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MONTHLY

MEDICAL

STAFF

NEWSLETTER ProgressNotesVOLUME 8

Malnutrition - What Can You Do?

In This Issue Malnutrition - What Can You Do?...P 1 Medical Executive Committee Approvals……………………….…...P 1 Very Important Clinical Updates.….P 2-5 Patient Experience Update………..P 6 Cardiology Update 2017.….………P 6 HIPAA Tip…………………………...P 7 . Holiday Festival……………..….…..P 8 Medical Staff Calendar....….….......P 9 New Practitioners………………......P 10 Physician/AHP Roster Updates…..P 11

D E C E M B E R 2 0 1 6

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Identifying malnutrition can be tricky as criteria have changed – no longer can we depend on albumin or prealbumin as primary diagnostic criteria. Studies increasingly suggest these acute phase proteins lack specificity and sensitivity as indicators of nutritional status. Instead, the diagnosis of malnutrition can be made using specific characteristics delineated in the consensus statement by the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition.1 These charac-teristics include reduced energy intake, weight loss, subcutaneous fat and/or muscle loss, fluid accumulation, and reduced functional capacity. The Registered Dietitian Nutritionists are currently assessing patients for malnutrition using these characteristics. If their clinical assessment supports a diagnosis of severe or moderate malnutrition for your patient, you will be contacted regarding their findings. As the physician, it is critical to include the malnutrition (moderate or severe) diagnosis in your assessment/plan in addition to an intervention statement (which could be as simple as “nutrition intervention per dietitian”). This will facilitate timely nutrition intervention and appropriate classification of severity of illness for coding and reimbursement purposes. 1. White J, et al. Consensus Statement of the Academy of Nutrition and Dietetics and American Society for Parenteral and En-teral Nutrition: Characteristics Recommended for the Identification and documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012; 112(5): 730-738.

Medical Executive Committee Approvals

Items approved at the last Medical Executive Committee meeting can be viewed by using this website link and selecting the particular month: http://www.torrancememorial.org/For_Physicians/Medical_Staff/MEC_Approval.aspx . If you have any questions, please contact the Medical Staff Services Department at (310) 517-4616.

Very Important Clinical Update

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SEE ATTACHMENT FOR COMPLETE SOP

Who: 4W, 7T, 7E What: ED—IP SBAR Trial When: Nov. 14th, 2016 for 30 days Why: Increase inter-unit commu-nication and patient safety

FOR QUESTIONS CONTACT:

Daniel Palma or Shahin Thomas

Ext. 30029 / 71341

ED—IP ADMISSIONS TRANSFER & SBAR HANDOFF TRIAL

Situation: Kaizen event took place in November to address the

high percentage of Code Blue & RRTs of patients admitted via

the ED within 24 hours

Background: No formal process /standard operating procedure

to properly transfer patients from ED to inpatient unit except ICU.

This led to an increase in patient safety concerns and lack of

communication when transfer of care took place.

Recommendation: Develop new SOP to include expectations of

ED and IP unit staff when transferring patient care and institute

verbal report.

Very Important Clinical Update

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See attached policy or visit the Capsule via TMI

for RN’s roles and responsibilities regarding patients undergoing MRI with a

SURESCAN® pacemaker:

PC.E. 182a: SCANNING PATIENTS WITH A SURESCAN® PACEMAKER OR

DEFIBRILLATOR POLICY

FOR QUESTIONS CONTACT:

Maria Olton ext.

25455 or

79171

Susan Castillo

ext. 76648

or 4645

Who: MRI personnel & All RNs

What: Revised Surescan MRI Policy PC.E. 182a

When: Nov. 22, 2016

Why: New pacemaker/ defibrillator is MRI compatible

MRI AND PATIENTS WITH SURESCAN® PACEMAKERS

Situation: There is a new policy outlining procedure for

patients with a Surescan® pacemaker who require an MRI

Background: Previously, patients with pacemakers could

not undergo an MRI

Recommendation: Patients with a Surescan® pacemaker

can undergo an MRI in the 3.0 Tesla MRI machine only

Very Important Clinical Update

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ENDOSCOPY CENTER EMR GOES LIVE

Situation: Endoscopy Center will now be charting in Power-

Chart in the EMR

Background: Previously, the endoscopy center was charting

on paper

Recommendation: Pre-procedure & post-procedures will be

documented in PowerChart, intra-procedural documentation

will remain on paper for now.

