ProgressNotes. Standards of Behavior. Tip of the Month. Stroke Program Receives Silver Plus Recognition. this issue

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1 VOLUME 4 ISSUE 6 J U N E 2012 ProgressNotes MONTHLY MEDICAL STAFF NEWSLETTER TORRANCE MEMORIAL MEDICAL CENTER this issue Stroke Program Recognition P.1 MEC Approvals P.2 Medical Staff Calendar P.3 Roster Updates P.4 Standards of Behavior Tip of the Month In the spirit of community and respect for our fellow co-workers, please take note of the Standards of Behavior tip of the month. Developed by the Pride & Communications Council, Standards of Behavior were created to encourage staff to acknowledge one another with positive attitudes and use examples to demonstrate how this can be accomplished. Display your professionalism. Please wear your name badge at chest level or above so our patients, doctors, co-workers and visitors can read your name. Dr. Wyman Demonstrates CTO Procedure (left to right) R. Michael Wyman, M.D., cardiology, and Chuck Ellis, Media Services, prepare the Torrance Memorial s Catheter Lab for a live demonstration of angioplasty performed on a patient with chronically totally occluded coronary arteries (CTOs). Cardiologists from around the country visited Torrance Memorial last week to participate in a live two-day workshop, where they watched Wyman perform the procedure via closed circuit television from a West Tower conference room. Wyman was the principle investigator in the FDA approval trial for the BridgePoint medical device, which enables surgeons to unblock blockages that previously required bypass surgery. Stroke Program Receives Silver Plus Recognition Torrance Memorial s Stroke Program has achieved Silver Plus recognition through the Get With The Guidelines : Turning Guidelines into Lifelines quality achievement program. The Silver recognition was achieved by reaching 85 percent or higher compliance to core standard levels of care as outlined by the American Heart Association and American Stroke Association for 12 consecutive months. In addition. Torrance Memorial qualified for Silver Plus for demonstrating 75% compliance to 7 out of 10 stroke quality measures in that same period. The next goal is achievement of Gold recognition, which requires compliance for 24 consecutive months. Congratulations to the Stroke team for a job well done! First Name Last Name, M.D.

2 Medical Executive Committee Approvals The following items were presented and actions were approved at the May 8, 2012 Medical Executive Committee meeting: The following items were approved at the May 8, 2012 meeting of the Medical Executive Committee: Treasurer s Report A. April 2012 Treasurer s Report Anesthesia Department A. Revised Anesthesia Department Rules & Regulations, Appendices Appendix II Discharging Patients After Anesthesia to Nursing Unit Revisions: All surgical patients are kept in the PACU except for: a. Patients that are going to be recovered in critical care units. b. Patients that have received no sedation for the hour 30 minutes preceding recovery room admission. providing the following nursing discharge criteria are met: 1. General anesthesia patients must have regained consciousness and be oriented to time and place provided they were oriented to time and place pre-operatively. 2. Patient should be able to breathe deeply and cough except for patient returning to a critical care unit with mechanically assisted ventilation. The airway is clear and danger of vomiting and aspiration is past. 3. Vital signs are stabilized. Notify anesthesiologist if pulse < 50 or > 120; Blood pressure systolic < 90 or > Spinal and epidural anesthesia patients should have sensation and movement in lower extremities. 5. Patient is kept a minimum of 30 minutes for observation after vasoactive drug injections, narcotic injections and patient controlled analgesia loading dose. 6. Patient is kept a minimum of 30 minutes after endotracheal extubation in the PACU and after maintaining Oxygen saturations above 90% by pulse oximeter. 7. Patients must not have any unexpected bleeding from surgical site. 8. If any post-operative or post-anesthesia problems, patients must be further evaluated by the anesthesiologist or the surgeon. The R.N. will relay the status of the patient to the anesthesiologist prior to discharge. 9. The pre-operative condition of each patient is the baseline for overall evaluation 10. Patient is to be discharged only with a PACU scoring above 7. If less than 7, the R.N. will relay the status of the patient to the anesthesiologist. 11. Dressing, if any, should be dry and intact. No excessive bleeding or drainage from operative site. 12. Nausea should be at a minimum before discharge and fluids may be taken, if tolerated. 13. For Gastrointestinal patients, notify the physician if abdominal distention. It is the standard of practice at Torrance Memorial Medical Center that medical staff members will be credentialed for the use of sedation and analgesia. The following indicates the privilege criteria by which physicians will be credentialed. Granting Privileges The Anesthesiology Department is responsible for granting privileges and evaluating the privilege criteria. No revisions to the criteria will be made without approval by the Anesthesiology Department. Continuous Quality Improvement Cases will be referred for review to the Anesthesia Department based upon criteria as established and approved by the Anesthesiology Department and individual department performance improvement efforts. The overall monitoring of sedation and analgesia remains the responsibility of the Anesthesiology Department. Appendix III Criteria for Sedation and Analgesia (Moderate Sedation) Privileges MODERATE SEDATION The definition of Sedation and Analgesia (Moderate Sedation) will remain consistent with those outlined in the Sedation policy located in the Patient Care Manual. All practices (i.e., policies, monitoring, equipment needs, charting) will also remain consistent of those identified in the Sedation and Analgesia (Moderate Sedation) policy. (Continued on page 5) 2

