Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF Nov. 9, 2012, issue | Archived Issues

FDA conducting ongoing safety review of Mirapex

Pharmacy focus

The U.S. Food and Drug Administration is alerting healthcare professionals about a possible increased risk of heart failure with Mirapex (pramipexole), which is used to treat the signs and symptoms of Parkinson’s disease.

» 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 - November 2012 (PDF)

run for her this weekend

The eighth annual run for her® 5k run and friendship walk – benefiting the Cedars-Sinai Women's Cancer Program at the Samuel Oschin Comprehensive Cancer Institute – will take place on Sunday, Nov. 11, at Pan Pacific Park.

» Read more

A strong approach to frailty

Older adults who are hospitalized commonly suffer complications such as falls and associated fractures, bedsores, undernourishment and delirium during their hospital stay and soon after discharge. Older adults identified as "frail" are most at risk of these complications. To ensure these patients receive the best care possible, Cedars-Sinai Medicine's Frailty Task Force rolled out the Frailty Project in July 2012.

» Read more

New CT scanner could lead to 'hole' new outlook

Cedars-Sinai's new Lightspeed CT scanner keeps things simple: The bigger the hole, the better the view. And the scanner, which the Radiation Oncology Department rolled out recently, boasts a pretty big hole – big enough to produce four-dimensional scans.

» Read more

MEC 'Morning After' report

Highlights from the Nov. 5 Medical Executive Committee meeting include important announcements regarding CS-Link™ and changes in bylaws, rules and regulations.

» Read more

Update: barium contrast shortage

There continues to be a North American barium shortage; however, the S. Mark Taper Foundation Imaging Center was fortunate to receive a small and unexpected delivery. This will enable you to continue ordering esophagrams, upper GIs, small bowel series, barium enemas and video swallowing studies.

» Read more

Learn about diabetes at 'dance' to end the disease

Diabetes is the largest health burden in the nation. It is a precursor to several other diseases, it often leads to debilitating impairments such as blindness and kidney failure. Cedars-Sinai's Diabetes Outpatient Treatment and Education Center, along with the Division of Diabetes, Endocrinology and Metabolism, will host a free community event Nov. 16 in the Harvey Morse Auditorium designed to raise diabetes awareness. It's called a Dance to End Diabetes.

» Read more

Core Laboratory offers PSA reflexive panel

In response to requests from physicians, the Core Laboratory will offer a Prostate-Specific Antigen reflexive panel. When the reflexive algorithm is ordered, a total PSA value will be obtained. For total PSA values between 4 and10 ng/ml, a reflexive test for free PSA will be run.

» Read more

run for her this weekend

run for her 220pxThe eighth annual run for her® 5k run and friendship walk – benefiting the Cedars-Sinai Women's Cancer Program at the Samuel Oschin Comprehensive Cancer Institute – will take place on Sunday, Nov. 11, at Pan Pacific Park.

More than 1,000 Cedars-Sinai employees, family and friends have registered for this year's event.

Learn more about participating in run for her or sign up at www.runforher.com.

Money raised by run for her is strictly for research and awareness. Run for her was designed, in partnership with Cedars-Sinai, by Kelli Sargent, who lost her mother to ovarian cancer. Sargent is now a senior team lead and producer in Community Relations and Development. The inaugural event took place in a Cedars-Sinai parking lot in 2005.

A strong approach to frailty

Remember the flower children and beatniks of the '50s and '60s? These symbols of youth are now candidates for hip and knee replacements, not to mention a host of other medical treatments. In fact, nearly a third of Cedars-Sinai patients are 65 or older now.

Unfortunately, older adults who are hospitalized commonly suffer complications such as falls and associated fractures, bedsores, undernourishment and delirium during their hospital stay and soon after discharge. Older adults identified as "frail" are most at risk of these complications.

To ensure these patients receive the best care possible, Cedars-Sinai Medicine's Frailty Task Force rolled out the Frailty Project in July 2012. Successfully pre-piloted on 7SE for a year and now being tested in five additional units, the project uses a team approach to identify older adults who are at risk of frailty within 24 hours of admission so they can receive targeted interventions.

"We are trying to augment patient care without interfering with routine management by the attending physician," says Jeff Borenstein, MD, MPH, medical director for Applied Health Services Research, Cedars-Sinai Medicine. "Highlighting those issues that are directed to a patient's underlying health state allows us to address them with interventions that may prevent adverse events in the hospital and possibly reduce readmissions."

Nurses use a SPICES assessment tool that looks at six risk factors for frailty: Sleep disorders, Problems with eating, Incontinence, Confusion, Evidence of falls and Skin breakdown. Patients ages 65 and older who meet one or more SPICES criteria undergo a detailed multidimensional assessment by a Frailty team that is comprised of a physician, a gerontology trained nurse, a clinical pharmacist, a case manager and a social worker. The assessment includes a cognitive screening, a delirium screening, a functional assessment and an evaluation of the presence of social isolation.

