this research study. Participants cannot have had any previous history of lung cancer, but patients with emphysema, bronchitis, or other smoking-related conditions will be accepted.

For more information or to find out if you qualify for this study, contact Emory HealthConnection at 404-778-7777 or the National Cancer Institute's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).


Real-time defense against bioterrorism

SECEBT combines vast resources to respond to biologic threats and infectious diseases.

SECEBT partners

The Carter Center

Centers for Disease
Control and Prevention

Emory University

University of Florida

University of Georgia

Georgia Institute of Technology

Georgia Research Alliance

Georgia State University

Health departments in Florida,
Georgia, Kentucky, Mississippi,
and South Carolina

Medical College of Georgia

Medical University of
South Carolina

Mercer University

University of Mississippi
Medical Center

Morehouse School of Medicine

Region IV, US Public Health Service

Veteran Affairs medical centers
affiliated with SECEBT partners


As threats from biologic agents and infectious diseases build, the lines are blurring between human-induced disease like the anthrax of fall 2001 and natural diseases such as West Nile virus. This double dose of disease starkly illustrates the need for radical thinking as to how to prevent, diagnose, and treat emerging infectious diseases before they become epidemics.

To tackle emerging diseases in real time, the Woodruff Health Sciences Center (WHSC) has taken the lead in establishing a new regional partnership -- the Southeastern Center for Emerging Biologic Threats (SECEBT).

"In the past three decades, more than 30 new or increasingly toxic infectious agents have been identified," says Jeffrey Koplan, vice president for academic health affairs and former director of the Centers for Disease Control and Prevention (CDC). "Our false sense of security provided by the barriers of geography and time has been eliminated. We need to develop new models for conducting research and interacting with one another if we intend to respond to biologic threats rapidly and efficiently."

Working with Emory infectious disease faculty, epidemiologists, emergency medicine experts, and government relations and communications staff, Koplan spearheaded SECEBT.

Although scientists often compete for funding and publication, in a crisis mode much can be gained by collaborating on research and by sharing facilities and information. Universities can obtain better real-time information by working closely with state public health and federal agencies about the need for specific kinds of research. Those agencies can benefit from knowledge from research universities.

"Two elements are missing in emergency preparedness. First is a cooperative relationship within academic disciplines, such as engineering, agriculture, behavioral medicine, public health clinical practice, immunology, and emergency medicine," says Koplan. "The other is an ongoing partnership between universities and state and local health agencies and federal agencies.

"Much of the value of this exchange occurs before untoward emergencies occur," he continues. "In an actual emergency, the government steps to the front and takes the lead. When the next event occurs, we hope more academic institutions will complement government activities and support them instead of just doing Monday-morning quarterbacking. With every week that passes, we are in a better position than we were before."

West Nile virus demonstrated the need for rapid communication and cooperation. Health care personnel must be alert to the possibility of such new diseases, and scientists need the information as quickly as possible to develop blood tests and other diagnostic tools. One group might learn how antibiotics work against a virulent disease, while another group works on a new vaccine or tests an old one. Meanwhile, public health agencies must rapidly communicate to a wide audience about developments in controlling the outbreak.

Many scientists within the SECEBT partner institutions are well positioned to be prime participants in biothreats surveillance, having been on the front lines as leaders in global disease prevention and elimination efforts for smallpox, anthrax, HIV/AIDS, tuberculosis, and other emerging diseases. The vast combined resources of the partners include biosafety level 3 and 4 labs for studying lethal airborne agents, a vaccine center, primate center, agriculture and engineering schools, food safety programs, laboratory research in emerging and highly toxic pathogens, extensive trauma facilities and emergency preparedness expertise, programs in public health preparedness, drug development, education and training, and international collaborations. At Emory alone, scientists already are involved in nearly 50 research projects related to threatening biologic agents.

SECEBT is not intended to usurp ongoing activities within the partner institutions, but to share knowledge and expertise within the partnership and with outside partners and pursue funding for bioterrorism research and preparedness. For example, Emory has teamed with several large research universities to apply for NIH bioterrorism funds.