3 Medical Staff Calendar June Monday Tuesday Wednesday Thursday Friday 1 7:00a Surgery Dept...WT-Aud :30p Cardiology...WT-D 12:30p Infection Control/ P&T...WT-C 8:00a Endocrinology.WT-B 12:30p CME Conference..HCC 1&2 12:30p MSPI.WT-D 7:30a IRB.WT-D :30a Physician Alignment...WT-B 12:30p Credentials..WT-C 12:30p Med Ed/Library Comm.HCC-4 12:30p Medication Safety...WT-C 5:00p Professional Relations...WT-C 6:00p MEC...WT-D 7:00a Anesthesia PI..WT-Aud 12:30p CME Conference..HCC 1&2 12:30p Medicine PI..WT-D :00p Burn & Wound.WT-C 7:00a Breast Program...WT-B 7:00a Pract. Well Being WT-C 12:00p Radiology Dept...WT-Aud 12:30p CME Conference..HCC 1&2 9:00a Emergency Dept.WT-D 12:30p Pediatric Dept.WT-Aud :00p Bariatric Surgery.WT-C 12:30p OB/GYN Dept..WT-Aud 12:30p Utilization Mgmt...WT-A 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 6, 2012 A Plague on Both Your Houses: Infectious Diseases in Shakespeare Robert Kaplan, M.D. U.C. Irvine School of Medicine June 13, 2012 Management of Menopause Nancy Greep, M.D. UCLA School of Medicine June 20, 2012 Anemia Kouichi Tanaka, M.D. UCLA School of Medicine June 27, 2012 NO CONFERENCE July 4, 2012 NO CONFERENCE July 11, 2012 Motivational Interviewing: Techniques for Improving Patient Behavior Change & Compliance Morris Gelbart, Ph.D. Torrance Memorial Medical Center 3

4 Welcome New Practitioners on Staff Photo Not Available Sunil Rangappa, M.D. Cardiology 4201 Torrance Blvd. Torrance, CA Phone: (310) Fax: (310) Physician Roster Updates Change of Address/phone/fax Tiffany Becker, M.D. Pediatrics 827 Deep Valley Dr., Ste. 201 Rolling Hills Estates, CA Phone: (310) Fax: (310) Hyun Lee, D.O. Internal Medicine Hawthorne Blvd., Ste. 116 Torrance, CA Phone: (310) Fax: (310) April Cherness, M.D. Pediatrics 3440 Lomita Blvd., Ste. 352 Torrance, CA Alexander Stein, M.D. Cardiothoracic Surgery 1000 W. Carson St. Box 423 Rm 3L2 Torrance, CA Fax: (310) The Medical Staff Newsletter Progress Notes is published monthly for the Medical Staff of Torrance Memorial Medical Center. Thomas G. Simko, M.D. Chief of Staff Robin S. Camrin, CPMSM, CPCS Vice President, Medical Staff Services & Performance Improvement 4

