CPMC / Stanford Collaboration

1. CPMC / Stanford Collaboration Ryan Dougherty, MD CPMC Adult Program Director March 2019

2. California Pacific Medical Center History and Background

3. Origins of CPMC at California Campus • California campus opens 1875 as the state’s first hospital created for women by women • Charlotte Blake Brown, MD born in Philadelphia, travelled as missionary with family, settled in Napa, medical degree at Philadelphia Women’s College • Returned to SF 1874, met resistance to female doctors, teamed up with group of women in SF – women’s health hospital (Pacific Dispensary for Women and Children) • Established first nurse training program on west coast • Expanded to women’s and children’s health (Children’s Hospital of SF) • Future site of the CPMC pediatric CF practice with Dr. Karen Hardy

4. Davies Campus • Founded in 1854 as the German Hospital for influx of German immigrants coming for gold rush • One of the first pre-paid health care plans: $1/month access to hospital bed • Today: home of specialized stroke care, physical rehabilitation, reconstructive surgery (hand, microsurgery, transgender

5. Pacific Campus: Many Firsts for California • 1857: Elias Cooper, MD founded first medical school on the west coast (Cooper Medical College) • “Father of medical research in the West” • Became Stanford Medical School in 1909 (School moved to Palo Alto in 1959) • Pacific Presbyterian Hospital is born • CA first successful caesarian birth • SF first use of chloroform for surgery, alcohol dressings to prevent infection • 1990s: advanced specialized care in cardiac/transplant (nation’s first nine way, two day kidney transplant chain in 2015) UCSF-CPMC

6. Campuses merging together across San Francisco • 1991 Pacific Presbyterian Hospital and Children’s Hospital of San Francisco merged to form California Pacific Medical Center (CPMC) • 1998 Davies Medical Center added as third campus • 2007 St. Luke’s became fourth campus * Van Ness * * *

7. Campuses merging together across San Francisco • 1991 Pacific Presbyterian Hospital and Children’s Hospital of San Francisco merged to form California Pacific Medical Center (CPMC) • 1998 Davies Medical Center added as third campus • 2007 St. Luke’s became fourth campus Van Ness * * * Mission Bernal

8. Interesting stats (2014) • Non-university academic, specialty hospital • Largest hospital within the Sutter hospital system • Medical residents and fellows: 105 • UCSF, Dartmouth medical students • Births: 5,947 • CPMC Research Institute (established 1959), started the nation’s largest clinical research program for ALS (Lou Gehrig’s disease) • Dr. Paul Mohabir completed pulmonary / critical care fellowship

9. Adult CF Program at CPMC Past, Present and Future

10. Adult CF Program at CPMC: Past • Originated with Dr. Karen Hardy (pediatric) who partnered with Dr. Christopher Brown (adult) 1990 to start CPMC’s first adult program • CFF center accreditation 2007 • After my training fellowship at UCSF 2009, I joined CPMC with interest in CF care, became center director in 2012 • 2017: CPMC became affiliate program of Stanford – working “collaboration” • Programs with fewer than 40 patient encouraged to become affiliates • Best of both worlds: private practice group and community hospital in SF + highly specialized university expertise of Stanford (research trials, expert consultants, quality care protocols, access to transplant) • Provide ease of transition for pediatric patients at CPMC, living in SF

11. Adult CF Program at CPMC - Present • Inpatient services: • Interventional radiology (world class) • ENT • Rehab / exercise, Infectious diseases, microbiology lab • Palliative care team (advanced lung disease symptom and pain management) • Experienced, caring nurses (20-30 yrs experience with CF) • Unique Research projects: Novabioticscysteamine phase II study • Started with a patient inquiry • CPMC enrolled first patient in the U.S.

12. Adult CF Program at CPMC - Present • Outpatient services • Focused, individualized care (3-5 patients / clinic), twice a month • Excellent coordination of patient care (Carolyn Hruschka, NP) • Full team (NP coordinator, three CF attending physicians, dietician, social worker, mental health coordinator, respiratory therapist, research coordinator) • Overarching goal: to provide high quality, compassionate care for adults with CF

13. Inpatient services CPMC

14. Inpatient services CPMC • Intensive inpatient program (young adults) • IV antibiotics • Physical therapy • High calorie diet • Results: • FEV1 46% to 55% • FVC 62% to 68% • Wt gain 2kg • Increase in exercise endurance time from 9.5 to 16.6 min • (Alison et al. Phys Ther. 1994 74(6):583-91)

15. Alta Plaza Park

16. Adult CF Program at CPMC - FutureVan Ness Campus (VNC) – State of the Art • Brand new hospital Van Ness Avenue, medical office building across the street • Close proximity between Stanford/CPMC pediatric group and CPMC adult group • SF Lung and Sleep: Advanced lung disease outpatient center

17. Peds and Adult Inpatient Unit at VNC

18. Adult CF Program at CPMC - Future • Maintaining expertise of our care team utilizing resources from Stanford: • Stanford CF grand rounds and journal clubs • Quality improvement meetings • Site visits • Quarterly meetings • Quality care protocols • Research meetings • Patient and Family Advisory Board (Dr. Vinnie Jha) • Pediatric to adult team transition • Quality improvement projects (PDSA “Plan-Do-Study-Act” model)

19. Quality improvement project – GI symptom tracker • Objective: obtain a more objective understanding of GI symptoms among our CF adults • Rationale: few patients reporting difficulty with adherence or symptoms (“everything is fine”) • Administer the “GI Symptom Tracker” questionnaire by Abbvie (part of the “I Can” program) in waiting room prior to clinic visit • Findings: • 69.2% reported various symptoms “often or always” • 61.5% reported adherence challenges to taking enzymes • 75% of patients who reported either frequent symptoms and/or adherence challenges were below goal BMI (BMI < 22 females, <23 males)

20. Quality improvement project – GI symptom tracker • Important to objectively assess GI symptoms and adherence with enzymes • Opportunities for improving patient GI health and well being: • Enzyme dose, assess need for acid suppression • Strategies for improving compliance • The “CF Gut” is complex: • Hepatobiliary problems • Constipation • Gastric emptying • Peptic ulcer disease • Malignancy • Celiac disease • Lactose intolerance • Eosinophilic esophagitis • Cdiff colitis • Gastroesophageal reflux disease • Small intestinal bacterial overgrowth • Dysbiosis (loss of normal colon bacteria) • Dysmotility • Medication side effects

21. CPMC Adult CF Program San Francisco Lung and Sleep 1100 Van Ness Avenue, Suite 1005 San Francisco, CA 94109 415-923-3421 www.sflung.com (Contact Us)