Cedars-Sinai Medical Center

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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF March 27, 2015 | Archived Issues

Recognition for Arena, Charlton, Jones, Karlan, Spiegel

Elizabeth A. Arena, MD, has been awarded board certification in complex general surgical oncology, Timothy P. Charlton, MD, represented the American Academy of Orthopaedic Surgeons this month in Washington, Heather Jones, MD, has received a grant from the National Institutes of Health for lung research, Beth Y. Karlan, MD, will receive the 2015 Distinguished Service Award from the Society of Gynecologic Oncology, and Brennan Spiegel, MD, MSHS, has been named co-editor-in-chief of The American Journal of Gastroenterology.

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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 - March 2015 (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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Clinical Documentation Integrity Course Set

Participants Can Earn Two Continuing Medical Education Credits

Members of the medical staff can take a "Clinical Documentation Integrity Power Course for Physicians" that will meet the first Tuesday of each month from April 7-Dec. 1. Sessions will take place from 3:30-6:30 p.m. in various locations. Participants need to attend just one session. Two continuing medical education credits will be available.

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CS-Link Tip: Blood Administration Orders Change

This week's CS-Link™ tip comes from Chief of Staff Chris Ng, MD. Two enhancements to blood administration orders and panels in CS-Link went live on March 24.

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Here Is Your Chance to Honor a Deserving Nurse

Nomination Deadline for Maggie Stempson-Carter Award Is March 27

Online nominations for the 2015 Maggie Stempson-Carter Excellence in Caring Award for eligible nurses have been extended. Nominations will be accepted through Friday, March 27. This annual award is given on behalf of the medical staff to a Cedars-Sinai nurse who exemplifies professionalism, clinical excellence and caring.

» Read more

Cedars-Sinai Improves Professorial Structure

Workshops on Enhancements Scheduled for March 30-31

The Cedars-Sinai professorial structure has been enhanced. These changes will better recognize individuals who make sustained and significant contributions to clinical scholarship and important contributions to collaborative research projects. Workshops on the changes will take place March 30 and 31, from noon-1 p.m. in the Advanced Health Sciences Pavilion.

» Read more

Topics Sought for Morgenstern Debate

The Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition committee is soliciting suggestions for a topic for this annual event. The debate will convene for its 12th year on Friday, June 5, at 8 a.m. in Harvey Morse Auditorium.

 

» Read more

Cardiology Leader Cribier to Receive Corday Prize

The Eliot Corday, MD, International Prize in Heart Research will be presented to Alain Cribier, MD, (pictured at right) emeritus professor at the University of Rouen, France. The ceremony will take place Tuesday, April 7, at 4 p.m. in Harvey Morse Auditorium.

 

» Read more

Simulated Surgery Has Real Teamwork at Its Heart

For the team working on the surgical repair of a ventricular septal defect in the Cedars-Sinai Women's Guild Simulation Center for Advanced Clinical Skills, the focus was on the infant "patient" — a life-size, computer-controlled mannequin. But no matter how technically dazzling the mannequin was, the surgical team from the Guerin Family Congenital Heart Program approached it simply as a tool for reaching a crucial goal: to improve patient safety by working as a seamless unit.

» Read more

Gut Bacteria May Limit Effect of Bariatric Surgery

Some patients do not experience the optimal weight loss from bariatric surgery, and the cause may be a specific methane-producing organism in the gastrointestinal tract, according to new research by Ruchi Mathur, MD, director of the Cedars-Sinai Anna and Max Webb and Family Diabetes Outpatient Treatment and Education Center.
 

» Read more

P & T Approvals, FDA Warning About Sofosbuvir

Pharmacy Focus

See highlights of the February meeting of the Pharmacy and Therapeutics Committee. Also, the U.S. Food and Drug Administration has issued a warning about hepatitis C drugs containing sofosbuvir.

» Read more

Coming This Summer: Fireworks, Sand 'N' Snore

Summer has a couple of treats in store for medical staff members and their families: Independence Day fireworks and Smokey Robinson at the Hollywood Bowl on July 2, and Sand 'N' Snore on Sept. 11.
 

