Cedars-Sinai

Medical Staff Pulse Newsletter

Recognition for Chugh, Marban, Metz, Sandler

Physician News

Eduardo Marbán, MD, PhD, and Sumeet Chugh, MD, have won awards from the American College of Cardiology; Richard J. Metz, MD, is being honored by the National Hemophilia Foundation; and Howard Sandler, MD, will receive an award from the Honors Program at the University of Connecticut.

» 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 - April 2014 (PDF)


Milestones

Do you know of a significant event in the life of a medical staff member? Please let us know, and we'll post these milestones in Medical Staff Pulse. Also, feel free to submit comments on milestones, and we'll post the comments in the next issue. Click here to email us your milestones and comments.

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Cedars-Sinai Designing 'O.R. of the Future'

Partnership With Military Aims to Streamline, Improve Trauma Care

Cedars-Sinai has partnered with the U.S. military to design the "operating room of the future" that will enable emergency medical teams to respond more quickly and effectively to patients with life-threatening injuries. The project is called "OR 360."

» Read more

CS-Link Tip: Using SmartPhrases

This week's tip is from Chief of Staff Chris Ng, MD. Never type the same thing twice in CS-Link™. Instead, remember that you can make a SmartPhrase on the fly.

» Read more

High-Quality Care Doesn't End With Discharge

A new collaboration between Cedars-Sinai and five highly vetted home health agencies seeks to ensure that patients discharged from the hospital to home health receive the highest-quality care.

» Read more

Switch to ICD-10 Delayed; Preparation Continues

Cedars-Sinai will continue preparing to switch to ICD-10, although the U.S. government has delayed implementation of the coding system for a year. A federal law that took effect April 1 pushes the compliance date for ICD-10 to Oct. 1, 2015. The deadline had been Oct. 1 of this year.

» Read more

New Parking Rates for Patients, Visitors

Cedars-Sinai will implement new patient and visitor parking rates effective May 1. In keeping with prevailing parking rates in this area, Cedars-Sinai will no longer provide free parking, and the daily cost of validated self-parking will be increased from $4 to a maximum of $5.

» Read more

Fireworks, Sand 'N' Snore Are on the Horizon

Summer has a couple of treats in store for medical staff members and their families: the Independence Day celebration at the Hollywood Bowl on July 3, and the Sand 'N' Snore sleepover on Sept. 5.


» Read more

Morgenstern Debaters to Tackle Robotics

Robotics in medicine is the subject of this year's Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition. The debate will convene for its 11th year on Friday, June 6, at 8 a.m. in Harvey Morse Auditorium.


 

» Read more

FDA Warns of Epidural Corticosteroid Injections

Pharmacy Focus

The U.S. Food and Drug Administration is warning that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis and death.

» Read more

Movie History, From Mount Sinai to Cedars-Sinai

Medical Center Is Home to DeMille's Ten Commandments Tablets

Cedars-Sinai is connected to the biblical story of Exodus by a rare piece of cinematic history — a set of Ten Commandments tablets that were commissioned by the legendary director Cecil B. DeMille.

» Read more

Cedars-Sinai Designing 'O.R. of the Future'

Cedars-Sinai surgeons train on a mannequin during an OR 360 trauma simulation in February.

Partnership With Military Aims to Streamline, Improve Trauma Care

Cedars-Sinai has partnered with the U.S. military to design the "operating room of the future" that will enable emergency medical teams to respond more quickly and effectively to patients with life-threatening injuries.

Under the project, called "OR 360," research teams have reconfigured the operating room with movable walls and equipment for more flexible use, identified ways to eliminate disruptions during surgery, and developed an iPhone® app that provides diagnostic information about blood pressure and other vital signs before patients arrive in the emergency room.

OR 360 in the News

More than 430 media outlets across the nation, including the New York Times, featured an Associated Press story about OR 360.

Among those that picked up the story were Bloomberg Businessweek and Yahoo! Health.

