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A BI-WEEKLY PUBLICATION FROM THE CEDARS-SINAI CHIEF OF STAFF March 10, 2017 | Archived Issues

Meetings and Events


Grand Rounds


Upcoming CME Conferences

Click below to view a complete list of all scheduled Continuing Medical Education conferences.

CME Newsletter - March 2017 (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.

Submit your milestones and comments.

Study to Examine Opioid Use, Chronic Pain Patients

Opioid Use and Chronic Pain callout

Cedars-Sinai investigators are gearing up to study the most effective ways for doctors to discuss opioid use with chronic pain patients in an effort to reduce the impact of pain while curbing overuse of these addictive drugs. The research team has received $2 million from the Patient-Centered Outcomes Research Institute to conduct the study, which launches this year.

» Read more

Topics Sought for Morgenstern Debate

Morgenstern

The 14th annual Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition will convene on Friday, June 2. The debate committee is soliciting topics that are timely and relevant to all specialties.



» Read more

With Grant, Biological Pacemakers Closer to Reality

With a new $3 million grant from the National Institutes of Health, Cedars-Sinai Heart Institute investigators are moving closer to their goal of developing a biological pacemaker that can treat patients afflicted with slow heartbeats. The novel, minimally invasive gene therapy turns patients’ normal heart cells into pacemaker cells that regulate heart function — potentially replacing electronic pacemakers one day.

» Read more

Reminder About Antimicrobial Use Guidelines

The Cedars-Sinai Antimicrobial Stewardship Committee publishes specific antimicrobial use guidelines, incorporating current literature and local resistance patterns. Resources include empiric treatment recommendations for frequently encountered bacterial and fungal infections, as well as recommendations for duration of antimicrobial therapy.

» Read more

CS-Link Tip: Switching to Widescreen View

cs-link logo

The visit navigator on CS-Link™ will feature only the widescreen view beginning Sunday, March 12. The widescreen will be the default view in ambulatory encounters, and users will not have the ability to toggle back to the classic view.

» Read more

New Vision for Cedars-Sinai Research Enterprise

brainstorming-session-co-2

The research enterprise at Cedars-Sinai has achieved unprecedented growth in scope, staffing and publications in prestigious journals over the past few years. Its future success depends on meeting new challenges in funding, space and organization. Those were key takeaways from the Academic Affairs Research Retreat 2017, which brought together leaders of Cedars-Sinai's research departments, divisions and institutes for the first time in six years.

» Read more

New Process for Blood Draws Paying Off

It's rare to find a patient who enjoys having blood drawn. Yet it's an experience most patients have to face. Approximately 70 percent of healthcare decisions rely on some component of lab testing, much of which depends on the work of phlebotomists. These trained specialists face a tough challenge: how to ensure patients are satisfied with a service many would rather avoid.

» Read more

Study to Examine Opioid Use, Chronic Pain Patients

Opioid Use and Chronic Pain 480

A new Cedars-Sinai study will use computer alerts to prompt doctors to speak with other patients before renewing opioid prescriptions.

Cedars-Sinai investigators are gearing up to study the most effective ways for doctors to discuss opioid use with chronic pain patients in an effort to reduce the impact of pain while curbing overuse of these addictive drugs.

The research team has received $2 million from the Patient-Centered Outcomes Research Institute to conduct the study, which will launch this year.

The new research effort comes as patients, doctors, law enforcement authorities and others struggle with an opioid overdose epidemic in the U.S. that claimed more than 33,000 lives in 2015, according to the Centers for Disease Control and Prevention. Opioid-related deaths have quadrupled since 1999, driven partly by overdoses from prescription pain relievers in a country where more than 100 million people suffer from chronic pain.

"More people die of drug overdoses in the U.S. than car accidents or guns. This sobering statistic reveals a massive, nationwide epidemic of opioid addiction that is costing lives and money," said Brennan M. Spiegel, MD, director of Cedars-Sinai Health Services Research, who will lead the team. "Our study will test whether we can use the electronic health record to disrupt how pain treatments are discussed and managed between patients and providers, with the goal of reducing inappropriate overuse of opioids."

When aiming to limit opioid use, most studies may rely on prescription claims data to gauge results. The Cedars-Sinai project is different because it also will use patient feedback, which is critical for successful management of chronic pain.

Working with patients, consumer advocates, addiction specialists and primary care providers, the team will spend a year comparing the effectiveness of two established communication strategies used by doctors who treat chronic pain patients. Educational material will be shared with some of the patients prior to office visits, while computer alerts will prompt doctors to speak with other patients before renewing opioid prescriptions.