» Read more

Clinical Documentation Integrity Course Set

Members of the medical staff can take a "Clinical Documentation Integrity Power Course for Physicians" that will meet the first Tuesday of each month from April 7-Dec. 1. Sessions will take place from 3:30-6:30 p.m. in various locations. Participants need to attend just one session.

Under the Affordable Care Act, physicians will have to justify treatments and demonstrate satisfactory quality outcomes. Clinical documentation therefore will need to be accurate and timely and to reflect the scope of services provided.

Objectives of the course:

  • Explain the role of the Clinical Documentation Integrity Department at Cedars-Sinai
  • Discuss how hospitals and physicians are rated
  • Explore the DRG system and how documentation affects profiles
  • Understand the interplay among SOI, ROM, LOS and reimbursement
  • Compare ICD-9 and ICD-10 documentation requirements
  • Compare Cedars-Sinai’s score to those of similar hospitals
  • Learn definitions for common diagnoses
  • Recognize documentation that is vague and nonspecific
  • Identify documentation strategies to reflect the true severity of illness of the patient

Two continuing medical education credits will be available.

For more information, call Clinical Documentation Integrity at 310-423-3052.

CDI Power Course for Physicians (PDF)

CS-Link Tip: Blood Administration Orders Change

This week's CS-Link™ tip comes from Chief of Staff Chris Ng, MD. Two enhancements to blood administration orders and panels in CS-Link went live on March 24:

  • Blood administration orders will have defaulted times that can be changed as needed.
  • "0.9 percent normal saline continuous IV infusion PRN for transfusion reaction" will be added to the transfusion panel and will fall off in 12 hours if not used. This allows nurses to provide normal saline at a To Keep Open rate if the patient has a transfusion reaction and does not have other fluid orders.

Cedars-Sinai blood administration policy states that the physician must order a duration time for blood administration, in accordance with California’s defined nursing scope of practice.

The defaults for each blood product order will be based on the product and population, as detailed in the table below. Stem cells do not yet have a defaulted duration.

Blood ProductDefaulted Duration
pRBCs adults3 hours (ED: 2 hours)
pRBCs pediatrics and neonatesNo default
Platelets adult1 hour
Platelets peds1 hour
Plasma adults1 hour
Plasma peds1 hour
Granulocytes adults3 hours
Granulocytes peds3 hours
Cryoprecipitate (Factor VIII) adults15 minutes
Cryo peds30 minutes
Cryo neonates2 hours
Hematopoietic stem cellsNo default

For more information, along with screen shots illustrating the changes, see this PDF in CS-Link Central.

You can schedule a training session with Lisa Masson, MD, (lisa.masson@cshs.org) or Alex Bram (alex.bram@cshs.org).

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

Here Is Your Chance to Honor a Deserving Nurse

Nominations for Maggie Stempson-Carter Award Is March 27

Online nominations for the 2015 Maggie Stempson-Carter Excellence in Caring Award for eligible nurses have been extended. Nominations will be accepted through Friday, March 27.

This annual award is given on behalf of the medical staff to a Cedars-Sinai nurse who exemplifies professionalism, clinical excellence and caring. Originally known as the Excellence in Caring Award, it was renamed in 2005 in honor of the late Maggie Stempson-Carter, RN, who received the award in 2004.

Click here to submit a nomination online. Only medical staff members may submit nominations.

The award recipient will be selected by the Excellence in Caring Award Medical Staff Selection Committee and will be honored at the Nurses Week awards ceremony Wednesday, May 13, at 1 p.m. in Harvey Morse Auditorium.

If you submitted a nomination last year and would like your nominee to be considered for this year's award, please contact Chris Ng, MD, chief of staff and co-chair of the MD/RN Collaborative, at chris.ng@cshs.org.

Cedars-Sinai Improves Professorial Structure

The Cedars-Sinai professorial structure has been enhanced. These changes will better recognize individuals who make sustained and significant contributions to clinical scholarship and important contributions to collaborative research projects.

