Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF June 8, 2012 Issue | Archived Issues

A remembrance of David L. Rimoin, MD, PhD

Cedars-Sinai memorial set for Monday

Please join colleagues and members of the Rimoin family in a program to celebrate the life and accomplishments of the late David L. Rimoin, MD, PhD. The event will be Monday, June 11, at 4 p.m. in Harvey Morse Auditorium.

» Read more

Law requires security prescription forms to include prescriber's preprinted address

Pharmacy focus

A new California law will take effect July 1 requiring security prescription forms for controlled substances to include the preprinted address of the prescriber.

» Read more

As bridge soars, AHSP reaches another major milestone

They arrived on campus a few weeks ago under police escort and have cast an imposing shadow on Sherbourne Avenue with their sheer heft and size. Friday, June 15, a crane will lift the first half of the enormous, 184-foot-long trusses into place to form the pedestrian bridge connecting the Advanced Health Sciences Pavilion to the medical center on the fifth-floor level.

» Read more

New guideline for patients with headache in the ED

Most headaches can be accurately evaluated by clinical history and physical exam. Diagnostic neuroimaging in these cases is neither needed nor desirable, as it is more likely to yield false positive findings while exposing many patients to unnecessary and harmful radiation.

» Read more

President's Perspective: the efficiency-quality paradox

At first, it seems counterintuitive: How can you increase efficiency while also enhancing quality? Isn’t one or the other inevitably going to slip? On top of that, can this possibly work at a place like Cedars-Sinai - a very large, complex, pluralistic organization?

» Read more

Cedars-Sinai receives nation's first accreditation for obstetric anesthesia fellowship

Year-long program offers advanced training, research for future leaders in field

Cedars-Sinai has received the Accreditation Council for Graduate Medical Education's first approval for an obstetric anesthesiology fellowship program.

» Read more

Yu named director of Cedars-Sinai's Neuroscience Critical Care Unit

Wengui Yu, MD, PhD, a research scientist and clinician specializing in stroke treatment and neurocritical care, has been named director of Cedars-Sinai Medical Center's Neuroscience Critical Care Unit.


» Read more

Researchers identify genetic mutation causing rare form of spinal muscular atrophy

Scientists have confirmed that mutations of a gene are responsible for some cases of a rare, inherited disease that causes progressive muscle degeneration and weakness: spinal muscular atrophy with lower extremity predominance, also known as SMA-LED.


» Read more

Cedars-Sinai physician definitively links IBS and gut bacteria

An overgrowth of bacteria in the gut has been definitively linked to irritable bowel syndrome in the results of a new Cedars-Sinai study which used cultures from the small intestine. This is the first study to use this "gold standard" method of connecting bacteria to the cause of the disease that affects an estimated 30 million people in the United States.

» Read more

A remembrance of David L. Rimoin, MD, PhD

Cedars-Sinai memorial set for Monday

Please join colleagues and members of the Rimoin family in a program to celebrate the life and accomplishments of the late David L. Rimoin, MD, PhD. The event will be Monday, June 11, at 4 p.m. in Harvey Morse Auditorium.

If you wish to make a gift in Dr. Rimoin's memory, please visit www.discoveringforlife.org/Rimoin.

Dr. Rimoin was director of the Cedars-Sinai Medical Genetics Institute, the Steven Spielberg Family Chair in Pediatrics and a pioneer in research in skeletal disorders and abnormalities who played a pivotal role in developing mass screenings for Tay-Sachs and other heritable disorders. He died May 27 after a diagnosis of Stage 4 pancreatic cancer early last month.

Law requires security prescription forms to include prescriber's preprinted address

Pharmacy focus

A new California law will take effect July 1 requiring security prescription forms for controlled substances to include the preprinted address of the prescriber.

Security prescription forms that do not have the preprinted address of the prescriber can be dispensed by the pharmacist until July 1. Prescription forms not in compliance are invalid and cannot be accepted on or after July 1.

Additionally, licensed health care facilities or clinics exempt under Section 1206 (those having 25 or more licensed physicians or surgeons preprinted on the form) are not required to preprint the category of licensure and license number of their facility or clinic (Health & Safety Code 11162.1[c][2]).