Team members huddle to develop a frailty plan that is communicated to the attending physicians, nurses and other members of the care team. Recommended interventions may include anything from sleep hygiene and frequent cognitive orientation to medication substitutions and speech-language pathology assessments. Many of the interventions that help frail patients can be implemented by nursing staff and do not require physician approval.

"Preventing delirium is one of the main goals of the Frailty Project," Borenstein says. "Once delirium gets going, it's hard to treat, so we want to catch it early. You can prevent it by doing simple things like letting people sleep at night and frequently orienting them to where they are. We also have to think twice before we use certain drugs on elderly people because some of them can contribute to delirium."

Education Program Coordinator Larry Santiago, MSN, RN-BC, says the Frailty Project has been successful largely because it uses a team approach that "allows members of the team to see things they might not have seen otherwise."

The evidence-based Frailty Project is one of several best practices developed by Cedars-Sinai Medicine, under the direction of Glenn D. Braunstein, MD, vice president for Clinical Innovation, and Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer, to ensure Cedars-Sinai consistently helps patients by doing "the right thing for the right patient in the right setting at the right time with the right resources."

New CT scanner could lead to 'hole' new outlook

Cedars-Sinai's new Lightspeed CT scanner keeps things simple: The bigger the hole, the better the view.

And the scanner, which the Radiation Oncology Department rolled out recently, boasts a pretty big hole – big enough to produce four-dimensional scans. Howard M. Sandler, MD, chair of Radiation Oncology, (pictured above with the scanner) believes this will lead to even better results and images.

"I'm super excited about this piece of technology," says Sandler, who also is the Ronald H. Bloom Family Chair in Cancer Therapeutics. "When (manufacturers) are building a diagnostic CT scanner, they are interested in having the highest-quality images for diagnostic purposes and, as part of that, the machine's design typically has a small hole because it gives them better resolution.

"But for radiation treatment planning, radiation oncologists sometimes want patients to be in certain positions with which the standard-sized doughnut hole often interferes. In a nutshell, we need the hole a little bigger."

The standard CT – or computed tomography – scanner has a bore 70 centimeters in diameter. The GE Lightspeed RT16 CT scanner's bore is 80 centimeters, which is 14 percent greater in diameter, Sandler says.

"While in diagnostics the larger size bore, or hole, might not matter because they are looking at the heart or something in the center of the patient, which is still going to be visual, but in radiation oncology, when we're creating three-dimensional treatment planning, we need every piece of the patient in the scanner," Sandler says. "Secondly, and for patients of any size, sometimes when we are treating them, we need them in an optimal position, such as sticking their arms out to the side or above their head. With this larger bore, we have more freedom to do better positioning."

For nearly 20 years, radiation treatment planning has relied on the three-dimensional model for patients. However, and despite the fact those CT scanners deliver quality images, they aren't always adequate, Sandler says.

One reason for that is because tumors move. Enter the Lightspeed's capabilities to produce 4-D images, which Sandler says will allow doctors to track a tumor's movement during the breathing cycle. Tracking that, he says, can help cut down side effects.

Sandler says Radiation Oncology currently schedules about seven patients per day for radiation treatment planning, and there's even more excitement regarding the scanner's potential. It could be useful in planning treatment of other abdominal tumors, such as pancreatic cancer, in which tumors also move, and in breast cancer.

MEC 'Morning After' report

Highlights from the Nov. 5 Medical Executive Committee meeting include important announcements regarding CS-Link™ and changes in bylaws, rules and regulations.

CS-Link™ update

CS-Link was upgraded to the 2010 version. There are a lot of new features that should increase productivity.

There was one problem: Smartlinks were temporarily disabled. As a result, they did NOT refresh automatically. This has been corrected.

Do the following to ensure your documentation is correct:

  • Do not copy forward notes from either Nov. 4 or 5
  • Review any documentation you created on Nov. 4 and 5 to ensure that the smartlinks reflect the information intended to be communicated
  • Use fresh templates or smartlinks (these are highlighted green) for documentation to prevent pulling in smartlinks that are not refreshing

Bylaws revisions

You will be asked to vote on these amendments in a week or two.

