sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY October 2013 | Archived Issues

Excellence in a Time of Uncertainty

Message From the Chair

Along with everyone else, Cedars-Sinai is assessing the impact of the many changes occurring in our healthcare delivery system. While the implementation of the Affordable Care Act is just beginning, we are already seeing a number of meaningful alterations in the "business side" of medicine.

» Read more

New Flu Vaccination Policy Announced

Effective Dec. 15, Healthcare Workers Must Be Vaccinated or Wear Masks in Patient Care Areas

To help ensure our patients' safety and to comply with a recent mandate issued by the County of Los Angeles Public Health Officer, Cedars-Sinai is implementing a new influenza vaccination policy.

» Read more

Surgeons Cross Borders to Improve the Lives of Children

Cedars-Sinai pediatric surgeons have been embarking on overseas trips to perform transformative operations on children who have no specialists in their homeland. At the same time, our surgeons mentor the local surgeons with limited operative experience to help raise their skill level and independence.

» Read more

Surgery Chief Addresses Importance of Work Satisfaction

Bruce L. Gewertz, MD, delivered a lecture this month about the importance of surgeons finding satisfaction in their work, telling the annual meeting of the American College of Surgeons that greater fulfillment can keep physicians happier and in the workforce longer.

» Read more

Residents Receive Fellowship Matches

This year's fellowship matches for Cedars-Sinai surgical residents have been announced.

» Read more

Hydroxyethyl Starch Solutions Removed From Formulary

Pharmacy Focus

Due to the risks associated with the use of hydroxyethyl starch (HES) solutions, and the availability of safer and equally efficacious alternatives, the Pharmacy and Therapeutics Committee has approved the removal of Hespan from the formulary.

» Read more

Excellence in a Time of Uncertainty

Message From the Chair

Along with everyone else, Cedars-Sinai is assessing the impact of the many changes occurring in our healthcare delivery system. While the implementation of the Affordable Care Act is just beginning, we are already seeing a number of meaningful alterations in the "business side" of medicine.

In our region, a number of commercial health plans have implemented narrow networks of physician providers, which will predictably restrict patient choice, especially for specialty care. Although Los Angeles has been an outlier to date, other areas of the country have experienced major consolidation of their markets with mergers of previously competitive institutions and accelerated alliances of physicians and hospitals in "full time" arrangements. Finally, hospitals are seeking to enroll potential patients from wide geographic areas in accountable care organizations. Cedars-Sinai is actively engaged in many of these efforts.

It is clear that there will be consequences, some obvious and some unanticipated, associated with such major changes in the single largest sector of the economy. That said, it is important that we not allow this level of uncertainty to distract us from the superb work the Department of Surgery does and the tremendous resources in human capital and facilities we represent.

With the opening of the Advanced Health Sciences Pavilion, we have added nearly 50 percent more capacity to the overall clinical and research space of Cedars-Sinai. The fifth floor operating room is functioning exceptionally well and will be at full capacity in the near term. Plans are being made to build out the fourth floor of AHSP as additional operating room space within the next two years. The new surgical research space (Center for Clinical Innovation) at 825 San Vicente has finally been approved for occupancy and will be a most welcome hub for our research administration and a haven for faculty and residents to pursue academic projects. An opening reception will be held in the very near future to orient members of the department to this facility.

Our residencies, both "new" (orthopedics and urology) and "old" (general surgery and cardiothoracic) continue to attract the best and the brightest. We recently were approved for a new surgical oncology fellowship, one of the few such programs in a hospital not exclusively devoted to cancer. Our residents continue to distinguish themselves as clinical partners in our care of patients as well as future leaders in academic fields. There is hardly a national surgical meeting at which our residents and faculty are not strongly represented on the program, including three resident presentations at this fall's Clinical Congress of the American College of Surgeons (Alexandra Gangi, MD, Scott Short, MD, and Ryan Spurrier, MD).

We have maintained success in our pursuit of the most competitive federal and nonfederal research funding. In particular, our basic science programs in uro-oncology, stem cell biology and molecular imaging have published important papers in high-impact journals in the last year. The stress on the budget of the National Institutes of Health has inspired our scientists to submit even more original grants and successfully cast their net toward the California Institute for Regenerative Medicine and other funding streams.

We continue to develop new clinical programs. With the recruitment of Alistair Phillips, MD, to join with cardiologist Evan Zahn, MD, we have revitalized our congenital heart surgery program. This clinical product line will only enhance the prominence of our internationally known programs in heart transplant and structural heart disease.

In summary, we are experiencing the challenge of "living in interesting times." The next few years will undoubtedly bring some important changes in the underpinnings of academic medical centers. Still, the strength of our clinical volume, the diversity of our private and full-time surgical practitioners and our extraordinary adaptability over the last few years argues strongly for our continued success.