View all changes in Pharmacy Law that took effect in 2012 at www.pharmacy.ca.gov/laws_regs/new_laws.pdf

As bridge soars, AHSP reaches another major milestone

They arrived on campus a few weeks ago under police escort and have cast an imposing shadow on Sherbourne Avenue with their sheer heft and size. Friday, June 15, a crane will lift the first half of the enormous, 184-foot-long trusses into place to form the pedestrian bridge connecting the Advanced Health Sciences Pavilion to the medical center on the fifth-floor level.

The bridge itself will go up in two sections.The first section to be erected on Friday, June 15, weighs 75 tons and is the larger of the two.It will connect to the Pavilion on the east side of Sherbourne. The second, smaller section will be erected on Sunday, June 17, and will connect to the medical center on the west side of Sherbourne. For several weeks, a gap of approximately five feet will be visible between the bridge and the medical center until the expansion joint that completes the bridge is installed.

The fifth-floor pedestrian bridge represents another major construction milestone for the Pavilion, which is now fully enclosed. Workers already are installing flooring and drywall inside the 11-story, 820,000-square-foot building, scheduled to open in summer 2013.

Once completed, the Pavilion will feature outpatient clinics, procedure space and state-of-the-art research laboratories with large open lab suites and shared office spaces. These innovative, open design spaces will allow physicians and scientists to collaborate closely in developing new procedures and treatments for patients. Inside the two-story George W. Schaeffer Lobby on the Plaza Level, employees, patients and visitors will have access to the AHSP café, an education center, the Board Room, Imaging, Pre-Procedure Center and the Outpatient Pharmacy. The Pavilion also features six stories of parking, including three that are subterranean.

New guideline for patients with headache in the ED

A 54-year-old man came into the ED describing intermittent headaches for several weeks that would not go away with use of over-the-counter painkillers. He read on the Internet that his symptoms could be due to a brain tumor or hemorrhage and became increasingly concerned. His primary care provider was not available to see him for another three weeks so he decided to go to the hospital to get it checked out. He asked for an MRI or a CT scan.

This scenario occurs not infrequently in emergency departments throughout the country, with Cedars-Sinai being no exception. Overuse of diagnostic testing and procedures increase costs to patients, taxpayers and employers, drives up insurance premiums, and thus represents a poor quality of care. Most headaches can be accurately evaluated by clinical history and physical exam. Diagnostic neuroimaging in these cases is neither needed nor desirable, as it is more likely to yield false positive findings while exposing many patients to unnecessary and harmful radiation.

To help ensure that patients receive the most appropriate care at the right time and cost, a Cedars-Sinai Medicine task force has created a new guideline for the appropriate use of neuroimaging for people presenting with a traumatic headache in the ED. Patients who do not meet the indications listed in the following guideline   CSM Neuroimaging Guidelines (PDF) may be treated without emergent diagnostic neuroimaging.

The new guideline provides:

  • A list of supportable indications for neuroimaging in the ED;
  • Identification of preferred modalities for each indication;
  • A list of indications when CT or MRI may be appropriate, but not emergent

"Our goal is to reduce and eliminate the utilization of diagnostic neuroimaging in patients who don’t need them, while ensuring that patients with high-risk features receive rapid diagnosis with the best test supported by current evidence in the literature. We want our practice to be the best in both quality and cost-effectiveness,” said Sam Torbati, MD, vice chair of the Emergency Department." A similar test of change was implemented six months ago in the ED for non-Code Brain ischemic stroke patients and has been very successful in reducing redundant brain imaging, allowing many patients to be discharged home instead of being admitted. Both protocols are aimed at doing the right test for the right patient in the right setting, or no testing at all if not clinically indicated.”

This guideline was developed by the Cedars-Sinai Medicine task force after conducting a comprehensive review of published indications developed by expert bodies such as the American College of Radiology and the American College of Emergency Physicians. These indications were aggregated into a single guideline that has been approved by the Department PICs of Emergency Medicine, Neurology, Neurosurgery, Internal Medicine and Radiology, according to Glenn D. Braunstein, MD, vice president of Clinical Innovation.

