ProgressNotes. this issue

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1 VOLUME 5 ISSUE 5 M A Y 2013 ProgressNotes MONTHLY MEDICAL STAFF NEWSLETTER TORRANCE MEMORIAL MEDICAL CENTER this issue MEC Approvals P.1-3 Medical Staff Calendar P.4 Medical Executive Committee Approvals The following items were presented and actions were approved at the May 14, 2013 Medical Executive Committee meeting: A. Physician Biography Guidelines TREASURER S REPORT A. March Treasurer s Report ANESTHESIA DEPARTMENT A. Department of Anesthesia Rules & Regulations Appendix III, Criteria for Sedation and Analgesia Privileging MODERATE SEDATION Members of the Medical Staff who wish to perform Moderate Sedation, other than Anesthesiologists, must hold privileges to administer Moderate Sedation. See specialty clinical privilege application card for qualifications, requirements, proctoring. Education: (a) M.D. or D.O.; 2. Training/Experience: (a) Documentation of 3 cases performed within the last 12 months. (b) Current ACLS Certification or PALS Certification provided by an AHA (American Heart Association) approved program, (Neonatologists and Emergency Department physicians are exempt as these specialists demonstrate competency for the rescue by training, expertise and regular involvement with the rescue of patients) AND (c) The successful completion of the Torrance Memorial Sedation Self-Study Module. (Except Anesthesiologist, all specialties must take the module); 3. Proctoring: (a) Each procedure proctored will include the evaluation of the sedation administered.; 4. Current Competence: (a) In order to maintain privileges, physician must administer sedation and analgesia for at least 3 patients in any Joint Commission approved/accredited hospital or ambulatory care center per year. Competency will be reevaluated at the time of reappointment. DEEP SEDATION Members of the Medical Staff Physicians who wish to perform Deep Sedation, other than Anesthesiologist, must hold privileges to administer Deep Sedation. See specialty clinical privilege application card for qualifications, requirements and proctoring. In addition, two cases proctored by an anesthesiologist or a physician who holds deep sedation privileges are required. Deep Sedation privileges may be requested by the following physicians in addition to the above 1-4: Training/Experience (a) Board Certified or successful completion of the fellowship from the following: Emergency Medicine, Electrophysiologist, Cardiologists with Cardioversion Privileges, Critical Care, Pulmonary Disease, or Neonatology. (b) The successful completion of the Torrance Memorial Deep Sedation Self Study Module. (Except Anesthesiologist, all specialties must take the module) 2. In order to maintain privileges, a privilege holder must administer sedation and analgesia for at least 3 patients in any Joint Commission approved/accredited hospital or ambulatory care center per year. Documentation will be reevaluated at the time of reappointment. 3.

2 Medical Executive Committee Approvals The following items were presented and actions were approved at the May 14, 2013 Medical Executive Committee meeting: ANESTHESIA DEPARTMENT (CONTINUED) Department of Anesthesia Rules & Regulations Appendix III, Criteria for Sedation and Analgesia (Continued) Revisions (Continued): Practitioners who hold deep sedation privileges will be considered qualified to hold moderate sedation privileges and will not need to take the moderate sedation test. 4. Continuous Quality Improvement: The overall monitoring of sedation and analgesia remains the responsibility of the Anesthesiology Department. B. Revised language which outlines credentialing requirements for privilege Deep Sedation and Administration of Moderate Sedation: Deep Sedation Qualifications: 1. Board Certified or successful completion of a fellowship in one of the following: Electrophysiology, Cardiology, Critical Care Medicine, Pulmonary Diseases, Neonatology OR Board Certified or successful completion of a residency in Emergency Medicine; AND 2. Current ACLS or PALS certification provided by an American heart Association (AHA) approved program. Exclusions: Neonatology and Emergency Medicine; AND 3. Documentation of three cases performed within the last 12 months; AND 4. Successful completion of the Sedation Test (initial request and every 2 years). Exclusion: Anesthesiology. Must be Board Certified Cardiologist with Cardioversion Privileges or Board Certified Electrophysiologists Administration of Moderate Sedation Qualifications: 1. Current ACLS or PALS certification by an American Heart Association (AHA) approved program. Exclusion: Neonatology and Emergency Medicine. 2. Documentation of three cases performed within the last 12 months. 3. Successful completion of the Moderate Sedation TestModule(initial request and every 2 years). Exclusion: Anesthesiology C. Sedation Test D. Sedation Learning Module EMERGENCY DEPARTMENT A. Revised Indications for 12 Lead ECG PEDIATRIC DEPARTMENT A. Revised Clinical Privilege Application Card for Department of Pediatrics Gastroenterology and Endoscopy Proctoring: See Medical Staff Proctoring Policy/Procedure Pediatric Gastroenterology Core: Addition of (includes parenteral nutrition) Esophagogastroduodenoscopy (EGD) [Upper Endoscopy]: Proctoring Requirements: 1 5 A minimum of 1 case must be proctored. Additional proctoring will be determined by the Dept. Chief Colonoscopy (or Sigmoidoscopy): Proctoring Requirements: 1 5 A minimum of 1 case must be proctored. Additional proctoring will be determined by the Dept. Chief. Deletion of privilege 8.14-Parenteral Nutrition RADIOLOGY DEPARTMENT A. Revised Department of Radiology Paracentesis or Thoracentesis Post-Procedural Notes B. Department of Ultrasound Policy/Procedure entitled, Utilizing Wall Suction for Paracentesis C. Patient Care Policy/Procedure entitled, Tissue Specimen Labeling/Handling BIOETHICS COMMITTEE A. Department of Administration Policy/Procedure entitled, Health Care Decisions for Unrepresented Patients II 2