Bruce L. Gewertz, MD
Surgeon-in-Chief
H and S Nichols Endowed Chair in Surgery
Chair, Department of Surgery
Vice President, Interventional Services
Vice Dean, Academic Affairs

New Flu Vaccination Policy Announced

Effective Dec. 15, Healthcare Workers Must Be Vaccinated or Wear Masks in Patient Care Areas

To help ensure our patients' safety and to comply with a recent mandate issued by the County of Los Angeles Public Health Officer, Cedars-Sinai is implementing a new influenza vaccination policy. The policy requires all healthcare workers to receive a flu vaccination or, if they decline vaccination, to wear a surgical mask while working in patient care areas. Enforcement of the policy will begin on Dec. 15.

Health Officer Order on Influenza Vaccination (PDF)

The policy applies to all paid and unpaid employees, including medical staff, contractors, students and volunteers, who work in areas where patient care is provided or who otherwise have direct contact with patients. In addition to inpatient areas on the main campus, this includes outpatient areas such as ambulatory care and urgent care clinics.

Flu Shot Community Event

Cedars-Sinai is offering flu shots to the community at a free event Sunday, Nov. 3, from 10 a.m. to 2 p.m. in ECC A-C. Employees, family members and others may attend.

Free parking will be available in Lot 2.

The event is sponsored by the Department of Community Health and Education and the Department of Nursing Services.

For more information, call ext. 3-9581.

Flu Shot Community Event - Nov. 3 (PDF)

"On Oct. 2, the County of Los Angeles Public Health issued an order mandating that healthcare workers wear a mask during flu season if they do not receive their annual flu vaccination," said Rekha Murthy, MD, director of Hospital Epidemiology. "The order affects acute care hospitals such as Cedars-Sinai, as well as skilled nursing facilities in the county. It will remain in effect until March 31, 2014, when the flu season typically ends, although that period can be extended if necessary."

"We hope that all CSMC employees as well as members of the medical staff, many of whom have already been vaccinated, will help to protect our patients by getting their flu vaccination and complying with this new policy," said Chief Operating Officer Mark Gavens and Chief of Staff Steve Galen, MD. "Beginning Dec. 15, we will distribute 'badge buddies' to everyone to help us enforce the policy. Individuals who have been vaccinated will wear green badges and those who have not been vaccinated will wear orange badges, in addition to putting on a surgical mask while in patient care areas."

According to the County of Los Angeles Public Health, policies mandating vaccination or masking have been shown to raise vaccination rates among healthcare personnel above 95 percent. Currently, the rates of healthcare personnel vaccination in Los Angeles range between 40 to 60 percent. Last year, 71 percent of Cedars-Sinai employees were vaccinated.

The green and orange badges will be distributed beginning in mid-November. For those employees who have already been vaccinated, the badges will be given to their managers/directors for distribution to appropriate personnel.

If you have questions, please contact your manager or Hospital Epidemiology. Thank you for your assistance in making the medical center as safe as possible for our patients.

Surgeons Cross Borders to Improve the Lives of Children

Above and inset: Photos from previous trips to China by Cedars-Sinai surgical teams

Cedars-Sinai pediatric surgeons have been embarking on overseas trips to perform transformative operations on children who have no specialists in their homeland. At the same time, our surgeons mentor the local surgeons with limited operative experience to help raise their skill level and independence.

Philip Frykman, MD, associate director of Pediatric Surgery, is travelling to China in October 2013 for his third trip to do at least 17 complex anal malformation procedures on children who have been abandoned because they have been deemed "damaged" and "unfixable."

David Kulber, MD, director of the Plastic Surgery Center of Excellence, recently returned from Mozambique, where for a week he performed reconstructive procedures on children and training the only plastic surgeon in the hospital, who had limited operating experience. Robert Bernstein, MD, medical director of the Cedars-Sinai Orthopaedic Center and vice chair for Clinical Affairs, plays a role in the Mozambique project to help identify physicians who Cedars-Sinai surgeons can have an impact on so they can begin teaching and creating a modern medical system that is self-sustaining.

Andrew Freedman, MD, goes to Guatemala annually to perform urologic procedures on children. Children from Kenya and Ghana have even travelled to the United States to have Freedman perform procedures they otherwise could not get in their country.

Thus far, each time Frykman has returned from China, he has quickly received news one of the children he "fixed" is now in the process of being adopted. In 2011, 11 patients had surgery and four were adopted. In in 2012, 12 patients had surgery, and all are now adoption candidates with one pending. This year, he will be operating in two suites in the Luoyang Women's and Children's Hospital.

Frykman's trip this year is focused on a heavier case load and sustainability just like the project in Mozambique. Shiwei Zhai, MD, the surgeon he is training in China, has a skill set that is significantly improving, and operating room visits for observation from interested surgeons has grown. They will be coming from four large hospitals in Luoyang — building relationships with local surgeons is important in achieving the sustainability portion of the mission.

