Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF Nov. 30, 2012 | Archived Issues

MEC rule defines the role of 'Attending Physician'

The word "attending" is used a lot around here. You can be an attending on the medical staff. You can be a member of the attending category of the medical staff. And now there’s a specifically defined "Attending Physician." The Medical Executive Committee has made some important changes defining the roles of the Admitting Physician and Attending Physician. This should clarify who made the decision to admit a patient and who is responsible for dealing with problems and with critical test results.

» Read more

Now when the ED calls, you will know

Cedars-Sinai has implemented a new Emergency Department Caller ID system so that physicians will know immediately when the ED is calling them for an emergent patient care issue. Now, when the ED calls you on a cellphone, the number (310) 423-2295 will display on the screen. If you program this number into your phone's contact list, it will display both CSMC_ED and the number.

» Read more

Got your flu shot yet?

Flu season is officially under way, and all Cedars-Sinai staff members are encouraged to get their flu shots to help protect the health of our patients and keep them from harm. Faculty physicians must either receive or decline their flu vaccination before Dec. 12.

» Read more

Spend a night in the museum

Medical staff members and their families are invited to "An Overnight at the Museum," a dinner and sleepover adventure at the Natural History Museum of Los Angeles County. Participants will eat dinner among the animals of the African savannah, visit the new Dinosaur Hall, and sleep among the mammals of North America. Events include a scavenger hunt for kids.

» Read more

Best practice in COPD and pneumonia: old habits left in the cold

As we enter the winter "respiratory" season, physicians are reminded to follow best practices by discharging pneumonia and COPD patients who have achieved clinical stability. According to the Cedars-Sinai Medicine task forces on pneumonia/COPD, there is limited benefit in keeping patients with community-acquired pneumonia or COPD in the hospital once they've met clinical stability criteria. For pneumonia patients, there is no benefit to "observation" after switching from intravenous to oral antibiotics.

» Read more

Ideas sought for Great Debate topic

The Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition committee is soliciting suggestions for a topic for this annual spring event.

» Read more

Enhanced Care Program offers nurse practitioner for skilled nursing facility patients

Cedars-Sinai is launching a new program aimed at keeping a closer eye on patients who have transitioned from the acute-care facility into a skilled nursing facility (SNF). As part of the new Enhanced Care Program, a Cedars-Sinai nurse practitioner will be offered to assist attending MDs with the care of their SNF patients.

» Read more

Accolades abound for quality care

Cedars-Sinai Medical Group has been honored to receive significant recognition of achievement over the past few months, earning two prestigious statewide distinctions for excellence.

» Read more

Circle of Friends honorees for October

The Circle of Friends program honored 139 people in October. Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai.

» Read more

The house call gets an electronic update

With a new twist to a tried-and-true process, Cedars-Sinai Medical Group has brought back the house call to provide an in-person and virtual care team visit to the homes of patients with complex, high-risk health issues. Patients like Walter Blue, who, in his own words, has "had a tough time of it" since his first surgery last March, although he certainly has maintained a good attitude and sense of humor.

» Read more

MEC rule defines the role of 'Attending Physician'

The word "attending" is used a lot around here. You can be an attending on the medical staff. You can be a member of the attending category of the medical staff. And now there’s a specifically defined “Attending Physician.”

The Medical Executive Committee has made some important changes defining the roles of the Admitting Physician and Attending Physician. This should clarify who made the decision to admit a patient and who is responsible for dealing with problems and with critical test results.

"Every patient needs an Attending Physician whose name will be listed on the CS-Link™ banner. If you are the Attending Physician for a patient, the laboratory and radiology departments will know that they can count on you to help if a test is ordered and the person who ordered the test isn't reachable," said Chief of Staff Scott Karlan, MD. "The medical staff expects the Attending Physician to accept those responsibilities. If you’re the attending physician and you’re not available, you need to make sure someone else is."