Several outlets also ran an AP photo gallery of a recent trauma simulation and an accompanying video on YouTube.

Los Angeles' local ABC station also covered the story.

The initiative, drawing on practices from surgery, psychology, aviation and other disciplines, focuses on addressing potential breakdowns in the coordination of trauma care during the so-called "golden hour," when prompt medical attention can mean the difference between life and death.

"Our goal is to improve the efficiency and effectiveness of acute trauma care in both civilian and military settings by introducing innovations in communication, technology, workflows and the way medical personnel perform their jobs," said Bruce L. Gewertz, MD, surgeon-in-chief and chair of the Department of Surgery at Cedars-Sinai, who also holds the Harriet and Steven Nichols Distinguished Chair in Surgery. "The quicker we get patients cared for, the better the outcomes."

Physicians from Cedars-Sinai and military hospitals on two continents, along with researchers from several universities, have analyzed the complex processes of trauma care — from the moment a doctor's pager is triggered to the time a patient arrives in a trauma bay to the patient's transfer to an intensive care unit.

The aim of this research has been to find ways to simplify the time-pressured nature of trauma care. Gewertz said that means improving communication and teamwork among medical staff, making better use of technology and re-engineering the operating room so that bulky equipment pivots effortlessly around surgical teams rather than cluttering work spaces.

The trauma drill took place in a simulated operating room, designed by Cedars-Sinai researchers, that features flexible, moving walls and pieces of equipment attached to ceiling tracks that pivot around surgical teams.

OR 360 has been funded by $3.8 million in grants from the U.S. Department of Defense. Cedars-Sinai has collaborated with personnel at military medical centers in the United States and Europe.

Important partners in these efforts have included faculty members from the University of Washington, University of Wisconsin-Madison and University of Central Florida. Private sector representatives have come from Coolfire Solutions, a mobile application developer in St. Louis, and the Surgical Safety Institute, a consulting firm in Tampa, Fla., that applies aviation safety techniques to the operating room.

Members of this wide-ranging team have based their work on "human factors" research to evaluate the interplay of teamwork and technology, as well as operating room culture and workspaces, among other things.

This analysis has zeroed in on "surgical flow disruptions" — such as missing equipment, tangled IV tubes, extraneous conversations and delays in getting specialists or interpreters to the operating room — that can interrupt or slow the work of surgical teams. A broad body of research has found a direct link between flow disruptions in the operating room and surgical errors.

To learn how military hospitals avoid these types of disruptions, members of the Cedars-Sinai team visited military surgical teams in the U.S. and Europe to observe their practices and to interview surgeons, nurses and other medical personnel. Team members took away important lessons about standardizing the setup of trauma bays and how to better use technology in the operating room.

"The quicker we get patients cared for, the better the outcomes," said Bruce L. Gewertz, MD, surgeon-in-chief and chair of the Department of Surgery at Cedars-Sinai.

As an outgrowth of the visits and subsequent research, Cedars-Sinai has introduced several of its own innovations to streamline trauma care, including:

  • Creating color-coded trauma bays, allowing staffers to more quickly locate supplies and equipment.
  • Installing whiteboards in trauma bays that display key patient information such as age, gender, pre-hospital vital signs and field treatment, providing important facts as trauma teams respond to fluid situations.
  • Developing an iPhone application that puts patient diagnostic data at the fingertips of surgeons, nurses, pharmacists and other trauma team members as they converge on a case from different parts of the medical center.
  • Conducting pre-briefings in trauma bays before trauma patients arrive, allowing doctors, nurses and others to understand their roles and to ensure that the correct equipment and medications are ready.

These changes have produced promising early results.

The whiteboards and pre-briefings, for example, reduced the time to capture the first radiological images by more than 10 percent and the time to draw blood for the first lab tests by more than 20 percent. The standardized, color-coded trauma bays reduced the time needed to collect supplies by about 15 percent.

