March Update

Welcome to the March Medical Staff Update!

There were many policies, protocols, and guidelines that were created or revised. The list is as follows. If you wish to review the policies please ask at the Medical Staff Office.

New Policies

  • Air Break During Hyperbaric Oxygen Treatment (HBO)
  • CCC Histopathy Prior to Treatment
  • Chemotherapy Administration Safety Standards
  • Misoprostol Labor Induction or Fetal Demise
  • Nutrition Care Process
  • Protocol: Emergency Department Expedited Care

Revised Policies

  • 24 hour Coverage for Pediatric Patients
  • Drug Formulary Process
  • Drug-Nutrient Interactions
  • Fentanyl Transdermal Patch
  • Guideline: Adult Anticoagulant Reversal
  • Management of Drug Shortages
  • Management of Patient Allergies or Intolerance Records
  • NICU Standard Concentration for Continuous Infusions
  • Protocol: Adult Anticoagulation Warfarin (Coumadin)
  • Protocol: Antimicrobial Stewardship Program (ASP)
  • Use of Treatment Rooms in Pediatrics

A new update to the General Medical Staff Rules and Regulations regarding the qualifications of a proctor are as follows.

O. 3. d. Proctors must have completed proctoring themselves, and must be members of the Active or Courtesy staff at Desert Regional Medical Center. The only exception to this requirement will be if there is a demonstrated need to bring someone outside of the medical staff to proctor for a specific privilege, case or physician.

The Transfusion Committee has made a change regarding the number of pooled units of cryoprecipitate in an order. It is now 1 pooled unit instead of 2. This does not effect the Massive Transfusion Protocol.

Please remember to vote for the upcoming Bylaws revisions.

Please log in to see the Physician Satisfaction Brochure.

Informed Consent

For the purposes of this discussion when referring to the patient we are referring to the patient or the patient’s durable power of authority (DPOA).

It is the sole responsibility of the physician to obtain the informed consent from the patient. Nursing is unable to obtain the patient’s written consent for procedure until they are able to document that the physician has fully discussed the informed consent with the patient.

There are 2 methods that will contemporaneously document that an informed consent discussion between the physician and patient has occurred.

  1. The physician has completely filled out, signed, dated, and timed the hospital’s Consent to Surgery/Procedure form.
  2. Create an electronic note within PowerChart documenting the informed consent discussion with the patient.

If either of the above methods have not been accomplished there is no reliable method that nursing has to verify that an informed consent discussion has taken place. Dictating an informed consent discussion does not guarantee that it will be available in the proper timeframe.

If nursing cannot verify the informed consent discussion they will not be able to have the patient sign the Consent to Surgery/Procedure form and the patient will not be taken from their unit to the procedure area.

This is a requirement from CMS.


Tenet is in the middle of a general restructuring of existing PowerPlans to ensure best practices and compliance with existing regulations. This will be a painful process as we will have to recreate many of our existing saved PowerPlan favorites. We will strive to take some of the pain out of this process by holding open sessions for physicians to work with the Clinical Informaticists in recreating your workflows.

This is an ongoing process at the corporate level and ignoring it will only create more discontent and disturbances. What will happen is many PowerPlans will become “devirtualized”. What his means is that they will go away and any saved favorite PowerPlans based upon these devirtualized parent plans will become unusable.

We must be proactive in updating our workflows to utilize the newer versions of these PowerPlans, ensuring our continued ability to provide the highest quality patient care.

Stay tuned for information regarding these open sessions. If you would like to be proactive you may also make an appointment it’s one of the Clinical Informaticists to assist you with the process.

The preliminary round of devirtualization will begin in March. We will attempt to notify those providers who will be impacted by email. Please ensure that your contact information is up to date with the Medical Staff office.