The research-based Professorial Series and the clinical-educator-based Clinical Professorial Series have been restructured into three tracks:

  • Physician/PhD investigator: requiring high-quality basic or translational research, and extramural, peer-reviewed federal or national funding
  • Clinical scholar: requiring significant clinical scholarship exemplified by impactful publications, innovative clinical trials programs, educational outcomes research or creation of innovative biotechnologies
  • Clinical educator: requiring documentation of high-quality clinical service and exemplary teaching and educational leadership

Academic Human Resources is offering workshops to provide administrators and faculty with the opportunity to learn more about these enhancements. Workshops are scheduled for:

  • Monday, March 30, noon-1 p.m., Advanced Health Sciences Pavilion, PEC 8
  • Tuesday, March 31, noon-1 p.m., Advanced Health Sciences Pavilion, PEC 1

For additional information, please see the Academic Human Resources site on the Intranet.

To read the full memo about this change from Shlomo Melmed, MD, senior vice president of Academic Affairs and dean of the medical faculty, and Bruce Gewertz, MD, surgeon-in-chief, chair of the Department of Surgery, vice president for Interventional Services and vice dean of Academic Affairs, please click the PDF link below.

Cedars-Sinai Professorial Structure Enhancements (PDF)

Topics Sought for Morgenstern Debate

Leon Morgenstern, MD, was the founding director of surgery for Cedars-Sinai. He died in 2012.

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

The debate will convene for its 12th year on Friday, June 5, at 8 a.m. in Harvey Morse Auditorium.

The topic must be timely and controversial. It must appeal to a cross section of the medical center. Send suggestions to Leo Gordon, MD, at leo.gordon@cshs.org. Surgical residents interested in participating in the debate should contact Dr. Gordon.

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

Cardiology Leader Cribier to Receive Corday Prize

Alain Cribier, MD

The Eliot Corday, MD, International Prize in Heart Research will be presented to Alain Cribier, MD, emeritus professor at the University of Rouen, France. The ceremony will take place Tuesday, April 7, at 4 p.m. in Harvey Morse Auditorium.

The prize honors a physician or scientist who has conducted groundbreaking research leading to fundamental changes in the practice of cardiology or cardiac surgery.

For 20 years, Cribier has been chief of Cardiology at Hospital Charles Nicolle at the University of Rouen. He became widely recognized for having performed the first balloon aortic valvuloplasty for the treatment of calcific aortic stenosis in 1985, the first mitral commissurotomy with a reusable metallic device in 1996, and after 15 years of research, the first nonsurgical implantation of an aortic valve prosthesis in 2002.

The latter has become a breakthrough technology for patients who would be put at high risk by conventional surgery. More than 200,000 patients worldwide have been treated using the technique.

To attend the presentation, RSVP to Matthew Karimi-Pouia at 323-866-6231 or matthew.karimi-pouia@cshs.org.

Simulated Surgery Has Real Teamwork at Its Heart

The "patient" in the simulation was a life-size, computer-controlled mannequin.

For the team working on the surgical repair of a ventricular septal defect in the Cedars-Sinai Women's Guild Simulation Center for Advanced Clinical Skills, the focus was on the tiny "patient."

The infant was a life-size, computer-controlled mannequin, anatomically correct from its synthetic skin (complete with fat and fascia planes) to its articulated joints, sculpted bones, and pliable muscles and tendons; and from its respiratory system that "breathed" to its circulatory system that maintained blood pressure and pumped ersatz blood. The mannequin's heart had holes between its upper chambers, and another between its lower chambers (atrial and ventricular septal defects).

But no matter how technically dazzling the mannequin was, the surgical team from the Guerin Family Congenital Heart Program at the Cedars-Sinai Heart Institute approached it simply as a tool for reaching a crucial goal: to improve patient safety in the complex and fast-paced environment of cardiac surgery by working as a seamless unit.

"The challenge is that we are all exceptionally well-trained as individual practitioners, but too often the integration of the individual into team delivery of healthcare is poorly done," said Alistair Phillips, MD, co-director of the Congenital Heart Program and chief of the division of Congenital Heart Surgery at Cedars-Sinai.

"The beauty of the sim center is that it has real, live information that is communicated to us exactly as we would see it in the O.R.," said Alistair Phillips, MD (left).