Cedars-Sinai researchers also are evaluating ways to reduce delays and errors during handoffs, when patients are transferred from one medical space to another (for example, from the operating room to an intensive care unit). And they have designed and built a simulated operating room that features flexible, moving walls and pieces of equipment attached to ceiling tracks that pivot around surgical teams. The lab fosters creative solutions to complex logistical challenges in the operating room.

"This is a new way to think about the improvement and delivery of healthcare," Ken Catchpole, PhD, director of Surgical Safety and Human Factors Research at Cedars-Sinai, said of the overall project. "It's not just about new techniques or technologies or drugs, but how all those things work in unison. By putting the patients and clinicians at the center of the system and designing everything directly for their needs, we can develop trauma care for the 21st century that is fast, efficient, safe and of the highest quality possible."

The initiative was supported by a contract that was awarded by the U.S. Army Medical Research and Materiel Command and managed by the Telemedicine and Advanced Technology Research Center under Award Nos. W81XWH1011039 and W81XWH1110813.

The simulated operating room fosters creative solutions to complex logistical challenges.

CS-Link Tip: Using SmartPhrases

This week's tip is from Chief of Staff Chris Ng, MD. Never type the same thing twice in CS-Link™. Instead, remember that you can make a SmartPhrase on the fly.

Highlight your phrase, then click the green plus sign in the Documentation header. A pop-up box appears where you can name and save your SmartPhrase.

Click here for more CS-Link training updates for physicians.

High-Quality Care Doesn't End With Discharge

A new collaboration between Cedars-Sinai and five highly vetted home health agencies seeks to ensure that patients discharged from the hospital to home health receive the highest-quality care.

The program, called Enhanced Home Health 2.0, went into effect March 3. It provides full-time, on-site liaisons from Accredited Home Health, Assisted Home Health, Caring Like Family Home Health, Dynamic Home Care and Universal Home Care, who meet with patients before discharge to prepare them for the transition to home-based care. The liaisons are at Cedars-Sinai on weekdays from 8 a.m.-6 p.m.

Early results show the arrangement's promise. Patients in a 2013 pilot study of the program were more accepting of home healthcare and received the services more quickly.

The five agencies follow an evidence-based protocol that includes seven "touch points," or points of contact, that home health staff members make with patients in the first two weeks after discharge to address issues, answer questions, identify problems and schedule visits. Among the touch points are "tuck-in" phone calls on the first and second Fridays after discharge to ensure patients' needs are met before weekends, when closed physician offices make hospital readmissions more likely.

"In the old days, a newly discharged patient who became short of breath at 9 p.m. on a Saturday would call 911 and end up back in the hospital Emergency Department," said Neil Romanoff, MD, MPH, Cedars-Sinai vice president for Medical Affairs. "Now, that same patient can receive a 'tuck-in' phone call on Friday from her home health nurse, who can identify red flags and help her avoid the breathing problems that would lead to a 911 call."

Trying to Reduce Readmissions

Cedars-Sinai has been investigating ways to reduce 30-day readmission rates for several years and began studying the impact of post-discharge home healthcare in December 2011. An early analysis showed patients and families often turned away services and that physicians were often unresponsive when agencies called with questions.

In January 2013, Cedars-Sinai launched a six-week pilot program with four home health agencies that agreed to make frequent contact with patients in the first two weeks after discharge. Readmissions dropped by 32 percent in the first two weeks after discharge, but when the pilot was discontinued, the rate of readmissions returned to the higher baseline rate.

A Cedars-Sinai Performance Improvement committee decided to try a new approach that involved collaborating with a small group of home health agencies that would work with the hospital to improve outcomes. Romanoff proposed a style of collaboration based on a model of vendor relationships he learned about while serving as a judge for the Malcolm Baldrige National Quality Awards, he said.

"It's all about creating win-win relationships with your vendors," Romanoff said. "In win-win relationships, each party defines what it wants and needs from the relationship to be successful."

