I S S U E

8

MONTHLY

MEDICAL

STAFF

NEWSLETTER ProgressNotesVOLUME 8

In This Issue

Critical Blood Shortage…………………….….P 1-2

Changes in CBC Differential Reporting….….P 3

New CBC Differential Morphology Grading...P 4

Changes to Free T3 Testing…………..….….P 5

Changes to Troponin I Assay…………….…..P 6

Troponin I Interpretative Guidelines…….……P 7

Medical Executive Committee Approvals…...P 7

Torrance Memorial Drills for Hazmat Incident …………………………………...……P 8-9

HIPAA Tip………………………………….…...P 10

Medical Staff Calendar....……..………………P 11

New Practitioners on Staff..…...……………...P 12

Physician/AHP Roster Updates……..............P 13

A u g u s t 2 0 1 6

1

Critical Blood Shortage

June 30, 2016 To all medical staff members: I have received notification from the American Red Cross that there will be a critical blood shortage this summer. While there will be some blood available, our supply will be significantly limited by the American Red Cross. This is an industry wide issue and all blood suppliers are experiencing shortages. It will be incumbent upon the ordering physicians to assure that blood products are managed judiciously in order to assure that there is blood available for our patients throughout the summer months. The Blood Bank will be closely monitoring inventory levels throughout this shortage. Torrance Memorial’s Blood Bank will be stepping up donor recruitment efforts to help augment our blood supply at the medical center. More information regarding that effort will be forthcoming. If you have any questions, please feel free to contact me. Thank you in advance for your assistance. John Kunesh, M.D. Medical Director, Blood Bank

2

Please Share with Staff

URGENT: BLOOD DONORS NEEDED To tackle the current national blood shortage, expected to get worse, the Torrance Memorial Blood Donor Center and the American Red Cross are encouraging staff, physicians, volunteers, and the community to donate blood. Torrance Memorial’s Blood Donor Center, located on campus, would like donors to schedule appointments, if possible. By scheduling appointments, the Blood Donor Center can actively manage the inventory of blood and blood products available to our patients. Call 310‐517‐4647 to make an appointment. If you are on a

prescribed medication, be sure to mention this when arranging your appointment, and remember to eat before arriving at the center.

The demand for blood is ever-increasing. It is used daily in the medical center and much more must be accessible for emergencies. Blood supplies are used to treat accident and burn victims, internal bleeding, shock, blood deficiency diseases, and for surgeries. Regular blood donors ensure a fresh supply of blood is available, when needed. Blood may be donated as often as every eight weeks.

Donations made at Torrance Memorial stay at Torrance Memorial and help our patients and institution.

Who is Eligible to Donate?

• Persons, aged 17 or older. • Individuals weighing at least 110 lbs.

• Healthy people with no history of hepatitis.

Location: Outpatient Center, 2nd Floor

Hours: Monday: 8 a.m. to 6 p.m.

Tuesday – Thursday: 8 a.m. to 3:30 p.m. Friday: 8 a.m. to 3 p.m.

Call today to make your appointment and

Give the Gift of Life!

.

Changes in CBC Differential Reporting

3

July 6, 2016    TO:  Medical Staff  RE:  Changes in CBC Differential Reporting   On July 13, 2016 the Laboratory will be upgrading the middleware software used in Hematology.  With this upgrade, we will be implementing new CBC differential morphology grading based on guidelines from the International Council for Standardization in Hematology, (ICSH).    Attached is a complete list of all of the changes.  Here are the most significant changes:  

The grading scale will now be from 1+ to 3+.    

Grading Scale Interpretations 

1+ Few

2+ Moderate 

3+ Many 

 

Rouleaux and Red Cell inclusions will now be reported as present without any gradation. 

Platelet estimations will now be reported as normal, decreased, or increased. 

The term Atypical Lymphocyte will become obsolete and replaced with either Variant Lymphocyte or Reactive Lymphocyte. 

