ProgressNotes. this issue TORRANCE MEMORIAL MEDICAL CENTER

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1 VOLUME 4 ISSUE 3 M A R C H 2012 ProgressNotes MONTHLY MEDICAL STAFF NEWSLETTER TORRANCE MEMORIAL MEDICAL CENTER this issue Torrance Memorial Urgent Care P.1 Medical Staff Calendar P.2 Roster Updates P.3 MEC Approvals P.4-6 NEW TORRANCE MEMORIAL URGENT CARE Staffed By Emergency Medicine Physicians New Extended Hours Accepting Most Insurance Plans

2 Medical Staff Calendar March Monday Tuesday Wednesday Thursday Friday 1 2 7:30a IRB...WT-D :00a Cardiac Mortality Rev...WT-C 12:30p Cardiology...WT-D 12:30p Infection Control/P&T.WT-C 12:30p Patient Safety..WT-B 12:30p CME Conference..HCC 1&2 12:30p Critical Care.WT-D 12:30p Pediatric PI..WT-Aud 8:00a Oncology..WT-D :30p Credentials..WT-C 12:30p Medical Ed./Library..HCC-4 12:30p Medication Safety.WT-C 6:00p MEC...WT-D 7:00a Anesthesia Dept.WT-Aud 12:30p CME Conference..HCC 1&2 9:00a Emergency Dept.WT-C 12:30p Pediatric Dept.WT-Aud 12:00p Donor & Transfusion...WT-D :00p Burn & Wound...WT-C 7:00a Practitioner Well Being..WT-C 12:30p Medicine Dept.WT-D 12:30p CME Conference..HCC 1&2 12:30p Credentials..WT-C :30p Stroke Committee..WT-D 4:00p Bariatric Surgery.WT-C 7:00a Breast Program...WT-B 12:30p OB/GYN Dept.WT-Aud 12:30p Bioethics..WT-B 12:30p Palliative Care.WT-D 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) March 7, 2012 Breast Cancer Diagnosis & Treatment Debasish Tripathy, M.D. USC School of Medicine Commercial Support: None March 14, 2012 Recent Advances in Ophthalmology Kenneth Lu, M.D. USC Doheny Eye Institute Commercial Support: None March 21, 2012 Pulmonary Hypertension David Ross, M.D. UCLA School of Medicine Commercial Support: Actelion March 28, 2012 NO CONFERENCE April 4, 1012 Falls Prevention in the Elderly Steven Castle, M.D. UCLA School of Medicine Commercial Support: None

3 JOIN US AS WE Celebrate DOCTOR S DAY FOOD FUN PRIZES MARCH 30 Torrance Memorial Medical Center Invitation to follow Physician Roster Updates LEAVE OF ABSENCE David Edelman, M.D. Neurology REINSTATE FROM LEAVE OF ABSENCE Joseph S. Carey, M.D. Cardiothoracic Surgery RESIGNATION Michelle L. Furuta, M.D. Psychology Alice Goldin, M.D. Pediatrics Anthony W. Lam, M.D. OB/GYN Hai X. Le, M.D. Internal Medicine Yanina A. Queen, D.O. Pediatrics Sharon M. Theodore, M.D. Ophthalmology Eric N. Silbiger, D.O. Family Practice Mark J. Wang, M.D. Orthopedics 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 3