"We all agree that the No. 1 focus is a healthy child at the end of surgery," Phillips said. "Along the road to getting there, though, we each have different goals that we personally think are the most important."

According to a report by the American Heart Association published in August 2013, most preventable surgical errors in cardiac operating rooms arose not from failures in technical skills but from breakdowns in teamwork and communication.

To address these potential communication failures, and to give the Congenital Heart Program's surgical team a real-time, high-stakes arena in which to practice, Phillips turned to the Women's Guild Simulation Center, commonly referred to as the sim center.

The sim center includes two operating rooms, an intensive care unit, an Ob-Gyn room, a trauma bay and a neonatal intensive care unit. All are fully functioning and, when needed, can be pressed into immediate service. Each environment is connected to one of two control rooms, where technicians use computers to create and control an infinite range of medical scenarios for teaching or practice purposes.

Phillips designed a simulation in which an infant exhibiting "failure to thrive" symptoms undergoes surgery for repair of a large ventricular septal defect. Working with Russell Metcalfe Smith, the sim center's manager, Phillips crafted a meticulous scenario for the surgery and a subsequent scenario for the Congenital Cardiac Intensive Care Unit.

"We had a prototype congenital heart baby designed specifically for the scenario, which makes it that much more immersive for the people in the O.R.," Metcalfe Smith said. "It takes a significant amount of time for a team to learn to function together, which is why simulations like this need to take place on a regular basis."

Phillips' approach to honing the congenital cardiac team's interpersonal skills starts with erasing traditional hierarchical markers. To his team he is "Alistair," not "Dr. Phillips," a distinction he believes makes it easier for team members to participate fully in discussions and critiques.

Each simulation begins with a "pre-brief," a document that lays out each participant's goals for the surgery, the order in which the surgery will proceed, and the after-care duties of nursing staff.

"We start with a team huddle," in which the team members state the goal and the procedures by which the goal will be met, Phillips said.

In the simulation with the infant mannequin, the goal was the closure of the septal defect with a Gore-Tex patch, the surgical procedure was a sternotomy, and the main concern was ensuring that all holes (known medically as shunts) were closed to control postoperative bleeding and improve heart function. After the anesthesiologist, perfusionist, O.R. nursing team and ICU teams stated their goals and procedures, the team was ready to begin.

Each environment in the sim center is connected to a control room, where technicians use computers to create and control an infinite range of medical scenarios for teaching or practice purposes.

In the sim center's operating room, with team members scrubbed in and gowned, the surgery proceeded in real time. As the mannequin's heart was stopped and circulatory function moved to bypass, the perfusionist quietly answered queries about heart rate, blood pressure and oxygen saturation.

Meanwhile, on the other side of the operating room's large window, Metcalfe Smith and his team huddled over a bank of keyboards, monitors and readouts.

Planning for this simulation took a few weeks. Setting up the operating room, which included programming the scenario, took 72 hours. As the operation proceeded, the sim center team made sure that each step of the surgery, including prearranged complications for the O.R. team to react to, was executed as planned.

"What makes this special is the collection of professionals running through the sequence, training together to perfect the surgical experience," Metcalfe Smith said. "When you're all training together, when you're continually working toward a common goal, then you can improve communication, which has a significant impact on safety and outcomes."

After surgery, the patient was prepared for transport and then transferred to the ICU, where the team handoff is conducted. The handoff is a crucial part of the medical care transition — the operating room team has to efficiently and accurately communicate what is going on with the patient. Cedars-Sinai has found that an enhanced handoff can dramatically reduce medical care issue during the first 24 hours after surgery, improving patient safety.

In the ICU, the team was tested with changing clinical scenarios that allow for very unusual but potentially very harmful clinical events.

After the procedure, Phillips and the O.R. and ICU teams met in a conference room for a step he considers as important as the surgery itself — the debriefing. Seated in a circle, team members asked and answered questions and raised issues they encountered during the simulation.

The general consensus from the surgical team: The simulation went well.

Discussion included technical glitches for the sim center team to deal with before the next simulation, and ways the surgical team could improve. From seemingly small changes, such as moving a medical device a few inches, to refining the information to offer when asked a direct question, the Congenital Heart Program's surgical team honed its approach.

