Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF May 11, 2012 Issue | Archived Issues

New FDA alerts

Pharmacy focus

The U.S. Food and Drug Administration issued updates and warnings for phenytoin, fosphenytoin, dronedarone, aliskiren and other drugs.

» Read more


Physician news

David Rimoin, MD, PhD, named an American College of Physicians master, Ilana Cass, MD, selected for the Executive Leadership in Academic Medicine fellowship, a Kawasaki disease study by Moshe Arditi, MD, honored at conference, and Robert H. Baloh, MD, PhD, received ALS Association award.

» Read more


Meetings and events


Grand rounds

Click here to view upcoming Grand Rounds.


Upcoming CME conferences

Click below to view a complete list of all scheduled Continuing Medical Education conferences.

CME Newsletter - May 2012 (PDF)

Calling Code Sepsis

New protocol reduces mortality in septic inpatients

A new sepsis protocol to administer appropriate antibiotics within the first hour of the onset of sepsis is already producing dramatic results at Cedars-Sinai.

» Read more

Test changes in the Core Laboratory

There are many changes taking place in the Core Laboratory. In conjunction with Cedars-Sinai Medicine, the Core Laboratory is constantly looking for improvements that can be made to enhance the quality of care, improve utilization and maintain fiscal responsibility.

» Read more

CS-Link update for physicians

The next phase of the CS-Link™ journey is "optimization." This means you will see changes designed to continue to help improve your efficiency. Our medical staff and house officers have endured tremendous change with great success.  As always, your suggestions are welcome. A few tips and reminders follow:

» Read more

86 residents matched with Cedars-Sinai this year

Students from Johns Hopkins, Yale and Cornell are among the 86 new residents who will come to Cedars-Sinai this summer.

» Read more

RSVP now for summertime fun

Medical staff members and their families are invited to take part in two Cedars-Sinai summer traditions: Independence Day at the Hollywood Bowl and Sand N' Snore at the Jonathan Beach Club.


» Read more

PATHway to success

Flawless state inspection for Department of Pathology and Laboratory Medicine

The Department of Pathology and Laboratory Medicine lived up to its motto of "Always ready, all the time," when a recent state inspection found its facilities and procedures meet the highest standards.

» Read more

What do you know about organ donation?

Cedars-Sinai's Organ Donor Council is conducting a brief 18-question survey of all employees to evaluate individual knowledge, perceptions and beliefs regarding organ donation. Please take a few minutes to participate: www.zoomerang.com/Survey/WEB22FHFS966SR

» Read more

Two Chinese orphans treated by Cedars-Sinai team find their 'forever homes'

Just months after a Cedars-Sinai team traveled to China as part of an international mission to help orphans considered unadoptable because of their medical conditions, two of the team's tiny patients have found new homes.


» Read more

The art of healing

Cedars-Sinai's vast art collection owes its legacy to a patient's recovery a half-century ago

The art collection at Cedars-Sinai, a remarkable assemblage of more than 4,000 paintings, sculptures, photos, drawings and lithographs, was born in a quiet moment of healing.

» Read more

Calling Code Sepsis

New protocol reduces mortality in septic inpatients

A new sepsis protocol to administer appropriate antibiotics within the first hour of the onset of sepsis is already producing dramatic results at Cedars-Sinai.

Patients for whom the Code Sepsis protocol was used had a mortality rate that was significantly lower than that of patients for whom the protocol was not used. The mortality index for Code Sepsis patients dropped from a baseline of 1.67 to 1.0, according to the Cedars-Sinai Medicine Task Force that created and implemented the Code Sepsis protocol.

"This is the first initiative of Cedars-Sinai Medicine to demonstrate an actual decrease in mortality," says Glenn B. Braunstein, MD, vice president of Clinical Innovation. "We are extremely pleased with the results so far and now our challenge is to increase usage of the protocol."

Task force members launched Code Sepsis earlier this year after conducting a detailed analysis of the guidelines set out in the Surviving Sepsis Campaign, a global effort led by the Society for Critical Care Medicine, to reduce deaths from severe sepsis and septic shock. Sepsis has been ranked as the 10th-leading cause of death in the U.S.

"Research has shown that antibiotics given in the first hour is the most important measure to improving outcomes," said Heather Jones, MD, co-chair of the task force. "Mortality increases significantly with every hour of delay."

