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PHYSICIANS’ EDITIONnovemBer-december 2016 • Volume 17 Issue 11

• NOVEMber-DECEMBER 2016

Deadline to submit time-sensitive December 2016 packet isFriday, November 18.

Deadline to submit articles for the January 2017 issueof Physicians’ Edition is Friday, December 16.

Physician Editor: David L. Slater M.D., FCAP

Managing Editor: Laurie Smith

Manager, Physician Education and Communication

november-december physician photographer rais vohra m.d.In This Issue:

NOVEMBER-DECEMber physician photographer

rais vohra m.d.California Poison Control System

UCSF Fresno Emergency MedicineIn spring 2016 I had the opportunity to travel to two cities

in India as a Visiting Professor of emergency medicine, a new specialty within their rapidly developing health care sector. It was a wonderful journey for many reasons – I was born in Bombay (now Mumbai) and thus honored to return to that dynamic metropolis in order to share my passion for emergency medicine and toxicology with a new generation of young physicians. Afterwards I spent a week in the southern city of Madurai, where the ancient temple of the venerated goddess Meenakshi attracts legions of Hindu devotees and sightseers.

India is often described as a land of contrast – whatever you say about it, the opposite is equally true. These photographs reflect these diverging tendencies as I experienced them first-hand, of a society which is at once accelerating headlong into a global culture with unprecedented opportunities and complications, while also remaining connected to the immutable traditions and complicated histories that are the hallmark of its cultural inheritance. Note: All photos were taken with iPhone 6s; the color photos are from Mumbai, while the monochrome images are taken in and around Madurai.

My old neighborhood

Good Advice! at the Gandhi Museum

Mumbai from the sky

3.......... Medical Staff President Corner

4 .........2017 Leadership5.......... Initial & AHP

Appointments6.......... Cancer Center

Construction to Start

7.......... Physician Accomplishment

8.......... MACRA Update11 ........ From the Desk of

Judi Binderman M.D.

11 ........Fight the Flu12 ........Eye Q Vision Care13 ........ AMA Updates its

Code of Ethics14 ........Antibiotics Week17 ........Latent Tuberculosis18 ........ 2017 Winter

CME Symposium

20 ........ Lung Nodule Program

21 ........World Stroke Day22 ........ Blood Transfusion

Information25 ........ Home Visits Make

A Difference26 ........Pharmacy Corner27 ........Zika Update27 ........ICD-10 Corner28 .......Tox Tidbits30 ........ Your Community

at Work31 ........Choosing Wisely31 ........ Brain Tumor

Support Group32 .......Clinical Content34 ........CME Highlights35 ........ Physician

Photographer of the Month

NOVEMber-DECEMBER 2016 •

Jeffrey Thomas M.D.Community Medical Centers

With my second term as President of the Medical Staff coming to an end, I would like to thank all of our members for the opportunity I have had to serve. Restructuring of our medical staff to include Fresno Heart and Surgical Hospital, ICD 10, multiple regulatory surveys, bylaws and privilege card revisions, and a few fun social events were among the highlights. I am pleased to leave the office in the very capable hands of Dr. Ajit Arora, who I am sure will do an exceptional job at the helm.

I must admit that the role of the President of the Medical Staff has changed significantly over the years. Our medical staff has been restructured at the facility and department levels where the vast majority of the true work is accomplished. In fact, the corporate MEC is no longer burdened with the lengthy meetings where policies and procedures are ironed out. Instead it now reviews and ratifies the good work of others. I am indebted to the department and committee members and chairs who selflessly attend meetings and complete these necessary tasks. I would like to formally thank these individuals and always encourage any member of the medical staff who is interested to become more involved.

Perhaps my greatest gratitude goes out to the administrative folks in the medical staff office. I cannot begin to explain the amount of work they do on behalf of our entire medical staff and its busy leaders. “I need a letter this afternoon” or “we need a room with phone conference tomorrow morning” or “e-mail all members of the MEC with this 91 page attachment for a meeting tonight,” or “excuse me, my parking pass isn’t working anymore” are daily requests they receive. They make us look great and we all appreciate their dedication under sometimes stressful circumstances.

In addition, I send a shout-out to all of our staff in peer review, quality, legal, and the countless administrative nurse managers who contribute to our cause on a daily basis. They provide and analyze data, implement policies, and have a steady finger on the pulse of what is happening within all our facilities.

Again, it has been an honor to serve as the President of the Medical Staff here at Community. We have a great group of people who strive to optimize the medical staff-hospital system relationship. Although our little “transition of office” is not quite as dramatic as what’s happening with our national government, it is important just the same! Thank you and have an exceptional holiday season.

A Changing of the Guard

CORNERMEDICAL STAFF PRESIDENT


CardiologyBipin Joshi M.D., Chair

Sundararajan Srikanth M.D., Vice-Chair

Clinical SpecialtiesJohn Pollard MD., Chair

Richard Adams Ph.D., Vice-Chair

Emergency MedicineJames Comes M.D., ChairDanielle Campagne M.D.,

Vice-Chair

Family Medicine Arlin Venturina M.D., ChairIvan Gomez M.D., Vice-Chair

Medicine Abhishek Tandon M.D., ChairJorge Martinez-Cuellar M.D.,

Vice-Chair

Ob-GynTejinder Sandhu M.D., ChairFenglaly Lee M.D., Vice-Chair

PediatricsNew Sang M.D., Chair

Christian Faulkenberry-Miranda M.D., Vice-Chair

RadiologySusan Barrows M.D., Chair

Frank Chang M.D., Vice-Chair

SurgeryJohn Garry M.D., Chair

Babak Eghbalieh M.D., Vice-Chair

2017 LEADERSHIP

FHSH Medical Staff LeadershipJanuary 1, 2017 – December 31, 2018

Facility Executive Advisory CommitteeRandall Stern M.D., Chair

Shamsuddin Khwaja M.D., Vice-Chair

CRMC Medical Staff LeadershipJanuary 1, 2017 – December 31, 2018

Facility Executive CommitteeBabak Eghbalieh M.D., Chair

Wagih Ibrahim M.D., Vice-Chair

CCMC Medical Staff LeadershipJanuary 1, 2017 – December 31, 2018

Facility Executive CommitteeMichael Gen M.D., Chair

Siew Ming Lee M.D., Vice-Chair

CardiologyThampi John M.D., Chair

MedicinePatrick Louis-Jacques M.D., Chair

SurgeryChristina Maser M.D., Chair

Kamell Eckroth-Bernard M.D., Vice-Chair

CardiologyUsman Javed M.D., Chair

Alfred Valles M.D., Vice-Chair

Emergency MedicineMichael Cawdery M.D., ChairBrian Horan, M.D., Vice-Chair

Medicine / Family Medicine / Psychiatry / Psychology /

Physical Medicine & RehabilitationGloria Jimenez M.D., ChairVijay Joseph Daniel M.D.,

Vice-Chair

Ob-Gyn / PediatricsLura Reddington M.D., Chair

Anand Rajani M.D., Vice-Chair

RadiologyPaul Speece M.D., Chair

Frank Chang, M.D., Vice-Chair

Surgery / PathologyMark Cunningham M.D., ChairSiew Ming Lee M.D., Vice-Chair


CORNERMEDICAL STAFF PRESIDENT

Monteith Austin M.D.Department: SurgerySpecialty: Thoracic-Cardiovascular

Kalyani Chandra M.D.Department: MedicineSpecialty: Nephrology

Carlos Claudio-Rodriguez M.D.Department: MedicineSpecialty: Nephrology

David Collins D.O.Department: MedicineSpecialty: Internal Medicine

Daniel Hernandez M.D.Department: OB/GYNSpecialty: OB/GYN

Stewart Kerr M.D.Department: SurgerySpecialty: Orthopedic Surgery

Richard Lamour M.D.Department: SurgerySpecialty: Orthopedic Surgery

Nicholas Levine M.D.Department: SurgerySpecialty: Neurosurgery

Victor McCray M.D.Department: SurgerySpecialty: General Surgery

Shahriar Mokrian M.D.Department: PediatricsSpecialty: Pediatric Neonatology

Jonathan Romanyshyn M.D.Department: SurgerySpecialty: General Surgery

Arang Samim M.D.Department: CardiologySpecialty: Cardiology

Tamara Shamlian D.D.S.Department: SurgerySpecialty: General Dentistry

Robert Slack M.D.Department: MedicineSpecialty: Neuro-Critical Care

Erick Stephanian M.D.Department: SurgerySpecialty: Neurosurgery

Dereck Taggard M.D.Department: SurgerySpecialty: Neurosurgery

Thimmaiah Theethira M.D.Department: MedicineSpecialty: Internal Medicine

Ying Wu M.DDepartment: MedicineSpecialty: Rheumatology

Initial Appointment to the Medical Staff effective October 13, 2016

New Medical Staff Members Approved by the Medical Executive Committee and the Board of Trustees

Daniel Allan Bentley P.A.Department: SurgerySpecialty: Thoracic and Cardiac Surgery

Jordan Scott Bevan P.A.Department: SurgerySpecialty: Neurosurgery

Maximillian Cruz P.A.Department: Emergency MedicineSpecialty: Emergency Medicine

Robert Ford C.RN.A.Department: SurgerySpecialty: Anesthesiology Kathleen Gorman N.P.Department: PediatricsSpecialty: Pediatric Neonatology

Marne B. Johnson N.P.Department: SurgerySpecialty: Neurosurgery

William Jones P.A.Department: SurgerySpecialty: Neurosurgery

Jannifer Matos P.A.Department: Emergency MedicineSpecialty: Emergency Medicine Christopher Moorman P.A.Department: SurgerySpecialty: Neurosurgery

Initial Appointment to the Medical Staff effective October 13, 2016

New Allied Health Professionals Approved by the Medical Executive Committee and the Board of Trustees


Community Medical Centers Board of Trustees approved funding for a $68 million, 100,000-square-foot re-gional cancer treatment and research center – the first of its kind in the San Joaquin Valley.

Construction starts early next year on the three-story Center to be locat-ed on the Clovis Community campus, adjacent to Highway 168. The center is planned to open as early as summer 2018. Cancer services and expertise currently provided in mul-tiple locations, including Community Regional Medical Center, the Cali- fornia Cancer Center in north Fres-no, and Clovis Community Medical Center, will be consolidated here to provide a seamless experience for pa-tients.

“This project will house the lat-est in cancer treatments, research and clinical trials. Central California deserves to have this not-for-profit cancer center completed as quickly as possible to serve all the patients and families in our re-gion,” said Tim Joslin, president & CEO, Community Medi-cal Centers. “In my decade at Community, this is perhaps the single most important project I’ve had the privilege to plan. And it will serve Valley families for decades to come.”

In approving funding Community’s board also approved design plans that include space for up to four linear accelerators for radiation treatment, the latest in digital imaging, CT and MRI scanners, and the newest version of CyberKnife, a laser surgical system used to treat hard-to-reach tumors.

“Our board was extremely excited and supportive about bringing all of our cancer services and the newest technology under one roof,” said Paul Ortiz, vice president of Community’s cancer services. “I’m excited to be developing a comprehensive outpatient Cancer Center that will be a one-stop-shop for our patients. It will enhance how we care for patients, help us better coordinate care between different physicians and, at the end of the day, improve outcomes.”

Ortiz noted that the need for outpatient chemotherapy, cancer surgeries and radiation treatments in the Valley is expected to increase by 29% and 16% respectively within the next decade, and the American Cancer Society predicts

Construction to Start on Community’s 100,000-square-foot Cancer Center

1 in 3 women and 1 in 2 men will get cancer in their lifetime. Statistics like these make it imperative that the Valley have a Center that consolidates all required expertise, technology, research, and support services so that families don’t feel the need to travel elsewhere for treatment, said Ortiz.

“The goal is to build a world-class cancer treatment facility to keep patients closer to their homes and their families’ support,” agreed Christopher Perkins M.D., board-certified medical oncologist.

The vision for the Cancer Center is to bring comprehensive outpatient services under one roof including imaging, radiation and chemotherapy and to facilitate a multidisciplinary team of physicians and support staff to provide one place for patients to come for their clinic visits, lab work, medications, and support services. All this currently requires visiting

different providers in different locations.“Consolidation of outpatient cancer services under one

roof goes a long way toward providing faster and more convenient care for our patients. It also allows physicians to collaborate more efficiently, and ultimately elevates the level of cancer care in the Valley,” said Dr. Uma Swamy, radiation oncologist at Community’s California Cancer Center.