 If you have any questions about any of these changes, please contact me or Lisa Hughes, Senior CLS in the Hematology Laboratory.   Sincerely,     John Kunesh, M.D.                                               CLIA Director, Laboratory                   

New CBC Differential Morphology Grading based on ICSH GuidelinesNote : The grading of RBC, WBC and Platelet morphology is subjective and varies slightly between CLS's

Parameter 1+/hpf 2+/hpf 3+/hpf 4+/hpf Few/1+,% Mod/2+,% Many/3+,%

Schistocytes and Helmut cells 1‐2 3‐9 10‐50 >50 <1% 1‐2 >2

Sickle cells 1‐2 3‐9 10‐50 >50 NA 1‐2 >2

Spherocytes 1‐2 3‐9 10‐50 >50 NA 5‐20 >20

Target cells 1‐2 3‐9 10‐50 >50 NA 5‐20 >20

Elliptocytes 1‐2 3‐9 10‐50 >50 NA 5‐20 >20

Acanthocytes 1‐2 3‐9 10‐50 >50 NA 5‐20 >20

Teardrops 1‐2 3‐9 10‐50 >50 NA 5‐20 >20

Polychromasia 4‐9 10‐19 20‐50 >50 NA 5‐20 >20

Ovalocytes NA 5‐9 10‐50 >50 NA 5‐20 >20

Burr cells NA 5‐9 10‐50 >50 NA 5‐20 >20

Stomatocytes NA 5‐9 10‐50 >50 NA 5‐20 >20

Hypochromasia NA 20‐39% 40‐60% >50 NA 11‐20 >20

Rouleaux Present Present Present Present Present Present Present

Howell‐Jolly body Present Present Present Present Present Present Present

Malarial parasites Present Present Present Present Present Present Present

Basophilic stippling 1‐2 3‐9 10‐50 >50 NA 5‐20 >20

1+/100 2+/100 3+/100 4+/100

Current WBC/PLT morphology: WBC's WBC's WBC's WBC's Few/1+ 2+% 3+%

Hypersegs 2‐3 4‐9 10‐15 >15 NA 4‐8 >8

Dohle bodies 2‐3 4‐9 10‐15 >15 NA 2‐4 >4

Hypogranulation 2‐3 4‐9 10‐15 >15 NA 4‐8 >8

Toxic granulation NA 5‐19 20‐50 >50 NA 4‐8 >8

Vacuoles NA 5‐19 20‐50 >50 NA 4‐8 >8

Giant platelets NA 5‐9 10‐25 >25 NA 11‐20 >20

Agranular platelets NA 5‐9 10‐25 >25 NA 11‐20 >20

Auer rods Present Present Present Present Present Present Present

Morhology (numeric guidelines) Few/1+ 2+% 3+%

Anisocytosis (RDW) NA 16‐20 20‐25 >25 NA 11‐20 >20

Macrocytosis (MCV) NA 105‐115 115‐135 >135 NA 11‐20 >20

Microcytosis (MCV) NA 65‐75 50‐60 <50 NA 11‐20 >20

Platelet Estimation

Adult Newborn Platelet Estimate New Platelet Estimate

140‐440 200‐475 Normal Normal

0‐29 0‐29 Decreased markedly Decreased

30‐99 30‐99 Decreased moderately Decreased

100‐139 100‐199 Decreased sligtly Decreased

441‐499 476‐499 Increased slightly Increased

500‐559 500‐559 Increased moderately Increased

=/>600 =/>600 Increased markedly Increased

Name Changes:

Atypical  Lymphocytes (to be split) 1. Varient Lymphocytes

2. Reactive Lymphocytes

Current RBC morphology grading: New RBC morphology grading: 

(Note: MCV and RDW based)

4

New CBC Differential Morphology Grading

.

Changes to Free T3 Testing

5

July 7, 2016     TO:  Medical Staff  RE:  Changes to Free T3 Testing  Currently, Free T3 testing is sent to Mayo Medical Laboratories.  On July 13th, Free T3 testing will come in‐house on the Siemens Advia Centaur XP.  The Centaur assay will be available for patients age 13 and above. (Patients less than 13 years of age will have Free T3 testing sent to ARUP).  With this conversion, the following reference range changes will take place: 

Reference range change:  o  Mayo Reference range = 2.0 – 3.5 pg/mL o TMMC Reference range is age specific:   

Adolescent (13 – 20 years):  2.0 – 5.0 pg/mL  Adults (>20 years):  2.3 – 4.2 pg/mL 

 Correlation studies between the Mayo methodology and the Centaur methodology yielded a correlation coefficient of 0.9243 with an average negative bias of 0.5%.    We are pleased to bring this test in‐house to decrease turnaround times and more efficiently handle patient testing.  A friendly reminder however that Free T3 should only be ordered to monitor a patient on therapy and should not be used as part of a normal thyroid screening process.  There is no thyroid screening test algorithm that includes Free T3.   Sincerely,    John Blakey, M.D. Medical Director, Chemistry       