Medical centers such as Cedars-Sinai have large talent pools ranging from subspecialists to super subspecialists. An admitted patient will usually receive care from more than one physician. This team approach is great for patients, but it comes with some unintentional consequences, Karlan said. A long-standing problem happens when lab tests or X-rays are ordered and results come back with an urgent or critical value and the individual who ordered the test can't be located. The lab or radiology then typically call the nursing station to find a physician in charge, but the physician who admitted a patient on Monday might not be around on Wednesday.

Sometimes, it can take hours to locate someone to help – a problem for a patient who requires urgent attention.

The MEC recognizes that it's not reasonable to expect doctors to be on call all the time, but someone needs to "captain the ship," Karlan said.

  • If you're taking the night off and your partner is covering, you may not need to do anything. If you use an answering service and they connect your calls to the covering doctor, then that doctor will be able to handle any problems that arise.
  • If your answering service isn't very efficient, or if you're leaving town for a while, you should log in to CS-Link and change the name of the Attending Physician to the physician covering for the patient.
  • If you wish to transfer the patient to another doctor, you can assign them as Attending Physician, after getting their consent.

"There may be some bugs to fix, but right now, our concern is ensuring that it is clear to the nurses, the lab and radiology who is responsible for trouble-shooting problems," he said.

Physicians who do not want this responsibility have the option of making coverage arrangements with another physician or using a hospitalist. However, Karlan cautioned, the person designated as Attending Physician is not likely to get all that many phone calls.

"The bottom line is, the buck stops with you – if you're listed as the Attending Physician, you need to be available," he said.

Now when the ED calls, you will know

Cedars-Sinai has implemented a new Emergency Department Caller ID system so that physicians will know immediately when the ED is calling them for an emergent patient care issue.

It used to be that every call  coming from Cedars-Sinai displayed the same number - (310) 423-3277. As a result no one knew when the ED was calling. 

Now, when the ED calls you on a cellphone, the number (310) 423-2295 will display on the screen. If you program this number into your phone's contact list, it will display both CSMC_ED and the number.

Calls to landlines (office and home phones) using AT&T and Verizon will display CSMC_ED along with the 310-423-2295 number. Calls made to Time Warner VoIP land lines will display Cedars ME along with the (310) 423-2295 number.

Got your flu shot yet?

Flu season is officially under way, and all Cedars-Sinai staff members are encouraged to get their flu shots to help protect the health of our patients and keep them from harm.

Faculty physicians must either receive or decline their flu vaccination before Dec. 12. Those who fail to meet this requirement will not be allowed to work after Dec. 12 until they comply. Those who decline the flu vaccine must complete Flu School in Healthstream and submit the certificate of completion and declination form to Employee Health Services or one of the stationary clinics. Please do not send forms via intra-office mail.

You can receive a free flu vaccine at the following clinics:

  • Today (Nov. 30), from 7 a.m. to 4 p.m. at Employee Health Services
  • Today, from 7:30 a.m. to 3 p.m. in HMA Lobby
  • Today, from 4 p.m. to 10 p.m. in HMCC-6
  • Dec. 3, from 7:30 a.m. to 3 p.m., HMCC-1
  • Dec. 4, from 7:30 a.m. to 3 p.m., HMA Lobby
  • Dec. 5, from 7:30 a.m. to 3 p.m., HMA Lobby
  • Dec. 6, from 7:30 a.m. to 3 p.m., HMA Lobby
  • Dec. 7, from 7:30 a.m. to 3 p.m., HMA Lobby

For more information, please call Employee Health Services at ext. 3-3322.

Spend a night in the museum

Medical staff members and their families are invited to "An Overnight at the Museum," a dinner and sleepover adventure at the Natural History Museum of Los Angeles County.

Participants will eat dinner among the animals of the African savannah, visit the new Dinosaur Hall, and sleep among the mammals of North America. Events include a scavenger hunt for kids. A buffet breakfast is included.

The cost is $60 per adult and $40 per child under 12. The cost for those who don't spend the night is $50 per adult and $20 per child under 12.

For more information and reservations, see click the PDF link below or contact Cheryl Verne at ext. 3-2681.