The goal of Code Sepsis is to ensure that blood cultures are drawn promptly and that the first doses of antibiotics are given to patients in under one hour. The antibiotic selection is derived from the CSMC Empiric Antimicrobial Treatment Guidelines and the protocol is a multidisciplinary approach that involves the nursing, pharmacy and even phlebotomy staff.

When a physician identifies a potentially septic patient, he or she uses the Code Sepsis order set to order antibiotics, fluids and appropriate labs. The physician then verbally notifies an RN that a Code Sepsis has been initiated. Alternatively, an RN can activate the process by alerting a physician that there is a patient exhibiting new signs concerning for severe sepsis.

The RN immediately pages a pharmacist, who then reconciles antibiotic orders and promptly hand-delivers the antibiotics to the floor. Some antibiotics, like Zosyn, are now in the Pyxis as part of this initiative. The RN then draws cultures and labs and, within one hour, hangs the antibiotics.

"Like a Code White or a Code Brain, time is of the essence in these patients," said Phil Zakowski, MD, co-chair of the task force.The protocol has reduced the average time of delivery of the initial dose of antibiotics from 211 minutes (about 3.5 hours) to 69 minutes.

"Nursing and Pharmacy have done an incredible job in meeting this one-hour goal," Zakowski said.

Test changes in the Core Laboratory

There are many changes taking place in the Core Laboratory. In conjunction with Cedars-Sinai Medicine, the Core Laboratory is constantly looking for improvements that can be made to enhance the quality of care, improve utilization and maintain fiscal responsibility.

In the next month, expect to see the following changes:

  • Implementation of an advanced fourth-generation Abbott HIV Antigen/Antibody Combo assay that can detect HIV infection up to 20 days earlier than our current assay. The FDA-approved assay can simultaneously detect both HIV-1 or HIV-2 antibodies, and the P24 antigen associated with HIV-1. It will be available seven days per week. The new test will be available to order on May 16.
  • Free T4 test will be performed in-house by direct immunoassay instead of sending out to a reference lab. This will significantly improve turn-around time and will reduce the cost per test. Free T4 by equilibrium dialysis will be available in special cases, but because studies show it is equivalent to direct immunoassay in the majority of cases, it will not be on the test menu. Because of the change in laboratories, the reference range will change slightly from 0.8 -1.8 ng/dL, to 0.7 - 1.48 ng/dL. Reference ranges will be reported with the result value.
  • A new test code will be added to the menu for Adjusted free T4 Index in Pregnancy. This is a calculation done on free T4 that takes into account the variations in thyroid-binding globulin and albumin concentrations in pregnancy. This test remains available if needed for other patient populations at the discretion of the physician.
  • 1,25 (OH)2-vitamin D will be removed from the test menu. The Endocrine Society’s Clinical Guidelines, published in 2011 in the Journal of Clinical Endocrinology and Metabolism, recommends use of 25(OH)D as the test of choice to evaluate vitamin D deficiency and recommends against the use of 1,25(OH)2D except in acquired and inherited disorders in the metabolism of 25(OH)D and phosphate. For those rare conditions, it may still be ordered as a "write out" on a down-time paper requisition. A related article on vitamin D will appear in the next issue of Pulse.
  • Testosterone will be brought in-house and run by liquid chromatography, tandem mass spectrometry (LC/MS/MS). This highly sensitive test can measure testosterone levels in women and men with very low levels and will reduce the turn-around time significantly. This test will be available three times per week with a turn-around time of two days. There will be no change in reference range.
  • Anion Gap will be reported in mEq/L (milli-equivalents per liter) instead of the current practice of reporting mmol/L (milli-moles per liter). This is to conform to international standards and will not change the actual value (the values reported for anion gap remain the same with either unit of measure) as these units are equivalent in this instance.
  • The Substance Abuse Panel (SAS) screen for five drugs will be removed from the Cedars-Sinai Test menu. Substance Abuse Panel Extended (SASE) will be kept in its place, which is a panel of nine drugs of abuse. SASE is a more comprehensive screening panel that includes the same five drugs as the SAS panel. SASE will cover the original substances: opiates, cocaine, amphetamines, barbiturates and PCP. It also includes: methadone, benzodiazepines, Darvon® (propozyphene) and cannabinoids. There will be no change in reference range or sensitivity.