  • Article VII – Executive Committee – redistributes membership on the MEC
  • Article XII, Section 12.1.1 – clarifies that loss of licensure results in termination unless request for review is granted
  • Article V, Section 5.1 and 5.3 – Removing references to "reapplication"

Rules and regulations

1. Provider Designation (Sections 1.1.1, 1.1.2, 1.1.8, 1.1.24, 1.3, 2.1, 3.2, 3.4, 3.6, 3.8, 4.5.3, 4.7, 4.10, 4.15, 4.16, 4.20.2, 4.21.1, 6.1, 9.6, 10.11, 16.2, and 16.3)

• From now on, when you admit a patient, you'll be asked to specify the name of the Admitting Physician and Attending Physician.
• The Admitting Physician is the person who made the decision to admit the patient. They are responsible for assuring that the patient has appropriate admission orders and documentation.
• The Attending Physician is responsible for oversight and problem solving. If you are listed as Attending Physician, expect to be called for critical or urgent lab results, Imaging results and other patient care issues. You can transfer this responsibility to another physician, by calling and getting their consent, and then changing this designation in CS-Link.
• If you admit a patient that you plan to manage in the hospital, you should list yourself as the Admitting Physician and Attending Physician.

For more information, click on the following PDF: Provider Designations - November 2012 (PDF)

2. Article II, Section 2.1.7 – Cedars-Sinai will be phasing out the Affiliate category. We will be contacting the 40 physicians in this category and helping them transfer to another category, if appropriate. For more information, click on the following PDF: Affiliate Category - November 2012 (PDF)

3. Article XXI, Section 21.3.4 – Medical Staff dues waiver – Medical Staff members who volunteer to work in our clinics supervising residents, but admit none of their own patients, may qualify for a dues waiver. For more information, click on the following PDF: Medical Staff Dues - November 2012 (PDF)

4. Article IV, Section 4.5.5 – Outside Reports – We continue to accept H&Ps and other reports from physicians who are not on our medical staff; however, they must be typed or dictated using the Cedars-Sinai dictating system.

5. Article III, Section 3.1 – Nondiscrimination language – You're not allowed to illegally discriminate against patients or staff.

6. Article XVI, Section16.6 – You don't have to be on our medical staff to order tests at Cedars-Sinai.

Physician hand-hygiene compliance

Physician hand-hygiene compliance was a bit lower in October – 95 percent.

The MEC approved a plan for cracking down on three-peat hand hygiene offenders:

Physicians who have taken the Hand Hygiene Class (after a second offense) and are then noncompliant for the third time (three-peaters) within a two-year period, will be referred to peer review. They also will be asked to meet with a panel including the chief medical officer, chief of staff, vice president of medical affairs, epidemiology medical director and possibly the chair from their department to discuss their noncompliance.

This panel will then determine appropriate interventions, which could include a temporary suspension from the medical staff.

Election update

The MEC formed a Nominating Committee to identify candidates for medical staff secretary and treasurer:

  • William Brien, MD – chair
  • Michael Alexander, MD
  • Jeff Caren, MD
  • Anthony Chin, MD
  • Daniel Margulies, MD

Department elections

  • Medicine:
    Department representatives to the MEC: Asher Kimchi, MD (second term) and Clement Yang, MD (second term)
  • Ob/Gyn:
    Clinical Chief – Ruth Cousineau, MD (first term)
    Department representatives to the MEC: Robert Katz, MD (first term) and Scott Serden, MD (first term)

Task Force on Civility

Last month, the MEC voted to create a Task Force on Civility. This month, it approved the initial members. The task force will be starting small, but adding members once it is up and running. Contact the chief of staff or vice chief of staff if you are interested in joining this task force.

The initial members are:

  • Scott Karlan, MD
  • Sarah Kilpatrick, MD, PhD
  • Steve Galen, MD
  • Joel Geiderman, MD
  • Chris Ng, MD
  • Michael Langberg, MD
  • William Brien, MD
  • Zab Mosenifar, MD
  • Paul Silka, MD
  • Harry Sax, MD
  • John Harold, MD
  • Andy Klein, MD
  • Paul Hackmeyer, MD

2013 list of committees/task forces approved for "committee service"

To run for MEC (and become chief of staff), you have to serve on several medical staff committees. All standing committees count. The MEC approved a list of additional committees for credit:

  • Readmission Task Force (reports to PEAC) HAI Task Force
  • Leadership Development Co-Chairs (this would allow for one additional year for the Co-Chairs who have already completed the Leadership Development Program)
  • IRB Panel
  • Medication Safety (Operations Committee)
  • MD/RN Collaboratives
  • CS-Medicine Working Group Committees
  • Patient Safety Committee and subcommittees
  • Pain Management Task Force
  • Falls Task Force
  • Task Force on Civility
  • Subcommittees of standing medical staff committees

Update: barium contrast shortage

There continues to be a North American barium shortage; however, the S. Mark Taper Foundation Imaging Center was fortunate to receive a small and unexpected delivery. This will enable you to continue ordering esophagrams, upper GIs, small bowel series, barium enemas and video swallowing studies.

