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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF May 9, 2014 | Archived Issues

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 2014


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.

Click the "Read more" link to see this issue's milestones.

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MEC Morning After Report

See highlights of the May 5 meeting of the Medical Executive Committee.

» Read more

A Pause for Patient Safety

New Process Succeeds in Tests, Will Expand Housewide

Sometimes, the best solution is the simplest one. To help prevent the accidental removal of patient tubes and lines, a simple, three-step process, Pause-Clear-Go, has proven so successful that it is being rolled out across the medical center.

» Read more

Congratulations to Leadership Program Graduates

Congratulations to the more than 20 physicians who graduated this month from the Cedars-Sinai Medical Staff Leadership Development Program. The program is aimed at training and motivating future leaders of the medical staff.

» Read more

CS-Link Tip: Borrowing SmartPhrases

This week's tip is from Jonas Green, MD, the associate medical director of Clinical Effectiveness at the Cedars-Sinai Medical Care Foundation. You can borrow other people's SmartPhrases in CS-Link™. This is very useful when you know a colleague has expertise in an area or has written some phrases covering a procedure or topic.

» 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. Kicking off the first Cedars-Sinai Founders Day, the debate will convene for its 11th year on Friday, June 6, at 8 a.m. in Harvey Morse Auditorium.



» 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

Lupus, Antiphospholipid Work-Ups Offered

Two new panels available at Cedars-Sinai integrate the current International Society for Thrombosis and Hemostasis consensus criteria for evaluation of lupus anticoagulant and antiphospholipid syndrome.

» Read more

$8 Million NIH Grant to Fund Trial of Stroke Drug

Cedars-Sinai stroke intervention researchers have been informed that the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health, will award an $8 million grant to fund a multicenter Phase II clinical trial of an experimental drug for stroke.

» Read more

Replacement of Nurse Call System Closes 5 SW

To help further enrich the health, safety and satisfaction of our patients, Cedars-Sinai will replace its current nurse call system with the Responder 5 Nurse Call System on 5 Southwest. In addition, the flooring will be replaced in the entire unit as part of renovation efforts. To complete this work, 5 Southwest is closed for the next three weeks.

» Read more

MEC Morning After Report

Highlights of the May 5 meeting of the Medical Executive Committee are summarized in the PDF link below.

Morning After Report - May 2014 (PDF)

A Pause for Patient Safety

New Process Succeeds in Tests, Will Expand Housewide

Sometimes, the best solution is the simplest one. To help prevent the accidental removal of patient tubes and lines, a simple, three-step process, Pause-Clear-Go, has proven so successful that it is being rolled out across the medical center.

"After surgery, patients have so many lines and drains in them that it's easy to overlook one during transport," said Christine Chuey, RN, CN III. "In 3 OR, we were experiencing numerous incidents of lines and drains that were almost pulled out but were caught at the last minute. We decided to find a way to prevent these near misses in the O.R."

Components of Pause-Clear-Go

  • Pause — the primary care provider calls out "Pause," and everyone stops
  • Clear — the assisting care provider calls out "Lines … Drains … Airway" and the primary care provider answers "All clear"
  • Go — either the primary care provider or assisting provider calls out "Go" to signal that the patient is safe to reposition, turn or transfer

The Medical Intensive Care Unit (MICU) team on 7 Saperstein was experiencing the same problem, which can result in unintended consequences not only for patients, but for their families and care providers. When lines are accidentally pulled out, it can interrupt treatment, cause complications and create distrust between patients and healthcare teams.

The issue simultaneously attracted the attention of two separate unit-based safety project teams: SCORE (Safe Care in the O.R. Every time) and Normalized Deviation.

SCORE is a grass-roots effort that enables front-line surgical staff and physicians to address safety concerns in the O.R. SCORE team leaders include Bruce Gewertz, MD, chair of Surgery and vice president of Interventional Services, Julian Gold, MD, co-chair of Anesthesiology, Bryan Croft, vice president of Service Line Operations, and Jan Decker, RN, director of O.R./Anesthesiology/Surgery Center.

The Normalized Deviation team, led by Neil Romanoff, MD, vice president of Medical Affairs and associate chief medical officer, addresses the small, continuously occurring defects that eventually become "normalized" as part of daily routine.