WHSC has committed seed funds for collaborative projects within the SECEBT partner institutions. Collaborative opportunities and resources are on SECEBT's new website, www.secenterbiothreats.org.


Healthy execs=healthy companies



Greg Williams, CIO of Georgia Pacific,
takes an exercise stress test as part of
his Executive Health physical under the
supervision of Emory physician
David Propp.


WANT TO KNOW MORE?

To learn more about the many activities
currently under way in the Woodruff
Health Sciences Center, visit
whsc.emory.edu


Companies such as Home Depot, UPS, Coca-Cola Enterprises, and others, big and small, want their executives in top form physically and mentally and believe top-notch health care is a good investment. Busy execs want hassle-free health care in a hurry.

That makes business sense too for Emory Healthcare, which has revamped its 20-year-old Executive Health program to better provide physicals, screenings, and other services for corporate leaders.

"We wanted to offer the comprehensive detailed evaluations and customer service that executives demand," says internist Dave Roberts, medical director of Executive Health. "Unfortunately, cost-cutting measures have squeezed out this exceptional, patient-focused care. Insurance that covers routine physicals tends to pay for only the most basic studies and at such steep discounts that many physicians have to limit the time they spend with their patients as well as the number of ancillary tests."

But executives want their exams and tests on the same day in the same place, and they want someone to schedule them. Their companies are willing to pay for these extra conveniences and tests -- from $1,200 to $4,000, depending on what they choose from Executive Health's menu of services.

Executive Health itself hasn't always been fiscally healthy, though. "In the early years, we didn't have our own staff or dedicated space to handle more patients so we didn't market the program," says Carole Johnson, manager of Executive Health. The executive lounge was in the hard-to-find tunnel level of Clinic A. Executives had to go to areas scattered around campus for tests.

Today, the program's new dedicated space in the 1525 Building houses clinical and administrative staff, who work only with Executive Health patients. Emory physicians have developed specific care protocols, and now an exam with ancillary tests (except colonoscopy) takes only half a day.

Managers coming to Executive Health find a lounge equipped with a fax, copy machine, Internet hook-ups, coffee, juice, and the latest business periodicals. They go to one area for comprehensive health examinations. Depending on the patient's age and needs, the program can be customized to offer everything from an exercise tolerance tests and colonoscopy to an ultrafast CT scan to image calcified plaque inside coronary arteries or lungs. By the end of 2003, all tests except colonoscopy will be at 1525.

The executive receives his or her test results. The patient's doctor reviews them as well as a risk assessment and answers any questions before the executive goes home.

In this Issue


From the Director  /  Letters

Battling back

New picture of health

Big idea on a nanoscale

Moving forward  /  Noteworthy

On point:
  Medical liability -- the crisis is now

A fine kettle of soup

Executive Health also has partnered with a behavior modification program called Intervent. Counselors use lab and CT results as well as lifestyle behaviors to assess cardiac risk and design an action plan to reduce the risk for heart disease. The plan includes exercise, nutrition, weight management, and smoking-cessation programs.

The new, improved Executive Health is drawing praise as well as more patients. More than 40 companies now send executives from as far away as Europe to Emory for their annual checkups. Atlanta-based companies often have executives make appointments while they are in the city for company meetings. "We are recruiting new corporations to the program and hope to go from serving 700 patients in 2002 to 1,200 next year," Johnson says.

"Executive Health is not a boutique practice," adds program administrator Graham Fox. "The physical is a corporate benefit that companies purchase for their top management much like they purchase a company car. The difference is that through Executive Health, they purchase peace of mind for their executives and their businesses by keeping their managers happy and productive."

Randall Rollins, a spry septuagenarian and full-time chairman of Rollins, Inc., agrees. "It's a good investment from both a personal and a company standpoint. Not only do the doctors have the expertise to diagnose problems, but Emory has the resources to take care of those problems."

 


Copyright © Emory University, 2002. All Rights Reserved.
Send comments to the Editors.
Web version by Jaime Henriquez.