Besides bringing a multidisciplinary team approach to fighting cancer, the Center would continue to enhance its clinical trials program in collaboration with the University of California San Francisco’s medical staff to bring the lat-est cooperative and industry sponsored clinical trials to the Valley. The ultimate goal is to become a “Designated Can-cer Center” by the National Cancer Institute, said Ortiz. Ten such centers exist in California, but none in the San Joaquin Valley.

“We expect this to be a recognized best-practice location – elevating cancer treatment, research and ultimately positive patient outcomes for Valley families,” said Michael Peterson M.D., Associate Dean and Chief of Medicine of the UCSF Fresno Medical Education Program.

Reported by Erin Kennedy. Reach her at [email protected].

Community’s regional cancer center will be three stories tall and house the latest imaging and radiation treatment technology, chemo-therapy, pharmacy, lab and support services.

Community’s planned regional cancer center would be loacted at the north end of the Clovis Community Medical Center campus. This view is looking directly south with the L-shaped cancer center in the foreground.

mailto:[email protected]


Dr. Ron Lichtenstein and the staff of the California Pregnancy Center were honored with the first Health Officer’s Pillar of Public Health Award presented by the Fresno County Department of Public Health (FCDPH). Dr. Lichtenstein was recognized for his valuable assistance in the FCDPH’s response to the on-going local syphilis/congenital syphilis epidemic. He and his staff were commended for their early diagnosis, rapid treatment and thorough care throughout pregnancy that prevented countless numbers of babies from being born with this terrible disease.

“Without your tireless, professional efforts this county would surely suffer the horrific consequences of many more babies being born with this terrible disease,” said Health Officer Dr. Ken Bird. “I sincerely admire the work you have done in keeping the residents of this county healthy and very much look forward to our future work together.”

FCDPH held a reception at Community Regional Medical Center where Health Officer Dr. Ken Bird recognized Dr. Lichtenstein and staff at a luncheon in their honor.

physician Accomplishment

Fresno County’s First ‘Pillar of Health’ AwardPresented to Dr. Ron Lichtenstein and Staff

By Mary Lisa Russell, Sr. Communications Strategist

Health Officer Dr. Ken Bird (left) and Dr. Ron Lichtenstein

Health Officer Dr. Ken Bird, Dr. Lichtenstein and his staff.

Continued on page 23

“It is an incalculable added pleasure to any one’s sum of happiness if he or she grows to know, even slightly and imperfectly,

how to read and enjoy the wonder-book of nature.”

– Theodore Roosevelt, 26th US president and Naturalist

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On October 14, the Department of Health and Human Services (HHS) issued the final rule implementing the Physician Quality Payment program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As the rule is complex and is 2,398 pages long, what follows is a high level overview.

By way of background, MACRA came into being in April of 2015 when congress passed this bill and did away with the Sustainable Growth Rate (SGR). MACRA established two tracks for providers, the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APM). MIPS was designed for providers who are reimbursed through fee-for-service, while APM was designed for physicians who are involved in risk based payment programs e.g., Next Generation Accountable Care Organization (ACO) Model and Medicare Shared Savings Program (MSSP) Tracks 2 and Track 3. MIPS combines Meaningful Use, Value Based Payment Modifier, and the Physician Quality Reporting System all into one program. Medicare estimates these programs will affect roughly 100,000 providers on the APM side and 500,000 on the MIPS side. Providers who qualify for the program but do not participate in the APM or MIPS paths will receive a 4 percent negative payment adjustment. Eligible providers include those who annually bill Medicare for more than $30,000 or care for more than 100 Medicare beneficiaries. This applies to: Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists.

UPDATEMACRA

Warning: Multiple Acronym Alert!

By Tom Utecht M.D., CMC Chief Medical and Quality Officer

If you are still reading, you are probably asking what does an eligible provider need to do. For the MIPS program in calendar year 2017, you are required to:

• Report on at least one quality outcome measure of a minimum of 90 days (there are over 200 measures, 80% which are tailored for specialties)

• Attest that you completed between two and four (depends on group size) quality improvement activities for a minimum of 90 days (over 90 activities to choose from)

• Fulfill 6 different EHR activities for a minimum of 90 days e.g. e-Prescribing, Sending Summary of Care

For calendar year 2018, cost reporting will be necessary – this will be based on ten different episodes of care cost.

A few early thoughts/take aways – 60% of the score is based on the quality measures, so focus on this area is important. If possible, consider trying to meet the 2018 calendar year requirements in 2017, this will serve as practice for the harder requirements in 2018. Finally, don’t ignore the cost category, it will be worth 30% of the score in CY 2019.

Below are resources for further information:• www.ama-assn.org/go/medicarepayment• https://qpp.cms.gov/docs/Quality_Payment_Program_

Overview_Fact_Sheet.pdfBy the way, in the Final Rule, there are 72 acronyms.

My favorite is a river in New Mexico and Texas, PECOS, just kidding, it stands for – “Medicare Provider Enrollment, Chain, and Ownership System.”

Editor’s Note: With the finalization in late October of the MACRA Rule, we were pleased to receive article content from both Dr. Utecht and CMC’s Government Reimbursement Director, James Cole. These articles have somewhat different emphasis and so we present them both for our readers. By the way, experts say MACRA is likely to be implemented essentially unchanged despite big changes in Washington, DC. It passed

with nearly unanimous bipartisan support, it buried the very problematic SGR legacy, it purports to controls costs, and it moves Medicare away from strictly fee-for-service payment. Not only that but most aspects of MACRA do not depend on Affordable Care Act provisions. If anything it may be the Alternate Payment Models that change, not the MIPS part of it which is more relevant to most providers, at least initially.

http://www.healthcarefinancenews.com/news/macra-will-move-forward-largely-untouched-when-trump-steps-experts-say

www.ama-assn.org/go/medicarepayment

https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf


Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the

Physician Fee Schedule, and Criteria for Physician-Focused Payment Models: Final Rule with Comment Period

By James Michael Cole, Director, Government Reimbursement

UPDATEMACRA

Since publication of the Proposed Rule, CMS received over 4,000 formal comments and held meetings around the country attended by over 100,000 people. The result is a Final Rule that provides further flexibilities from the proposed rule in order to help clinicians transition into the new payment system. The provisions of this Final Rule are effective on January 1, 2017. CMS will continue to accept comments 60 days after the date of filing for public inspection at the Office of the Federal Register.

Transition Year – 2017CMS refers to the first performance

year, 2017, as a transition year, providing choices to eligible clinicians to participate in ways appropriate for their practice. The Pick Your Pace provision allows for four ways of participating in 2017 in order to avoid a negative payment adjustment. Non-reporting in 2017 will lead to an automatic negative adjustment of 4 percent in 2019.

Option 1: Test the program. By reporting one measure each in the quality and improvement activity categories or reporting the measures in the advancing care information category, clinicians can avoid a negative adjustment in 2019.

Option 2: Partially report. By reporting one measure in each performance category for a full 90 days in 2017, clinicians can avoid a negative adjustment and have the opportunity to possibly receive a small positive adjustment in 2019.

Option 3: Fully report. By reporting fully for 90 days to a full year, a clinician can earn a moderate

positive payment adjustment and may be eligible for additional payment adjustments as exceptional performers.

See MACRA on page 10

In some respects participants in Alternate Payment Models (APMs) will have a simpler and more predictable experience than MIPS participants.

Here is that comparison:

Over time, the positive and negative payment features of MIPS will look like this:


MACRA Compared to Current Law: Bonuses, Penalties and Payment Updates

California Medical Association: (800) 786-4262 or [email protected] Page 1 of 1

Year

BONUS (excludes Exceptional Bonus)

PENALTIES FEE SCHEDULE INCREASES (regardless of performance)

Current MACRA Current MACRA Current MACRA MIPS+ QAPMs MIPS+ QAPMs MIPS APMs

2015 0 N/A N/A -4.5%

N/A N/A -21% under SGR

N/A N/A

2016 0 N/A N/A -6% N/A N/A 0% +0.5% +0.5% 2017 0 N/A N/A -9% 0% 0% 0% +0.5% +0.5% 2018 0 N/A N/A -10% 0% 0% 0% +0.5% +0.5% 2019 0 +4% +5% -11% or more 0%* 0%* 0% +0.5% +0.5% 2020 0 +5% +5% -11% or more -5% 0% 0% 0% 0% 2021 0 +7% +5% -11% or more -7% 0% 0% 0% 0% 2022 0 +9% +5% -11% or more -9% 0% 0% 0% 0% 2023 0 +9% +5% -11% or more -9% 0% 0% 0% 0% 2024 0 +9% +5% -11% or more -9% 0% 0% 0% 0% 2025 0 +9% +5% -11% or more -9% 0% 0% 0% 0% 2026 + 0 +9% 0% -11% or more -9% 0% 0% +0.25% +5.75%

* CMS will not impose penalties for the 2017 performance reporting period for physicians who report for one patient on one quality measure, one improvement activity, or the four required EHR Advancing Care Information measures. However, physicians who choose not to report any performance data will be subject to a 4% penalty.

+ Bonuses and penalties in MIPS, not including exceptional performance bonuses, must be budget neutral.

APMs shall receive 5% bonus payments.

UPDATEMACRA

MACRA Compared to Current Law:Bonuses, Penalities and Payment Updates

* CMS will not impose penalties for the 2017 performance reporting period for physicians who report for one patient on one quality measure, one improvement activity, or the four required EHR Advancing Care Information measures. However, physicians who choose not to report any performance data will be subject to a 4% penalty.+ Bonuses and penalties in MIPS, not including exceptional performance bonuses, must be budget neutral.APMs shall receive 5% bonus payments

California Medical Association: 800-786-4262 or [email protected].

Continued from page 9

Option 4: Participate in an Advanced Alternative Payment Model (AAPM). Those receiving 25% of Medicare payments or seeing 20% of Medicare patients through an AAPM in 2017, can earn a 5% incentive payment in 2019.

For More InformationHospitals & Health Networks 5 Things to Take Away

from the MACRA Final Rule: http://www.hhnmag.com/articles/7748-things-to-take-away-from-the-macra-final-rule?utm_campaign=101816&utm_medium=email&utm_source=hhndaily&eid=254468997&bid=1560321

Final Rule: https://qpp.cms.gov/docs/CMS-5517-FC.pdfExecutive Summary: https://qpp.cms.gov/docs/QPP_

Executive_Summary_of_Final_Rule.pdf

Press Release: www.hhs.gov/about/news/2016/10/14/hhs-finalizes-streamlined-medicare-payment-system-rewards-clinicians-quality-patient-care.html

Quality Program Fact Sheet: https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

Small Practice Fact Sheet: https://qpp.cms.gov/docs/QPP_Small_Practice.pdf

Alternative Payment Models in the Quality Payment Program: https://qpp.cms.gov/docs/QPP_Advanced_APMs _in_2017.pdf

Quality Payment Program Web Site: https://qpp.cms.gov

Submit a Formal Comment electronically: https://www.regulations.gov

http://www.hhnmag.com/articles/7748-things-to-take-away-from-the-macra-final-rule?utm_campaign=101816&utm_medium=email&utm_source=hhndaily&eid=254468997&bid=1560321

https://qpp.cms.gov/docs/CMS-5517-FC.pdf

https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf

www.hhs.gov/about/news/2016/10/14/hhs-finalizes-streamlined-medicare-payment-system-rewards-clinicians-quality-patient-care.html

https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

https://qpp.cms.gov/docs/QPP_Small_Practice.pdf

https://qpp.cms.gov

https://www.regulations.gov


https://qpp.cms.gov/docs/QPP_Advanced_APMs_in_2017.pdf


By Judi Binderman M.D.Community Medical Centers Chief Medical Information Officer

“Whatever you can do or dream you can, begin it. Boldness has genius, magic, and power in it.”

– Johann Wolfgang von Goethe

JUDi binderman M.D.

As we start turning to the end-of-year activities, there’s still a lot happening:

New Code status orders will go live on November 29, to more closely align with the POLST form. There is an online training video available if you would like more information.

e-Prescribing of Controlled Substances is now open to anyone interested in enrolling. We’re seeing a steady 3-5 people completing the identify proof process daily; everyone I’ve talked to is loving the convenience of being able to e-prescribe all of a patient’s medications.