4 Medical Executive Committee Approvals The following items were presented and actions were approved at the February 14, 2012 Medical Executive Committee meeting: Treasurer s Report A. December 2011 Treasurer s Report Medicine Department A. Revised Clinical Privilege Application Card for Department of Medicine Physical Medicine and Rehabilitation NOTE: With the review of the Department of Medicine Chief or his/her designee, review of 2 (two) office based #47.52 Electromyography (EMG), Nerve Conductions, Nerve Blocks, and Botox Injections may be accepted to meet the proctoring requirements for that procedure. At least 1 (one) EMG, Nerve Conduction, Nerve Block, and Botox injection case must be proctored in the hospital setting. Deletion of privilege Electromyography (EMG) B. Revised Clinical Privilege Application Card for Department of Medicine Sleep Medicine Deletion of privilege Electromyography (EMG) Obstetrics & Gynecology Department A. Revised Division of Nursing Obstetrics Policy/Procedure entitled, Chain of Command for Reaching the Obstetrician Pediatric Department A. New Department of Pediatrics Clinical Privilege Application Card Allergy and Immunology B. New Department of Pediatrics Clinical Privilege Application Card Nephrology C. Revised Department of Pediatrics Clinical Privilege Application Card General Pediatrics General Pediatrics Core #71.00 Privileges to admit, evaluate, diagnose, perform history and physical exam and treat pediatric patients from 0 to 18 years of age, and perform procedures that are not life-threatening.,except for those special procedure privileges listed below Privileges include treatment of major complicated illnesses, splinting of simple fractures, cautery of anterior nares, drainage of subungual hematoma, gastric lavage, incision and drainage of superficial abscesses, intraosseous line placement, peripheral arterial puncture, laceration repair, local anesthesia, nail removal, nasogastric tube placement, placement of intravenous line, reduction of radial head subluxation, removal of cerumen, removal of foreign body (cornea, conjunctiva, ear, nose), skin tag removal, injection (subcutaneous, intradermal, intramuscular), transfusion, typanometry, uncomplicated debridement of a burn or wound, venipuncture, wart destruction, needle aspiration (other than knee), and care of well newborns weighing greater than 2000 gm (including care of peripartum hyperglycemia that resolves within four hours of birth), which encompasses care for physiologic jaundice. Deletion of Signature Line for Chairman of Pediatrics PI Subcommittee D. New Department of Pediatrics Clinical Privilege Application Card Critical Care Surgery Department A. Revised Clinical Privilege Application Card for Department of Surgery Ophthalmology Minor Core Privileges Privileges to admit, evaluate, consult, perform history and physical exam, and provide non-surgical and surgical care to patients of all ages except where specifically excluded from practice and except for those special procedures listed below to correct or treat illnesses, injuries, and disorders of the eye, including its related structures and visual pathways. Privileges include use of local anesthetics and parenteral sedation for ophthalmologic condition, insertion of intraocular lens, and the following minor procedures: Eye Verrcua, chalazia and biopsy; lid lesions, lacerations 4

5 Medical Executive Committee Approvals (continued) The following items were presented and actions were approved at the February 14, 2012 Medical Executive Committee meeting: Surgery Department (Continued) A. Revised Clinical Privilege Application Card for Department of Surgery Ophthalmology (Continued) Revisions (Continued): CO2 Laser Privilege Qualifications: Documentation of training during (a) residency training program; or (b) six-hour hands-on laser training course Argon Laser Qualifications: Documentation of training during (a) residency training program; or (b) six-hour hands-on laser training course. Addition of the following privileges: XX-Oculoplastic Surgery Core Plastic surgery procedures such as: scar revision; rhytidectomy; local flaps; dermabrasion and chemabrasion; musculocutaneous flaps Integumentary procedures such as: grafts, partial thickness; grafts, full thickness; pedicle flaps Head and neck procedures such as: fractures, face Qualifications: 1. Board Certified or previously board certified in ophthalmology; 2. Documentation of training during residency or fellowship training program Proctoring Requirements: 1 # of cases required Init App: 25 # of cases required Reapp: 25 XX-Minor burns (minor burns in adults of <15% TBSA, and burns in children <10%) associated with ophthalmologic procedure. Qualifications: 1. Documentation of training during residency or fellowship training program; 2. Must hold privilege XX-Oculoplastic Surgery Core; 3. Documentation of 2 cases in the past two years in a hospital setting. Proctoring Requirements: 1 # of cases required Init App: 2 # of cases required Reapp: 2 B. Revised Clinical Privilege Application Card for Department of Surgery Cardiothoracic Surgery Impella 5.0 Proctoring Requirements: 3 By MD provided by Abiomed 0 C. Patient Care Policy/Procedure entitled, Accepting BICU Transfers from a Transferring Emergency Department D. Division of Nursing Surgical Services Policy/Procedure entitled, Electrosurgery Equipment, Use of E. Division of Nursing Operating Room Policy/Procedure entitled, Pneumatic Toruniquet Use Bylaws Committee A. Revised General Staff Rules & Regulations C. MEDICAL RECORDS 3a. A Complete History and Physical is required within 24 hours after of admission for all patients. (PC EP4) A Transfer Summary containing all elements of a History and Physical and written by a physician on the medical staff at Torrance Memorial Medical Center can be used as a History and Physical. An adequate History and Physical must contain the following elements: (MS EP6) Chief Complaint Details of Present Illness Medical History Relevant Physical Examination/System Review Statement of Conclusions or Impressions Drawn from Admission B. Revised Medical Staff Services Policy/Procedure entitled, Proctoring PROCEDURE Each Provisional Staff member and Clinical Privilege holders shall undergo a period of observation by designated proctors as described in Article VII, Section 7.3 of the Bylaws. The observation shall be designed to evaluate the member s (1) proficiency in the exercise of clinical privileges initially granted and (2) over-all eligibility for continued staff membership and advancement within staff categories. Observation of Provisional Staff member and Clinical Privilege holders shall follow whatever frequency and format each Department deems appropriate in order to evaluate the Provisional Staff member or Clinical Privilege holder satisfactorily, including, but not limited to, concurrent or retrospective chart review. Mandatory consultation, and/or direct observation. Appropriate records shall be maintained. The result of the observation shall be communicated by the Department Chief to the Credentials Committee. 5