If you have questions or would like more information about these test changes, please contact Hossein Sadrzadeh, PhD, at (310) 248-7648, Kimia Sobhani, PhD, at (310) 423-5405, Holli Mason, MD, at (310) 423-5360, or Wanda Chan-Cheung at (310) 423-7869.

CS-Link update for physicians

The next phase of the CS-Link™ journey is "optimization." This means you will see changes designed to continue to help improve your efficiency.

Our medical staff and house officers have endured tremendous change with great success.  As always, your suggestions are welcome. A few tips and reminders follow:

Entering orders

When ordering a medication please make every attempt to locate the drug on an order set or order entry list.  Do not free text medications, doses and frequencies in the Administration Instruction or Comment section (F6) of another order.

To discontinue a medication or procedure, use the "Order Management"activity tab and use the "Discontinue" button.  Do not cancel medications or procedures using Administration Instruction or the Comment section (F6) of another order.

When entering Administration Instructions or Comments (in F6 section) in a medication order composer, please verify your orders with Nursing or Pharmacy personnel.

Please do not use Nursing Communication Orders to hold, discontinue medications or to start a new medication.

Printed prescriptions

Physicians need to sign prescriptions when printed on the units.  Electronic signatures are NOT in place nor is electronic routing to pharmacies. ePrescribing and eSignature can occur after the upgrade to EPIC version 2010.

"Self help"

There are several ways to help yourself to use CS-Link more effectively:

New navigator

There is a new navigator to improve the ease of pre and post procedural/surgical orders and documentation. See the April 27 issue of Pulse for a review or go to the Physician Resource Center in Room 2806 for personalized instruction.

 

CS-Link Update for Physicians - May 2012 (PDF)

86 residents matched with Cedars-Sinai this year

Students from Johns Hopkins, Yale and Cornell are among the 86 new residents who will come to Cedars-Sinai this summer.

Cedars-Sinai recruited residents from 46 different U.S. medical schools from Hawaii to New York, said Mark Noah, MD, director of the Internal Medicine Residency Training program and director of both Graduate and Continuing Education within the Department of Academic Affairs at Cedars-Sinai.

The medical center offered 87 positions in the residency match program and 86 were filled through the match process.

"The schools that sent us the most students were UCLA, USC, UC Irvine, Georgetown, Albert Einstein, Tufts, Boston University and the University of Illinois," he said. "We also have graduates from schools such as Johns Hopkins, Yale, Cornell, Northwestern and Washington University coming to the program."

RSVP now for summertime fun

Medical staff members and their families are invited to take part in two Cedars-Sinai summer traditions: Independence Day at the Hollywood Bowl and Sand N’ Snore at the Jonathan Beach Club.

Celebrate Independence Day at the Bowl

Celebrate our country's Independence Day with rousing patriotic music and the familiar tunes of special guest Barry Manilow at the Hollywood Bowl on Tuesday, July 3.

Tickets are $125 per adult and $60 per child under age 12. Parking passes also are available: valet at $35 or lower terrace at $17.

Call Cheryl Verne (in the office of Marjorie Santore Besson) at (310) 423-2681 to reserve your tickets before Friday, May 25.

Click here to see photos and story from last year.

Save your spot at Sand N' Snore

It's not too early to dig out the tent and camping gear for this year's Sand N' Snore. The dinner, sleepover and breakfast starts on Friday, July 20, at the Jonathan Beach Club in Santa Monica. Those who don't want to sleep on the sand are welcome to enjoy dinner and the evening with colleagues and their families.

There's a limit of one tent per physician. Tickets for the whole event are $60 per adult and $40 for each child 12 and younger. Tickets for Friday's dinner only are $45 per adult and $20 for each child 12 and younger.

Call Cheryl Verne (in the office of Marjorie Santore Besson) at (310) 423-2681 to reserve your spot.

Click here to see photos and story from last year.

PATHway to success

Flawless state inspection for Department of Pathology and Laboratory Medicine

The Department of Pathology and Laboratory Medicine lived up to its motto of "Always ready, all the time," when a recent state inspection found its facilities and procedures meet the highest standards.

