Thursday, April 26, 2007

Innovative Hospital At Work: Cedars Sinai. Los Angeles

Preparing Physicians and Patients for Procedures for Safety’s Sake

Last week Anne Zieger, editor of Fierce Health Care ( called.. She had come across and wanted to know to learn what I knew about innovative hospitals. Her widely visited website has since announced it’s sponsoring an event called Health IT Innovators Awards. Fierce Health Care is calling for news from all innovative hospitals.

First on my list was Cedars-Sinai Medical Center in Los Angeles. Over the last ten years, the Cedars-Sinai medical center has built a Procedure Center and is now supporting a group of four “proceduralists” – internists wholly dedicated to performing procedures on hospital patients.

In 2005 each of these four proceduralists performed more than 2000 procedures. They received extra certification in fluoroscopy, conscious sedation, upper airway endoscopy, percutaneous tracheostomy, ventilator management, and ultrasonography. Their pooled complication rates, tracked through PDAs, was less than 1%, far below the norm for other hospitals.

Cedars-Sinai’s doctor leaders – Mark J. Ault, MD, and Bradley T. Rosen, MD, MBA -- say proceduralists greatly improve patient safety. In fact, Ault and Rosen envision procedularists as the next notch up in the patient safety movement, now being widely pursued among the nation’s 5000 hospitals. Proceduralists are an emerging specialty for general internists, and is closely allied to the evolution of the speciality of “hospitalist,” now about 10 years old.

Besides increasing patient safety and performing procedures, the Cedars Sinai proceduralists train incoming interns on nonhuman tissue models and wide sterile barriers. Other drivers behind the procedural movement are:

• helping residents comply with work-hour rules,
• enhancing resource use,
• reducing length of hospital stays.

The Cedar Sinai Procedure Center is designed to help interns, residents, and proceduralists themselves to prepare for and to improve in-house procedures – often performed in a critical care environment

One More Safety Step - Outpatient Preparation of Patients for Procedures

Now Cedars-Sinai has carried its patient safety campaign one step further. The medical center, in this case the Risk Management department, has extended preparation for surgical procedures to patients before they enter the hospital.

Patients forget up to 85% what they were told by their doctor about an upcoming procedure within 10 minutes of leaving the office. This may occur because patients are dealing with the stress of an upcoming surgery or medical procedure.
To enable patients to learn more about an upcoming procedure at their own pace and in the comfort of their home, an interactive web-based education program called Emmi (Expectation Management and Medical Information) is being rolled out across the medical center by Cedars-Sinai's Risk Management Department.

Patients access the Internet program from any computer, using an access code issued by their doctor. It’s worth noting the Emmi program requires no change in any hospital’s IT program. All that is needed is a patient’s computer access to the Internet, now approaching nearly universal access in many parts of the country.

Using easy-to-grasp language and drawings, Emmi walks patients through about 80 common operations (with more to come), from pre-op to post-op. The 20-30 minute teaching session explains benefits, risks, and options. It allows patients to pause the program and e-mail questions to their doctor. These may be followed up later during an office visit. There is a record of what patients viewed.

Emmi educates and prepares patients, and it helps them become more focused when talking with their doctor. This saves time for doctors, makes the informed consent process more consistent, and reduces length of office visits. Carolyn Bell, RN, director of Risk Management, says, "Other benefits include improved patient satisfaction, more efficient physician-patient interactions, reduced burden on front office staff and reduced malpractice risk."

Last summer The Center for Weight Loss Surgery was the first department at Cedars-Sinai to start the program. Since then, the Orthopaedic Center, Pediatric Services, Institute for Spinal Disorders, Minimally Invasive Urology Institute, Center for Digestive Diseases and the Heart Center have adopted it. To date, nearly 1,000 access codes have been issued to patients for procedures ranging from angioplasty, laparoscopic gastric banding (LAP-BAND) surgery, total hip, and knee replacement to colonoscopy.

"Our patients are arriving for consultation more fully informed than ever before," said Scott Cunneen, M.D., director of Bariatric Surgery. "Many potential questions have been answered prior to the patient's arrival, allowing us to focus on the most important issues. This is what technology is supposed to do -- make our job easier! I wish the Emmi program was available for every procedure."


1. Ault, M. J and Rosen, NBS, “Proceduralists – Leading Patient Safety Initiatives , New England Journal of Medicine, 356:1789-1790, 2007.

2. Rosen, BT, Ault, MJ, Ng, PK, ”The Proceduralist: An Emerging Specialty for General Internists, J Gen Int Med, 2005:20:Suppl 1:25, abstract.

3. Ault, MJ, Rosen, BT, Ault B, “The Use of Tissue Models for Vascular Access Training: Phase 1 of the Procedural Patient Safety Initiative, J Gen Intern Med, 21:514-517, 2006.

4. Cedars-Sinai Medical Staff Pulse
, “New Web-Based Program Helps Patients Understand Procedures, Risks, March 22, 2007.


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