ENDOSCOPY RNs WILL DOCUMENT IN:

1. i-View– Assessment & Vital Signs

2. Power Orders – Orders & EBNs

3. MAR – Medications

4. Form Browser – History form

PHYSICIANS WILL DOCUMENT IN:

1. Physician Notes/Op reports

2. Medication Reconciliation

3. Power Orders

Who: Endoscopy Center & All RNs What: EMR Go-live

When: Nov. 15th, 2016 Why: stream-line & centralize documentation

FOR QUESTIONS CONTACT:

Clin IT ext.

44988

Very Important Clinical Update

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INDWELLING CATHETER BUNDLE:

Situation: Year to date, TMMC has had 21 CAUTIs

Background: CAUTI’s are a hospital-acquired patient harm

event and is COMPLETELY preventable. EBP guidelines have

helped other facilities achieve ZERO CAUTIs.

Recommendation: Follow EBP guidelines & TMMC Policy &

Procedures

10 STEPS TO REMAIN CAUTI FREE

1. Must have MD ORDER for catheter insertion

2. Assess that your patient meets INDICATION for catheter insertion

3. Perform meticulous PERI-CARE before inserting a catheter

4. Use strict ASEPTIC TECHNIQUE during insertion

5. Do not pre-inflate the BALLOON prior to insertion

6. MAINTAIN the catheter to prevent infection (orange sticker, stat lock, no loops, below bladder, hanging on side or foot of bed without touch-ing the floor, green clip attached to bed sheet)

7. Perform & document CATHETER CARE every shift

8. PEER REVIEW CHECKLIST to assess every shift for necessity of catheter (form can be found in Capsule under FORMS)

9. REMOVE catheter using Nurse-Initiated Foley Removal Protocol (does not require MD order)

10. If patient does not void within 8 hrs, obtain order for BLADDER PROTOCOL

Who: ALL RNs, CNAs, & Techs What: 10 steps to remain CAUTI-free When: NOW Why: Eliminate CAUTIs

FOR QUESTIONS CONTACT:

Infection Prevention

ext. 2057

Patient Experience Update

CARDIOLOGY UPDATE 2017 CONVENTIONAL WISDOM AND BEYOND

For physicians & healthcare professionals only

NEW TOPICS

Robotic Mitral Valve Surgery Marc Gillinov, M.D.

Point-Counterpoint Debate: Medical Therapy vs. Cardiac Surgery William French, M.D., FACC & Jack Sun, M.D.

Advanced Heart Failure Jaime Moriguchi, M.D., FACC

Neurorestoration: Improving Function After Stroke Charles Liu, M.D.

Heart Disease in Women Karol Watson, M.D.

Cardiovascular Benefits of Antihyperglycemic Agents Anne Peters, M.D.

The Cardiorenal Syndrome Thomas Heywood, M.D.

Transcatheter Aortic Valve Replacement Paul Teirstein, M.D., FACC

Prevention & Treatment of Cardiovascular Disease Through Lifestyle Change Mimi Guarneri, M.D., FACC

SPRINTing to Better Blood Pressure Goals

Ronald Victor, M.D.

Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation Michael Shehata, M.D., FACC

Stroke Risk Reduction in Atrial Fibrillation Salman Azam, M.D.

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Friday April 7, 2017 8:00 a.m. - 5:00 p.m.

For more information call (310) 517-4720 or visit our website at http://www.torrancememorial.org/cardiosymposium

HOW DO YOUR PATIENTS GRADE YOUR COMMUNICATION SKILLS??? Questions asked of in-patients regarding physician communication are:

During this hospital stay, how often did doctors treat you with dignity and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

Ratings include Never, Sometimes, Usually, Always. ALWAYS is the only answer that counts towards your score. The most recent physician score was 80% which seems pretty good except that score is at 34th of the Press Ganey percentile rank. That means that the physician communication at other facilities is scoring much better than Torrance Memorial. Please think about these questions when you are speaking with your patients and their families. We are currently working on a reporting methodology that will allow us to drill down on improvement opportunities.