Besides accreditation by the College of American Pathologists, the department must ensure it meets all federal and California laws and regulations. An April 17 visit from a state Department of Public Health Laboratory Field Services examiner found zero deficiencies in Cedars-Sinai’s compliance with California clinical laboratory laws and regulations.

"During our inspection, we were commended for the quality of our operation and the size and scope of our testing," said Mahul Amin, MD, chair of the Department of Pathology and Laboratory Medicine. "The success of this inspection is a reflection of the dedication every member of our department to quality patient care and daily commitment to holding our laboratories to the highest professional standards."

The examiner added in her summation that she could "tell this is a great place to work."

For the Pathology and Laboratory Medicine department, this successful inspection is just another step on what its PATHway - the name the department has given its formal quality and compliance management programs.

These programs provide a quality commitment to every patient and physician using the department's clinical laboratories that "every life deserves a quality laboratory test or opinion at the speed of right." The PATHway goal is to proactively address accreditation and regulatory requirements and to engage the leadership and staff members of each laboratory section.

PATHway also is a guiding force in the College of American Pathology Interim Self-Inspection, required to maintain this key accreditation. The self-inspection offers an opportunity to identify more improvements to maximize efficiency, accuracy and best practices throughout the department’s operations.

"Our internal inspectors strive very hard to identify possible deficiencies, and every section takes these findings very seriously," Amin said. "By continually challenging itself to improve, our staff ensures that we are always providing the most advanced and best care available."

What do you know about organ donation?

Cedars-Sinai's Organ Donor Council is conducting a brief 18-question survey of all employees to evaluate individual knowledge, perceptions and beliefs regarding organ donation. Please take a few minutes to participate: www.zoomerang.com/Survey/WEB22FHFS966SR

Your assistance will help researchers design strategies to increase donation, there by benefitting all those waiting for life-saving organs.

Cedars-Sinai understands the increasing need for organs for waiting transplant recipients. More than 900 people await life-saving heart, lung, liver, kidney and pancreas transplants at Cedars Sinai's Comprehensive Transplant Center. Despite the desperate need, there appears to be a lack of awareness and suitable donors.

The council is working with Ali Salim, MD, Darren Malinoski, MD, and Danielle Schulman, MPH, on this effort.

Two Chinese orphans treated by Cedars-Sinai team find their 'forever homes'

Just months after a Cedars-Sinai team traveled to China as part of an international mission to help orphans considered unadoptable because of their medical conditions, two of the team's tiny patients have found new homes.

In November, pediatric surgeon Philip K. Frykman, MD, PhD, led a team to Maria's Big House of Hope, a medical foster home in Louyang that is home to 140 orphans, some with anorectal malformations.Team members included: Janet Kimble, RN, Keith Kimble, MD, pediatric anesthesiologist, Scott Short, MD, surgery resident, Jennifer Ross, RN, pediatric intensive care unit nurse, and Claire Esguerra, LVN, surgical technician.

Children with such malformations are far less likely to find adoptive families in China than other orphans. But after receiving care from the Cedars-Sinai team, which traveled in conjunction with Mending Kids International, two boys from Maria's Big House of Hope have been adopted by families in the U.S.

Click here to read our first story about Maria's Big House of Hope.

"One of the babies is being adopted by a family in Colorado and the other is being adopted by a family in New York," said Kimble, one of the nurses who traveled with the team.

The baby in New York now lives with a Chinese family there, Kimble said.

The other adoptee, a little boy the team called Alvin, will join a Colorado family who had hoped to adopt twins. Adopting Alvin has brought the family a happy surprise.

"After we left, we learned from one of the nannies at the orphanage that Alvin has a twin brother," Kimble said. The twin has a cleft lip that already has been repaired and his cleft palate will be operated on after the boys join their new family in May, Kimble said.

"They had been told that finding twins was unlikely," Kimble said. "But now they've got their set of twins."

As for the Cedars-Sinai team, Kimble said they are thrilled to learn about the results of their work.

"That was the whole idea, to give these kids a better chance to find forever homes," she said. "The fact that it happened even faster than we thought is really great. Everyone is so happy."

Shown above: (l-r) Dr. Frykman photographs X-rays while Claire Esguerra, LVN, and her sister, Debbie Cabatu, LVN, prep for surgery.