Cedars-Sinai sent requests for proposals to 200 of about 700 home health agencies in its service area, said Neema Haria, MHSA, a project manager in Cedars-Sinai Performance Improvement. After considering factors such as readmission rates, the use of information technology systems and capacity, the selection committee narrowed its choices to 13 home health agencies and talked to their representatives about how to make the arrangement work, Haria said.

"We told them what we need and then asked what they need from us," Romanoff said. "A lot of what they said was basic, like 'We need an accurate face sheet' or 'We need to know, when patients are being discharged, if they are going home or to their sister's.' We all learned a lot from those discussions."

Cedars-Sinai selected five home health agencies for the arrangement. To align the agencies' values with Cedars-Sinai's, agency employees went through a hospitality service recovery program that focuses on how to deal with challenging situations. In addition, the agencies' on-site liaisons went through an orientation process that included health clearances, criminal background checks and signed confidentiality agreements so they could have remote, read-only access to patient health information on CS-Link™.

Patient assignments are rotated among the agencies unless patients or their physicians express a preference for a particular home health agency. Physicians may refer patients to other home health agencies, but only the five agencies have on-site liaisons and have agreed to follow the protocol of seven touch points.

Most Referred Patients Use the Service

So far, about 70 percent of the 475 patients referred to home health have received services from the five agencies, said David Esquith, LCSW, Cedars-Sinai's manager of Medical Social Work. The remaining 30 percent either chose outside home health agencies or declined the service.

"With outside agencies, a patient in need of home health services goes home and then a nurse comes out, does an assessment and starts putting everything in place," he said. "Having the agency liaison see the patient before discharge means the home health agency gets all the information it needs ahead of time, so there is less of a time gap between when the patient gets home and when services begin.

"There's also a much higher acceptance rate, because patients are sometimes wary when they get a call from a nurse at home," he said. "But if they're introduced to a liaison in the hospital, they tend to be more open about having a nurse come out."

As part of the agreement, Cedars-Sinai and the five agencies agreed to monitor one another on quality and performance. To help establish a spirit of cooperation among the agencies, Cedars-Sinai averages their readmission rates together.

"When we picked these five agencies, they were competitors, but they have come together as a group and are supporting each other when they need it," Romanoff said. "It's truly a team effort."

Physicians can refer patients to Enhanced Home Health using the home health referral available on CS-Link. For more information, please contact Case Management at 310-423-4446.

Switch to ICD-10 Delayed; Preparation Continues

Cedars-Sinai will continue preparing to switch to ICD-10, although the U.S. government has delayed implementation of the coding system for a year.

A federal law that took effect April 1 pushes the compliance date for ICD-10 to Oct. 1, 2015. The deadline had been Oct. 1 of this year.

The new compliance date for the ICD-10 coding system is Oct. 1, 2015.

The training that Cedars-Sinai physicians and employees have undergone in preparing for ICD-10 is still valid. The education modules already assigned will remain available in HealthStream for completion or review. Any coursework completed will be recorded and will not need to be taken again. No new education modules are anticipated before April 2015.

The medical staff training sessions occurring in April and May 2014 will proceed as scheduled. These sessions will focus on improvement of documentation and will include an overview of enhancements when CS-Link™ is upgraded June 7. All other peer-to-peer sessions will resume after January 2015.

The ICD-10-CM (Clinical Modification) training for physician office coders will proceed as scheduled in August.

Cedars-Sinai is awaiting further guidance from the federal Centers for Medicare and Medicaid Services regarding the delay.

The switch to ICD-10 is mandated by the federal Department of Health and Human Services. The change will result in an increase from about 17,000 codes in ICD-9 to more than 140,000 in ICD-10.

For more information and updates regarding ICD-10 activity at Cedars-Sinai, visit the ICD-10 Project page on the Intranet or the ICD-10 Implementation page at CS-Link Central.