Investigators will survey all patients one month after their visits to gauge their quality of life, overall health (including pain, fatigue, energy and concentration) and how well communications with their doctors have worked. The study also will capture pain medication use through electronic health records and pharmaceutical claims data. Program direction will be overseen by Michelle S. Keller, MPH.

"Incorporating patients' perspectives into the study design ensures that the findings will be relevant to real people in general medical practices, and not just some highly selected sample," said Itai Danovitch, MD, MBA, chair of the Department of Psychiatry and director of Addiction Psychiatry at Cedars-Sinai. "The focus on assessing quality of life means the study will extend beyond evaluating symptoms and will tell us whether the interventions impact health in a way that patients themselves find meaningful."

The Patient-Centered Outcomes Research Institute is an independent, nonprofit organization authorized by Congress in 2010 to fund research that will provide patients, their caregivers and clinicians with evidence-based information needed to make better-informed healthcare decisions.

Topics Sought for Morgenstern Debate

The 14th annual Dr. Leon Morgenstern Great Debates in Clinical Medicine Resident Competition will convene on Friday, June 2. The debate committee is soliciting topics.

The chosen topic must cut across all specialties and must be of timely importance to the Cedars-Sinai community.

Please send suggestions to Leo Gordon, MD, Morgenstern Debate coordinator, at leo.gordon@cshs.org.

Last year's debate is available for viewing. Contact Gordon for access.

With Grant, Biological Pacemakers Closer to Reality

Eugenio Cingolani, MD

With a new $3 million grant from the National Institutes of Health, Cedars-Sinai Heart Institute investigators are moving closer to their goal of developing a biological pacemaker that can treat patients afflicted with slow heartbeats. The novel, minimally invasive gene therapy turns patients’ normal heart cells into pacemaker cells that regulate heart function — potentially replacing electronic pacemakers one day.

"Although implantable pacemakers have helped save millions of lives since they were invented in the 1960s, biological pacemakers could result in a healthier alternative," said Eugenio Cingolani, MD, the principal investigator in the project and the director of the Cedars-Sinai Heart Institute’s Cardiogenetics Program. "Devices can malfunction or become infected, while biological pacemakers avoid such complications."

Specialized pacemaker cells are found naturally in the heart. This tiny cluster of cells generates electrical activity that spreads throughout the heart in an orderly pattern to create rhythmic muscle contractions — heartbeats. But if pacemaker cells go awry, the heartbeats slow down, causing fainting or even sudden death. Patients with slow heartbeats who are healthy enough to undergo surgery often look to an electronic pacemaker as their only treatment option.

As a practicing cardiac electrophysiologist, Cingolani has first-hand experience with heart rhythm devices and their limitations. He and his team of investigators are working toward delivering a gene directly to a patient’s heart during a minimally invasive catheter-based procedure. The gene would then convert normal heart cells into pacemaker cells that keep the heart beating steadily.

"In 2012, our team was the first to show that we can inject a single gene, called Tbx18, into a regular heart cell and turn that cell into a specialized pacemaker cell," said Eduardo Marbán, MD, PhD, co-principal investigator on the project and director of the Cedars-Sinai Heart Institute. "This new funding will help us complete long-term safety and efficacy data using clinical-grade gene delivery systems, hopefully leading to a clinical trial in which we can test the therapy in selected patients."

If the upcoming safety studies are successful, Cingolani says the biological pacemaker could be tested in patients within five years.

Reminder About Antimicrobial Use Guidelines

The Cedars-Sinai Antimicrobial Stewardship Committee publishes specific antimicrobial use guidelines, incorporating current literature and local resistance patterns. Resources include empiric treatment recommendations for frequently encountered bacterial and fungal infections, as well as recommendations for duration of antimicrobial therapy.

These resources can be accessed through CS-Link™ via Web Activities > Medication Guidelines, or directly from antimicrobial orders, via a reference link found below the drug product.

The guides are available on the Cedars-Sinai intranet.

Assistance with antimicrobial recommendations is available from antimicrobial stewardship pharmacists Monday through Friday, 8 a.m.-5 p.m. The pharmacists can be reached at 310-423-5352.

CS-Link Tip: Switching to Widescreen View

The visit navigator on CS-Link™ will feature only the widescreen view beginning Sunday, March 12.

The widescreen will be the default view in ambulatory encounters, and users will not have the ability to toggle back to the classic view. The move supports a commitment to provider best-practices and the efficiencies gained with using widescreen functionality.

Please report any widescreen issues to groupcs-linkwidescreen@cshs.org.