President's Perspective: the efficiency-quality paradox

Thomas M. Priselac
President and CEO

At first, it seems counterintuitive: How can you increase efficiency while also enhancing quality? Isn't one or the other inevitably going to slip?

On top of that, can this possibly work at a place like Cedars-Sinai - a very large, complex, pluralistic organization? The answer is yes, and what is notable at Cedars-Sinai is the way we've resolved the efficiency-quality paradox: by recognizing that efficiency is an intrinsic part of our continuous effort to improve quality, and that it takes the engagement and collaboration of everyone throughout the institution to achieve our goal of doing the right thing for our patients - in the right setting, at the right time, with the right resources.

Our efforts encompass both clinical and operational initiatives to improve quality and efficiency, and I'm pleased to report that we already have some early wins in both areas, thanks to the innovative ideas that have been coming from so many of you throughout the health system. Make no mistake, we still have a long way to go, as the financial realities of declining reimbursements remain harsh, and we must do a lot more to increase efficiency and reduce costs. But your progress to date is truly impressive, and I'd like to share a few examples.

Re-examining our clinical processes

In clinical areas, the Cedars-Sinai Medicine initiative continues to make a positive impact on patient care through the efforts of more than 300 healthcare professionals who serve on our clinical best-practice teams. We now have about 20 multidisciplinary teams, with physicians, nurses, case managers, social workers, pharmacists and others working together to research and develop best practices for a long list of specific diseases and conditions.

With guidance from the clinicians involved, we've implemented improvements in clinical processes for a number of high-volume, typically short-stay surgical procedures such as hip and knee replacements and non-malignant gynecologic surgeries, as well as for common conditions that bring people to the hospital - including atrial fibrillation, pneumonia and diabetes. Length of stay, which has a major impact on costs, has declined overall by about 10 percent as a result of a wide range of changes in clinical practice that also improve outcomes for patients, including faster diagnostic testing and evaluations, rapid response to infections, comprehensive treatment planning from pre-admission to post-discharge, and education to guide patients through recovery and prevent complications.

The way the Cedars-Sinai Medicine effort has reduced length of stay for non-malignant gynecologic surgeries provides examples of the types of changes that make a difference. The team's research on best practices for post-operative care showed that many patients do better with earlier removal of the Foley catheter and an earlier transition from IV to oral pain medication. They found that these steps lower the risk of infection, reduce side effects and enable patients to resume activity more quickly.

The team worked with physicians on changing post-operative orders for these patients, and with nurses to engage them in helping patients reach certain milestones each day they are in the hospital. The next step is education to align patient expectations with post-operative treatment plans so that everyone is working toward the same goal - a smooth recovery that allows patients to return home within the expected time frame for their procedure, or even sooner.

Increasing operational efficiency

Equally important are the efforts by our staff to increase efficiency of operational performance based on nationwide research on best practices in hospital operations. While all hospitals are closely examining how they use staffing resources - because labor represents a hospital's largest single operating cost - we also are looking in many other directions to reduce expenses.

For example, one major area of focus is re-engineering our supply-chain operations. Supplies represent the second largest cost to hospitals. We can reduce costs by as much as $18 million a year in supplies alone through strategies that enable us to get better prices without sacrificing high quality. This involves increasing our participation in purchasing coalitions and cooperatives with other major medical centers to gain more leverage on pricing, and working with our physicians to reduce variation in the types of medical devices we order - for orthopedic and cardiac procedures, for example.

Even seemingly trivial things can add up, given the size of Cedars-Sinai. For example, the Purchasing Department recently found that we currently offer as many as 729 different types of pens for use across Cedars-Sinai. If that number was reduced, enabling us to increase the volume of each type of pen purchased, we could significantly reduce their unit cost. Seems like a small thing, but it all adds up.

Technology plays a major role in our drive to become more efficient. As part of CS-Link™, we've implemented a new bar coding system that has streamlined pharmacy operations while also reducing the risk of errors. And we're just beginning to realize the potential of CS-Link as a tool for increasing safety while lowering costs.