Cardiology Update 2017

QUESTION: I NOTICED A FRIEND (OR CO-WORKER, ETC.) IS LISTED ON OUR HOSPITAL CENSUS AND I KNOW HE/SHE WOULD NOT MIND IF I WENT BY HIS/HER ROOM TO VISIT. IS THIS A HIPAA VIOLATION? ANSWER: Yes, it is a HIPAA Privacy Violation and California Law Violation of patient privacy. Using patient information obtained from your job or the hospital for personal reasons such as sharing with friends, family or to visit the patient is a violation. The patient information you have access to or obtain from work is to be used only for the purpose of patient care and treatment. The law states that information obtained on the job is to be kept confidential and not used or disclosed for personal reasons. All patient medical information is considered confidential. Patient Protected Health Information (PHI) comes in many forms such as:

Seeing a patient in a clinical department waiting to be seen Hearing information being discussed in your department or other area Viewing information on paper or electronically Oral communication

All patients at Torrance Memorial Medical Center have the right to expect our confidentiality. We must provide our patients the privacy and confidentiality they are entitled to, and if you obtain information about a friend (or co-worker, etc.) who is in the hospital from an external source (outside of the hospital or your job), or directly from the patient, then it is not a violation to visit the patient. REFERENCES: Policy # 1410.01 “Uses and Disclosure of Protected Health Information” Policy # 1410.03 “Confidentiality of Protected Health Information” Policy # 1410.20 “Corrective Action Process for Security Incident of Patient Confidentiality” HIPAA Form # 14 “Confidentiality Agreement” 45 CFR 164.502(a),164.506, 164.308 and 164.512. SB 541 and AB 211

HIPAA Tip

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Festiv

al Tre

es

for P

re-Sa

le

Nov

. 29 -

Dec

. 1

Public Exhibit & Boutique Shopping

Special Events - Reservations Required

Tuesday, November 29.…………………….…………………………………………....………...1:30 - 3:30 p.m.

Wednesday, November 30..……………………………………………………...………………...10 a.m. - 9 p.m.

“Senior Day #1” - Free admission for seniors & the physically challenged..…………...10 a.m. - 2 p.m.

Thursday, December 1……………………………………………………………………………..10 a.m. - 9 p.m.

“Senior Day #2” - Free admission for seniors & the physically challenged.....………...10 a.m. - 2 p.m.

Community Service Group Night - Special Rate of $2 for admission...……………….... 4 p.m. - 9 p.m.

Friday, December 2 - CLOSED TO THE PUBLIC

Saturday, December 3………………………………………………………………...…………...10 a.m. - 9 p.m.

Sunday, December 4………………………………………………………………...……………..10 a.m. - 4 p.m.

$5 General Admission - Children 5 and under are free.

Enjoy beautifully decorated holiday trees, boutique, food court and local entertainment.

NOVEMBER 29 - DECEMBER 4, 2016 Located in the white tent at Medical Center Drive and Skypark Drive.

33rd Annual

Donated by Toyoto Motor Sales, USA, Inc. Call 310-517-4703 to buy

opportunity drawing tickets.

Win a Lexus! Grand Prize

2017 Lexus RX 350

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3330 Lomita Blvd., Torrance, CA 90505 . www.TorranceMemorial.org/HolidayFestival . 310-517-4606 8

Festival Fashion Show - $125 per person - Tuesday, November 29, 9:30 a.m. - 3:30 p.m.

Festival Gala - $300/person, $550/couple - Friday, December 2, 5:30 p.m. - 10:30 p.m.

Lunch with Santa - $15 per person - Sunday, December 4, 11 a.m. - 1 p.m.

Monday Tuesday Wednesday Thursday Friday

1 7:00a Breast Tumor Board..WT-Aud 7:45a Gen Tumor Board…..WT-Aud 12:30p Medical Staff PI……..….WT-D

2 7:00a Lung TumorBoard..WT-Aud 7:00a Surgery Dept…….....WT-B 7:30a IRB…………………..WT-D

5 12:30p Cardiology………..…WT-D

6 12:30p Donor & Transfusion…..WT-C

7 7:00a CV Review Conf……….WT-D

8 7:00a Breast Tumor Board..WT-Aud 7:45a GI Tumor Board….....WT-Aud 8:00a Oncology Steering….WT-Aud

9 7:00a Lung TumorBoard..WT-Aud

12 12:30p Credentials……….....WT-C

13 6:00p Medical Executive……..WT-D

14 7:00a CV Review Conf……….WT-D

15 7:00a Breast Tumor Board..WT-Aud 7:45a CNS Tumor Board….WT-Aud

16 7:00a Lung TumorBoard..WT-Aud 7:00a Plastic Surgery……...WT-D

19

20

21 7:00a CV Review Conf……….WT-D

22 7:00a Breast Tumor Board..WT-Aud 7:45a GI Tumor Board….....WT-Aud

23 7:00a Lung TumorBoard..WT-Aud

26

27

28 7:00a CV Review Conf……….WT-D

29 7:00a Breast Tumor Board..WT-Aud 7:45a Gen Tumor Board…..WT-Aud

30 7:00a Lung TumorBoard..WT-Aud

CME CONFERENCES Wednesdays, 12:30 p.m. Hoffman Health Conference Center

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

Torrance Memorial Medical Center designates this live activity for a maximum of 1 AMA PRA Category I creditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This credit may also be applied to the CMA Certification in Continuing Medical Education. For up-to-the-minute conference information call (310) 784-8776 or visit: http://www.torrancememorial.org/For_Physicians/Wednesday_CME_Conferences.aspx