"In the ICU, the problem with lines usually occurs during repositioning of the patient, because critically ill patients have so many lines attached to them," said Adolfo Famas, RN, assistant nurse manager on 7 Saperstein. "We had an average of one pulled line each month that was related to the repositioning, turning and transferring of patients. Although that may sound like a small number, it's important to us that we ensure it never happens to a single patient."

To address the issue, the SCORE and Normalized Deviation teams began testing the Pause-Clear-Go time-out system prior to moving any patient.

"Following implementation, O.R. staff members have reported a decreased near-miss rate from 64 percent to 28 percent," said Ann Gilligan, RN, MSN-BC, assistant nurse manager in the O.R. "In addition, the MICU has not experienced a single incident since September 2013. As we continue to implement this system housewide, we anticipate that the number of near misses will decline even further."

Congratulations to Leadership Program Graduates

Congratulations to the more than 20 physicians who graduated this month from the Cedars-Sinai Medical Staff Leadership Development Program.

The program is aimed at training and motivating future leaders of the medical staff.

Participants attended a series of lectures and joined an off-site weekend retreat. In addition, each participant managed a performance improvement project that will impact their patients and practice, allowing hands-on use of the tools and concepts introduced in the program.

The 2014-15 Medical Staff Leadership Development Program will start in September. A call for nominations will be issued soon. Participants are nominated by department chairs and members of the Medical Executive Committee.

Medical Staff Leadership Development Program, Class of 2013-14 graduates

First row (from left): Anuj Desai, MD, Pediatrics; Paola Aghajanian, MD, Obstetrics and Gynecology; Michelle Pearl, MD, Emergency Medicine; Sandra Thomasian, MD, Emergency Medicine; Melissa Wong, MD, Obstetrics and Gynecology; Mona Sabeti, MD, General Internal Medicine

Second row (from left): Swamy Venuturupalli, MD, General Internal Medicine/Rheumatology; Anat Ben-Shlomo, MD, General Internal Medicine/Endocrinology; Afshin Afrashteh, MD, General Internal Medicine/Inpatient Specialty Program; Mark Choi, MD, General Internal Medicine/Inpatient Specialty Program; Jennifer Anger, MD, Urology; Gil Melmed, MD, program co-chair; Richard Tuli, MD, Radiation Oncology

Third row (from left): Joel Geiderman, MD, co-chair, Emergency Medicine; Sam Torbati, MD, co-chair, Emergency Medicine; Shaun Miller, MD, program co-chair; Joseph Giaconi, MD, Imaging; Bahman Shamloo, MD, Anesthesiology; Rishi Gupta, MD, General Internal Medicine/Palliative Care; Arash Asher, MD, Physical Medicine and Rehabilitation

Not pictured: Farin Amersi, MD, Surgery; David Choi, MD, Anesthesiology; Ryan DellaMaggiora, MD, General Internal Medicine/Inpatient Specialty Program; Karyn Eilber, MD, Urology; Maha Guindi, MD, Pathology and Laboratory Medicine; Rebecca Hedrick, MD, Psychiatry; Scott Karlan, MD, program co-chair; Jon Kea, MD, General Internal Medicine/Inpatient Specialty Program; Amanda Ruiz, MD, Psychiatry

CS-Link Tip: Borrowing SmartPhrases

This week's tip is from Jonas Green, MD, the associate medical director of Clinical Effectiveness at the Cedars-Sinai Medical Care Foundation.

You can borrow other people's SmartPhrases in CS-Link™. This is very useful when you know a colleague has expertise in an area or has written some phrases covering a procedure or topic.

Go to the Epic button and open your MySmartPhrase tools. Then use the Open button to open another user's phrase file. From there, you can use the center tab and add yourself to that phrase's list of users.

The link below will take you to a more detailed description at CS-Link Central.

Remember, you can schedule physician efficiency training at your office by emailing Alex Bram at alex.bram@cshs.org or Lisa Masson at lisa.masson@cshs.org.

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

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 inaugural Cedars-Sinai Founders Day (see story below).

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.


Cedars-Sinai's First Founders Day

The daylong Founders Day celebration on Friday, June 6, will commemorate the opening of Cedars-Sinai on June 6, 1976.

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

Making its debut on Founders Day will be an exhibit tracing the growth of Cedars-Sinai from its first days as the Kaspare Cohn Hospital — founded in 1902 — to today's medical center. The exhibit, a project of the Cedars-Sinai Historical Conservancy, will be in the hallway outside the Medical Library.

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.