Beacon for chemotherapy orders is now LIVE at the Clovis AIC. Things have gone smoothly, and the providers are excited about the ease and convenience of placing orders, administering chemo and documenting it all in one place. We continue to work on additional protocols to get

ready for the CRMC AIC and inpatient care… date not yet set for those.

From the IT side of the house – if you need help from the Help Desk, but can’t wait on the line, you can now leave a number for them to call you back! The new process went live late last week, and so far, the return calls have actually been successfully able to reach the individual, and resolve issues. Give it a try next time you need assistance!

Short and sweet – just a teaser before the holidays! Happy Thanksgiving!

from THE DESK OF

http://forum.cmcinet.org/departments/emphealth/Lists/Flu%20Declination/DeclinationForm.aspx?Source=/departments/emphealth


Eye-Q Vision Care is living up to its name with their gift to Community Medical Centers’ regional cancer and research center, putting them in the “Visionary” level of giving, one of the highest donor recognition levels.

This gift will help build the only comprehensive cancer center of its kind in the San Joaquin Valley, combining services and expertise currently provided in multiple locations to create a seamless patient experience. The center is planned to open as early as 2018.

For nearly 40 years, Eye-Q Vision Care and Community have partnered to be leaders in both eye care and healthcare for the Valley – each embracing the other’s mission and goals. And once again, they are helping answer the call of the growing community.

“We are honored to be one of the first to fund this comprehensive cancer center, which is so needed in the Valley,” said Brian Cavallaro, M.D., Board President of Eye-Q Vision Care. “We all live and work in this community – it’s home – and we see the need for cancer care services every day in our own families, our patients and employees. We want to do our part.”

Eye-Q: A Visionary for Valley Cancer PatientsBy Ashlie Day

Community Medical Foundation

Eye-Q Vision Care Board of Directors from left: Alan V. Nerenberg M.D., Brian E. Cavallaro M.D., Richard L. Moors M.D., F. Campbell Waldrop M.D., Samuel P. Hinton M.D., B. Michael Walker M.D.

Katie Zenovich, Community’s vice president of Corporate Development and Chief Development Officer, hopes this gift from Eye-Q Vision Care encourages other businesses and individuals to realize the need for comprehensive cancer care in the Valley and step up to help build it. “We are so grateful for Eye-Q Vision Care’s continued support. I hope others consider joining us on this journey to build this one-of-a-kind cancer center, so all those touched by this devastating disease can get the world-class care they need in one place, right here at home,” Zenovich said.

Last month, Eye-Q Vision Care took their giving a step further with their employees and chose to give all proceeds from their breast cancer awareness campaign, #EyeSeePink, to the Marjorie E. Radin Breast Care Center at Clovis Community Medical Center.

You too can join Eye-Q and help build this much needed cancer center. Donate today by calling Community Medical Foundation at 559-459-2670 or visit our website at www.CommunityMedical.org/Beat-Cancer. Your gift to this project provides hope for all those in the Valley who have been or will be touched by cancer.

www.CommunityMedical.org/Beat-Cancer


Editor’s Note: The AMA Code of Medical Ethics has long served as a benchmark for the profession, both internally among physicians and with respect to how the American public and media regard the medical profession’s ethical standards.

For the first time in more than 50 years, after a multi-year process which involved stakeholders within and outside of the medical profession, the AMA has now updated (“modernized” is the term they use) this comprehensive document.

In the Code, these Principles are followed by 11 chapters that include opinions representing interpretations of relevant Principles as they applied to a specific matter of ethical import in medicine. Those chapters and examples of topics addressed.

The Modernized Code of Ethics is available to AMA members on line. For those with medical staff and/or education leadership roles or who just have an interest in the field, this is an important new resource (also available in book form for purchase).

AMA Updates its Code of Ethics

AMA Principles of Medical Ethics1. A physician shall be dedicated to providing competent medical

care, with compassion and respect for human dignity and rights.2. A physician shall uphold the standards of professionalism, be honest

in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

4. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

5. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

6. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

7. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

8. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

9. A physician shall support access to medical care for all people.

Chapters in the Modernized AMA Code With Sampling of Topics Addressed in Ethics Opinions

Code Chapters Ethics OpinionsPatient-Physician Relationships Patient rights; use of chaperones; treating self or familyConsent, Communication & Decision Making Use of placebo in clinical practice; pediatric decision making; professionalism in the

use of social mediaPrivacy, Confidentiality, & Medical Records Filming patients for public education; confidentiality post-mortem; confidentiality and

electronic medical recordsGenetics & Reproductive Medicine Third party access to genetic information; cloning for reproduction; abortionCaring For Patients at the End of Life Advance care planning; withholding or withdrawing life-sustaining treatment; euthanasiaOrgan Procurement & Transplantation Organ donation after cardiac death; umbilical cord blood banking; xenotransplantationResearch & Innovation Safeguards in the use of DNA databanks; international research; release of data from

unethical experimentsPhysicians & the Health of the Community Routine universal screening for HIV; disparities in health care; physicians’

responsibilities in disaster response and preparednessProfessional Self-Regulation Reporting incompetent or unethical behavior by colleagues; financial relationships with

industry in continuing medical education; physician participation in interrogationInter-Professional Relationships Peers as patients; industry representatives in clinical settings; ethics committees in

health care institutionsFinancing & Delivery of Health Care Physician stewardship of health care resources; retainer practices; fee splitting

https://www.ama-assn.org/about-us/code-medical-ethics

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Get Smart about Antibiotics Week will be observed November 14-20, 2016, That happens to coincide with the kick off of Community Regional Medical Center’s (CRMC) physician led Antimicrobial Stewardship Pro- gram. This annual one-week obser- vance is to raise awareness of the threat of antimicrobial resistance and the importance of appropriate antimicrobial prescribing.

Antimicrobial use is the single most important factor leading to antimicrobial resistance worldwide. It is estimated that up to 50% of all antimicrobials prescribed are not necessary or are not effectively prescribed. For these reasons, Community Medical Centers’ leadership has committed resources for antimicrobial stewardship. The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, such as toxicity and the emergence of resistant pathogens. In order to promote appropriate antimicrobial usage CMC has instituted the following measures:

• Committees that review/focus on antimicrobial stewardship

• Policies that support antimicrobial stewardship• Mandatory “Indications of Use” for all systemic

antimicrobial medications and mandatory duration during order entry

• Reserved Antimicrobial policy• Order sets and guidelines available for specific

antimicrobials and disease states• Facility specific antibiograms are available on the

Intranet (CMC Forum under the Documents tab > Reference folder > Antibiograms)

• Offer education for providers, staff and patients/caregivers

These are only a few examples, as the Antimicrobial Stewardship Program (ASP) at each facility continues to

expand. As part of the inclusion of National Quality Form and Centers for Disease Control and Prevention core elements for the new Medication Manage- ment Antimicrobial Stewardship standard an “Antibiot-ic Time Out” af-ter 48 hours will be implemented

on November 29, 2016 (see New 48 Hour Review for Antimicrobials education flyer on page 16 for additional information). Avoiding the use of unnecessary antimicrobials reduces the risk of Clostridium difficile infections (CDI). Discontinuing unnecessary antimicrobials in patients with new diagnoses of CDI will improve the clinical response to CDI treatment and minimize the risk of recurrence. Many physicians regularly review antimicrobial therapy, but it is imperative antimicrobial therapy be reviewed early in the course of therapy to optimize selection, dosing, route and duration of antimicrobial therapy. Reducing our CDI rates is an Infection Control priority across all CMC facilities.

Practitioners at CRMC may notice Antimicrobial Stewardship recommendations in the electronic health record progress notes from physician ASP team members. These recommendations do NOT substitute for an Infectious Diseases (ID) consult. If an ID consult is desired please feel free to consult ID for further input of patient management. It is essential practitioners give ASP recommendations thoughtful consideration and implement as appropriate.

See Get Smart on page 15

By Naiel Nassar M.D., UCSF Fresno Infectious Diseases Director, Antibiotic Subcommittee Chair; and Marisa Méndez PharmD., M.P.H., B.C.P.S., Antimicrobial Stewardship Coordinator

Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die as a direct result of these infections. – CDC

ANTIBIOTICS WEEK

NOVEMBER-DECEMber 2016 •

At right is an update of the total number of antimicrobial stewardship activities tracked for each facility since November 2015.

Get SmartContinued from page 14

ReferencesCenters for Disease Control and Prevention. Get Smart About Antibiotics. www.cdc.gov/getsmart/week/overview.html. Accessed September 1,

2016.CDC Core Elements of Hospital Antibiotic Stewardship Programs. www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf. Accessed 5/5/16.Cohen S, Gerding D, Stuart J, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for

Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31:431-455.

Drekonja DM, Amundson WH, Decarolis DD, et al. Antimicrobial use and risk for recurrent Clostridium difficile infection. The American Journal of Medicine. 2011;124:1081-1087.

Joint Commission Perspectives. Approved: New Antimicrobial Stewardship Standard. July 2016, Vol 36, Issue 7. www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf

Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. The Journal of Antimicrobial Chemotherapy. 2012;67:742-748.

National Quality Forum. National Quality Partners Playbook: Antibiotic Stewardship in Acute Care. May 2016.

ANTIBIOTICS WEEK

“If you look at what you have in life, you’ll always have more. If you look at what you don’t have in life, you’ll never have enough.”

– Oprah Winfrey, media personality, businesswoman and philanthropist

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www.cdc.gov/getsmart/week/overview.html

www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf

www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf


ANTIMICROBIALSOne of the elements of the new Medication Management Antimicrobial Stewardship

Standard is performing an evaluation of ongoing antimicrobial treatment need, after a set period of initial treatment (“Antibiotic Time Out” after 48 hours);

• Under the Orders navigator a Review button will appear if a patient has an active antimicrobial order for at least 48 hours

ANTIBIOTICS WEEKATTENTION: PHYSICIANS

New 48-Hour Review for AntimicrobialsAntimicrobial Stewardship Standard: Evaluating Whether Initial Antimicrobial

Treatment is Still Warranted

Important New Antimicrobial Stewardship Standard from The Joint Commission“Antibiotic Time Out” after 48 hours will be implemented on November 29, 2016

• The physician or licensed independent practitioner (LIP) should review the antimi-crobial order and determine if the order needs to be continued, modified, or discontinued.

> Selecting Review will acknowledge the physician/LIP would like to continue the an-timicrobial for the duration specified in the original order (e.g. ceftazidime will be continued for 5 days).

> The Review button will only appear after the first 48 hours. Once acknowledged it will not re-appear for the same active order.

> Other healthcare providers can view the reconciliation audit report to assist in determining if the physician/LIP intended for an antimicrobial to be continued or decided to take another action (Renew, Let Expire, Modify, or Discontinue).

Rationale:• The continued need for antimicrobial therapy should be evaluated after 48 hours when

more patient specific and dia-gnostic information is available.

Workflow:• After 48 hours of a consecutive antimicrobial order a review option will appear• If no action is taken, nothing will appear in the reconciliation audit report. The order will

remain active for the duration specified• The antimicrobial stewardship team will utilize this report to assist with antimicrobial

review


Last year in Fresno County 40 cases of tuberculosis (TB) were identified among county residents. To date this year 51 individuals have been diagnosed with the illness, including a local high school student.

This number is considerably lower than the 102 cases reported in 2004, but the fairly steady decline in those numbers from 2004 to 2012 has stabilized and slightly reversed itself in recent years.

While this infectious illness is not endemic in this country, as it is in many parts of the world, and while the incidence nationally continues to slowly decrease, we do not seem to be anywhere near its elimination in the U.S.(as defined by the CDC’s Division of Tuberculosis Elimination as fewer than one case per million population).

TB control in this country is accomplished through four activities which include:

• Prompt identification and adequate treatment of persons that have active disease.

• Prompt and complete identification of individuals who have been exposed to someone with TB disease, evaluation for TB infection or TB disease, and treatment of either of these.

• Screening of all individuals for TB infection risk and testing of those that are known to be at higher risk for infection with TB or at higher risk for developing TB Disease if infected.