New Vision for Cedars-Sinai Research Enterprise

Joan August writes down ideas during a brainstorming session

Joan August, vice president of Service Line Operations, writes down ideas during a brainstorming session at the Academic Affairs Research Retreat 2017.

The research enterprise at Cedars-Sinai has achieved unprecedented growth in scope, staffing and publications in prestigious journals over the past few years. Its future success depends on meeting new challenges in funding, space and organization.

Those were key takeaways from the recent Academic Affairs Research Retreat 2017, which brought together leaders of Cedars-Sinai's research departments, divisions and institutes for the first time in six years. Participants reflected on the institution's scientific achievements and debated the best course for the next five years.

In two addresses to the gathering, Shlomo Melmed, MD, executive vice president of Academic Affairs and dean of the medical faculty, recounted Cedars-Sinai's 115-year history and outlined a vision for growth. Noting Cedars-Sinai's dual roles as a hospital and scholarly research center, he said: "No one is like us. Our academic mission transcends all our missions. We are one integrated fabric."

While Cedars-Sinai's scientific enterprise dates at least to the 1940s, powered at that time by an influx of Jewish refugee investigators fleeing from Europe, it "just exploded" starting in 2010, Melmed said. New research departments, institutes and cores devoted to regenerative medicine, neurology, diabetes, imaging, health services and other disciplines were created.

Nicole Leonard

Nicole Leonard, JD, MBA, vice president of Research, outlined space management plans for the enterprise.

In five years, from 2010 to 2015, Cedars-Sinai rose to ninth from 16th among nonuniversity hospitals in total funding from the National Institutes of Health. In 2016, its investigators obtained over $60 million in new federal awards, accounted for $31 million in technology transfer revenue and published more than 1,300 papers in academic journals. Recent studies have appeared in the New England Journal of Medicine, the Journal of the American Medical Association, the Nature and Cell journals and other high-impact publications.

"We're having one of the best years ever in research," said Melmed, a professor of Medicine. But he cautioned the future will bring a serious funding crunch, driven by "a national consensus that we're spending too much on healthcare" and societal reluctance to invest in research and development.

To cope with the new economic climate, the scientific community at Cedars-Sinai must lower the costs of generating knowledge, cultivate new funding and be selective about where it aims to excel, said Melmed. To define the value of research to society, he added, "we need to turn discovery into health" by translating basic science into clinical practice. He cited the Cedars-Sinai Heart Institute as a paradigm for integrating these realms.

In another address, Nicole Leonard, JD, MBA, vice president of Research, described how the meteoric growth of the scientific enterprise is outstripping available space. Noting that Cedars-Sinai is situated on a compact campus surrounded by high-priced real estate, she said, "Now is the time to implement a new space management system." Among the current and planned projects:

  • Advanced Health Sciences Pavilion: reworking the eighth and ninth floors to provide more space for offices, wet laboratories and Comparative Medicine
  • Steven Spielberg Building: converting the freezer room to wet laboratories, converting clinical laboratories to research laboratories and adding a sterile processing research pharmacy
  • Davis Research Building: upgrading the Comparative Medicine infrastructure and accommodating an advanced magnetic resonance imaging system
  • Pacific Design Center in West Hollywood: renting new research space

On the retreat's second day, leaders of Cedars-Sinai's new programs in precision health, health delivery science and bioinformatics and functional genomics shared their work. Attendees also broke into small groups to brainstorm about how to improve the research enterprise, especially in synergy with the health system. A major topic was how to leverage Cedars-Sinai's expanding network of regional affiliates to extend the system's academic vision and clinical trials outreach.

Leonard said her team was working to consolidate and analyze the new initiatives that were discussed at the gathering. Some benefits were immediately apparent from the retreat, which also included a scientific presentation on circadian rhythms by Steve Kay, PhD, director of Convergent Biosciences at the Keck School of Medicine of USC.

"Many of the research leaders said they really appreciated the opportunity to come together in a social way and learn about one another's work," Leonard said.

Shlomo Melmed at Academic Affairs Research Retreat 2017

Shlomo Melmed, MD, executive vice president of Academic Affairs and dean of the medical faculty, speaks with retreat participants.

New Process for Blood Draws Paying Off

It's rare to find a patient who enjoys having blood drawn. Yet it's an experience most patients have to face. Approximately 70 percent of healthcare decisions rely on some component of lab testing, much of which depends on the work of phlebotomists.

These trained specialists face a tough challenge: how to ensure that patients are satisfied with a service many would rather avoid.

