Medical Staff Voice – February 25, 2019

JW Moore Tuesday CME Conference – “Adult Congenital Heart Disease: Preparing for the Surge”

Rose Tompkins, M.D., Assistant Director of Cedars-Sinai Adult Congenital Heart Program, will present a lecture on “Adult Congenital Heart Disease: Preparing for the Surge”.  She will 1) Discuss awareness about the increasing prevalence of Adult Congenital Heart disease, and 2) Discuss common congenital heart disease diagnoses encountered in adult practice.

The conference will take place on Tuesday, February 26, 2019, at noon, in Nichols Auditorium. Lunch will be provided and Category 1 & 1-A CME will be available.  If you would like to view this lecture online, please contact the CME Coordinator, Christeva Vazquez at or 805-948-5638 to be added to the webinar list.

Restraints Applied for Violent Behavior

Patients who have restraints ordered and applied for violent behavior must be seen by the physician within one (1) hour of having the restraints applied.  The “one-hour-face-to-face” assessment must include documentation of the following.

  • The patient’s immediate situation;
  • The patient’s reaction to the intervention;
  • The patient’s medical and behavioral condition; and
  • The need to continue or terminate the restraint or seclusion.

The time-frame for the renewal of restraints applied for violent behavior is based on the age of the patient. For example:  if after 4 hours an adult patient (age 18 or greater) still requires restraint for violent behavior, a nurse may get a 4 hr. renewal from the physician for up to 24 hours.  At the end of the 24 hours, it is determined the patient still needs restraint, the physician must see and assess the patient before issuing a new order.

  • 4 hours for adults 18 years of age or older;
  • 2 hours for children and adolescents 9 to 17 years of age; or
  • 1 hour for children under 9 years of age.

Hospital Acquired Infections Notification

A reminder that the CMHS Infection Prevention and Control Department expects to be notified whenever a hospital or healthcare-associated infection is suspected or recognized.  While we have surveillance systems in place, immediate notification by the physician is preferred and allows us to begin the investigation process quickly to determine cause and solution. The Department will complete the investigation, keep you informed and work to ensure the best outcomes for your patients. Contact information:

Physician Suspension for Medical Records Policy Update

As of Monday, 02-18-19 CMHS implemented the approved updated Physician Suspension for delinquent Medical Records Policy. This policy affects CMH, OVCH and CMHS Clinics.

  1. Physicians will be given 7- and 14-day notifications of their delinquent charts prior to suspension.
  2. Physicians on a rotating schedule are expected to complete any potential suspendable deficient items prior to going off rotation.  When the Hospitalist scheduled rotation ends they will have 48 hours to complete their chart deficiencies.  For example, when a physician is off of rotation starting on 10/1/18 midnight, they have until 10/3/18 midnight to complete chart deficiencies.
  3. Physicians scheduled for vacation or rotation are to notify the Health Information Management (HIM) Department prior to going on vacation; any potential suspendable items are to be completed prior to going on vacation. To advise HIM of your impending vacation please send your communications to or

Please contact the HIM Department if you would like to receive a copy of the complete updated CMHS Physician Suspension for Medical Records Policy at 805 948-4691.

Thank you,
Health Information Management

Sodium Bicarbonate shortage

We’ve just been notified of another sodium bicarbonate shortage. Both the abbojects and vials are unavailable from our distributor until mid-June. We have a very limited stock of 50 meq/50mL abbojects remaining in a few pyxis machines and in crash carts. We have stock of about 150 50 meq/50mL vials but don’t expect this to last until June. Our buyer is reaching out to 503B compounders to increase our order of compounded syringes but often in shortage situations they cannot increase our order amount.

We will be reinstituting the management strategies we used during the last bicarb shortage in 2017 to preserve our remaining stock for crash carts, severe metabolic acidosis, and TCA/salicylate overdoses.

CMH Weekly Medical Staff Calendar – February 25- March 1

8:30 am Emergency Division – NA (front)

12:00 pm Board of Trustees- BR
12:00 pm JWM Education Conf – NA

5:30 pm Surgery Cmte - BR
12:00 pm General CA Conf – BR

OVCH Weekly Medical Staff Calendar – February 25 – March 1

Surgery Department
@ CMH or Online

12:00pm @CMH
Board of Trustees

Final Thoughts

“There is nothing noble in being superior to your fellow men. True nobility lies in being superior to your former self.”

– Ernest Hemingway

Keep the faith,

Stan Frochtzwajg, M.D.
Chief Medical Officer
Community Memorial Health System – Medical Staff Voice Blog link

Tracey Shoop – Physician Liaison – & (805) 490-3860
Megan O’Neill – Business Development Manager – & (805) 207-8216
Scott Goodfriend, M.D. – Physician Advisor – & (805) 701-3514
Medical Staff Office – (805) 948-5662

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