• Application of control measures in high risk settings. The Fresno County Department of Public Health

(FCDPH) works closely with local healthcare providers in identifying and treating individuals with TB disease, and with local healthcare facilities in applying control measures in high risk settings. The department works in large part on its own in identifying, evaluating, and treating contacts to individuals with TB disease. These measures are well

Screening for Latent Tuberculosis Infection in Adults: Clinical SummaryPopulation Asymptomatic adults at increased risk for infectionRecommendation Screen for latent tuberculosis infection (LTBI). Grade: BRisk Assessment Populations at increased risk for LTBI include persons who were born in, or are former residents of, countries with

increased tuberculosis prevalence and persons who live in, or have lived in, high-risk congregate settings (eg, homeless shelters and correctional facilities). Local demographic patterns may vary across the United States; clinicians can consult their local or state health departments for more information about populations at risk in their community.

Screening Tests Screening tests include the Mantoux tuberculin skin test and interferon-gamma release assays; both are moderately sensitive and highly specific for the detection of LTBI.

Treatment and The CDC provides recommendations for the treatment of LTBI at:Interventions www.cdc.gov/tb/topic/treatment/ltbi.htm.Balance of Benefits The USPSTF concludes with moderate certainty that the net benefit of and Harms screening for LTBI in persons who are at increased risk for tuberculosis is moderate

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org.

Screening for Latent Tuberculosis: New US Preventive Service Task Force Recommendations are Important for TB Control

Submitted by Ken Bird M.D., Fresno County Public Health Officer

established and quite effectively implemented in our county, and little can be done to improve their efficacy other than maintaining a high degree of suspicion of TB for all patients presenting with respiratory or systemic symptoms.

The same cannot be said, however, for the process of screening for TB infection risk, and elimination of TB in this country depends on its full implementation.

Recently, the United States Preventive Services Task Force, recognizing the importance of this activity, released a reportrecommending screening for latent TB infection (LTBI) – see Table below – in populations at increased risk, which includes persons who were born in, or are former residents of, countries with increased TB prevalence and persons who live in, or have lived in, high-risk congregate settings (such as homeless shelters and correctional facilities). Print readers can find it in JAMA (free access) by searching “Screening for Latent Tuberculosis Infection in Adults US Preventive Services Task Force Recommendation Statement.”

FCDPH released a Health Information notice to local providers on November 2 recommending that providers screen ALL patients for risk for TB infection and test those patients determined to be at higher risk according to tools available from the California Department of Public Health for both adults and children.

Patients thus identified, tested, and found to have TB infection should be offered treatment for the infection once clinically active TB disease is ruled out by appropriate clinical evaluation which includes chest x-ray. This LTBI treatment can now be offered as a nine month course of daily isoniazid, a four month course of daily rifampin, or a twelve week course of weekly isoniazid plus rifapentine.

The tools and the knowledge to eliminate TB in our community, and our state, are available to us, but we have to use them.

www.cdc.gov/tb/topic/treatment/ltbi.htm

http://www.uspreventiveservicestaskforce.org

http://jamanetwork.com/journals/jama/fullarticle/2547762#UpdateofPreviousUSPSTFRecommendation

sponsored by:

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GOLF TOURNAMENT - Friday, February 24thJoin the golf tournament that will take place on Arizona’s dazzling TPC Golf Course at the Fairmont Scottsdale Princess, home of the PGA Waste Management Phoenix Open. Hosted by Santé Health Foundation and Community Medical Centers.

HIGHLIGHTS INCLUDE:

World-Renowned Pediatric Neurosurgeon, Inspirational Speaker, New York Times Best-Selling Author, Syndicated Columnist and former Candidate for President of the United States

Benjamin Carson, MDMayo trained Family Practice Physician with a unique combination of ground level experience in medicine, coaching and personal and business development.

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The UCSF Fresno / Community Medical Centers Lung Nodule Program is a robust program focused on early diagnosis and expedited treatment of lung cancer. This program works on two major mantras: first to speed cancer diagnosis and cancer staging; and secondly to improve survival by rapid treatment access and a meticulous periodic follow-up of these patients for 5 years. The key is a multi-disciplinary team that meets weekly to decide diagnostic work ups and then treatment plans. The team includes skilled endoscopists who both biopsy lung nodules and sample suspicious regional nodes at the same time, reducing the need for follow up procedures.

This kind of treatment is crucial to the central San Joaquin Valley. Per the recent Cancer Statistic Data (CA CANCER J CLIN 2016; 66:7-30), California has the highest number of newly diagnosed lung cancer patients compared to any other state in the country. Community Regional Medical Center and the California Cancer Center provides care to over half of the lung cancer patients diagnosed in Fresno County each year. The American Cancer Society’s “California Cancer Facts and Figures 2016” details cancer diagnoses by counties. A total of 403 patients (see the Table 1 below) were newly diagnosed with lung cancer in Fresno County; of these 211 patients were diagnosed and cared for at Community facilities. This trend has been consistently maintained over several years.

Community’s Lung Nodule Program Catches Cancer Earlier, Speeds Treatment

By Daya Upadhyay M.D., UCSF Associate Professor of Medicine, Lung Nodule Program Medical Director, Dir. of Translational Research in Medicine, Pulmonary, Critical Care and Sleep Medicine at UCSF Fresno

CMC data: New lung cancer cases from 2010 to 2015:

Year Diagnosed 2010 2011 2012 2013 2014 2015

No. of Patients 246 221 243 211 213 224

Table 2: CMC data: Lung Cancer Diagnosis

Lung Cancer Stageat the Diagnosis I II III IV Unknown All Stages

Lung Nodule Program – 2015 58% 6% 20% 16% 0% 108–100%

Lung Nodule Program – 2010 19% 8% 15% 53% 5% 45–100%

California cancer facts 2016 data from American Cancer Society:Table 1: Observed New Cancer Cases, 2013

Since the conception of Lung Nodule Program in 2009, we have progressively advanced the care of lung nodule and lung cancer patients. Nearly half of all lung cancer patients now cared for at Community have been diagnosed and followed within the Lung Nodule Program. Moreover, because of the aggressive approach to early detection of cancer in the Lung Nodule Program, the percentage of lung cancer diagnosed at Stage 1 has significantly increased from 19% in 2010 to 58% in 2015. (See the Table 2 below.) Early detection and early management are the only factors that have been shown to improve survival in lung cancer. Therefore, the change in the diagnostic paradigm to detection of lung cancer at Stage 1 in over two-thirds of our patients will have significant impact on improved survival over the next five years. All of these patients are periodically followed-up in the Lung Nodule Program to assess responses to treatment and any evidence of recurrence.

This impact of early stage diagnosis and survival is the result of hard work and invested time put in by the Lung Nodule Program’s care team at Community. In order to diagnose those 108 patients with lung cancer in 2015, we had to provide care for more than 1,500 patients with lung nodules last year to detect the nodules which were in fact lung cancer.

However, this investment in the time and work is critically essential to save lives in lung cancer. This is because early stage lung cancer patients are completely asymptomatic and usually early stage lung cancer presents as a small lung nodule or a spot in the lung. It takes the expertise of the Lung Nodule Program team to differentiate nodules from infections such as Valley Fever to that of cancer etiology.

To help catch even more lung cancers at these early, more curable stages, we’re encouraging primary care physicians with patients who are long-time smokers, or who have smoked significant years in the past, to order lung screenings and refer these patients right away when lung lesions are found. Working together we can increase our cure rates.


On Saturday, Oct. 29, we highlighted the 11th annual World Stroke Day at Community Regional Medical Center with a special walk and festivities to raise awareness of stroke symptoms, educate our community and celebrate our survivors. On this day, communities across the globe raise awareness and promote education of this serious disease. Stroke is treatable – but you must know the facts, how to recognize stroke symptoms fast and where to seek treatment.

In the United States alone, almost 800,000 people have a stroke each year. Stroke kills approximately 130,000 Americans per year, accounting for one death every 4 minutes on average. It is the fifth-leading cause of death and the leading cause of serious disability. This is responsible for an estimated $34 billion annual cost, due to both the direct health expenses of treating stroke related health problems and providing care for those left with permanent disability, as well as the indirect costs of missed work and lost productivity in the workforce. Although long thought of as a disease afflicting the elderly, recently published research demonstrated a 44% nationwide increase in stroke among younger adults, ages 25 to 44.

Here in the Central Valley we face additional challenges. The rate of new stroke in Fresno County is higher than the California state average. Additionally the rate of deaths from stroke in Fresno, Kings, Tulare, Merced, and Stanislaus counties are among the highest in the nation according to the Center for Disease Control and Prevention (CDC). High blood pressure and obesity, both risk factors developing stroke, are higher in Fresno County than the state average.

These are sobering statistics by any measure. But there is good news as well.

The methods used to treat a new stroke these days are more effective than any time in history. The last several years have witnessed the emergency of highly effective endovascular stroke therapies (i.e. treatments involving physically removing the blockage of a brain blood vessel) in addition to the previously available intravenous therapy (i.e. injecting a “clot-busting” medication into a vein).

To date, there have been numerous large studies published involving a wide variety of stroke patients across four continents demonstrating the ability of the newer endovascular treatments, especially in combination with intravenous treatment when possible. I am proud to have personally witnessed such improvements in patients that I have had the honor to treat along with the two other members of our endovascular neurosurgical team at Community Regional Medical Center.

In numerous cases, patients who came in with strokes severe enough to have been fatal or severely disabling

instead were able to return home after a brief hospital stay with no significant residual symptoms.

As of 2013, the stroke program at Community Regional has been able to provide this new service to hundreds of patients in the Central Valley, including patients from Fresno, Clovis, Visalia, Tulare, Madera, Merced, Sonora, and Hanford among other communities.

As the only stroke center in the Valley equipped to perform endovascular treatments, we are also proud of the relationships we have built with other Central Valley area hospitals to rapidly transfer patients to Community Regional if they are eligible for endovascular stroke treatment. We also have the Central Valley’s only dedicated neurologic intensive care unit (ICU) and team of neurointensive care physicians and nurses to manage the most complex stroke patients, including bleeding strokes and ruptured brain aneurysms. By contrast, previously Central Valley patients with complex stroke and ruptured brain aneurysms had to be sent to medical centers hours away, wasting critical time and adding travel expense for loved ones.

We also have more knowledge about what you can do to avoid a stroke than any time in history. New research published this year found that 90% of stroke worldwide can be prevented by modifying several important risk factors. These include treating high blood pressure, quitting cigarette smoking, avoiding excessive alcohol use (i.e. more than 2 drinks per day for a man or more than 1 drink per day for a woman), reducing weight for individuals who are overweight or obese, treating high cholesterol, switching to a diet rich in fish, vegetables, and fiber (and low in processed foods and red meats); engaging in regular exercise, and reducing overall stress levels. Incidentally, regular exercise is itself a proven method to reduce overall stress, while also reducing the risk of both stroke and heart disease in other ways.

Finally, perhaps the most single most important thing you should know about stroke is to call 9-1-1 as soon as possible if you or someone who love develops stroke symptoms. According to the American Stroke Association, 91% of patients who obtain modern stroke treatment within 2 ½ hours have a very good outcome. Time is of the essence, and every minute counts.

World Stroke Day and Valley Stroke CareBy Amir Khan M.D.


See Transfusion on page 23

JAMA: SPECIAL COMMUNICATIONClinical Practice Guidelines From the AABB:

Red Blood Cell Transfusion Thresholds and Storage

Jeffrey L. Carson M.D.; Gordon Guyatt M.D.; Nancy M. Heddle, MSc; Brenda J. Grossman M.D., MPH; Claudia S. Cohn M.D., Ph.D.; Mark K. Fung M.D., Ph.D.; Terry Gernsheimer M.D.; John B. Holcomb, M.D.;

Lewis J. Kaplan M.D.; Louis M. Katz M.D.; Nikki Peterson B.A.; Glenn Ramsey M.D.; Sunil V. Rao M.D.; John D. Roback M.D., Ph.D.; Aryeh Shander M.D.; and Aaron A.R. Tobian M.D., Ph.D.

Editor’s Note: This important communication (JAMA Online, Oct. 2016) is available open-access at JAMA website. Print readers can easily find it by title. We share with readers the Abstract and some CMC-related commentary below.

Methods: A literature search for randomized clinical trials (RCTs) evaluating hemoglobin thresholds for RBC transfusion (1950-May 2016) and RBC storage duration (1948-May 2016) without language restrictions. The results were summarized using the Grading of Recommendations Assessment, Development and Evaluation method.