In congenital heart surgery, where at any one time 10 people may be taking care of a patient, the team trumps the individual, Phillips said.

"After the scenario, you can adjust where people stand, change the position of the bypass machine, adjust where the scrub nurse stands in relation to the surgeon, and you get to see how each change affects communication," Phillips said. "The beauty of the sim center is that it has real, live information that is communicated to us exactly as we would see it in the O.R., and we can, in the safest way, review how it affects the patient."

The goal of the simulation was to improve patient safety through better teamwork.

Gut Bacteria May Limit Effect of Bariatric Surgery

The benefits of weight-loss surgery, along with a treatment plan that includes exercise and dietary changes, are well documented. In addition to a significant decrease in body mass, many patients find their risk factors for heart disease are drastically lowered and blood sugar regulation is improved for those with Type 2 diabetes.

Ruchi Mathur, MD

Some patients, however, do not experience the optimal weight loss from bariatric surgery. The presence of a specific methane gas-producing organism in the gastrointestinal tract may account for a decrease in optimal weight loss, according to new research by Ruchi Mathur, MD, director of the Cedars-Sinai Anna and Max Webb and Family Diabetes Outpatient Treatment and Education Center.

"We looked at 156 obese adults who either had Roux-en-Y bypass surgery or received a gastric sleeve. Four months after surgery, we gave them a breath test, which provides a way of measuring gases produced by microbes in the gut," Mathur said. "We found that those whose breath test revealed higher concentrations of both methane and hydrogen were the ones who had the lowest percentage of weight loss and lowest reduction in BMI (body mass index) when compared to others in the study."

The methane-producing microorganism methanobrevibacter smithii is the biggest maker of methane in the gut, Mathur said, and it may be the culprit thwarting significant weight loss in bariatric patients. Mathur and her colleagues are conducting further studies to explore the role this organism plays in human metabolism.

While that research continues, bariatric patients may still have options to improve weight loss after surgery.

"Identifying individuals with this pattern of intestinal gas production may allow for interventions through diet. In the future, there may be therapeutic drugs that can improve a patient's post-surgical course and help them achieve optimal weight loss," Mathur said.

The study, "Intestinal Methane Production is Associated with Decreased Weight Loss Following Bariatric Surgery," was done in collaboration with the Mayo Clinic. Mathur presented the paper this month at the 97th annual meeting of the Endocrine Society in San Diego.

P & T Approvals, FDA Warning About Sofosbuvir

Pharmacy Focus

Highlights of the February meeting of the Pharmacy and Therapeutics Committee are summarized in the PDF link below. Also, the U.S. Food and Drug Administration has issued a warning about hepatitis C drugs containing sofosbuvir.

P & T Approvals - February 2015 (PDF)

FDA: Sofosbuvir/Amiodarone Combination Can Lead to Bradycardia

The FDA is recommending that drugs containing sofosbuvir, such as Sovaldi and Harvona, not be prescribed concurrently with the antiarrhythmic drug amiodarone. Bradycardia — serious slowing of the heart rate — can occur when the drugs are taken together, according to the FDA. If alternative treatment options are unavailable, the FDA recommends heart monitoring in an inpatient hospital setting for the first 48 hours. Subsequently, monitoring in a doctor’s office or self-monitoring of the heart rate should take place every day through at least the first two weeks of treatment.

For more information, click here.

Coming This Summer: Fireworks, Sand 'N' Snore

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

Hollywood Bowl Fireworks — July 2

Celebrate Independence Day at the Hollywood Bowl with fireworks and music by the Hollywood Bowl Orchestra, along with Motown legend Smokey Robinson.

The event on Thursday, July 2, is open to Cedars-Sinai physicians and their immediate family members. Cost is $135 per adult and $65 per child 3-11 years of age.

Valet and Lower Terrace parking passes also are available.

A photo from the 2014 Hollywood Bowl event

Sand 'N' Snore — Sept. 11

The dinner, sleepover and breakfast starts Friday, Sept. 11. Details will be announced.

To reserve a place for either event, contact Cheryl Verne, in the office of Marjorie Santore Besson, at 310-423-2681 or cheryl.verne@cshs.org.