Museum Sleepover - Feb. 8, 2013 (PDF)

Best practice in COPD and pneumonia: old habits left in the cold

As we enter the winter "respiratory" season, physicians are reminded to follow best practices by discharging pneumonia and COPD patients who have achieved clinical stability. According to the Cedars-Sinai Medicine task forces on pneumonia/COPD, there is limited benefit in keeping patients with community-acquired pneumonia or COPD in the hospital once they've met clinical stability criteria. For pneumonia patients, there is no benefit to "observation" after switching from intravenous to oral antibiotics. (For best practices on treating pneumonia and COPD, click the PDF link at the end of this story.)

"Cedars-Sinai physicians are not resistant to change — we want to do the right thing," says Dani Hackner, MD, associate chair of the Department of Medicine and medical director of Case Management. "But it's helpful to remember that while we may have been in the habit of doing what traditionally seemed to be good practice, some of those habits may not be supported by evidence."

Other "habits" that are not supported by evidence: frequent chest X-rays and prescribing bronchodilators such as albuterol and ipratropium routinely in pneumonia cases.

"On the other hand, large volumes of secretions, co-morbid COPD or asthma and active wheezing are clinical indications for bronchodilators," Hackner says. "Patients with bronchiectasis, cystic fibrosis or ciliary dysmotility benefit from bronchodilators. Patients with routine pneumonia, whether it's simple or complex hospital-acquired infections, generally don't need them."

Developing best practices for pneumonia, a common condition that kills 50,000 Americans every year, was one of the first projects addressed by Cedars-Sinai Medicine, a comprehensive initiative launched in 2010 to improve the efficiency, effectiveness and appropriateness of patient care.

Another C-S Medicine task force tackled the common but under-diagnosed condition of COPD, which affects as many as 24 million people in the United States. The task force completed a comprehensive review of the literature and held interdisciplinary meetings to develop treatment guidelines endorsed by the Pulmonary COE. One of its key successes was the reduction of inappropriate use of Xopenex (levalbuterol), an expensive medication not shown to be clinically better than generic albuterol for adults without allergy or malignant arrhythmias to albuterol.

Under the direction of Glenn D. Braunstein, MD, vice president for Clinical Innovation, Cedars-Sinai Medicine aims to ensure the medical center consistently helps patients by doing "the right thing for the right patient in the right setting at the right time with the right resources." Key supporters in the improvement initiatives for respiratory disease include Roy Artal, MD, Michael Lewis, MD, Phillip Zakowski, MD, and Zab Mosenifar, MD.

Guidelines for Treating Pneumonia (PDF)

Ideas sought for Great Debate topic

The Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition committee is soliciting suggestions for a topic for this annual spring event.

The debate will convene for its 10th year at 8 a.m. Thursday, April 25, 2013, in ECC A-C. Topics must be timely and must be of interest to the many departments and sections within the medical center.

Submit suggestions to Leo A. Gordon, MD, FACS, coordinator, Great Debates in Clinical Medicine, Leo.Gordon@cshs.org.

The 2012 debate focused on the influence of technology on the traditional doctor-patient relationship.

Enhanced Care Program offers nurse practitioner for skilled nursing facility patients

Cedars-Sinai is launching a new program aimed at keeping a closer eye on patients who have transitioned from the acute-care facility into a skilled nursing facility (SNF).

As part of the new Enhanced Care Program, a Cedars-Sinai nurse practitioner will be offered to assist attending MDs with the care of their SNF patients. If the attending MD agrees to participate, the nurse practitioner will meet with patients prior to discharge from the medical center and again within 24 hours of their admission into the skilled nursing facility. The nurse practitioner will then work closely with the attending MD and nursing staff at the facility to monitor the patient's progress and condition.

The nurse also will work with staff at the nursing facility.

"We're offering, at no risk and no cost to the attending physicians, a nurse practitioner to help them more closely manage their SNF patients," said Bradley Rosen, MD, medical director of the Enhanced Care Program, which officially launched Nov. 12. "This nurse will frequently be on site to ensure patients stay on track to recovery. … No one is taking over patients; we're simply providing an extra pair of eyes and ears to help their patients stay healthy and on track to recovery."