Lupus, Antiphospholipid Work-Ups Offered

Two new panels available at Cedars-Sinai integrate the current International Society for Thrombosis and Hemostasis consensus criteria for evaluation of lupus anticoagulant (L.A.) and antiphospholipid syndrome.

Lupus Anticoagulant Panel (2 light blue top tubes)

Indication: Exploration of an unexplained prolonged aPTT in a patient who is not bleeding

Includes:

  • Screening dRVVT
  • Screening PTT-LA
  • Thrombin time
  • PT
  • Interpretation

Reflex testing (if indicated): dRVVT mixing study; confirmatory dRVVT; PTT-L.A. mixing study; confirmatory Staclot-L.A.*

Methodology: L.A. testing consists of a panel of assays designed to optimize diagnostic potential. Screening steps are performed first for two phospholipid-dependent assays. If the screen is positive in one or both, then mixing steps are performed for the respective assay to assess inhibitor effect; if inhibitor effect is demonstrated, its phospholipid dependence is evaluated in the confirmatory step.

Limitations: L.A.s are heterogenous in terms of antigenic recognition. aPTT reagents are variable in their phospholipid composition. Variability in the ability to detect L.A.s exists between different assays and between different labs. Consequently, no single assay allows detection of all L.A.s.

Interfering substances: Coumadin®, heparin, direct thrombin inhibitors, direct FXa inhibitors

*Note: Staclot-L.A. (also known as L.A. by hexagonal) is a confirmatory assay for L.A. that should only be evaluated when the screening PTT-LA is positive. It is not available to order separately from the Lupus Anticoagulant Panel.

Antiphospholipid Syndrome Panel (2 light blue top tubes, 1 red top tube)

Indication: Suspicion for antiphospholipid syndrome in patients with an elevated aPTT and history of arterial or venous thrombosis and/or recurrent fetal loss; systemic lupus erythematosus

Includes:

  • Lupus Anticoagulant Panel (see above)
  • Anti-cardiolipin IgG, IgM, IgA antibodies
  • Anti-β2GPI IgG, IgM, IgA antibodies
  • Interpretation

Reflex testing (if indicated): dRVVT mixing study; confirmatory dRVVT; PTT-LA mixing study; confirmatory Staclot-L.A.

Methodology: See Lupus Anticoagulant Panel above. An enzyme-linked immunosorbent assay is performed for antiphospholipid (anti-cardiolipin and anti-β2GPI) antibody testing.

Limitations: See Lupus Anticoagulant Panel above. False positive syphilis tests (RPR, VDRL) can occur in patients with anti-cardiolipin antibodies and vice versa.

Interfering substances: See Lupus Anticoagulant Panel above.

Patient Preparation

Anticoagulation therapy will affect L.A. assay results:

  • Coumadin and direct Factor Xa inhibitors severely affect the PT and dRVVT assays.
  • Unfractionated heparin and direct thrombin inhibitors severely affect the aPTT and PTT-LA assays. Most dRVVT reagents contain a neutralizing agent for therapeutic levels of UFH.
  • For reliable L.A. interpretation, samples should not be taken from patients receiving anticoagulation.

Reporting

The quantitative results will be accompanied by an interpretation of assay results. For the three-step L.A. testing, appropriate sequential testing with an interpretive report will follow.

$8 Million NIH Grant to Fund Trial of Stroke Drug

Cedars-Sinai stroke intervention researchers have been informed that the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health, will award an $8 million grant to fund a multicenter Phase II clinical trial of an experimental drug for stroke.

The drug, 3K3A-APC, will be used in combination with recombinant tissue plasminogen activator, or rtPA — the "clot-busting" drug currently approved to treat ischemic strokes shortly after onset. In laboratory rodent studies, 3K3A-APC, used in combination with rtPA, had a protective effect on the lining of blood vessels, eliminating hemorrhaging, reducing brain damage and improving animals' mobility after stroke. The new drug has completed a Phase I trial in 64 healthy volunteers to assess safety and dosing levels.

Ischemic strokes block arteries, depriving the brain of oxygen. The existing clot-buster, rtPA, may restore blood flow and often reverse the effects of a stroke if administered within three hours after symptoms begin. The drug, however, increases risk of internal bleeding in some patients, which can have brain-injuring and other harmful effects.