Previously in Medical Staff Pulse:

New Intranet Section Gives Healthcare Coding Tips (Dec. 20, 2013)

Physicians and Office Staff — Not Just Coders — Need to Prepare for ICD-10 (Sept. 27, 2013)

New Parking Rates for Patients, Visitors

Cedars-Sinai will implement new patient and visitor parking rates effective May 1. In keeping with prevailing parking rates in this area, Cedars-Sinai will no longer provide free parking, and the daily cost of validated self-parking will be increased from $4 to a maximum of $5.

The daily maximum for nonvalidated self-parking will be set at $10 for all medical center parking lots. This represents a cost savings of $5 from the previous maximum rate of $15 that was charged in some Cedars-Sinai lots.

Effective May 1, the new patient and visitor parking rates will be:

  • $10 daily maximum for nonvalidated self-parking in parking lots P1, P2, P3, P4, P5, P6 and Mark Goodson Building
  • $5 daily maximum for validated self-parking in lots P1, P2, P3, P4, P5, P6 and Mark Goodson Building (validations are available only for outpatient visits and the first and last day of admissions)
  • $25 for a packet of 10 tickets for patients with multiple clinic visits (transplant, rehab, cancer, etc.)
  • $30 for a one-week pass in lots P1, P2 and P4
  • $50 for a two-week pass in lots P1, P2 and P4
  • $100 for a one-month pass in lots P1, P2 and P4

Valet parking is available in lots P3 and P4 and at the S. Mark Taper Foundation Imaging Center for an additional $5. Gratuities are not accepted.

For additional information, please contact the Parking Office at 310-423-5535.

Fireworks, Sand 'N' Snore Are on the Horizon

Summer has a couple of treats in store for medical staff members and their families.

Hollywood Bowl Fireworks — July 3

Celebrate Independence Day at the Hollywood Bowl with fireworks and music by the Hollywood Bowl Orchestra, along with Steve Martin and the Steep Canyon Rangers, featuring Edie Brickell.

The event on Thursday, July 3, is open to Cedars-Sinai physicians and their immediate family members. Cost is $130 per adult and $65 per child 3-11 years of age.  

Valet and Lower Terrace parking passes also are available.

To see coverage of the 2013 celebration, click here.

A photo from last year's Independence Day event at the Hollywood Bowl

Sand 'N' Snore — Sept. 5

The dinner, sleepover and breakfast starts Friday, Sept. 5, 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 $45 for each child under age 12. Tickets for Friday's dinner only are $50 per adult and $25 for each child younger than 12.

A photo from the 2013 Sand 'N' Snore

To see coverage of the 2013 event, click here.

To reserve a place for either event, call Cheryl Verne, in the office of Marjorie Santore Besson, at 310-423-2681.

Morgenstern Debaters to Tackle Robotics

Heidi Reich, MD

Ryan Spurrier, MD

Robotics in medicine is the subject of this year's Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition.

The debate will convene for its 11th year on Friday, June 6, at 8 a.m. in Harvey Morse Auditorium. The topic will be "Robotics — Medicine or Marketing? Progress or Promotion?" Heidi Reich, MD, will argue that robotics is a medical advance. Ryan Spurrier, MD, will argue that robotics is medical marketing.

The debate will anchor the first Cedars-Sinai Founder's Day — a daylong celebration of the opening of the medical center on June 6, 1976.

For more information about the debate, contact Leo Gordon, MD, at leo.gordon@cshs.org.

To see coverage of last year's debate, click here.

FDA Warns of Epidural Corticosteroid Injections

Pharmacy Focus

The U.S. Food and Drug Administration is warning that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis and death.

The injections are given to treat neck and back pain, and radiating pain in the arms and legs. The effectiveness and safety of epidural administration of corticosteroids have not been established, and the FDA has not approved corticosteroids for this use. 