From a business perspective, the program is designed to save money associated with avoidable or preventable 30-day hospitalizations, for which the medical center will soon no longer be reimbursed, Rosen said.

The Enhanced Care Program was developed out of Cedars-Sinai's Readmissions Oversight Committee, in an attempt to better manage the post-discharge care of high-risk patients. The ECP subgroup is being led by Toni Hubenette, MD, and Kelley Hart. Although they represent a minority of Cedars-Sinai's overall discharges, these high-risk patients can be responsible for a large portion of healthcare expenditures, and some of these expenses can be conditions of this subset of patients is generally more chronic, Rosen said.

Leading up to the rollout of ECP, two six-week pilots of the program demonstrated impressive results, Rosen said.

There was a steady drop in readmissions once the pilot began, and when the pilot program stopped, readmissions spiked back up, Rosen said.

"The nurse practitioner was the common denominator," Rosen said. "It's not rocket science. This is about capturing medical problems earlier so that if someone has a urinary tract infection it can be treated before the patient becomes septic; if someone is short of breath or wheezing, they can be provided with appropriate treatments before they have respiratory failure."

Based on the success of the pilot projects, ECP has hired three nurse practitioners and a nurse educator.

Cedars-Sinai plans to eventually work with six local skilled nursing facilities, in two phases. Phase I, which began Nov. 12, includes the Rehabilitation Center of Beverly Hills, Hancock Park Rehabilitation Center and Sharon Care Center. Phase II, which will likely start early next year, will include Country Villa Wilshire, Country Villa Terrace and Country Villa Pavilion.

Rosen, who wants physicians affiliated with Cedars-Sinai to consider the program as an option, said attending physicians will continue to be the attending of record for their patient, be able to see their patients and document their encounters, and bill for the care of the patients like normal. Any malpractice issues related to the nurses involved fall to Cedars-Sinai Medical Center and Rosen as the program's medical director, he added.

"This new service fits into the larger health system strategy around population health and safe care transitions. The care of the patient doesn't just stop once they are discharged from the hospital," Rosen said. "We as a health system have an opportunity to do a better job making sure patients are doing well throughout their entire episode of care – from acute to sub-acute to home."

Accolades abound for quality care

Cedars-Sinai Medical Group has been honored to receive significant recognition of achievement over the past few months, earning two prestigious statewide distinctions for excellence.

"The awards are not our goal, but it's nice to have our efforts recognized," commented Tom Gordon, chief executive officer of the Cedars-Sinai Medical Network. "It's rewarding to know our patients are pleased with the clinical care and service we provide, and that, based on objective criteria, we are exceeding the standards of care in the state and contributing to the health and well-being of our community."

Top Performing Physician Group: Integrated Healthcare Association

The Integrated Healthcare Association has once again named Cedars-Sinai Medical Group a "Top Performer" in California, the eighth consecutive year the team has earned this honor. The consistency of the recognition is a direct result of the group's culture of continuous self-assessment and self-improvement.

The Medical Group ranked among the top 25 percent of the 200 physician groups assessed on select healthcare quality measures, including meaningful use of health information technology, patient experience and clinical measures that include priority conditions such as cardiovascular, diabetes, musculoskeletal, respiratory and prevention. The awards were presented at the IHA annual meeting in Los Angeles on Sept. 20.

Elite Status Performance: California Association of Physician Groups

For the sixth year in a row, Cedars-Sinai Medical Group has been ranked by the California Association of Physician Groups as one of 30 "elite status" physician groups in California. The recognition is based on CAPG's Standards of Excellence survey designed to reveal how well equipped physician groups are to provide high-value patient care.

The survey analyzed physician group capabilities in four areas, each considered central to providing high-quality care responsive to patient needs. The recognition, announced in May, is based on our ability to surpass stringent scoring standards in care management, information technology, accountability/transparency and patient care.

Circle of Friends honorees for October

The Circle of Friends program honored 139 people in October.

Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

Click here for more information about the program and for a list of past honorees.

  • David Alessi, MD
  • Michael J. Alexander, MD
  • Farin Amersi, MD
  • Nicole N. Apsay, RN
  • Martin Arreguin
  • Laura G. Audell, MD, MS
  • C. Noel Bairey Merz, MD
  • Jennifer Batugo, RN, BSN, PHN
  • Jana Baumgarten, MD
  • Gary S. Bellack, MD
  • Keith L. Black, MD
  • Earl W. Brien, MD
  • William W. Brien, MD
  • Christiane Michele J. Burnison, MD
  • Liza M. Capiendo, MD
  • Ilana Cass, MD
  • Christopher Chang, MD, PhD
  • Cheryl G. Charles, MD
  • Connie Chein, MD
  • Arnold C. Cinman, MD
  • Hart C. Cohen, MD
  • J. Louis Cohen, MD
  • Jason S. Cohen, MD
  • Jeffrey Conklin, MD
  • Stephen T. Copen, MD
  • Stephen R. Corday, MD
  • Barbara H. Cowen, MSW
  • Alice C. Cruz, MD
  • Catherine M. Dang, MD
  • Rick B. Delamarter, MD
  • Cheri Diaz
  • Marla C. Dubinsky, MD
  • Barry P. Duel, MD
  • Michael Engelberg, MD
  • Azita Far, MD
  • Margaret R. Farrell, RN, BSN
  • Yvette B. Federizo, RN, BSN, OCN
  • Kristen M. Feldkamp, RN, BSN, CBN
  • John D. Friedman, MD
  • Gerhard J. Fuchs, MD
  • Steven S. Galen, MD
  • Elayne K. Garber, MD
  • Armando E. Giuliano, MD
  • Sherry L. Goldman, RN, NP
  • Theodore B. Goldstein, MD
  • Mark P. Goodman, MD
  • Asa M. Grogan
  • Antoine Hage, MD
  • Jennifer Hajj, RN
  • John G. Harold, MD, MACC, MACP
  • Jeremy R. Herman, MD
  • Stuart Holden, MD
  • Asma Hussaini, MS, PA-C
  • Andrew Ippoliti, MD
  • Rhodora M. Jocson
  • Jay L. Jordan, MD
  • Stanley C. Jordan, MD
  • Saibal Kar, MD
  • Beth Y. Karlan, MD
  • Scott R. Karlan, MD
  • Ronald Karlsberg, MD
  • Cynthia A. Kenner
  • Michelle M. Kittleson, MD, PhD
  • Ellen B. Klapper, MD
  • Robert Klapper, MD
  • Jon A. Kobashigawa, MD
  • Suzy L. Laku, RN
  • Gary E. Leach, MD
  • Madeline S. Lerman, RN, BSN
  • Ronald S. Leuchter, MD
  • Andrew J. Li, MD
  • Michael C. Lill, MD, BS
  • Asa J. Lorre, RN
  • Rajendra Makkar, MD
  • Josephine T. Maleon
  • Adam N. Mamelak, MD
  • Harumi O. Mankarios, RN, OCN
  • Neel Mann, MD, MPH
  • Ruslan Marder
  • Robert J. McKenna, Jr., MD
  • Diane B. McWhorter, MSN, FNP, CDE
  • Gil Y. Melmed, MD, MS
  • Shlomo Melmed, MD
  • Avinash Mondkar, MD
  • JoMarie E. Monzon-Duller, NP
  • Florence G. Moreno, CNA
  • Jaime Moriguchi, MD
  • Charisse A. Murakami, RN, MSN
  • Jon Paul Nadres, RN
  • Rebecca A. Naor, PA-C
  • Ronald B. Natale, MD
  • Nicholas N. Nissen, MD
  • Charito Olay, III, RN
  • Amy Oppenheim
  • David A. Perkel, MD
  • Surasak Phuphanich, MD
  • Margareta D. Pisarska, MD
  • Robert B. Pompa, MD
  • Irving Posalski, MD
  • Srikanth S. Rao, DO
  • Svetlana Raysh, RN, BSN, PCCN
  • Judith Reichman, MD
  • Jenna Renella
  • Richard M. Ress, MD
  • Geraldine L. Rice, RN, ASN, AC-BC
  • Barry E. Rosenbloom, MD
  • Jason A. Rothbart, MD
  • Carmelita Runyan, RN
  • Stephen A. Sacks, MD
  • Howard M. Sandler, MD, MS
  • Jay N. Schapira, MD
  • Prediman K. Shah, MD
  • Edward J. Share, MD
  • Michael M. Shehata, MD
  • Robert J. Siegel, MD
  • Allan W. Silberman, MD, PhD
  • Amanuel Sima, MD
  • Tracey L. Solitare, RN, BSN, OCN
  • Christina J. Soto
  • Herbert Stein, MD
  • Theodore N. Stein, MD
  • Jerrold H. Steiner, MD
  • Megan M. Thomas
  • Alfredo Trento, MD
  • Leo Treyzon, MD, MS
  • Gregory Tsushima, MD
  • Mark K. Urman, MD
  • Alfredo Valenzuela
  • Jae Jae Velazquez
  • Swamy R. Venuturupalli, MD
  • Andrew Wachtel, MD
  • Ariel E. Weber, RN, BSN, CCRN
  • Joanna L. Wilson, RN
  • Robert N. Wolfe, MD
  • Edward M. Wolin, MD
  • Philip A. Yalowitz, MD
  • Menette Young
  • Christopher Zarembinski, MD
  • Millard H. Zisser, MD