Focusing on Patient Satisfaction

That question is important not only to Cedars-Sinai but also to the federal government. The Centers for Medicare and Medicaid Services regularly asks patients to rate their satisfaction with the care they received while in the hospital. Patients fill out surveys that include queries about the quality of hospital-based blood collection.

The answers to these questions bear directly on the work of Laboratory Support Services, which is responsible for about half of all blood drawn at Cedars-Sinai, said associate director Khalil Huballa.

Huballa’s department has sought to better understand patients’ experiences to improve the service its phlebotomists provide. The department decided about two years ago to take a deeper look at its interactions with patients and developed a lab-specific patient questionnaire.

"We came up with our own process that we wanted to participate in ourselves to monitor and see how we're doing," Huballa said.

The effort is paying off.

Before the initiative began, Laboratory Support Services received about 10 Standing Ovations from patients per month. Today, that number is closer to 50.

"We also have had about five of our phlebotomists receive the Circle of Friends recognition, wherein patients donate a gift to the medical center on behalf of that employee because of the services provided," Huballa said.

Identifying Shortfalls

The first step to improving patient care was identifying where the department was falling short. The department randomly selected patients to complete its questionnaire. Patients could give one of five responses that ranged from "poor" to "fabulous" when asked about their experience with phlebotomists.

"We wanted to gauge that patient's experience from the perspective of the process," Huballa said. “We could then take that and make a scale out of it and graph it, so we can see how it was trending for us."

Gaining Patient Feedback With Rounding

Once patients filled out the survey, they were visited by technical managers, team leads from Laboratory Support Services and sometimes staff from Quality Assurance. Rounding is ideally conducted within a few hours of the phlebotomist's visit so that the patient is most likely to recall the experience. Staff often solicited additional feedback from family members who were in the room during a blood draw.

"They all seemed to appreciate it," said Arlette Labostrie, a technical manager with Laboratory Support Services. "We found that when we said we were from the department, and the person who drew your blood this morning reports to me … they could see a direct link that we were aware. I honestly wish we had more time to do this type of work, because the patients seem to appreciate the fact that somebody cares."

Identifying Trends

Once the rounding got underway and survey results were tallied, two common complaints emerged. Patients said phlebotomists often failed to properly explain what they were doing and what to expect while having blood drawn. Patients also said phlebotomists sometimes did a poor job of listening.

"Sometimes our phlebotomists seem to be in a hurry," Labostrie said, noting that staff can feel pressure to complete a certain number of blood draws within an hour. That sense of urgency can lead to rushing and prevent phlebotomists from taking the time to clearly explain to patients what they're doing and why, Labostrie added.

Focus on Communication

Huballa said the department built a targeted approach to improve staff communication skills.

Phlebotomists said they needed more support to respectfully handle patients who seemed to question their expertise. It is not uncommon, for example, for patients to insist their blood be drawn from a particular arm. That can present challenges for trained phlebotomists who may identify the other arm as the best candidate for a good blood draw.

Alicia Santos, a technical manager with Laboratory Support Services, stressed the importance of phlebotomists hearing patients out.

"I tell them to listen to the patient whether they're right or wrong," Santos said. "If they want you to draw from the right arm, look at it. If you can't find a vein, explain to the patient you want to look at the other arm because you can't find a vein on the one they wanted."

The key, Santos added, is for phlebotomists to show they are listening and paying attention to patients’ needs. "At least work with the patient, even though you may end up drawing blood from the vein you wanted in the first place."

Finally, phlebotomists are instructed to ask patients if they can do anything else for them once the blood draw is completed — for example, asking if patients would like the door to their hospital room opened or closed to make them more comfortable.

"That seems to be very powerful," Labostrie said. "All of us have either been in a hospital or have family members in hospitals, and you know how hard it is. So, if somebody comes in — no matter who they are — and offers to do any little thing for you, I think it's much appreciated."

Service Recovery

As part of the Laboratory Support Services initiative, Huballa said the department also decided to adopt the hospitalwide service recovery practice.

"If for some reason during our patient rounding a patient was not happy with the services the phlebotomist provided, or in the event the patient complained to the nurse … we actually have our technical managers or team leads go and visit with the patient," he said.

Ongoing Training

The quest to continually improve patient satisfaction is an integral part of the department's day-to-day discussions.

According to Huballa, much staff training takes place in the form of huddles, one-on-one meetings between supervisors and phlebotomists, and monthly staff meetings, which always include time dedicated to the topic. Sometimes staff will watch videos or other training materials to keep up on issues that are integral to quality patient care.

"It's sort of constant," Huballa said. "We want them to keep in their mind what it is that they do, and how important that role is in taking care of their patients."