For RBC transfusion thresholds, 31 RCTs included 12 587 participants and compared restrictive thresholds (transfusion not indicated until the hemoglobin level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the hemoglobin level is 9-10 g/dL). The summary estimates across trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism.

For RBC storage duration, 13 RCTs included 5515 participants randomly allocated to receive fresher blood or standard-issue blood. These RCTs demonstrated that fresher blood did not improve clinical outcomes.

Findings: It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient.

Recommendation 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence).

A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe

thrombocytopenia (eg, patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence).

Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence).

Conclusions: Research in RBC transfusion medicine has significantly advanced the science in recent years and provides high-quality evidence to inform guidelines. A restrictive transfusion threshold is safe in most clinical settings and the current blood banking practices of using standard-issue blood should be continued.

Editor’s Note: This JAMA report is the world’s most thorough analysis of evidence-based RBC transfusion in non-acutely bleeding patients. The conclusions largely support our existing CMC Medical Staff Transfusion Guidelines – Our Guideline 4b (for post-op status) is more liberal than the AABB guidance, but AABB does not break out “post-op status” as a separate group as we do.

Indications:1) Acute Blood Loss: Maintain circulating blood volume

and fluid resuscitation. If timely hemoglobin and hematocrit testing is available, consider transfusion if hemoglobin is less than 7 g/dL in otherwise healthy patients, less than 8 g/dL in elderly patients and those with known ischemic cardiac or respiratory disease. If decision is based on blood loss:

a) 15-30% loss of blood volume RBC transfusion likely not required

b) 30-40% loss of blood volume RBC transfusion probably required

c) Greater than 40% loss of blood volume RBC transfusion almost certainly required

2) Massive transfusion protocol (MTP) includes 5 RBC, 5 plasma, and 1 pheresis platelet in each MTP pack.

3) Anemia in the absence of acute blood loss. NOTE: Single RBC unit orders are recommended for most situations, with clinical re-assessment prior to additional RBC transfusion.

Link is: http://jamanetwork.com/journals/jama/fullarticle/2569055

https://communitymedical.org/CMC/media/Corporate/Physician%20Newsletters/2016/2016_11_CMC_Transfusion_Guidelines_2014.pdf


TransfusionContinued from page 22

“Well-behaved women seldom make history.”

– Laurel Thatcher Ulrich, Historian

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a) Hemoglobin less than 7 g/dL: Stable hospitalized patients including critical care unit (target: up to 9g/dL). NOTE: Many younger patients safely tolerate lower hemoglobin if normovolemic.

b) Hemoglobin less than 8 g/dL: Patients with co-morbid conditions such as acute coronary disease, pulmonary disease, or acute septic shock: (target: up to 10 g/dL).

c) Hemoglobin less than 10 g/dL: Significantly sympto-matic patient with normal volume status (single RBC unit order is recommended)

4) Post-operative transfusion:a) Hemoglobin less than 7 g/ dL (insure adequate

volume status prior to RBC transfusion).b) Hemoglobin less than 10 g/dL: RBC transfusion

may be appropriate if any of the following are present organ hypoxia increased potential for or ongoing blood loss, volume status and risk factors for complications of inadequate oxygenation

5) Hemoglobin less than 10 g/dL and burn patient – at least 10% TBSA burn. A lower transfusion threshold may be appropriate depending on the clinical situation.

6) Other-Specify reason.

The other important part of this AABB Study was to look at the “age of red cells” issue. This is an area where excellent research has recently been done, establishing the safety of RBC of any allowed storage age across a wide range of adult and pediatric patients. At CMC we favor “fresher” RBC units for patients up to 4 months of age and for trauma patients up to 7 years of age; and these are typically readily available. The AABB Guidelines state there are some gray areas related to RBC age for large volume transfusion of very small patients.

Focus on Your Patient, Not the Transfusion

Statements to consider beforetransfusing a patient:

• A restrictive threshold (7.0-8.0 g/dL) should be used for stable patients.

• Transfusion decisions should be influenced by clinical symptoms and Hgb concentration.

• Single unit red cell transfusions should be the standard for non-bleeding patients.

• Re-assess your patient before ordering any additional unit of blood.

• Investigate and treat pre-operative anemia 2-4 weeksprior to surgical procedures.

• Don’t transfuse red blood cells for iron deficiency without hemodynamic instability.

• Transfusion of red blood cells or platelets should be based on the first laboratory value of the day unless the patient is bleeding or otherwise unstable.

• Avoid unnecessary blood draws. It only leads to unnecessary blood loss and transfusions.

For additional PBM resources and information about the PBM Certification, visit the PBM resources webpage: www.aabb.org/pbm

www.aabb.org/pbm


www.aabb.org/pbm


UCSF Fresno’s Vipul Jain M.D., and colleagues presented research findings from a population health management effort at Community Regional Medical Center to the CHEST 2016 annual meeting in October that had the PubMed press and his colleagues buzzing. Their data showed that one simple home visit by a health team to patients with severe asthma and COPD who didn’t show up for doctors’ appointments significantly improved office visit compliance and inhaler use, and reduced emergency visits by 40%.

Preliminary findings from their study were presented at CHEST, which brings clinicians and researchers from around the globe together annually to present unique research studies on pulmonary medicine, critical care medicine, and sleep medicine topics. This study was among the few that were highlighted by CHEST as providing novel insights. The Chronic Lung Program’s work is especially critical in a county where one in five people have asthma. Exacerbated by air pollution levels that are among the highest in the country, emergency departments at Community Medical Centers’ hospitals see dozens of people daily in respiratory distress.

Dr. Jain, a pulmonologist with expertise in severe obstructive lung disease and the medical director for the Chronic Lung Disease Program at Community, said, “Our goals were to see what was going on with these patients and maybe bring them into the program versus suffering through exacerbations and visits to the emergency room.”

A study published in 2014 by Dr. Jain showed that patients with severe asthma and/or COPD that were enrolled in the chronic lung program had reduced respiratory related ED visits by 79% and reduced hospitalizations at Community Regional by 65% over the year following enrollment into the program. The chronic lung program is one of the few integrated programs in the country with such success and was also found to be cost effective. “Our patients have improved lung function and reduced emergency room visits and hospitalizations for respiratory distress,” said Dr. Jain.

Noncompliance is known to be a problem nationwide in a subset of patients with chronic lung or heart disease.

One Simple Home Visit Makes Difference, Reduces Emergency Visits

By Erin Kennedy, Sr. Communications Strategist

About a fifth of the patients at Community’s Chronic Lung Program are estimated to be noncompliant to office visits. “The problem is that there is a small subset of patients that do not show up at the program, and you can’t help them,” Dr. Jain said. An intervention team was sent to find and visit these patients in their home if they missed three or more scheduled physician office visits, usually set up for patients coming to the Community Regional emergency room with acute lung problems.

The home visit team is comprised of a nurse practitioner, respiratory therapist and social workers. During home visits, Community’s team educates patients about the severity of their lung disease and also assess lung function with a portable spirometry. The team also look for triggers that may be present in the home environment for patients with severe asthma and COPD, and provide education in the home on medications, how to use inhalers and how to properly use supplemental oxygen.

“Our patients feel special when we visit them and it helps establish a patient-provider relationship” said D. Richard Allison, a nurse practitioner at the chronic lung program who also leads home visits. “And the home visits help us find simple problems that we can help solve to make big differences in our patients’ breathing.”

Allison described one patient who kept showing up short of breath with dangerously low oxygen levels. During a home visit, Allison and his team realized she wasn’t using her oxygen tank. “The distributor had been dropping off tanks at her home for two years and she didn’t know how

Vipul Jain M.D.,pulmonologist and medical director for the chronic lung disease program

Richard Allison, a nurse practitioner for the Chronic Lung Disease Program, educates a patient with severe COPD about inhalers and home oxygen therapy during a home-visit intervention.

See Home Visits on page 26


to use them,” Allison said. So the team taught her how and when to use her oxygen tank. Now she’s breathing easier.

Patients in this latest study all had severe asthma or COPD with two or more ED visits or hospitalizations in the year before they were enrolled in the chronic lung program at Community Regional. They also missed three or more scheduled doctor visits.

According to Richard Allison, ACNP 60 patients had home visits. The mean age of the patients included in the study was 55, and 63% were women. The average FEV1 was 1.55L (51% predicted); 14 of the patients (58%) were active

smokers, and 18 (75%) had a history of drug use.After a single home visit, compliance with office

visits increased from 68 to 133 visits in the following year. Similarly, ED visits decreased by 40% and patients’ compliance to maintenance inhaler use increased from 22% to 65%. However, hospital admissions did not appear to be reduced for these patients.

“These patients tend to be very sick with multiple problems, which may translate into noncompliance in some patients,” Dr. Jain said. “Often they are seeing four or five doctors, and many may feel like it’s all just too much to go to one more doctor visit. Even if a single home visit leads to just one less acute episode and emergency visit over the course of a year, that would be a big payoff for the patient and the medical team.”

Home VisitsContinued from page 26

Prescribing of Rivaroxaban: How to Achieve Two-Phase Medication Orders in Epic

By Staci Anderson, Pharm.D., BCPS, Medication Safety Coordinator- Pharmacy, Clovis Community Medical Center

cornerpharmacy

Rivaroxaban (Xarelto) is a new direct oral anticoagulant. While it has many clinical indications, it’s important to know the dosing for each indication as the doses vary widely. For example, for the indication of treatment of DVT/PE, the initial starting dose is 15mg orally twice daily for 21 days, followed by 20mg orally once daily for the

duration of treatment. This two-phase dosing regimen can be challenging to achieve in Epic ordering, especially upon discharge. Remember to enter these orders separately and appropriately, accounting for any doses that the patient may have received while in the hospital.


Editor’s Note: The CDC report notes that California has had 312 cases (8% of the states’ total). None of those have been determined to have been locally acquired.

Updated Zika Case Counts from CDC

As of November 2, 2016• Zika virus disease and Zika virus congenital infection

are nationally notifiable conditions.• This update from the CDC Arboviral Disease Branch

includes provisional data reported to ArboNET for January 1, 2015-November 2, 2016.

US StatesLocally acquired mosquito-borne cases reported........ 139Travel-associated cases reported .............................. 3,988Laboratory acquired cases reported ................................ 1Total ......................................................................... 4,128

Sexually transmitted ................................................ 34Guillain-Barré syndrome .......................................... 13

US TerritoriesLocally acquired cases reported ............................. 30,074Travel-associated cases reported ................................. 104Total ..................................................................... 30,178*

Guillain-Barré syndrome ......................................... 45*Sexually transmitted cases are not reported for US

territories because with local transmission of Zika virus it is not possible to determine whether infection occurred due to mosquito-borne or sexual transmission.

ZIKA ICD-10corner corner

Encephalopathy Documentation

Submitted by Sandra Sidel R.H.I.A., C.C.S., and Silva Seferyan R.H.I.T., C.C.S.

AVOID Queries for clarification by documenting specific terms for Encephalopathy. Enhanced documentation of Encephalopathy = assigning codes that accurately reflect the patient’s severity of illness and risk of mortality.

The underlying cause of Encephalopathy should be specified as:

• Metabolic• Toxic• Hypertensive• Alcoholic• Hepatic• Anoxic• Due to other disease(s)

If you would like more information or have any questions, please do not hesitate to contact Sandra Sidel. I can be reached at 559-459-6003/Ext.: 56003 or [email protected].

Tips to a Successful ICD-10 Transition

Submitted by Sandra Sidel R.H.I.A., C.C.S. HIM Coding Educator

Prior ICD-9 Documentation62 year old male with encephalopathy.

Improved ICD-10 Documentation62 year old male with metabolic encephalopathy.

The following documentation improvements are needed for ICD-10: Type, Underlying Cause

http://www.cdc.gov/zika/geo/united-states.html



Top Tips for a Safe Thanksgiving

Submitted by Rais Vohra M.D.California Poison Control System

UCSF Fresno Emergency Medicine

Thanksgiving is a joyful time for families to gather around the table to give thanks and celebrate. It’s also a likely time of year to send children and adults to the emergency room for food poisoning. According to the Centers for Disease Control and Prevention, there are nearly 76 million food poisoning cases yearly, with about 325,000 hospitalizations and approximately 5,000 deaths.