The house call gets an electronic update

With the help of a few home visits from nurse practitioner Florita Valenzuela, along with the support of his wife and son, Walter Blue has been able to recover at home after his serious health issues.

With a new twist to a tried-and-true process, Cedars-Sinai Medical Group has brought back the house call to provide an in-person and virtual care team visit to the homes of patients with complex, high-risk health issues. Patients like Walter Blue, who, in his own words, has "had a tough time of it" since his first surgery last March, although he certainly has maintained a good attitude and sense of humor.

Nurse practitioner Florita Valenzuela (top) and James Caplan, MD, (bottom) work as a team, in person and online, to support Walter Blue's recovery.

Blue's hospitalist, physicians, inpatient case managers and social workers identified him as a good candidate for house calls prior to his discharge from the hospital. In addition to his bypass surgery and kidney problems, he has high blood pressure, was very weak, had no appetite and lost 50 pounds. Until nurse practitioner Florita Valenzuela came into the picture, that is. "When I met Florita, I said, 'I've died and gone to heaven.' All of the post-Florita era has been uphill," he said with a smile.

Valenzuela worked with Blue and his family, helping them understand his problems and what he needed to do to manage his health, explaining what his son and wife could do to support his postsurgical recovery. She helped with appointment scheduling as well.

She electronically reported her health assessments back to Blue's primary care physician, James Caplan, MD, after each of her visits, so the information was accurate and timely for monitoring and treating his patient after surgery. In collaboration with Caplan, the ambulatory case manager and other members of the extended care team, she helped Blue get back his appetite and strength and incorporate exercise back into his life.

"Because I was taking so many medications, she arranged for me to talk with a pharmacist to make sure one medication wasn't counteracting another," Blue recalled. "There were duplications, so as a result, they reduced the number of high blood pressure pills I'm taking and I'm doing really well."

Valenzuela gets close to her patients, but she knows when it's time to say goodbye. "They're letting me into their private world, their home. I appreciate that," she explained. "Every time I came to check on the Blues, Walter was doing better, until one visit we realized he didn't need me anymore. And that was a really good thing."

Although it was a very difficult time for the Blue family, and Walter is still not back 100 percent, he describes himself as a very lucky man. "Dr. Caplan, my quarterback, kept getting me to the right specialists, and they were terrific," he said. "I had great physicians, so much support from my wife and son, and Cedars-Sinai's care was just marvelous." It was a happy ending for everyone.