Changes to Troponin I Assay

6

TO: Medical Staff RE: Changes to Troponin I assay Dear Doctor, The Laboratory is changing its assay method for Troponin I. The new assay is performed on the Siemens Dimension Vista 1500 utilizing luminescent oxygen channeling immunoassay (LOCI) technology. Utilizing the LOCI technology we will be able to decrease our analytical testing time from 20 minutes to 12 minutes. Implementation of this assay will begin 07/27/16 @ 0400. The new assay will be referred to as “Troponin I”. Testing for patients already in the process of serial troponin assays will continue to use the Troponin Ultra assay, currently in use, until they are discharged. All patients after the new assay start time will be tested with the new troponin I assay. Changes that will be seen on the patient’s chart are:

New test name – Troponin I New lower end sensitivity: 0.015 ng/ml New risk Stratification interpretative guidelines (attached)

With the increase in the lower end sensitivity from 0.006 to 0.015 ng/ml, we spent a great deal of time analyzing patient data. Correlation between the two assays is 98.1% with an upward bias of 5% with the new assay. To ensure this sensitivity change would not affect our patient population we analyzed 339 serial troponin ultra results, concentrating on the 64 patient serial troponin ultra results that were in the range of 0.006 (current low end sensitivity) and 0.015 (new assay lower end sensitivity). In reviewing all serial troponin draws from these patients, three tests would have fallen below the new assay lower limit of detection (0.015 ng/ml) on the first draw. All elevated troponin results (i.e. >0.015 ng/ml) were detected by the second draw. If you have any questions regarding these changes, please contract myself or the Technical Specialist, Jeannie Lavezzari. Sincerely, John Blakey, M.D. Medical Director, Chemistry

Troponin I Interpretative Guidelines

7

VISTA CARDIAC TROPONIN I INTERPRETATIVE GUIDELINES Risk Stratification: Cardiac Troponin I levels (>0.1 ng/mL): High risk of death or non-fatal MI Cardiac Troponin I level (0.046 - <0.1 ng/mL): Intermediate risk of death or non-fatal MI Cardiac Troponin I level (0.00 – 0.045 ng/mL): Low risk of death or non-fatal MI EXPECTED RESULTS: In a study of 199 samples from apparently healthy individuals, the reference interval encompassing the 99th percentile for the Siemens Dimension Vista® Cardiac Troponin I assay was 0.00 – 0.045 ng/mL. Statistically significant increases in mortality have been observed as a function of increasing levels of cardiac troponin I. In patients with acute coronary syndromes such as unstable angina or non-Q-wave myocardial infarction, cardiac troponin I levels provide useful prognostic information and aid in the early detection of patients with increased risk of death. Cut point was previously established at a level of 0.1 ng/mL. A joint committee of the American College of Cardiology and the American Heart Association defined the short-term risk of death or non-fatal MI in association with troponin levels.

Medical Executive Committee Approvals

Items approved at the last Medical Executive Committee meeting can be viewed by using this website link and selecting the particu-lar 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.

Torrance Memorial Drills for Hazmat Incident

8

On Thursday, June 23, 2016, Torrance Memorial conducted the first of its semi-annual hospital-wide disaster drill. The scenario hypothetically followed an accident involving a train, multiple cars and a bus that injured 43 mock patients. In this scenario, victims were exposed to chlorine gas and radioactive material. For the drill, volunteers were made up with moulage mimicking wounds and transported via ambulance to Torrance Memorial’s decontamination showers located in the Main Parking Garage. There they were hosed off by members of the volunteer Decontamination Team, triaged to the Emergency Department and then eventually reunited with family members. Observers from the City of Inglewood, Lawndale, Palos Verdes Estates, Torrance Fire Department, The Red Cross, LA County Public Works, Harbor UCLA Medical Center, Sempra Utilities and Area G – Emergency Management visited the Torrance Memorial campus to watch the drill in action. Torrance Memorial conducts disaster drills twice annually to assess its readiness for various worst-case scenarios and test the overall coordination of essential resources, equipment and staffing for emergent patient care. Recent past drills have included a mock pediatric surge, earthquakes, active shooters and campus-wide power outages. We wanted to send a big “Shout Out” to all our physicians that volunteered to participate in this exercise and especially to our Physician Champions: Dr. Andrew Shen, ED, Decontamination Unit Leader; Dr. Gretchen Lent, ED, Triage Unit Leader. Also, “Shout Out” to the ED Team that supported this event was truly impressive! Thanks to everyone for Your Support and we look forward to future disaster readiness activities.

Placing of makeup on volunteers

Arrival of victims

Continued on next page….