While food poisoning is a bit different from chemical overdoses and complications related to drugs of abuse, the poison center gets plenty of calls related to dietary contaminants. The good news is, food poisoning is extremely preventable. By following simple handling, cooking and storage suggestions, families can stay healthy and enjoy Thanksgiving dinner, as well as the games and the nap that comes after.

Food poisoning generally causes stomach pain, vomiting and diarrhea and usually appears within four to 12 hours after eating or drinking con-taminated food or drink. For the el-derly, children and infants, preg-nant woman and people suffering from compromised an immune system, food poisoning can be severe and sometimes fatal.

TOXT I D B I T S

CPCS’s Top 10 Thanksgiving Safety Tips 1. Wash your hands often especially in between handling foods that are

wet or dry. 2. Rinse fruits and vegetables thoroughly under cool running water and

use a produce brush to remove surface dirt. 3. If you purchased a turkey fresh and not frozen, refrigerate it immediately.

Do not rinse a turkey in water as that spreads salmonella. If you bought a frozen turkey, allow lots of time for it to thaw… 24 hours of thaw time per five pounds of turkey. As the bird thaws, water will accumulate, so keep the bird in a high walled pan and do not let the water touch any other food. Store on a bottom shelf of the refrigerator.

4. It is safest to not stuff a turkey, but rather put herbs inside the cavity to season it. Exotic stuffing with meat or shellfish (oyster) ingredients are risky. Always cook these on the stove top or in the oven, and not in the turkey. After carving, remove all stuffing from the bird before refrigerating it.

5. The biggest risk of food poisoning comes from undercooking the turkey. You can’t tell it’s done by how it looks! While recipes give you hints about testing for doneness, such as a golden brown color or seeing juices run clear, these are not enough. The only way to make sure your bird is cooked sufficiently to be safe to eat is to measure the internal temperature with a meat thermometer. It must reach 165 degrees F.

6. It may not be in mom’s recipe, but bring gravy to a full boil before serving.

7. Be sure to wipe down counters, cutting boards and utensils in between recipes especially if you have raw meat or leafy greens on the cutting board, both of which can carry salmonella. Use soap and hot water or, preferably, a sanitizer – especially if preparing to chop fruits or vegetables that will be served raw. Use different color cutting boards for meat vs. vegetables to avoid confusion.

8. Keep cold food like salads, gelatin molds and salad dressing refrigerated until just before serving. Once dinner is over, refrigerate leftovers. Food is not safe to eat if it has been sitting out for two hours or more. Toss it.

9. While store bought cookie dough and eggnog should be safe, be sure to purchase pasteurized eggs to use in homemade recipes.

10. After eating, take the remaining meat off the bird and store in a shallow container in the refrigerator. Don’t put an entire carcass into the refrigerator – it won’t cool down quickly enough.

See Tox Tidbits on page 29


Holiday Hazard Prevention Tips

Season’s Greetings! Encourage your patients and relatives to have a safe holiday by incorporating these special safety tips. 1. Make sure your home is “poison proof” if small children are

visiting. Secure all medicines, cleaning products and personal care products before your guests arrive. Poisonings can occur in the home of grandparents who may not remember how quickly children can move or how inventive they can be in exploring new spaces.

2. Take steps to prevent food poisoning. Prior to food preparation, clean all counters and cutting boards with hot water and soap, and wash your hands. After meals, refrigerate food promptly.

3. If you use alcohol or tobacco, make sure these products are out of reach of toddlers.

4. Keep your Christmas tree fresh with water early on, and keep all sources of flame well away from the tree. Put fresh batteries in all your smoke detectors.

5. Carbon monoxide can be a holiday killer. Never heat a home with a gas stovetop, gas oven or use charcoal indoors. Make sure your chimney flue is fully open before enjoying a holiday evening in front of the fireplace. Keep outdoor generators away from windows. Keep flammables away from floor furnaces.

6. Holiday gifts can have flat, coin-shaped batteries. If swallowed, these can cause serious injury. Keep all batteries away from babies, children and pets!

7. Don’t let babies or pets chew on foil wrapping paper. It may contain lead. Do not throw this paper into the fireplace either.

8. Store and serve food only in containers meant for food, and never put non-food items in food containers.

9. Lead can still be found in new and used children’s products, like toys, backpacks, lunchboxes and jewelry.

10. If using snow spray or flocking the tree indoors, be sure to open windows while applying it. Solvents in the spray cans may cause nausea, lightheadedness and headache.

Remember, you and your patients can learn more about a variety of poison-related issues by following CPCS on FaceBook (search: California Poison Control) and on Twitter [@poisoninfo]. Sign up for weekly safety text messages to your cell phone by texting “TIPS” to 69866. In case of an accidental poisoning, one call to 1-800-222-1222 will get you to immediate personalized attention from the specially trained staff of California Poison Control System – program the number into your cell phone now.

Happy holidays and best wishes for a truly magical new year in 2017!

Tox TidbitsContinued from page 28

november-december physician photographer

rais vohra m.d.

Meenakshi Temple South Tower

Gandhi Statue


Bringing Big City Expertise to the Cancer FightBy Erin Kennedy, Senior Communications Specialist

The current edition of “Your Community at Work,” the Community Medical Centers’ corporate social responsibility report, is about our cancer services. The November edition takes a look at: how our Lung Nodule Program speeds up the time from referral to treatment; a new way to deliver chemotherapy right to abdominal cancers; and how the longtime best practices of the Radin Breast Care Center help women feel supported and knowledgeable during their cancer fight.

“Your Community at Work” recently won “Best Publica-tion” in the national PR Daily’s 2016 corporate social responsibility contest. Finalists have included Fortune 500 companies such as Coca-Cola, MasterCard and JetBlue and the World Cocoa Foundation.

Here’s a link to the Web page that contains the current report as well as previous editions. You can click through the “Your Community at Work” archive by year and by month to find printable PDF versions as well as the larger individual online stories.

www.communitymedical.org/Community-at-Work

Print readers: Go to Communitymedical.org > Community Involvement (on the top tab) > Your Community at Work (on the right side menu in the page)

your community at work




We seem never to run out of Specialty Choosing Wisely lists, but Choosing Wisely is more than just lists. If you have not visited the campaign’s web site – choosingwisely.org – take time to do so. The Choosing Wisely campaign has now evolved over several years and it continues to grow in scope and influence. We have featured some of this added content in the past (like training videos), and let’s continue to look at other resources. The lists – with local commentary from your colleagues – will be back.

As a reflection of the greater depth of content than just lists, one of the resources is a collection of reports – commissioned from the Institute for Clinical and Economic Review (ICER) focusing on commonly overused, high profile tests and treatments.

In 2014, the ABIM Foundation, with support from the Robert Wood Johnson Foundation, provided funding to the Institute for Clinical and Economic Review (ICER) to provide brief analyses on several specialty societies’ Choosing Wisely recommendations around commonly overused tests and treatments.

Each of the reports, entitled “Choosing Wisely®

Recommendation Analysis: Prioritizing Opportunities for Reducing Inappropriate Care,” explores current practice variation and costs, and examine the sociological forces that contribute to the overuse use of the tests and treatments. Each report also includes a summary rating of the extent and harms of overuse, the difficulty of practice change, and the potential for savings.

Baseline reports are available for recommendations around:

• Carotid Artery Stenosis Screening in Asymptomatic Patients

• PCI For Stable Ischemic Heart Disease• Annual PAP Testing in Women 30-65 Years of Age• Imaging for Nonspecific Low Back Pain• Imaging for Uncomplicated Headache• Preoperative Stress Testing

Each of these reports is physician-authored. Section headers include “Current use and variation in practice”, “Sociology of practice (an interesting read that explores patient and provider influences that have led to our current state), and a “Summary statement: Drivers of overuse and opportunities for improvement”.

Don’t automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first. Continuous electronic FHR monitoring during labor, a routine procedure in many hospitals, is associated with an increase in cesarean and instrumental births without improving Apgar score, NICU admission or intrapartum fetal death rates. IA allows women more freedom of movement during labor, enhancing their ability to cope with labor pain and utilize gravity to promote labor progress. Upright positions and walking have been associated with shorter duration of first stage labor, fewer cesareans and reduced epidural use.

Don’t let older adults lie in bed or only get up to a chair during their hospital stay. Up to 65% of older adults who are independent in their ability to walk will lose their ability to walk during a hospital stay. Walking during the hospital stay is critical for maintaining functional ability in older adults. Loss of walking independence increases the length of hospital stay, the need for rehabilitation services, new nursing home placement, risk for falls both during and after discharge from the hospital, places higher demands on caregivers and increases the risk of death for older adults. Bed rest or limited walking (only sitting up in a chair) during a hospital stay causes deconditioning and is one of the primary factors for loss of walking independence in hospitalized older adults. Older adults who walk during their hospital stay are able to walk farther by discharge, are discharged from the hospital sooner, have improvement in their ability to independently perform basic activities of daily living, and have a faster recovery rate after surgery.

Don’t use physical restraints with an older hospitalized patient.Restraints cause more problems than they solve, including serious complications and even death. Physical restraints are most often applied when behavioral expressions of distress and/or a change in medical status occur. These situations require immediate assessment and attention, not restraint. Safe, quality care without restraints can be achieved when multidisciplinary teams and/or geriatric nurse experts help sta� anticipate, identify and address problems; family members or other caregivers are consulted about the patient’s usual routine, behavior and care; systematic observation and assessment measures and early discontinuation of invasive treatment devices are implemented; sta� are educated about restraints and the organizational culture and structure support restraint-free care.

Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it.Studies show sleep deprivation negatively a�ects breathing, circulation, immune status, hormonal function and metabolism. Sleep deprivation also impacts the ability to perform physical activities and can lead to delirium, depression and other psychiatric impairments. Multiple environmental factors a�ect a hospitalized person’s ability for normal sleep. Factors include noise, patient care activities and patient-related factors such as pain, medication and co-existing health conditions.

Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so.Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections in the United States. Most CAUTIs are related to urinary catheters so the infections can largely be prevented by reduced use of indwelling urinary catheters and catheter removal as soon as possible. CAUTIs are responsible for an increase in U.S. health care costs and can lead to more serious complications in hospitalized patients.

3

1

2

5

4

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a health professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician or nurse.

Fifteen Things Nurses and Patients Should Question

Released October 16, 2014 (items 1–5), Released April 23, 2015 (items 6–10), Released June 12, 2016 (items 11–15)

New CMC Brain Tumor Support Group:

This Added Patient Resource Seeks Speakers from Our Medical Staff

Submitted by William Silveira M.D. and Bonnie Harkins R.N.

Community Medical Centers has not had a Brain Tumor Support Group so this new group was created to fill the void. The Brain Tumor Support Group is for patients with any brain tumor, whether malignant or benign. Patients in the community who have been told they have a brain tumor, along with their family members and support systems, are invited. The purpose of this new Brain Tumor Support Group is to help teach each other. Learning in our group may arise from physician to patient, from patient to patient, and from patient to physician. We would like to include a component of formal presentation about a relevant topic important to group members. Equally important is a round table type discussion among members of the group to help facilitate the sharing of experiences of various treatments such as surgery, radiation therapy, chemotherapy and others, as well as side effects, diet, coping and psycho-social issues.

During our first session, we discussed the basic science behind radiation therapy, including how radiation is created, planned and delivered as well as an overview of many examples of radiation therapy in oncology. We also discussed radiosurgery delivered via CyberKnife. We discussed side-effects and newer treatment modalities as well.

The November 3rd meeting featured on-label liaison from Novocure to address Optune® therapy for glioblastoma. After talking to the group he was available for questions if needed.

The group meets on the first Thursday of every month at the California Cancer Center in the 2nd floor large conference room from 6-7:30 p.m. We are always looking for potential speakers. For questions about the group or to volunteer as a speaker please contact Bonnie Harkins R.N. at 559-451-3647 or by email at [email protected].

http://www.choosingwisely.org/resources/icer-baseline-reports

www.choosingwisely.org



clinical contentANNOUNCING UPDATED ORDER SETS BEING RELEASED

Submitted by Clinical Informatics/Clinical Content Team

Please see below for a list of Order Sets that were released into production between 09/27/2016 to 10/11/2016. If you identify a problem with one of the order sets please follow the procedure for corrective action or contact a member of the Clinical Content Team.