"Stroke is the fourth-leading cause of death in the United States and a leading cause of disability, often leaving people to live out their lives with limited cognitive and physical skills," said Patrick Lyden, MD, chair of Cedars-Sinai's Department of Neurology, director of the Stroke Program and the Carmen and Louis Warschaw Chair in Neurology. "When patients receive rtPA within the three-hour time frame, the beneficial effects are often dramatic. But the drug is not without its limitations and potential side effects. Our objective in this and other studies is to spare more lives and livelihoods by making treatments more effective with fewer risks."

The Phase II study will evaluate safety, tolerability and activity of 3K3A-APC when given after rtPA in patients who have experienced moderately severe ischemic stroke. The drug will be given intravenously as a 15-minute infusion every 12 hours for up to five treatments, and four dose levels will be evaluated. About 100 participants, ages 18 to 80, will be followed for 90 days.

APC — activated protein C — is a naturally occurring enzyme in the body that reduces inflammation, protects against cell death and acts as a blood thinner to prevent clotting. The drug 3K3A-APC is a synthesized and slightly modified protein that maintains APC's cell-protective and anti-inflammatory benefits while reducing anticlotting activity. It is designed, therefore, to protect brain cells and cerebral blood vessels while reducing the risk of treatment-related bleeding.

The clinical trial grant was awarded to Lyden, the study's principal investigator. He also was principal investigator of the Phase I trial and a major contributor to the clinical trial leading to Food and Drug Administration approval in 1996 of rtPA, still the only proven and approved drug for stroke treatment.

The award is in conjunction with a NeuroNEXT Infrastructure Resource Access award to ZZ Biotech LLC, the company developing 3K3A-APC. Kent Pryor, PhD, the company's chief operating officer, will be the principal investigator for this aspect of the study. ZZ Biotech also will enlist the collaboration of NeuroNEXT, a research network funded by the National Institute of Neurological Disorders and Stroke.

The institute created NeuroNEXT — the Network for Excellence in Neuroscience Clinical Trials — to increase its ability to explore promising treatments by partnering with academia, private foundations and industry. With this support, the researchers will have access to the NeuroNEXT Clinical Coordinating Center at Massachusetts General Hospital and the Data Coordinating Center at the University of Iowa. The University of Rochester in New York will provide a central laboratory, and about 15 NeuroNEXT centers will participate in the study.

The new drug originated in the laboratory of John Griffin, PhD, professor in the Department of Molecular and Experimental Medicine at the Scripps Research Institute, which licensed development rights to ZZ Biotech.

Berislav Zlokovic will be a co-investigator of the Phase II trial. Zlokovic is director of the Zilkha Neurogenetic Institute, professor and chair of the Department of Physiology and Biophysics at Keck School of Medicine at USC, and scientific founder of ZZ Biotech.

ZZ Biotech is a company developing APC and related products for stroke and other neurological disorders. Griffin is a member of ZZ Biotech's scientific advisory board, and Lyden is a consultant.

The title of the study is "ZZ-3K3A-201: A multi-center, Phase 2 study using a continual reassessment method to determine the safety and tolerability of 3K3A-APC, a recombinant variant of human activated protein C (APC), in combination with tissue plasminogen activator (tPA) in moderately severe acute hemispheric ischemic stroke."

Replacement of Nurse Call System Closes 5 SW

To help further enrich the health, safety and satisfaction of our patients, Cedars-Sinai will replace its current nurse call system with the Responder 5 Nurse Call System on 5 Southwest. The new system advances nurses' ability to monitor a variety of parameters and provides tools for real-time reporting and extractable data.

In addition, the flooring will be replaced in the entire unit as part of renovation efforts.

To complete this work, 5 Southwest is closed for the next three weeks. The closure began Wednesday, May 7. Medical patients routinely admitted and transferred to 5 Southwest will be placed in any available medical beds.

Patient rooms 5925, 5927, 5929 and 5931 — negative-pressure rooms — will be affected by this closure, and patients requiring negative-pressure rooms will be placed in other available negative-pressure rooms.

The unit is expected to reopen May 30, pending inspection, permission to reopen and housewide census.

If you have any questions regarding your patients or the work being performed, please contact Vice President and Chief Nursing Officer Linda Burnes Bolton, DrPH, RN, FAAN, at 310-423-5191 or burnesbolton@cshs.org, or Peachy Hain, RN, director of Medical, Surgical and Rehabilitation Nursing, at 310-423-6747 or peachy.hain@cshs.org.