3 Medical Executive Committee Approvals The following items were presented and actions were approved at the May 14, 2013 Medical Executive Committee meeting: CREDENTIALS COMMITTEE Approvals filed in Medical Staff Services please see Toni Woodard. INFECTION CONTROL/P&T COMMITTEE A. C.difficile Isolation/Hand Hygiene Practice B. Use of Ancef 2gm for Prophylaxis in >80 kg weight C. MERP Plan 2013 D. Therapeutic Interchange List E. Pharmacy Renal Adjustment Guidelines, Adult F. Formulary Removal of Refludan G. Additions to the IV Administration Guideline H. Pharmacy Policy/Procedure entitled, Drug Shortages I. Patient Care Policy/Procedure entitled, Improving the Safety of Medication Use (High Alert Medications/Look-Alike/Sound- Alike Medications/Black Box Warnings J. Revised NICU Initial Orders and Guidelines for Inhaled Nitric Oxide Therapy K. Revised NICU Admission Orders L. Revised Restraint Order Form M. Revised Patient Care Policy/Procedure entitled, Restraints N. Nutritional Formulary O. Food and Nutrition Services Policy/Procedure Manual P. Labor & Delivery Epidural Continuous and PCEA Infusion Orders Q. CPOE Orders and Order Sets Draft Pediatric General Admission Physician s Orders Draft Asthma Pediatric Admission Physician s Orders Draft Hyperbilirubinemia Neonatal Admission to Pediatrics Physician s Orders INSTITUTIONAL REVIEW BOARD Approvals filed in Medical Staff Services please see Yumi Lee. ONCOLOGY COMMITTEE A. Draft Patient Care Policy/Procedure entitled, Distress Assessment, Oncology Patient B. Revised Cancer Data Management Policy/Procedure entitled, Cancer Conferences QUALITY & PATIENT SAFETY COMMITTEE A. Medical Staff Mission B. Definition of Quality: Those sets of behaviors and practices that improve patient outcomes, reduce patient risk, enhance patient experience and reduce inefficiency. Quality is a prime goal and responsibility of every member of the medical staff, medical center leadership and all medical center employees. C. Medical Staff Goals D. Physician Communication Plan Recommendation that effective August 1, 2013, primary communication methodology by the Medical Staff Services Department to the Medical Staff and Clinical Privilege Holders be by . All communication including reappointment documents will be delivered in this manner. Members and Clinical Privilege Holders will be required to have a current address on file with the Medical Staff Services Department which they agree to check regularly. In addition, a mechanism will be developed to verify that addresses are current. 3

4 JUNE Monday Tuesday Wednesday Thursday Friday Medical Staff Calendar :00a Quality & Pt. Safety...WT-D 12:30p Cardiology...WT-D 12:30p Infection Control/P&T.WT-C 12:30p MSPI.WT-D 7:30a IRB.WT-D :00a CV Institute Committee.WT-D 12:30p Credentials..WT-C 12:30p Medical Ed/Library HCC-4 5:00p Professional Relations...WT-C 6:00p Medical Executive..WT-D 7:00a Anesthesia PI....WT-Aud 8:00a Endocrinology.WT-B 12:30p Gastroenterology WT-D 7:00a Heart Failure.WT-D :00p Burn & Wound...WT-C 12:30p Donor & Transfusion..WT-D 7:00a New Main Tower Planning Committee...WT-D 7:00a Practitioner Well Being..WT-C 12:00p Radiology Dept...WT-Aud 12:30p Surgery Dept...HCC 1&2 9:00a Emergency Dept.WT-D 12:30p Pediatric Dept.WT-Aud :00p Bariatric Surgery.WT-C 8:00a Medicine PI..WT-E 12:30p OB/GYN Dept.WT-Aud 12:30p Utilization Mgmt..WT-D 12:30p Bioethics..WT-B 12:30p Credentials..WT-C CME CONFERENCES Wednesdays, 12:30 pm Health Conference Center Torrance Memorial Medical Center is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. Torrance Memorial Medical Center designates this live activity for a maximum of 1 AMA PRA Category I credit TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education. For up-to-the minute conference information call (310) June 5, 2013 Update on HIV & Prevention of Maternal HIV Transmission Geeta Gupta, M.D. UCI School of Medicine Commercial Support: Gilead June 12, 2013 Percutaneous Aortic & Mitral Valve Replacement William Suh, M.D. UCLA School of Medicine Commercial Support: St. Jude Medical June 19, 2013 Lymphoma Management Leslie Popplewell, M.D. City of Hope National Cancer Center Commercial Support: None June 26, 2013 NO CONFERENCE July 3, 2013 NO CONFERENCE

5 Medical Staff Services 3330 Lomita Boulevard Torrance, CA Phone: (310) Fax: (310) Mailing Label ProgressNotes Vol. 5 Issue 6 June 2013 MONTHLY MEDICAL STAFF NEWSLETTER ProgressNotes TORRANCE MEMORIAL MEDICAL CENTER