The agency is requiring the addition of a warning to the drug labels of injectable corticosteroids to describe these risks.

More information is available at this FDA Web page.

Movie History, From Mount Sinai to Cedars-Sinai

Cedars-Sinai's replica Ten Commandments tablets are united briefly with a replica of the Commandments' deliverer — the statue of Moses at George Burns Road and Gracie Allen Drive.

Medical Center Is Home to DeMille's Ten Commandments Tablets

Cedars-Sinai is connected to the biblical story of Exodus by a rare piece of cinematic history — a set of Ten Commandments tablets that were commissioned by the legendary director Cecil B. DeMille.

The tablets, made during the filming of the 1956 epic "The Ten Commandments," were donated to the medical center decades ago. Unlike the lighter tablets that Charlton Heston held when he starred as Moses in the film, these tablets are crafted from red granite that came from Mount Sinai in Egypt.

Each tablet stands about 2 feet tall, is approximately 16 inches wide and weighs 50 pounds. According to a scholar who examined the lettering on the tablets, the hand-carved text is written in ancient Hebrew script.

Each granite tablet stands about 2 feet tall, is approximately 16 inches wide and weighs 50 pounds.

"These are the tablets that were displayed for years in the main lobby of Mount Sinai Hospital," said Jonathan Schreiber, director of Community Engagement at Cedars-Sinai. Mount Sinai Hospital was a predecessor of Cedars-Sinai.

"The Ten Commandment tablets are now held in our Historical Conservancy," Schreiber said. "They're an integral part of the history of the medical center, and will be a part of the upcoming Historical Conservancy exhibit."

The story of these replica Ten Commandments tablets begins with the film of the same name. Directed by DeMille, the film dramatizes the life of Moses and depicts the liberation of the Jews from centuries of slavery in Egypt. With a record-breaking budget of more than $13.2 million, much of the film was shot in the desert south of Cairo on one of the largest sets ever constructed.

On Oct. 15, 1954, the first sequence of the film — Moses returning from his life-altering meeting with God — was filmed on Mount Sinai, according to the official Cecil B. DeMille website. It was during this shoot that DeMille purchased the red granite, quarried on Mount Sinai, that was used to make the Ten Commandments tablets.

Cecilia DeMille Presley, a film preservation activist and the granddaughter of Cecil B. DeMille, remembers the trip to Egypt. The journey to Mount Sinai involved just a small crew: the director, Heston, the camera operator, a lighting crew and a few others.

"Everyone stayed at Saint Catherine's Monastery, and my grandfather just loved it there," Presley said. Saint Catherine's is the oldest continuously inhabited Christian monastery, with a 17-century history. "It was all quite an adventure."

Due to the great weight of the Mount Sinai granite, DeMille brought just a small amount of it back home, Presley said. Only a few Ten Commandments tablets were made. Two remain with the Cecil B. DeMille Foundation.

Presley said she wasn't surprised to learn that one of the sets of the rare tablets is in Cedars-Sinai's historical collection.

"My grandfather and my grandmother both were great supporters of the Mount Sinai Hospital from the very beginning," she said. "It makes sense that the tablets would have been a gift to the hospital."


Cedars-Sinai to Celebrate Founder's Day

The Ten Commandments tablets will be part of an exhibit that will make its debut as part of Cedars-Sinai's first Founder's Day. The daylong celebration on Friday, June 6, will commemorate the opening of the medical center on June 6, 1976.

The exhibit, a project of the Cedars-Sinai Historical Conservancy, will trace the growth of Cedars-Sinai from its first days as the Kaspare Cohn Hospital — founded in 1902 — to today's medical center. The tablets won't be on display but will be included via a video and accompanying story.

Kicking off Founder's Day at 8 a.m. will be the 11th annual Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition. At noon, there will be a presentation on the history of Cedars-Sinai. Both events will take place in Harvey Morse Auditorium.

Cedars-Sinai plans to make Founder's Day an annual event.