Command Center

Torrance Memorial Drills for Hazmat Incident

9

Triage (sorting of patients)

Treatment Areas (Immediate, Delayed, Minor Care areas)

Decontamination (washing)

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HIPAA TIP

10

QUESTION: CAN I LOOK UP OR ACCESS PATIENT PERSONAL OR MEDICAL INFORMATION OF A PATIENT WHO IS A FRIEND, SPOUSE, CHILD OR OTHER FAMILY MEMBER OR MY CO-WORKER, ON THE COMPUTER?

AANNSSWWEERR:: NO Never, unless you are the caregiver AND your job requires it for TPO. HIPAA prohibits access, viewing or disclosing of patient information (both personal and/or medical) unless your job requires it for TPO reasons. Staff members, who access, review or disclose patient information for any reason not related to the provision of care and treatment or another unauthorized purpose will be subject to formal discipline and possible termination by Torrance Memorial as set forth in our “Corrective Action” Human Resource Policy # 404 and may be subject to HIPAA and California regulation sanctions. Many of us who work at TMMC also live in the surrounding areas and we may see individuals we know (family, friends, neighbors, co-workers) being treated at TMMC. These individuals as well as individuals we do not know, have the same right of privacy. Information we obtain on job, stays on the job. All patients at TMMC have the right to expect our confidentiality. If you see someone you know in the hospital regardless of which area (inpatient/outpatient/emergency) it is a violation to disclose the individual is a patient being seen at TMMC. The law states; you are free to discuss with others PHI that you obtain on the job when your job requires it. PHI = PROTECTED HEALTH INFORMATION = Patient name, room number, address, phone number, diagnosis, SS#, meds, photographs, email etc. TPO = Treatment, Payment or HealthCare Operations REFERENCE: 45 CFR 164.502, 164.506, 164.308, 164.508, SB 541 and AB211 Policy 1410.01 “Uses and Disclosures of PHI” Policy 1410.03 “Confidentiality and Protection of PHI”; Policy 1410.13 “PHI Access Controls and Minimum Necessary”; Policy 1410.20 “Corrective Action Process for Security Incident of Patient Confidentiality” and Form # 14 “Confidentiality Agreement”

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August 2016 Medical Staff Calendar

Monday Tuesday Wednesday Thursday Friday 1

2 7:00a Breast Oncol Subc…....WT-D 12:30p Infect Prevention/P&T...WT-D

3 7:00a CV Review Conf……….WT-D 12:30p CME Conference….HCC-1&2

4 7:00a Breast Tumor Board..WT-Aud 7:45a Gen Tumor Board…..WT-Aud

5 7:00a Lung TumorBoard..WT-Aud 7:00a Surgery Dept………...WT-B

8 12:30p Credentials………......WT-C

9

10 7:00a Anesthesia PI….… ..WT-Aud 7:00a CV Review Conf……….WT-D 12:30p CME Conference….HCC-1&2

11 7:00a Breast Tumor Board..WT-Aud 7:45a GI Tumor Board….....WT-Aud

12 7:00a Lung TumorBoard..WT-Aud

15

16

17 7:00a CV Review Conf……….WT-D

18 7:00a Breast Tumor Board..WT-Aud 7:45a CNS Tumor Board…..WT-Aud

19 7:00a Lung TumorBoard..WT-Aud 7:00a Pancreat/Hepatic & Colon/ GI Oncol Subc…….WT-D

22

23

24 7:00a CV Review Conf……….WT-D

25 7:00a Breast Tumor Board..WT-Aud 7:45a GI Tumor Board….....WT-Aud 12:30p Credentials……….….....WT-C

26 7:00a Lung TumorBoard..WT-Aud

29

30

31 7:00a CV Review Conf……….WT-D

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

August 3, 2016 “Asthma Update” Raffi Tachdjian, M.D. UCLA School of Medicine Commercial Support: None

August 17, 2016 NO CONFERENCE

August 10, 2016 “Controversies in Cancer Screening” Lily Lai, M.D. City of Hope National Medical Ctr Commercial Support: None

August 24, 2016 NO CONFERENCE

August 31, 2016 NO CONFERENCE

September 7, 2016 “Fibromyalgia & Chronic Fatigue Syndrome” Daniel Arkfeld, M.D. USC School of Medicine Commercial Support: None

September 14, 2016 “Active Shooter in Healthcare” Mark Mooring, MPA, CPP, CHPA Proper Authorities Commercial Support: None

Welcome New Practitioners on Staff

Torin J. Cunningham, M.D. Surgery Miller Children’s Outpatient Center - Torrance 3640 Lomita Blvd., Ste. 102 Torrance, CA 90505 Phone: (310) 378-1716 Fax: (562) 933-6743