Epic PRL# Order Set Name Description of Changes1422 Acute Hemodialysis Biennial Review • Modified nursing communication for blood pressure parameters • Added Lidocaine 1% for dialysis site access • Modified sodium chloride and albumin orders to reflect current practice629 Adult Burn Service Change Request • Separated pain medications into severity of pain level mild, moderate and severe pain • Updated Mechanical Ventilator orders for cleaner workflow and eliminate unnecessary

orders1308 Adult Discharge Shell Z Change Request – Removed the order “IP to Care Transition Clinic Follow up” from the

order set. The provider staffing the Care Transitions clinic will no longer be there as of Friday, Sept. 23rd. As such, the clinic will not be in operation

1452 Amnio Infusion Supplemental Change Request – Added language to amnioinfusion administration to included maximum dose over 60 minutes and maximum total dose

1357 Bariatric Surgery Post Op Z Change Request • Added magnesium and phosphorus labs as part of the electrolyte replacement order1240 Bariatric Surgery Pre-Admit Z Change Request – Required to weigh patient on admission1226 Bariatric Surgery Pre-Op Z Change Request – Required to weigh patient on admission1847 Botulism Antitoxin Acquisition Pediatric New Order Set • Detailed order set including language for collaboration with California Department of

Public Health guidelines for treatment • Clinical laboratory for specific testing • Antitoxin administration instructions including reaction medications1151 Burn IP Pain Management Adult Biennial Review – Modification to pain medication panel to identify clear pain

management for mild, moderate, and severe level of pain 1550 Cardiovascular Surgery Discharge Orders Change Request – Removed the order “IP to Care Transition Clinic Follow up” from the

order set. The provider staffing the Care Transitions clinic will no longer be there as of Friday Sept 23rd. As such, the clinic will not be in operation

1702 CEC Iron Dextran Change Request • Modified dosage to reflect practice of test dose with following infusion • Modified rate of infusion231 Epidural / Spinal Analgesia Biennial Review • Monitoring language modified to ensure compliance with safety parameters,

regulations and guidelines • Added sedation level (RASS) for assessment guidelines1486 Headache Treatment ED Biennial Review – Added antiemetic medication section 1855 Neutropenic Fever ED New Order Set – Created to ensure patients who present to emergency department with

Neutropenic Fever got prompt emergent care1412 NICU Discharge Orders Change Request – Modified with correct discharge diet options533 Pediatric Patient Controlled Analgesia Change Request – Modified monitoring of patient controlled analgesia (PCA) to every 2

hours per policy573 Pharmacologic or Exercise Biennial Review Cardiac Nuclear Stress Test • Replaced brand names with pharmacological agent • Dipyridamole stress test restricted to CCMC with comment not to administer outside

of Cardiac testing1223 Post Chemo Embolization Admitting Biennial Review • Modification to nursing instructions for monitoring procedural sites to align with

practice • Clinical labs modified to include most utilized labs for this diagnosis304 Post CVU Orders Change Request – Modified language for dietary consult IP consult to dietary for

evaluation1387 Post-Op Intervention Cardiology Change Request • Modified femoral sheath removal orders for specific drawing of Activated Clotting Time

(ACT) • Modified medication orders Thienopyridines/Platelet Inhibitors, Aspirin, Beta Blockers,

and Lipid medications to be required fields. • Added contraindications to each required medication section 633 Post-Op Prostate Seed Implant Change Request – Removed the order “IP to Care Transition Clinic Follow up” from the Short Stay Discharge Orders order set. The provider staffing the Care Transitions clinic will no longer be there as of

Friday Sept 23rd. As such, the clinic will not be in operation


clinical content1563 Pre-Admit/Admit Joint Change Request

Replacement Surgery • Delineated phases of care for pre-admit, intraoperative and day of surgery • Modified pre-surgical skin cleanse prep to align with evidence base practice • Updated diagnostic procedures, clinical labs, diet, and IV fluid orders • Antibiotics were made to be required to ensure compliance with SCIP core measure 407 Radiology Pre Biopsy Drain Biennial Review – Updated Clinical labs to correct naming convention1577 Sepsis 6 Hour Bundle Change Request • Lactic acid lab Precheck • Language added to broad spectrum antibiotics to ensure they are being ordered prior

to narrow spectrum antibiotics • Reassessment verbiage added for RN to assess fluid status after each fluid bolus • Modified blood pressure mean arterial pressure goal to evidence base care range of

60-75Ventilator Order Project

1245 Acute Intracerebral Hemorrhage Revised mechanical ventilation order to prevent having more than one active ventilator order at one time, provides a cleaner workflow for providers

1367 Acute Ischemic Stroke Revised mechanical ventilation order to prevent having more than one active ventilator order at one time, provides a cleaner workflow for providers

1170 Acute Ischemic Stroke Post TPA Revised mechanical ventilation order to prevent having more than one active ventilator order at one time, provides a cleaner workflow for providers

1310 Acute Subarachnoid Hemorrhage Revised mechanical ventilation order to prevent having more than one active ventilator Admission order at one time, provides a cleaner workflow for providers721 Carbon Monoxide Poisoning HBOT Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers801 Clostridial Gas Gangrene HBOT Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers750 Crush Injury Compartment Syndrome Revised mechanical ventilation order to prevent having more than one active ventilator HBOT order at one time, provides a cleaner workflow for providers1309 Extracorporeal Membrane Oxygenation Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers668 HBOT IP Actinomycosis Removed Mechanical Ventilator order from EPIC 813 HBOT IP Compromised Skin Grafts/Flaps; Removed Mechanical Ventilator order from EPIC Prep for Grafting828 HBOT IP Decompression Sickness Removed Mechanical Ventilator order from EPIC773 HBOT IP Investigational Non-standard Removed Mechanical Ventilator order from EPIC880 HBOT IP Non-Clostridial Gas Gangrene Removed Mechanical Ventilator order from EPIC1134 HBOT IP Osteoradionecrosis - Mandible Removed Mechanical Ventilator order from EPIC1132 HBOT IP Radiation Tissue Damage Removed Mechanical Ventilator order from EPIC Integumentary/Soft Tissue795 HBOT IP Refractory Osteomyelitis Removed Mechanical Ventilator order from EPIC1472 ICU General Medical Admission Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1342 ICU Medical Admission Stroke Post Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1365 Mechanical Ventilation Adult Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1297 Mechanical Ventilation Pediatric Revised mechanical ventilation order for Pediatric/NICU patients with all modes

available with revised headers to include mode787 Necrotizing Soft Tissue Infections Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1346 NICU Admit Revised mechanical ventilation order for Pediatric/NICU patients with all modes

available with revised headers to include mode666 Pediatric Burn Service Revised mechanical ventilation order for Pediatric/NICU patients with all modes

available with revised headers to include mode1087 Pediatric PACU Revised mechanical ventilation order for Pediatric/NICU patients with all modes

available with revised headers to include mode216 Pediatric Trauma Surgery Revised mechanical ventilation order for Pediatric/NICU patients with all modes

available with revised headers to include mode43 Post Anesthesia PACU Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1355 Post Op Cardiothoracic Surgery Ventilator Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers304 Post-Op CVU Orders Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1212 Routine Admitting Neuro Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providers1322 Trauma Surgical ICU Admit Revised mechanical ventilation order to prevent having more than one active ventilator

order at one time, provides a cleaner workflow for providersThe following order set were retired

Epic PRL# Order Set Name Reason for Retirement1491 ED Head Neck Face Injury Treatment Biennial Review – Zero usage in the past year


CME HIGHLIGHTS NOVEMber-DECEMBER CRMC Perinatal M & M Title: “Rh Isoimmunization” Date: Wednesday, November 16, 2016 Speaker: Drs. Teresa Leung, Alok Kumar

and Tiffany Lin Time: 12:30 p.m.-1:30 p.m. Place: UCSF Fresno Center, 155 N. Fresno St.,

Fresno, CA 93701, Rm 136 CME: 1 CME

UCSF Fresno Department of Psychiatry Presents:

Title: “The Pharmacologic Treatment of Sleep Disorders in Psychiatry”

Date: Thursday, November 17, 2016 Speakers: Shawn Hersevoort M.D., M.P.H. Time: 4:00 p.m. Place: UCSF Fresno Center, 155 N. Fresno Street,

Room 116 CME: 1 CME

Please also see the enclosed individual flyers for more on these & other upcoming local CME activities to meet your CME needs.

SAVE THE DATE Clovis Community presents: Title: “Patient Blood Management: The Why?

Or Better Yet, The Why Not?” Date: Thursday, January 19, 2017 Speakers: Carolyn Burns M.D. Time: 12:30 p.m.-1:30 p.m. Lunch Provided Place: H. Marcus Radin Conference Center,

The Palm Room RSVP: 559-324-4002 or

[email protected] CME: 1.0 Applied for

november-december physician photographer: rais vohra m.d.

Mumbai Cityscape



november-decdember 2016PHYSICIAN photographer

Evening prayers

Fresh fruit

Mumbai Vehicles

Haji Ali Shrine

At left: Mahatma and the Beanstalk


november-decdember 2016PHYSICIAN photographer

november-decdember physician photographer:

rais vohra m.d.. See page 2 for details

Gateway of India

Above: Polio Free Mumbai

at Right: Fresh Milk for Sale

On average, 5% to 20% of the US population gets the �u each year

Did YOU

know? More than 200,000 people each year are hospitalized from the seasonal �u

AVOIDgetting sick

How toAvoid close contact with people who are sick

Frequently wash your hands

GET VACCINATED!Avoid touching your face

STOPthe spread of the �u

Stay at home and recuperate

Cover your cough or sneeze

Sanitize surfaces you touch

Like us on Facebook!cmc.news/�u1

PROTECT YOUR COMMUNITY

If you are sick

References: http://www.webmd.com/cold-and-�u/�u-statistics

FROM THE FLU

Wear a mask in public

Wednesday, November 16, 2016 from 12:30pm – 1:30pm

UCSF – Fresno, Room: 136155 N. Fresno Street, Fresno, CA 93701

Case Presentation

Obstetrics: Dr. Teresa LeungNeonatology: Dr. Alok Kumar

Principal Discussants

Obstetrics: Dr. Teresa LeungNeonatology: Dr. Alok Kumar

Pediatric Hematologist: Dr. Tiffany Lin

Target Audience

Any staff physician, resident physician, nurse, nurse practitioner, nurse midwife, physician assistant,or allied health professional working with the perinatal, neonatal, and/or pediatric population.

Objectives

At the end of the session, attendees will be able to:

1) Apply to practice, current clinical evidence and guidelines relating to Rh Isoimmunization.2) Gain insight into fetal Rh Isoimmunization, thereby improving patient safety & outcomes.3) Identify ethical concerns that apply to the clinical situation and anticipate barriers that may

adversely impact outcomes if not addressed across a diverse population.

1 CME will be offered RSVP is not required

Lunch will be provided

Program Director Dr. K. Rajani; Dr. D. Aguilar and Program Planner Bernadette Neve have no relevant commercial relationships to disclose.

This is an activity offered by Community Medical Centers, a CMA-accredited provider.Records of attendance are based on sign-in registration and are maintained only for

Community Medical Centers staff members who are credentialed as an MD, DO, CNM, NP, or PA.

Community Medical Centers is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA)to provide continuing medical education for physicians.

Community Medical Centers designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians shouldclaim 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.

Perinatal M & M Presents:

"Rh Isoimmunization"

PATIENT BLOOD MANAGEMENT: THE WHY? OR BETTER YET, THE WHY NOT?

Carolyn Burns, MD – Mediware Consulting & Analytics

SAVE THE DATE

DATE: Thursday, January 19, 2017 12:30 pm - 1:30 pm Lunch will be provided

LOCATION: H. Marcus Radin Conference Center The Palm Room

TARGET AUDIENCE: All physicians, nurses and allied health professionals. RSVP: Jessica Lipsius at: (559) 324-4002 [email protected]


Community Medical Center Dept. of Surgery-1st Floor 2823 Fresno Street Fresno, CA 93721

Tel: 559-459-3722 FAX: 559-459-3719

E-mail: [email protected]

Department of Surgery Critical Care/ Trauma Conference

Thursday 12p.m-1p.m November 2016

Date Topic Location Speaker

***DOS: Department of Surgery Conference Room Target Audience: CMC Faculty, community physicians, house officers, physician assistants, nurse practitioners, nurses and others potentially involved with patient care.