5 Medical Executive Committee Approvals The following items were presented and actions were approved at the May 8, 2012 Medical Executive Committee meeting: (Continued from page 2) MODERATE SEDATION 1. Education (a) M.D. or D.O. 2. Training/Experience (a) Completion of an AMA accredited training program in area of practice. (a) Experience in the administration of sedation and analgesia verified by training program or 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, (Neonatologist and Emergency Department physicians are exempt as these specialties demonstrate competency for rescue 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. Fellowship/Board (a) ABMS Certified/Qualified 4. Status/Other (a) Member in good standing of the Torrance Memorial Medical Staff 3. Proctoring (a) Each procedure proctored 4. Current Competence (a) In order to maintain privileges, physicians must administer sedation and analgesia for at least 3 patients in any Joint Commission JCAHO approved/ accredited hospital or ambulatory care center per year. Documentation Competency will be reevalu- DEEP SEDATION Physicians who wish to perform Deep Sedation, other than Anesthesiologists, must hold privileges to administer Deep Sedation. In addition, two cases proctored by an anesthesiologist or a physician who holds deep sedation privileges is are required. Proctors will be assigned by the Chief of Anesthesiology. Deep Sedation privileges may be requested by the following physicians in addition to the above 1-4. A. Appendix III Criteria for Sedation and Analgesia (Moderate Sedation) Privileges Revisions: 1. Training/Experience a. Board Certified or successful completion of a fellowship from the following: Emergency Medicine, or have recently (within a 3 year period) completed a certified residency program, Electrophysiologists, Cardiologist with Cardioversion Privileges, Critical Care, Pulmonology Disease, or Neonatology Board Certified Electrophysiologists. Board Certified Cardiologists with Cardioversion Privielges, Board Certified Critical Care (Continued on page 6) 5

6 Medical Executive Committee Approvals The following items were presented and actions were approved at the May 8, 2012 Medical Executive Committee meeting: (Continued from page 5) A. Revised Anesthesia Department Rules & Regulations, Appendices (Continued) Appendix III Criteria for Sedation and Analgesia (Moderate Sedation) Privileges Revisions: b. The successful completion of the Torrance Memorial Deep Sedation Self-Study Module. (With the exception of Anesthesiology, all specialties must take the module) 2. In order to maintain privileges, physicians competence a privilege holder must administer sedation and analgesia for at least 3 patients in any Joint Commission JCAHO approved/accredited hospital or ambulatory care center per year. Documentation will be reevaluated at the time of reappointment. 3. 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. Granting of Privileges The individual clinical departments will have the authority to grant privileges for sedation and analgesia utilizing the afore outlined privilege criteria. The anesthesiology Department is responsible for granting and evaluating the privilege criteria. No revisions to the criteria will be made without approval by the Anesthesiology Department. 4. Continuous Quality Improvement Cases will be referred for review to the Anesthesiology Department based upon criteria as established and approved by the Anesthesiology Department and individual Departmental Performance Improvement efforts. The overall monitoring of sedation and analgesia remains the responsibility of the Anesthesiology Department. Obstetrics & Gynecology Department A. Pain Management Teaching Tool Radiology Department Revised Policy/Procedure entitled, Scanning Patients with a Revo MRI TM SureScan Pacemaker Credentials Committee Approvals filed in Medical Staff Services please see Toni Woodard. Infection Control/P&T Committee A. Acetaminophen IV DUE Restriction B. IV Admininistration Insulin List C. Final Computerized Provider Entry Physician Order Set (CPOE) D. Changes to Current Emergency Medication Boxes in Radiology E. CHF Pre-Printed Orders F. Revised Adult Therapeutic Hypothermia Orders G. Revised Tote Box Contents H. TURP Post-Op Orders I. Blood and Blood Components, Administration of Policy/Procedure J. Bronchodilator Therapy Protocol K. Ordering and Transcribing Policy/Procedure L. Labeling of Medications Policy/Procedure M. Policy Revision List N. Medication Error Reduction Plan (MERP) O. Addition of NaCI to the IV Administration Policy Institutional Review Board Approvals filed in Medical Staff Services please see Yumi Lee. 6

7 Medical Staff Services 3330 Lomita Boulevard Torrance, CA Phone: (310) Fax: (310) Mailing Label ProgressNotes Vol. 4 Issue 6 June 2012 MONTHLY MEDICAL STAFF NEWSLETTER ProgressNotes TORRANCE MEMORIAL MEDICAL CENTER Torrance Memorial s Planned New Main Tower