One of the ironies we face as we adapt to healthcare reform is that doing the right thing for our patients in a more efficient way sometimes results in less revenue in the short term. This is because some of the payment models currently used by Medicare and private insurance companies are still “old-school” and do not yet fully reward effectiveness and efficiency. But this will change as our nation's healthcare system adopts new payment models more closely tied to performance. We're better prepared for the changes ahead, thanks to our comprehensive initiatives and your innovation, flexibility and teamwork.

Your ideas are always welcome as we continue to identify and implement strategies to increase efficiency and value throughout our organization. I'm confident that the steps we are taking will enable us to do even more for our patients, at less cost, and to serve as a role model for hospitals nationwide during this extraordinary period of change.

Cedars-Sinai receives nation's first accreditation for obstetric anesthesia fellowship

Year-long program offers advanced training, research for future leaders in field

Cedars-Sinai has received the Accreditation Council for Graduate Medical Education's first approval for an obstetric anesthesiology fellowship program.

The year-long fellowship provides advanced experience and training in all aspects of obstetric anesthesiology including research, administration and clinical management of both normal and high-risk patients. Fellows work with Cedars-Sinai's obstetric anesthesiologists, who are dedicated full time to caring for pregnant patients on the Labor and Delivery floor. Fellows will spend the bulk of their time on Labor and Delivery but also may undertake rotations in research, neonatal intensive care and in the Division of Maternal-Fetal Medicine.

"That we have full-time faculty dedicated solely to obstetrics and gynecology, and we are a leading and trusted provider of maternity services, with more than 7,000 births annually, makes Cedars-Sinai a very attractive medical center for fellows preparing for a career in obstetric anesthesiology," said Roya Yumul, MD, PhD, director of educational programs and core program director in the Department of Anesthesiology.

The program is led by Mark Zakowski, MD, obstetric fellowship program director, and Sivam Ramanathan, MD, (recently deceased) associate program director and obstetric research director.

The fellowship seeks to provide not only a strong clinical foundation but also development of future leaders in the field. Fellows are encouraged to participate in research, collaborating on ongoing projects or launching their own.

"Our goal is to not only produce physicians who will perform at the top of their field, but also innovators who will keep improving the quality, efficiency and safety of patient care," Yumul said.

The Accreditation Council for Graduate Medical Education is a private, nonprofit organization that evaluates and accredits about 8,700 medical residency programs in 130 specialties and subspecialties nationwide. This year is the first year it has offered accreditation in the subspecialty of obstetric anesthesiology.

Yu named director of Cedars-Sinai's Neuroscience Critical Care Unit

Wengui Yu, MD, PhD, a research scientist and clinician specializing in stroke treatment and neurocritical care, has been named director of Cedars-Sinai Medical Center's Neuroscience Critical Care Unit.

The recently expanded 24-bed unit, part of the Department of Neurology and Department of Neurosurgery, treats a high volume of patients with neurological disorders.

Yu's current research is focused on brain hemorrhage and treatment of severe traumatic brain injury. He has published articles in peer-reviewed journals on stroke, endovascular interventions such as intracranial stenting, and basic cellular research. As an educator, he has overseen the training of more than 60 resident physicians and clinical fellows.

"We are extremely fortunate to attract a nationally recognized leader of Dr. Yu's stature. Together with the top-notch team already in place, our critical care unit is now among the elite in the country," said Patrick D. Lyden, MD, chair of the Department of Neurology and the Carmen and Louis Warschaw Chair in Neurology. "Dr. Yu will expand our unit, attract promising young clinician-scientists and allow our unit to continue its fantastic growth and leadership."

Yu joins Cedars-Sinai from Dallas, where he served as an associate professor and division chief of Neurological Critical Care at the University of Texas Southwestern Medical Center and as medical director of the Surgical ICU at UT Southwestern University Hospital - Zale Lipshy, a neurosciences specialty hospital affiliated with the University of Texas Southwestern University Hospital. He also has worked at the University of California, both in San Francisco and Irvine.

Yu, who is board-certified in neurology, neurocritical care and vascular neurology, earned his MD at Jiangxi Medical College in Nanchang, China, and his PhD degree at McGill University in Montreal, Canada. He was a research associate in Beijing, China, and a postdoctoral fellow at Harvard Medical School. He completed an internship in internal medicine and a residency in neurology at the University of Missouri, Columbia, before entering a two-year fellowship in neurocritical care and stroke at UCSF.