Medical Staff Calendar December 2016

December 14, 2016 NO CONFERENCE

December 21, 2016 NO CONFERENCE

December 7, 2016 NO CONFERENCE

December 28, 2016 NO CONFERENCE

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February 1, 2017 “Medical Marijuana” Joseph Pierre, M.D. UCLA School of Medicine Commercial Support: None

January 4, 2017 “Hypertension Update” Stanley Franklin, M.D. U.C. Irvine School of Medicine Commercial Support: None

January 18, 2017 NO CONFERENCE

January 25, 2017 NO CONFERENCE

January 11, 2017 “Management of Sepsis” Thomas Cesario, M.D. U.C. Irvine School of Medicine Commercial Support: None

Welcome New Practitioners

Mary R. Doost, M.D. Medicine Milefchik-Rand Medical Group, Inc. 2841 Lomita Blvd., Ste. 135 Torrance, CA 90505 Phone: (310) 784-6954 Fax: (310) 326-5679

Elizabeth M. Hartman, P.A. Emergency Torrance Memorial Urgent Care 22411 Hawthorne Blvd. Torrance, CA 90505 Phone: (310) 784-3740 Fax: (310) 375-1392

Mike Q. La, M.D. Medicine UCLA Health Santa Monica Hospitalists 1250 16th St., Ste. C2304 Santa Monica, CA 90404 Phone: (310) 319-4698 Fax: (310) 319-4908

Maureen A. O’Neill, M.D. Pediatrics Providence Medical Associates - Hawthorne 11539 Hawthorne Blvd., 6th Floor Hawthorne, CA 90250 Phone: (310) 675-5370 Fax: (310) 978-3012

Gregory J. Poirier, P.A. Surgery Skyline Urology 3445 Pacific Coast Hwy., Ste. 310 Torrance, CA 90505 Phone: (310) 602-5005 Fax: (310) 373-7895

John J. Shun, D.P.M. Surgery South Bay Podiatry Group 1045 W. Redondo Beach, Ste. 106 Gardena, CA 90247 Phone: (310) 323-2887 Fax: (310) 323-8609

Swati Sikaria, M.D. Medicine Torrance Memorial Physician Network Cancer Care 514 N. Prospect Ave., 4th Floor Redondo Beach, CA 90277 Phone: (310) 750-3300 Fax: (310) 598-3187

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Address Change Basil Younes, D.O. Medicine 4201 Torrance Blvd., Ste. 750 Torrance, CA 90503 Phone: (310) 540-1953 Fax: (310) 792-1974

Leave of Absence Qing Tian, M.D. Surgery Steven R. Weinstein, M.D. Medicine Henry Wu, M.D. OB/GYN Resignation Rushdy M. Al-Moomen, M.D. Medicine Lorraine L. Anderson, M.D. Medicine Brian K. Chamides, M.D. Pathology Disaya Chavalitdhamrong, M.D. Medicine Diane M. Ferguson, M.D. Medicine Gang Li, M.D. Medicine Amy E. Mugg, M.D. Pediatrics Michael A. Tarnay, M.D. Emergency Leo C. Young, M.D. Family Practice Retired Lawrence W. Kneisley, M.D. Medicine

The Medical Staff Newsletter ProgressNotes is published monthly for the Medical Staff of Torrance Memorial Medical Center. Vinh Cam, M.D. Chief of Staff Robin S. Camrin, CPMSM, CPCS Vice President, Medical Staff Services & Performance Improvement ANK-12/2016

Physician/AHP Roster Updates

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ProgressNotes Vol. 8 Issue 12 December 2016

ProgressNotesMONTHLY

MEDICAL

STAFF

NEWSLETTER

Medical Staff Services 3330 Lomita Boulevard Torrance, CA 90505 Phone: (310) 517-4616 Fax: (310) 784-8777 www.TorranceMemorial.org

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