Objectives: Increased knowledge and improved proficiency in the management of critically ill

patients. Increased knowledge and awareness of the utility of comprehensive trauma and

critical care management. Improved awareness and management of the physiologic alterations associated with

trauma. BCPS and Program Director Nancy Parks, MD and Program Planner Kelley Medico

Montgomery have no relevant commercial relationships to disclose.

Community Medical Centers is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. Community Medical Centers designates

this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

11/3/16

Invasive intracranial monitoring Seq. East Nathan Deis, MD

11/10/16 TBD Seq. East Michael Darracq, MD

11/17/16 Traumatic Brain Injuries DOS Victoria Sharp, DO

11/24/16

No Conference Thanksgiving

November 2016

November 3 Case Presentation and Discussion of “Issues around Medication

Management and Parental Dynamics in Developmentally Delayed Transitional Age Youth”

Sarah Sicher, MD, Presenter Karen Kraus, MD, Discussant

UCSF Fresno Psychiatry Residency Program

November 10 Resident Retreat – No Grand Rounds

November 17 “The Pharmacologic Treatment of Sleep Disorders in Psychiatry”

Shawn Hersevoort, MD, MPH HS Assistant Clinical Professor

UCSF Fresno Psychiatry Residency Program

November 24 Thanksgiving Holiday

Community Medical Centers is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. Community Medical Centers designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. 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.

Surgery Residency Program Community Regional Medical Center Depart of Surgery. 1st Fl. 2823 Fresno Street Fresno, CA 93721 Tel: 559-459-3770 FAX: 559-459-3719

The Department of Surgery SURGICAL GRAND ROUNDS

November 2016

November 4, 2016 ABSITE REVIEW

November 11, 2016 ABSITE REVIEW

November 18, 2016 ABSITE REVIEW November 25, 2016 CANCELLED

7:30 a.m. – 8:30 a.m. CRMC Sequoia West Target Audience: CMC Faculty, community physicians, house officers, mid-level providers, nurses and others potentially involved with patient care.

Objectives: At the end of the session the attendees will be able to: • Demonstrate a commitment to carry out professional responsibilities while adhering to

ethical principles • Achieve increased competency and performance using newly integrated surgical

techniques • Improve the performance and competency of the faculty in teaching and increase the

knowledge of resident trainees Drs. and Program Planner Denise Goodman have no relevant financial disclosures.

Community Medical Centers is accredited by the Institute of Medical Quality/ California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.

Community Medical Centers designates this live activity for a maximum of 1.0_ AMA PRA Category 1 Credit(s)™. 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.

Community Medical Centers is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. Community Medical Centers takes responsibility for the content, quality and scientific integrity of this CME activity. Community Medical Centers designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. 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. Email: [email protected] P: 559-459-1777 F: 59-459-1999

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 1 2 3 4

7:00 - 8:00 am

Orthopaedic X-Ray GR Ortho Surgery Conf. Rm.

7:00 - 8:00 am

Ortho Surg-Adult Recon GR Ortho Surgery Conf. Rm

7:30 - 8:30 am

Chest Conference UCSF # 116

7:00 - 8:00 am

Orthopedic GR UCSF Rm. 136

7:30 – 8:30 am

FP Faculty Development UCSF Rm. 329 7:15 -

8:15 am Neuroscience Pt Case Present. East Med Plaza 3rd floor-NORC Conference Room

7:30 - 8:30 am

HPB Planning Conf. CRMC-Sequoia West Conf Rm

7:30 - 8:30 am

Surgical Grand Rounds CRMC- Sequoia West Conf. Rm

8:00 - 9:00 am

Medicine Grand Rounds UCSF Auditorium

7:30 -8:30 am

Cancer Conference CRMC-Sequoia West Conf. Rm

8:00 - 12:00 pm

Emergency Medicine UCSF Rm 136

8:30 - 9:30 am

Surgery Clinical Case Rev. CRMC-Sequoia West Conf. Rm

12:00 - 1:00 pm

Neurovascular Conference CRMC-TCCB3 Conf. Rm

7:30 - 8:30 am

Cardiac Cath & Intervention Cath Lab (7 West)

12:00 - 1:00 pm

Critical Care/Trauma CRMC- Sequoia East Conf Rm

8:30 - 12:30 pm

OBGYN Residency GR UCSF Rm 116

12:30 – 1:30 pm

Cardiology Grand Rounds CRMC-Sequoia West Conf Rm

12:00 - 1:00 pm

Brain Tumor/Cyberknife Conf. CRMC- Sequoia West Conf. Rm

4:00 - 5:00 pm

Psychiatry GR UCSF Rm 116

7 8 9 10 11

6:30 - 7:15 am

Ortho Surg.-Foot/Ankle/Hand SPOC

7:00 - 8:00 am


7:00 - 8:00 am


7:30 - 8:30 am


7:00 - 8:00 am


8:00 - 9:00 am

Medicine Grand Rounds UCSF Fresno Auditorium

7:30 -8:30 am


7:30 - 8:30 am

HPB Planning Conf. CRMC-Sequoia West Conf. Rm

7:30 - 8:30 am

Surgical Grand Rounds CRMC Sequoia West Conf. Rm

12:00 - 1:00 pm

Neurovascular Conference CRMC-TCCB3 Conf. Rm

7:30 - 8:30 am


8:00 - 11:45 am


8:30 - 9:30am

Surgery Clinical Case Rev. CRMC- Sequoia West Conf. Rm

12:30 – 1:30 pm


12:00 - 1:00 pm

Brain Tumor/Cyberknife Conf. CRMC- Sequoia West Conf. Rm

12:00 - 1:00 pm

Critical Care/Trauma & Emergency CRMC-Sequoia East Conf Rm

8:30 - 12:30 pm


4:00 - 5:00 pm


14 15 16 17 18

6:30 - 7:15 am


7:00 - 8:00am


7:00 - 8:00 am


7:30 - 8:30 am


7:00 - 8:00 am


8:00 - 9:00am


7:30 -8:30 am


7:30 - 8:30 am

HPB Planning Conf. CRMC-Sequoia West Conf. Rm

7:30 - 8:30 am

Surgical Grand Rounds CRMC Sequoia West Conf. Rm

12:00 - 1:00 pm

Neurovascular Conference CRMC-TCCB3 Conf Rm

7:30 - 8:30 am


8:00 - 12:00 pm


8:30 - 9:30 am

Surgery Clinical Case Rev. CRMC- Sequoia West Conf. Rm

12:30 – 1:30 pm


12:00 - 1:00 pm

Brain Tumor/Cyberknife Conf- CRMC- Sequoia West Conf. Rm

12:00 - 1:00 pm

Critical Care/Trauma CRMC- Sequoia East Conf Rm

8:30 - 12:30 pm


12:30 - 1:30 pm

Perinatal M&M-Conf.-CRMC UCSF-Rm. 136

12:30 -1:30 pm

Cancer Conference CCMC-Outpatient Conf. Rm.

2:00 - 3:30 pm

CRMC QPSC UCSF Auditorium

4:00 - 5:00 pm


CONTINUING MEDICAL EDUCATION November 2016 Page 1

CONTINUING MEDICAL EDUCATION November 2016 Page 2 MON TUESDAY WEDNESDAY THURSDAY FRIDAY 21 22 23 24 25

6:30 - 7:15 am


7:00 - 8:00 am


7:00 - 8:00 am


8:00 - 9:00 am


7:30 -8:30 am


12:00 - 1:00 pm

Neurovascular Conference CRMC-Sequoia East Conf Rm

7:30 - 8:30 am


12:30 – 1:30 pm


12:00 - 1:00 pm


28 29 30

6:30 - 7:15 am


7:00 - 8:00 am


7:00 - 8:00 am


8:00 - 9:00 am


7:30 -8:30 am


12:00 - 1:00 pm

Neurovascular Conference CRMC-Sequoia East Conf Rm

7:30 - 8:30 am


12:30 – 1:30 pm


12:00 - 1:00 pm


COMMUNITY MEDICAL CENTER Medical Staff Committee Meetings

November 2016

As of 10/26/16

Monday Tuesday Wednesday Thursday Friday

1 2 3 4

8:00am CCMC Emergency Medicine

CCMC Outpatient Conference Room

5:30pm CRMC Robotic Steering Committee

TCCB Surgery Conference Room

12:30pm CRMC Medicine

CRMC Sequoia West Room

12:30pm CCMC GI Subsection


6:00pm CRMC Facility Executive Committee


12:30pm Infection Control Committee

CRMC Sequoia East Room

7 8 9 10 11

12:30pm CRMC DOCS

CRMC 4 West NICU Conference Room

7:30am CRMC Family Medicine

UCSF Fresno 329

12:30pm Credentials Committee

CRMC Lab Conference Room

12:30pm FHSH Medical Advisory

FHSH Education Conference Room

5:00pm Pediatric Surgery Meeting


5:30pm Peds/Neo CFPRC


6:00pm CCMC

Surgery/Pathology/Anesthesia CCMC Outpatient Conference Room

12:30pm CRMC Pediatrics


6:00pm CRMC Surgery


5:30pm FHSH Well Being Subcommittee

FHSH Education Conference Room

4:45pm Quality Council


6:00pm Medical Executive Committee


7:00am CRMC Anesthesia Subcommittee TCCB Surgery Conference Room

7:30am FHSH Quality Patient Bariatric FHSH Riverpark Conference B

14 15 16 17 18

12:30pm CRMC Ob-Gyn


12:30pm CCMC Medicine/Family Medicine/ Psychiatry/Psychology/Physical

Med and Rehab Committee CCMC Outpatient Conference Room

6:00pm Well Being Committee


9:00am Formulary Subcommittee CRMC Sequoia West Room

12:30pm Ethics Committee


12:30pm CRMC EKG Review


2:00pm Pharmacy & Therapeutics


6:00pm FHSH Facility Executive Advisory

Committee FHSH Education Conference Room

12:30pm FHSH Quality Patient Safety FHSH Riverpark Conference B

2:00pm CCMC Multispecialty Peer Review


6:00pm CRMC Multispecialty Peer Review


8:00am FHSH Quality Practice Heart

Committee FHSH Riverpark Conference Room

B

12:30pm CME Committee

CRMC Lab Conference Room

COMMUNITY MEDICAL CENTER Medical Staff Committee Meetings

November 2016

As of 10/26/16

21 22 23 24 25

12:30pm CRMC Cardiology


9:00am CRMC Emergency Medicine

UCSF Fresno 116

Thanksgiving Day Holiday

Thanksgiving Day Holiday

28 29 30

2:00pm CRMC Utilization Review CRMC Sequoia East Room

nvited to CelebrateYOU AREI

Fresno Madera Medical SocietyInstallation & Awards Gala

Installation ofAlan Kelton, MD

Fresno Madera Medical Society President

Award WinnersChristopher Perkins, MD

Special Project - Art of Life 2016 Community Service Award

Morton Rosenstein, MDLifetime Achievement

2016 Community Service Award

Lifetime Achievement 2016 Community Service Award

Robert Libke, MD Andre Minuth, MDLifetime Achievement


Alex Moir, MDLifetime Achievement


Fort Washington Country Club10272 N. Millbrook Avenue, Fresno, Ca 92730

Friday, November 18, 20166 p.m. Social - 7 p.m. Dinner & Awards

Table of 8: $500 - Single Ticket: $65

Anyone can attend, for more information call (559) 224-4224 ext. 114

2017to

0 3 . 1 8 . 2 0 1 70 3 . 1 8 . 2 0 1 7

W W W . S I P A N D S A V O R F R E S N O . C O M

A L L P R O C E E D S B E N E F I T U C S F F R E S N O M E D I C A L E D U C A T I O N P R O G R A M S

Join UCSF Fresno for our 2017 Sip & Savor—a fun night inspired by the Las Vegas Strip, with over 50 local vendors of specialty food and beverage tastings featuring local culinary artisans, and an

array of wine and beer. Plus, enjoy casino night gaming and live music by Rockville!

SAVE MART CENTER SATURDAY, MARCH 18TH 6:30PM TO 11PM

SAVE dateT H E

Tickets $100 per person • $1,000 per table