Ian M. Matsuura, M.D. Radiology Torrance Radiology Medical Group - Skypark 3275 Skypark Dr., Ste. A Torrance, CA 90505 Phone: (310) 517-4675 Fax: (310) 784-4801

Brian J. Panganiban, P.A. Emergency Torrance Emergency Physicians, Inc. 3330 Lomita Blvd., Emergency Dept. Torrance, CA 90505 Phone: (310) 325-9110 Fax: (310) 784-3789

Abraham Rayhaun, M.D. Surgery Coast Neurosurgical Associates 2888 Long Beach Blvd., Ste. 240 Long Beach, CA 90806 Phone: (562) 595-7696 Fax: (562) 988-1559

Pinky R. Thakkar, P.A. Emergency Torrance Emergency Physicians, Inc. 3330 Lomita Blvd., Emergency Dept. Torrance, CA 90505 Phone: (310) 325-9110 Fax: (310) 784-3789

12

Address Change Latrice M. Allen, M.D. OB/GYN 3440 Lomita Blvd., Ste. 240 Torrance, CA 90505 Phone: (310) 539-5060 Fax: (310) 539-7899 Sharda S. Bhasin, M.D. OB/GYN 3440 Lomita Blvd., Ste. 240 Torrance, CA 90505 Phone: (310) 539-5060 Fax: (310) 539-7899 John Brian Boyd, M.D. Surgery 550 Deep Valley Dr., Ste. 283 Rolling Hills Estates, CA 90274 Phone: (310) 295-2287 Fax: (310) 606-2047 Whitney A. Burrell, M.D. Surgery South Bay Plastic Surgeons 3640 Lomita Blvd., Ste. 306 Torrance, CA 90505 Phone: (310) 784-0644 Fax: (310) 784-0544 Brian M. Gee, M.D. Medicine 4101 Torrance Blvd. Torrance, CA 90503 Phone: (310) 374-8191 Fax: (310) 303-6834 Lisa L. Jewell, M.D. Surgery South Bay Plastic Surgeons 3640 Lomita Blvd., Ste. 306 Torrance, CA 90505 Phone: (310) 784-0644 Fax: (310) 784-0544 Kay May M. Kwok, M.D. OB/GYN Torrance OB/GYN 3440 Lomita Blvd., Ste. 607 Torrance, CA 90505 Phone: (310) 530-5965 Fax: (310) 530-5008 Carline Louis-Jacques, M.D. OB/GYN 24241 Hawthorne Blvd., Ste. 201 Torrance, CA 90505 Phone: (310) 371-4994 Fax: (310) 371-4994

Tricia M. Manalastas, P.A.-C Surgery Precision Bone & Joint 2865 Atlantic Ave., Ste. 4221 Long Beach, CA 90803 Phone: (562) 912-7437 Fax: (562) 912-7440 David A. Markman, M.D. Surgery 4161 W. Redondo Beach Blvd., Ste. 300 Lawndale, CA 90260 Phone: (310) 370-5648 Fax: (310) 370-0449 Frances A. McKindsey, M.D. OB/GYN 3440 Lomita Blvd., Ste. 240 Torrance, CA 90505 Phone: (310) 539-5060 Fax: (310) 539-7899 Michael K. Newman, M.D. Surgery South Bay Plastic Surgeons 3640 Lomita Blvd., Ste. 306 Torrance, CA 90505 Phone: (310) 784-0644 Fax: (310) 784-0544 Yutaka Niihara, M.D. Medicine Emmaus Life Sciences, Inc. 21250 Hawthorne Blvd., Ste. 800 Torrance, CA 90503 Phone: (310) 214-0065 Fax: (310) 214-0075 Varona Nikore, M.D. Pediatrics 20911 Earl St., Ste. 100 Torrance, CA 90503 Phone: (310) 370-7759 Fax: (310) 370-1590 Charles W. Spenler, M.D. Surgery South Bay Plastic Surgeons 3640 Lomita Blvd., Ste. 306 Torrance, CA 90505 Phone: (310) 784-0644 Fax: (310) 784-0544 John Wong, M.D. Medicine HealthCare Partners 3330 Lomita Blvd., HCP 1st Floor Torrance, CA 90505 Phone: (310) 214-5722 Fax: (310) 793-4657

Leave of Absence Gang Li, M.D. Medicine Gene A. Naftulin, M.D. Surgery Resignation Carmen M. Mendez, M.D. Medicine Michael Nakata, M.D. Medicine Retired Edwin G. Caine, M.D. Medicine

The Medical Staff Newsletter Progress Notes 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-08/2016

Physician/AHP Roster Updates

13

ProgressNotes Vol. 8 Issue 8 August 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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