In the event our supplies are depleted, you and your patient will be notified.

As we receive more updates, we will alert you.

Our GI radiologists are available for questions at (310) 423-2723.

- From Richard J. Sukov, MD, FACR, chief, GI Radiology

Learn about diabetes at 'dance' to end the disease

Diabetes is the largest health burden in the nation. It is a precursor to several other diseases, it often leads to debilitating impairments such as blindness and kidney failure.

"Diabetes is a predisposing factor for multiple other conditions, especially cardiovascular disease," said Ruchi Mathur, MD, director of Cedars-Sinai's Diabetes Outpatient Treatment and Education Center.

The center, along with the Division of Diabetes, Endocrinology and Metabolism, will host a free community event Nov. 16 in the Harvey Morse Auditorium designed to raise diabetes awareness. Known as a Dance to End Diabetes, the event includes activities to get people up and moving, and asking questions about the disease. Endocrinologists, along with pharmacy, nutrition and diabetes educators, will be available to answer questions on a one-on-one basis, Mathur said. The event is open to patients, staff and community members.

Dance to End Diabetes

What: Free event for employees and community members (includes 30-minute Zumba® classes)

When: Friday, Nov. 16, from noon to 4 p.m.

Where: Harvey Morse Auditorium

More information: Call (310) 423-4774

"The problem is diabetes often doesn't cause an ache, a pain or a rash, so there may be nothing that brings patients to a physician," Mathur said. "It's insidious and falls by the wayside."

Other scheduled activities include Zumba® classes every half-hour starting at 12:30 p.m. In addition, vendors have been invited to present the newest technology in diabetes management, such as glucose monitors and insulin pumps.

"We want people to have an opportunity to talk to the vendors about the different meters and insulin pumps, insulin pens and other technology out there for diabetes management," Mathur said. "Our diabetes educators, pharmacists and nutritionists can also answer specific questions that patients, family members and those interested in diabetes may have."

A similar, much smaller event was held last year with about 150 people participating. That event was only for employees, Mathur said.

"This year, it's open to everyone. We are encouraging people to bring their friends and their family," she said. "This is not just for people with diabetes."

The Division of Diabetes, Endocrinology and Metabolism has partnered with the American Diabetes Association as a way to reach the community.

The Diabetes Outpatient Treatment and Education Center is a team-oriented, patient-centered program located in the Steven Spielberg Building at Cedars-Sinai. The center's staff provides treatment to patients with Type 1 and Type 2 diabetes, patients who are prediabetic, those with gestational diabetes and people who have a family history or risk factors for the disease.

An estimated 25 million people are living with diabetes in the United States today, and 80 million more are prediabetic and don't know it, Mathur said.

"Anything we can do to raise the public's awareness, prevent hospitalizations and reduce the socio-economic burden associated with diabetes, we plan to do it," Mathur said.

Dance to End Diabetes - Nov. 16, 2012 (PDF)

Core Laboratory offers PSA reflexive panel

In response to requests from physicians, the Core Laboratory will offer a Prostate-Specific Antigen reflexive panel. When the reflexive algorithm is ordered, a total PSA value will be obtained. For total PSA values between 4 and10 ng/ml, a reflexive test for free PSA will be run.

The value of both free and total PSA will be accompanied by a comment to assist in determining risk based on age and race. Total and free PSA may still be ordered separately, but the Core Lab hopes the new approach will decrease unnecessary testing of free PSA.

This should be particularly useful in the outpatient setting, as the patient will only need a single draw and will not need to return for further testing of PSA.

In other news: Mayo Medical Laboratories has announced (effective Oct. 4) that the methodology for beta-hCG as a tumor marker has changed to a Roche Cobas immunoassay. Mayo Medical Laboratories has indicated that the results yielded may be lower with the new methodology and that re-baselining is available upon request.

You may contact the Core Lab's client services number, ext. 3-5431, with requests for re-baselining your patients. The new reference values are as follows:

Reference values

  • Children
    • Males
      • Birth to 3 months: < or =50IU/L*
      • >3 months to <18 years: <1.4 IU/L
    • Females
      • Birth to <18 years: <1.0 IU/L

*hCG, produced in the placenta, partially passes the placental barrier. Newborn serum beta-hCG concentrations are approximately 1/400 of the corresponding maternal serum concentrations, resulting in neonate beta-hCG levels of 10 to 50 IU/L at birth. Clearance half-life is approximately two to three days. By 3 months, levels comparable to adults should be reached.

  • Adults (97.5 percentile)
    • Males: <1.4 IU/L
    • Females
      • Premenopausal, nonpregnant: <1.0 IU/L
      • Postmenopausal: <7.0 IU/L