The goal is to give Zhai graduated independence and ability to scrub with local pediatric surgeons. Frykman will be the keynote speaker at a regional pediatric surgery conference.

Our surgeons are making an impact on the international surgical landscape and helping to provide sustainability for countries that cannot currently serve the needs of their populations. Despite limited government support in some of these countries and outdated instruments, our surgeons are identifying leaders in their homelands and have these local and motivated surgeons participate in self-sustaining models that may even include trips back to the U.S. for specialized training.

These "indigenous surgeons" are making rounds, participating in operations and handling patient-care issues because of the long-term commitment our surgeons are making to help children outside the U.S. get the surgical care they so desperately need.

Previously in Medical Staff Pulse:

A photo from the 2013 medical mission to Guatemala

Surgery Chief Addresses Importance of Work Satisfaction

Bruce L. Gewertz, MD, delivered a lecture this month about the importance of surgeons finding satisfaction in their work, telling the annual meeting of the American College of Surgeons that greater fulfillment can keep physicians happier and in the workforce longer.

Gewertz, surgeon-in-chief, the H and S Nichols Distinguished Chair in Surgery and chair of the Department of Surgery, titled his lecture "Sustaining Fulfillment in Work and Life." He discussed how to achieve the type of work satisfaction necessary to remain motivated in surgical practice for an entire career.

"One needs to develop a skill set to identify and maximize personal fulfillment in work beyond mastery of the subject," Gewertz told the Clinical Congress gathering during his John J. Conley Ethics and Philosophy Lecture. "You can be the most technically proficient, financially secure surgeon, but if you don't find joy in what you do, it is a tragedy for you and the patients you serve."

Gewertz addressed the current state of joy and discontent among surgeons. He discussed research that shows why professionals are happy or unhappy in their work, and addressed key questions about what contributes to happiness: Does money make a difference? What kinds of personal relationships lead to happiness? What attitudes and behaviors influence happiness?

"It is certain that money alone won't do it," said Gewertz, vice president of Interventional Services, vice-dean of Academic Affairs and a Fellow of the American College of Surgeons. "You need to seek and maximize opportunities to discover the 'flow' and positivity of activities."

Gewertz has spoken about these issues in the past. In 2009, he delivered an address before the Western Surgical Association on the topic of "Life, Surgery and the Pursuit of Happiness."

In this latest lecture, Gewertz cited physician and surgeon satisfaction studies, including research by the American College of Surgeons, showing that surgeons practice more efficiently, joyfully and longer if they find greater satisfaction in their work. Not only is it an important issue on a human level for surgeons, he suggested, but it also is crucial on a societal level for surgeons to enjoy their lives and practices.

"We should encourage surgeons to practice as long as they are physically able and engaged rather than ignoring their frustration," he said. "The consequence of ignored frustration is early dropout from the surgery workforce."

Residents Receive Fellowship Matches

This year's fellowship matches for Cedars-Sinai surgical residents have been announced. They are:

Minimally Invasive Surgery Fellowship

  • Daniel Shouhed, MD – Mount Sinai, New York City
  • Brandice Durkan, MD – Cedars-Sinai

Trauma and Critical Care Fellowship

  • Cherisse Berry, MD – Shock Trauma Center, University of Maryland

Plastic Surgery Fellowship

  • Omar Hussain, MD – Mayo Clinic, Rochester, Minn.

Hydroxyethyl Starch Solutions Removed From Formulary

Pharmacy Focus

Due to the risks associated with the use of hydroxyethyl starch (HES) solutions, and the availability of safer and equally efficacious alternatives, the Pharmacy and Therapeutics Committee has approved the removal of Hespan from the formulary. All Hespan products have been removed from the units and ORs, and will no longer be available to order in CS-Link™.

The decision to remove Hespan from the formulary was based on a recent black box warning from the U.S. Food and Drug Administration for increased mortality and severe renal injury, as well as an additional warning for bleeding risk in certain settings for hydroxyethyl starch solutions.

Recommendations from the FDA include the following:

  • Do not use HES solutions in critically ill adult patients, including those with sepsis, and those admitted to the ICU.
  • Avoid use in patients with pre-existing renal dysfunction.
  • Discontinue use of HES at the first sign of renal injury.
  • Continue to monitor renal function for at least 90 days in all patients, as the need for renal replacement therapy has been reported up to 90 days after administration of HES.
  • Avoid use in patients undergoing open-heart surgery in association with cardiopulmonary bypass due to excess bleeding.
  • Discontinue use of HES at the first sign of coagulopathy.

Learn more at this FDA Web page.

Contact the Cedars-Sinai Drug Use Policy Center at 310-423-3784 with any questions.