6 Medical Executive Committee Approvals (continued) The following items were presented and actions were approved at the February 14, 2012 Medical Executive Committee meeting: B. Revised Medical Staff Services Policy/Procedure entitled, Proctoring (Continued) Revisions (Continued) Assignment of Proctors: Proctors will be assigned by the Chief of the practitioner s assigned department through the Medical Staff Services Department. The proctor assignment will be made at the time privileges are granted. Proctors must be members of the Medical Staff with unrestricted privileges, or in circumstances where the Medical Executive Committee determines it is appropriate, a proctor may be appointed who is not a member of the Medical Staff in his or her subspecialty. Proctors with unrestricted privileges are assigned by the Medical Staff Services Department on a rotational basis upon the privileges granted. Practitioners are also given a list of qualifying proctors to contact should the assigned proctors be unavailable. Notification of Proctor: It is the physician s responsibility to contact his/her proctor. The proctor must also be called when the physician schedules any elective procedures to assure his/her ability to attend and supervise observe procedures. COMPLETION OF PROCTORING Practitioners shall remain subject to proctoring until the Medical Executive Committee or Chief of Staff has been furnished with: FAILURE TO COMPLETE PROCTORING REQUIREMENTS If an initial appointee, practitioners granted new clinical privileges, and applicants to the medical staff granted temporary privileges, fails within the time of provisional membership to complete proctoring as required, or if a practitioner exercising new clinical privileges fails to complete proctoring within the time allowed by the Department; then the member shall be deemed to have voluntarily surrendered those specific privileges and the procedural rights set forth in Article IX shall not be applicable. In any case of such voluntary surrender of privileges in which the member has no remaining approved privileges, the member may be moved to an appropriate medical staff category or shall be deemed to have resigned the member s medical staff membership, and the procedural rights set forth in Article IX shall not be applicable. C. Revised Medical Staff Policy/Procedure entitled, Professional Practice Evaluation Reporting of Information Information on the professional practice of practitioners will be presented to the practitioner s department and/or other appropriate medical staff committee/forum. Information should be presented at intervals frequent enough (at least every nine months) to assure timely identification of issues, patterns, or trends. The following guidelines should be used in determining when information is reviewed by the department. Credentials Committee Approvals filed in Medical Staff Services please see Toni Woodard. Infection Control/P&T Committee A. Adult Subcutaneous Insulin Coverage Orders B. Annual Evaluation of the Infection Control Program C. NMT Pre-Op Areas D. Hand Hygiene Policy/Procedure E. Isolation Policy/Procedure F. Post-Cardiac Catheterization PCI Orders G. Medication/Food/Contact Allergies, Policy/Procedure H. Pre Procedure/Surgical Anesthesia Protocol I. Brilinta Drug Review J. Ozurdex Drug Review K. Order Clarification, Policy/Procedure L. Adult IV Solutions, Standardized, Titratable, Policy/Proceudre M. Post Cesarean Section Order Set N. Post Vaginal Order Set O. Dexmedetomidine (Precedex), Policy/Procedure P. Adverse Drug Events Policy/Procedure Q. Dispensing Policy/Procedure R. Medication Shortage Policy/Procedure S. Administration Policy/Procedure T. Formulary Changes U. LAST Emergency Box V. Do Not Crush Medication List W. Nutrition Risk Screening Process, Policy/Procedure X. Food and Nutrition Services Policy/Procedure Y. Formulary Addition, Peptamen Bariatric Formulary Z. Deletion Nutren Pulmonary from Enteral Nutrition Formulary AA. Formulary Interchange, Benzodiazepine Hypnotics BB. Laser Eye Procedure Pre-Op Orders CC. Laser Eye Center Intra and Post Procedure Orders DD. Physician s Orders Pre-Op Testing Orders for Cardiac Surgery EE. Pre-Op Orders for Cardiac Surgery FF. Cardiothoracic Surgery Post-Op Orders GG. PCU Transfer Orders for Cardiac Surgery HH. Thoracotomy Video Assisted Thoracic Surgery Post-Op Orders II. Lap Gastric Bypass/Sleeve Gastrectomy Post-Op Order JJ. Open Gastric Bypass Post-Op Orders KK. Outpatient Laparoscopic Placement of Adjustable Gastric Band Post-Op Orders LL. Laparoscopic Placement of Adjustable Gastric Band Post-Op Orders MM. Bariatric Surgery Hernia + Abdominal Wall Reconstruction Post-Op Orders W. Bariatric Surgery Hernia + Abdominal Wall Reconstruction Post-Op Orders Institutional Review Board Approvals filed in Medical Staff Services please see Yumi Lee. 6