The Neuroscience Critical Care Unit is on the eighth floor of the state-of-the-art Saperstein Critical Care Tower.

Researchers identify genetic mutation causing rare form of spinal muscular atrophy

Scientists have confirmed that mutations of a gene are responsible for some cases of a rare, inherited disease that causes progressive muscle degeneration and weakness: spinal muscular atrophy with lower extremity predominance, also known as SMA-LED.

"Typical spinal muscular atrophies begin in infancy or early childhood and are fatal, involving all motor neurons, but SMA-LED predominantly affects nerve cells controlling muscles of the legs. It is not fatal and the prognosis is good, although patients usually are moderately disabled and require assistive devices such as bracing and wheelchairs throughout their lives," said Robert H. Baloh, MD, PhD, director of Cedars-Sinai Medical Center's Neuromuscular Division and senior author of a Neurology article describing the new findings on DYNC1H1.

It is a molecule inside cells that acts as a motor to transport cellular components. Using cells cultured from patients, Baloh's group showed that the mutation disrupts this motor's function. The researchers found that some subjects with mutations had global developmental delay in addition to weakness, indicating the brain also is involved.

"Our observations suggest that a range of DYNC1H1-related disease exists in humans - from a widespread neurodevelopmental abnormality of the central nervous system to more selective involvement of certain motor neurons, which manifests as spinal muscular atrophy," Baloh said.

He pointed out that while this molecule is responsible for some inheritable cases of spinal muscular atrophy with lower extremity predominance, the genetic mutation is absent in others. The search continues, therefore, to find other culprit genetic mutations and develop biological therapies to correct them.

"Although this is a rare form of motor neuron disease, it tells us that dynein function - the molecular motor - is crucial for the development and maintenance of motor neurons, which we hope will provide insight into the common form of spinal muscular atrophy and also amyotrophic lateral sclerosis," Baloh said.

Citation: Neurology, March 28, 2012, published online ahead of print: "Mutations in the tail domain of DYNC1H1 cause dominant spinal muscular atrophy."

Cedars-Sinai physician definitively links IBS and gut bacteria

An overgrowth of bacteria in the gut has been definitively linked to irritable bowel syndrome in the results of a new Cedars-Sinai study which used cultures from the small intestine. This is the first study to use this "gold standard" method of connecting bacteria to the cause of the disease that affects an estimated 30 million people in the United States.

Previous studies have indicated that bacteria play a role in the disease, including breath tests detecting methane - a byproduct of bacterial fermentation in the gut. This study was the first to make the link using bacterial cultures.

The study, in the current issue of Digestive Diseases and Sciences, examined samples of patients’ small bowel cultures to confirm the presence of small intestinal bacterial overgrowth - or SIBO - in more than 320 subjects. In patients with IBS, more than a third also were diagnosed with small intestine bacterial overgrowth, compared to fewer than 10 percent of those without the disorder. Of those with diarrhea-predominant IBS, 60 percent also had bacterial overgrowth.

"While we found compelling evidence in the past that bacterial overgrowth is a contributing cause of IBS, making this link through bacterial cultures is the gold standard of diagnosis," said Mark Pimentel, MD, director of the Cedars-Sinai GI Motility Program and an author of the study. "This clear evidence of the role bacteria play in the disease underscores our clinical trial findings, which show that antibiotics are a successful treatment for IBS."

IBS is the most common gastrointestinal disorder in the U.S., affecting an estimated 30 million people. Patients with this condition suffer symptoms that can include painful bloating, constipation, diarrhea or an alternating pattern of both. Many patients try to avoid social interactions because they are embarrassed by their symptoms. Pimentel has led clinical trials that have shown rifaximin, a targeted antibiotic absorbed only in the gut, is an effective treatment for patients with IBS.

"In the past, treatments for IBS have always focused on trying to alleviate the symptoms," said Pimentel, who first bucked standard medical thought more than a decade ago when he suggested bacteria played a significant role in the disease. "Patients who take rifaximin experience relief of their symptoms even after they stop taking the medication. This new study confirms what our findings with the antibiotic and our previous studies always led us to believe: Bacteria are key contributors to the cause of IBS."