The art of healing

Cedars-Sinai's vast art collection owes its legacy to a patient's recovery a half-century ago

The art collection at Cedars-Sinai, a remarkable assemblage of more than 4,000 paintings, sculptures, photos, drawings and lithographs, was born in a quiet moment of healing.


Marcia Simon Weisman, left, and Andy Warhol

It was 1966 and Frederick R. Weisman, a Los Angeles business leader and art lover, had slipped into a coma after suffering a head injury. Though he returned to consciousness after several days in the hospital, he remained dazed and disoriented. His wife, Marcia Simon Weisman, also an influential art collector, grew alarmed as her husband struggled to remember her name.

"Mrs. Weisman would bring pieces from their private art collection to the hospital and leave them by her husband's bedside so he would see them when he opened his eyes," said John T. Lange, curator of the Cedars-Sinai art collection.

Selections from
our art collection

Click photo for larger image








One morning, Frederick Weisman looked at the jagged lines and splashes of color of the abstract painting his wife had brought in that day and said the artist's name aloud, "Jackson Pollock." He was right.

"He could make that connection to the work of art before he could make the connection to who his wife was," Lange said of Weisman's first step toward recovery. "There was an obvious relationship between the art and his recovery."

In 1976, when the expansion of the medical center was completed, the Weismans toured the new facility. Avid collectors of modern art since their first purchase in the 1950s of Jean Arp's polished bronze sculpture, "Self-Absorbed," the couple focused on placing art at Cedars-Sinai.

"They walked around and saw all these empty corridors with nothing in them," Lange said. "So they made a huge push to add art to the medical center."

The couple began by donating hundreds of pieces they owned,a notable collection that included works by Willem de Kooning, Jackson Pollock, Roy Lichtenstein, Frank Stella and Andy Warhol, as well as paintings by European modernists like Paul Cezanne, Pablo Picasso and Wassily Kandinsky, and surrealist art by Max Ernst, Joan Miro and Rene Magritte.

Marcia Weisman in particular became passionate about the idea of filling the hospital with great art. She urged everyone she knew in the art community to donate – gallery owners, art buyers, grateful patients, even the artists themselves.

"She was out there pounding the pavement herself," Lange said. "She started this history of giving art to the hospital."

In the beginning, the art on the walls was for sale, including a collection of early Persian and Renaissance paintings and reproductions displayed at the medical center in the late 1970s. The proceeds went to fund the art program. The practice since has been abandoned, and all donations become a permanent part of Cedars-Sinai's collection.

Though the Weismans eventually divorced, they remained good friends and continued their devotion to building the Cedars-Sinai art collection until their deaths. Today, an Arts Advisory Committee continues their work. The group, made of up art aficionados, most of who knew Marcia Weisman and thus keeps her singular vision alive, reviews every work offered to the medical center.

While Cedars-Sinai is grateful for the continuing generosity of donors, not all offerings fit the needs of the medical center.

"The advisory committee ensures that any gift pieces are appropriate, that the art being offered will fit the collection, and that it will physically fit into the space available," Lange said. "And we have to make sure it's appropriate for a hospital setting."

Size is one reason an art gift may be declined; it may also be that the work doesn't fit the needs of a facility devoted to healing.

"We're not a museum or a gallery," Lange said. "We have to be mindful of that. We're a hospital and we have a purpose."

Virtually every piece in the medical center's art collection is on display.In patients' rooms, museum-quality framed posters enliven the walls. A number of them have been donated by national museums, a testament to the growing awareness of the link between art and healing.

Throughout the hospital's corridors, lobbies and offices, paintings, photographs and lithographs transform the public spaces. Sculptures can be found everywhere, the larger ones outdoors in public courtyards and walkways. A sizable amount of the art is the original work of a growing number of contemporary masters.

For patients and their families, the art provides a source of comfort and inspiration. In a setting that's often very stressful, to find the heart and soul and meaning embodied in fine art can be a joyful surprise.

"Art heals– it's one of the things I see with patients every time I give them tours," Lange said. He recently spoke with a woman who has spent the last two months in the medical center.

"She said that she walks through the corridors and she looks at the art and for that bit of time, she's transported," Lange said. "Hearing her talk about how the art works for her, it reminds me of why I'm here, and why what we're doing with the collection makes sense."

If you would like to see the CBS Sunday Morning episode featuring our art program, please click here.